 On this nice snowy day, the first item on the agenda is the executive report, Susan Barrett. Yes, thank you, Mr. Chair. I have a few announcements today. First, I want to introduce everybody to Lynn Colms. She is our legal team, brand new attorney at the Green Mountain Care Board. She has moved here from San Francisco and I'm worried that she's going to want to move back after this weather. Fresh air here. Welcome Lynn. The second thing I wanted to do is let folks know that our December schedule is online as well as having copies of the table in the hallway. I want to review it because we have a couple of meetings that one day is all day, so let me just run through it with you. And this is subject to change, I will say. So please, members of the public, check our website or give us a call if you have any questions about our schedule. So next Wednesday, we do not have a board meeting. And then Wednesday, December 12th, we have a morning board meeting starting at 10 a.m. And we have the ACO budget with a potential vote. And then in the afternoon on the 12th, we have an afternoon board meeting starting at 1. And we're going to be hearing from the folks at the Vermont Department of Health on the state health improvement plan. Then on Monday, December 17th, we have a meeting scheduled starting at 1 p.m. Again, ACO budget with a potential vote scheduled. And then lastly, the last meeting, hopefully, of the year in 2018, Wednesday, December 19th, we start at 1 p.m. and we will be getting presentation on the HIE consent. Any questions from the board on that? And again, I just want to reiterate, please check our website or call. Our calendar is up to date, but it is subject to change. The third announcement I want to make is to let folks know that we are currently accepting applications for our new Green Mountain Care Board General Advisory Committee. The link is under what's new on our website on the Green Mountain Care Board website. Those applications are due next Friday, December 7th, those of business. And I just want to remind folks to fill out the online application and submit your CD or your resume to me or to Christina. And all the information is on that application. Any questions from the board or anything to add on that? Okay, great. And another meeting announcement next week, Tuesday, December 4th, the board will be conducting our data governance council meeting. And that's in this building on the fourth floor. That is an open public meeting. It is not a Green Mountain Care Board meeting. Members, it is the data governance council of the Green Mountain Care Board. And that's all I have to reiterate. Thank you, sister. The next item on the agenda are the minutes of Monday, November 19th. Is there a motion? Okay. It's been moved and seconded to accept the minutes of Monday, November 19th without any additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor, signify by saying aye. Aye, any opposed? Okay. I'm going to turn it over to the UVMHM team. And we're going to have an update on the inpatient psychiatric vets. And the progress that is to be made today and where we're headed in the future. So Dr. Bronsted, whenever your team is ready, I'm not sure who's leading off. We'll try and get this to work. Thank you very much for the opportunity to come for our second update on the psychiatric inpatient project. And I'm joined by Anna Noonan, who's the president at Central Vermont Medical Center, and Eve Hor, who's our director of strategic and business planning. And at your request, we're going to spend the bulk of today on Eve presenting really a pretty deep dive in what we've accomplished so far, as far as understanding what the true statewide need is for new inpatient psychiatry vets. So just to set some context and some introductory remarks and I'll let Anna give some remarks around what she's been working on, helping Eve and others communicate where we're at, and then we'll turn it over to Eve. But I thought we'd start with just some reminders of the context. In my experience, the last two legislative sessions have been very unique in the focus on mental health issues more so than I've ever experienced. And there have been a couple of things that have raised all of our awareness and drawn out attention. One is that there have been some issues with federal funding around the IB rules. And the real driver we've heard from communities, from patients, from families, and very loudly from our providers that we have a real problem with weight times for folks having mental health issues in our emergency rooms. And that really is just heighten all of our awareness. I'll take you back to spring of 18 when we were talking about 2017's financial results and the UVM Medical Center had some patient revenues that exceeded budget by $21 million and sort of the adjudication of that. Your budget order asked us to actually have us measurably increase in patient mental health capacity in Vermont using the $21 million to invest. And we came back around and said that we would very much like to do that. We see a critical need that we can help to fill. And we believed at that time that it would take us three to four years to actually go from the budget order to actually getting that capacity online. And in the July update, we let you know that we were focused on the Center Vermont campus right up the road here as where we would site that facility. Center Vermont Medical Center is central and it's in Vermont so it seemed like a good place to really have a facility that would meet the needs statewide and not just for the UVM Health Network. And it's really important when you start a big project like this to right at the outset define what you're trying to solve for and then stick with it. This scope creep can kill projects like this either financially or just by having time drag on and not getting to the finish line. And so we're really looking at focusing on one piece of a much broader set of problems around mental health services delivery in our state. We're looking at increasing capacity for adult psychiatric patients understanding again that there are many other issues that we need collaboratively to approach. I'd also just give you a little bit of a teaser a few weeks ago at the time of our first early snowstorm. We were planning with the University of Vermont Health Network to have one of our community breakfast and we were going to focus on our network's mental health strategic plan. We're bringing that back around and actually we're going to do it in Montpelier in January so that we can have some of the same folks that were invited to actually make it. And the reason to bring that up here is to let you know that there are a whole host of ways that we're collaborating with others in healthcare and in community benefit organizations to improve access to mental health services. And what we've also done at the same time, not to the exclusion of that, but we've worked to say okay, we're a healthcare delivery system. How can we up our game and what can we bring to the table as the University of Vermont Health Network to improve services for folks with mental health needs. And that's where the strategic plan comes in. And this is just one component of the strategic plan, the planning for the inpatient vet facility. And so to make sure that we're on track and that we'll get over the finish line, we're looking to design and create a UVM Health Network inpatient psychiatric facility on the Central Vermont campus that's going to improve inpatient care and create capacity for the entire state. And I believe you know about us now that in every opportunity we try to be very data driven and evidence based and that's a process that we've launched into to determine what the appropriate number of beds is that we need for the whole state. And to look at that and see what of that need this project can fill. And as I'm turning this over to Anna, I think the team has done a masterful job engaging many, many, many different constituencies and groups. And on the flip side, those groups have been very, very engaged and willing to come to the table to participate in picking the tires of the methodology and also to hear what the results of all of the good work is that Eve will be taking us through in a minute. So I'm going to turn this over to Anna for a few comments and then we'll get into the substance. Thank you, John. So when we came in July, we talked about three phases for this project, so I just want to summarize those again. You're going to hear primarily today how we have accomplished phase one, which is really looking at the size of the facility. And you're going to spend the bulk of today going through a deep dive into the data analysis and you'll hear how we've arrived at what we think is an approximate number for the size of the proposed facility. Phase two, which we'll be entering into shortly, is really starting to look at design and operational requirements for the facility. So what's the programming look like? And based on that programming, what would the design look like, staffing models? That's also the phase where we'll be starting to talk about the finances, both in the build and operating facility of this nature. And then phase three, we'll be operationalizing the plan. And as you're well aware, we'll be coming to you with those quarterly updates as we move forward. So one of the things we've been committed to in this process is really engaging stakeholders as we move through this planning process. And so we have identified a group, which we named the Psychiatric Inpatient Planning Stakeholders Group, affectionately called KIPPS. And this is a team of stakeholders. And I worked with Anne Bonahue and a few other individuals. Can I just interrupt you for a second? I received a text saying that we're having a problem with the system as far as the phone. I might have to redial. Okay. Sorry. No problem. I was wondering who was meeting, it was me. Hopefully that works. If not, it's a lost cause. Okay. Sorry about that. That's fine. So we have launched that stakeholder group. And just for the speed of moving the process forward, we've given you copies of who's populating that stakeholder group. So that was one of the attachments that we have forwarded. And I think it's available to members of the community as well that identify both the charter of that committee and who's populating that committee. And what I'm asked for is a big ask. I'm asked for individuals that are participating in that group to stay with us through the entire journey. In that one phase builds on the next and will build on the very final phase. And so we know that that's a big ask. But I have to say that the people that participated in the first KIPPS stakeholder group was very committed to staying engaged in these. That's what they verbalized. The next meeting is December 20th. And we'll be sharing an update of where we are in the early planning process for the programming piece of this project. And again, I would say that the engagement of that team has been incredibly valuable for us. And then additionally, we've also, outside of the actual steering committee, planning stakeholders group, we also have a number of presentations we've done and we've listed all of those for you so you can see where we've been in the last few months from October to date. I think it stops at the stakeholder group on the 20th. But basically, we're open to sitting down with just about anyone to go through the data. We think that building awareness around how we've approached the identification of the number of beds that we think we need to design for is going to help us in the long run. And it's been very insightful, I think, for even I have primarily been doing those presentations. You've really drive them, I will say, does a beautiful job of that. And it's been helpful. Even if they haven't asked a lot of questions, they may be just asking a little bit about methodology or deeper dives on some particular data points. But overall, it's been, I think, very, very helpful for us. So we intend to keep that engagement going through the entire cycle of the project. So on the next slide is that listing of presentations that we've done. And you can see it's a pretty wide group of individuals. And we did one as recently as last evening. So we're open to going to groups and continue to keep discussion going around how we arrived at this number. And we're open to people just challenging and saying, you know, how about you thought about this or that? And we've made adjustments along the way with some of those insights early on. So it's been very helpful for us, very informative. Any questions related to stakeholder engagement and how we've been getting progress to date with our community? I guess you've already said it, but I just want to reiterate, it doesn't sound like there's been negative feedback to this point. I mean, my perception is there hasn't been negative feedback. I think we have to spend time reinforcing the fact, as John mentioned, that we're solving for one piece of a very complex issue. And that's the adult inpatient need. So we want to make sure that everyone understands that there still needs to address the pediatric population and also care that happens in our community. So we have to always clarify what we're really solving for. And I think John uses the example of one log in the long jam. So we want to make sure people understand that this is one piece of a pretty complex puzzle. So with that, I'll turn it over to Eve. I just have a quick question on the timeline. Do you have an estimate of when you'll be done with phase one and how long you'll be in each phase? We're just about winding down phase one, the data piece of phase one. We are starting down with the programming and beginning to really take a deeper dive into the IMD rules and regulations. So we have another meeting as an example tomorrow where we're getting some feedback around the IMD very specifically. And what restrictions that may place on our numbers of beds that we could build going forward. I just don't know. I know there's been this discussion about some changes to IMD rules with federal government. And I'm just wondering how there's a lot of community now I think about what rules are currently in place and what rules may be in place. How does that federally factor in? We're just diving into that. Eric Miller is leading the charge on that. But if anything, the new rules will relax the tension around our beds because our analysis that Eve's going to present is contingent on all the current beds staying online and in practice. And with the unrevised IMD that we all know that that is kind of tenuous, it looks like with the revisions it may lessen that tension. So if anything, it's going to make our situation better. Is that okay, Eric? Thank you. We're also safe to say that any change will have to require a waiver. So it's not a dot deal no matter what. So we can't really assume that the exchange is going to occur. Correct. So I have one question about phase one where at least the community participation process. I recall there was some discussion about other issues on the Central Vermont Hospital campus being kind of understudied and that this would be just part of kind of assessment of needs and construction and resighting and things of that sort. So my question is how is the timing on this and the substance of this related to our campus issues? So what we're undertaking right now is a master's facilities planning process. The acute care setting at CBMC is 50 years old with a lot of different maintenance. So what we're doing right now is analysis of what we need to spend in the next five years to keep us going for the next 15, keeping things as they are just renovating. And what would it take to build something else? So we're doing that analysis right now and we're keeping both of these processes moving at the same time as one will inform the other. Thank you for asking that question. Okay, can everyone hear me okay? Great. We're going to jump in to the data analysis on E4. I am the network director for strategic and business planning for the UVM Health Network and the storyteller for the analytical part of today's presentation. So back to the IMD issue, we framed this problem of how many additional beds for adult inpatient psychiatry care we needed. We actually decided to hold constant the assumption that the IMD beds would remain in place for this part of the analysis. And then play with that, if you will, play with that change of assumption after this estimate of additional bed need. And that's turned out to be advantageous with this change in what's our thinking about IMD, the IMD roles. So we can hold that constant for now and it doesn't impact this analysis. So again, the focus is on additional adult inpatient site beds that we need. Just a quick word about data sources. So, as John mentioned, we are very heavily data driven in this analysis. So we use the Uniporm Hospital Discharge Dataset for the calendar year 2017. That was the most recent data that we had available. And we also made use of summary level VOD data from their inpatient psychiatry analysis. And we did that through a special data use agreement with VODs. And that turned out to be very helpful and we'll show you how that played into this analysis a little bit later on. And then we made use of the most current 12 months of robust data that we had at CBNC and at the Medical Center. We did that because we felt that we wanted to get the most recent data that we could. And we'll again show you how having our own data that we use some deeper dives to inform some assumptions that we use kind of for the estimate across the state. We'll point that out to you. A few acknowledgments, but I'd like to say piggybacking on Anna's comments. We're really grateful to a number of stakeholders. Every time we've done this presentation around we've learned something. It's been actually a lot of fun to be able to share this approach and hear other people ask questions, make comments. We're really grateful to Catherine Simonson or Charlotte McCorkle from Howard Center by the way who helped us do a deep dive on one of the assumptions that we used. And we've tried to employ that approach either to seek out the community to go test some assumptions as well as kind of hearing general feedback. So thanks to everybody, you may know many of those names, but it's been great. So we're going to start with the punchline and then tell you how we got to this answer. But when we approached the number of additional beds that we need for the state of Vermont for adult inpatient psychiatry, we came up with this equation that we needed five to nine beds to reduce delays for those patients who are already receiving inpatient psychiatric care at our hospitals but had to wait in the ED for lengthy periods of time before they were admitted to an inpatient site unit. And then 18 to 20 beds to meet the needs for patients who come to our EDs and wait for a bed but wind up stabilizing in the ED and are being discharged before a bed becomes available. And then six beds for forecasted growth for inpatient adult psychiatry over the next five to ten years. And that makes the total number, our estimate of the total number of additional adult inpatient site beds that we need in the 29 to 35 bed range. So how did we get there? Here we go. First we're going to start with a little bit of information about our current state, which will frame the way that we broke this problem down. Then it will tell you how we did the analysis on the delays, the beds to reduce delays for those patients already receiving inpatient site care. Then how we came up with the beds needed to meet that unmet need and then the growth rate. And then we'll get to our total. If you get lost, so this is a little bit of a lengthy analysis. Look up to the right-hand corner of the page and it'll tell you kind of what section we are in in the analysis. Okay, so here we go. Adult inpatient psychiatric capacity today. So around the state we have about 137 inpatient adult psychiatric beds. 63 of those better, about 46% are covered under the IMD reimbursement rules. So that's quite a lot. We're in six locations around the state, as many of you well know. About 45 level one beds and 92 kind of general inpatient psychiatry beds. So that's the mix there. I'm sure you're all aware we've seen reports from DMH and other places about how full we are on the inpatient side around the state. Nearly at 100% occupancy for level one beds. As you can see from the data below on the table, we're not seeing a large increase in the number of discharges, but that's because we're full. There isn't any more capacity to take more patients. And you can see we're really hitting that upper limit in the number of patient days across. We believe that we're seeing a slightly longer length of stay, and we believe it's a higher acuity of patients that's driving that longer length of stay. As you can see, the table that we're showing shows the community hospitals around the state. When we include VPCH and the parental referral retreat, we turn to our colleagues over at VOS, and what we see is a length of stay that's 23 days over the data that they looked at for patients who were discharged. But there's a number of patients who were in that study who hadn't been discharged, and if you look at that population of patients who are still in the system, if you will, that length of stay is 151 days on average. So we do have a small number of patients staying for a very long time. In our EDs, we're seeing significant growth in the number of patients coming, and we're also seeing significant increases in the number of patients and the length of stay for those patients. So 42% between 2016 and 2017 for the number of patients who are in our EDs for two big nights or more. Our average census is increasing steadily. I know you've all seen data around this problem in our EDs, and we just wanted to share a little bit of that. And I'm going to keep going in the interest of time unless anyone has any questions or comments they want to make. We'll jump in on that problem. When we looked at our own medical center data, and this was also validated with our CVNC data, and we looked at where are our patients coming from who make it to our inpatient psych units. And what we found was that 80% of our patients are coming from the ED, about 10% direct from the community, and 10% are transferred from our med-surge units. So pretty strong evidence that our ED effectively are serving as the front doors to our inpatient psych units today. These are cute little charts for one year of census charts for all of the EDs around the state. And just a couple of comments that strike me as I look at this data. One is that if you look at the EDs in Brattleboro, Rutland, Springfield, Berlin, and at the medical center, and you see those higher census in those EDs. So again, that kind of supports the fact that these EDs are in effect operating as the front door to our inpatient psych units. Brattleboro for the Brattleboro Retreat. But if you look across all the EDs, you see that there are a number of patients with a primary mental health diagnosis in our EDs at midnight very consistently. It's not a temporary thing. So we're seeing the porters and the copies, and I'm thinking North Country, every ED around the state is feeling the same kind of pain as just to what extent they're seeing these patients in their EDs. I had the opportunity to do this presentation to the VAZ, CMOs, and every single one of them, the head shaking about this problem and their ED issues was very evident. It really supported the data that you're seeing here. These are charts of our ED patients, both at the Medical Center and CBNC. Again, this is an opportunity where we took that deeper dive to look at our own data. A couple of things for everyone to note, first of all, the vertical scales show number of patients, but the scales themselves between CBNC and the Medical Center are different. The horizontal axis shows the number of hours a patient stayed in the ED. Each bar shows four hours, sorry to everybody, for the tiny little graphs from the back of the room. One other note is that we've had patients who are outlier, patients who stayed longer than that axis would show, but for the purposes of putting these two graphs side by side and absorbing them, we omitted those outliers. They are included in the modeling I'm going to talk about, but they're just excluded for these graphics. So what do these graphs say? First of all, the red bars are number of patients who waited in the ED with a primary mental health diagnosis. Excuse me, yeah. A primary mental health diagnosis or a diagnosis, a secondary diagnosis of suicide, ideation, or attempt. So we're grabbing both of those parts of the population. So the red bars are patients who come to the ED, are treated for a mental health condition, and are discharged. The green bars are patients who come to an ED and wait and are then transferred to another inpatient psychiatric facility in the state. And the blue bars are patients who come to the ED and then are admitted to an inpatient unit within the same facility. So we're kind of dividing everyone up into that. As you go out to the right on these graphs, these are the patients who are waiting and waiting for an inpatient psych bed. And so you can see that we have patients who wait 72 hours, 95 hours for an inpatient psych bed at the medical center or to be transferred to an inpatient psych bed at another facility. We also have patients that wait 95 and 120 hours and are stabilized enough so that they can be discharged and go home. But we have mental health patients who are staying in our EDs for a long time. So that's the ED issue. What about those 10% of patients coming into our inpatient psych units from another med-surge unit? So we looked at that to see are we missing any of those patients? Are they staying in med-surge units for so long that if we're going to build additional beds we need to think about the need from that source? And here's what we found. We actually looked to see if there were a distinct number of patients whose length of stay were appreciably longer than other patients with the same diagnosis. And what we found in short was there were a small number of those patients, about 13. We've done some other deep diving and corroborated that they're memorable patients but it's relatively a small number of patients who stay in a med-surge bed longer and have an inpatient psych bed available. They would have been transferred. So basically, our conclusion here was this is a small number, not worthy of a lot of work in a deeper dive, not going to make a big difference in the number of additional beds we need around the state. Similarly, direct admits from the community. So 10% of our total, if you will. So this is where we're very grateful to a deep dive we did with Catherine Simonson and Charlotte McCorkle from Howard. We talked about patients from the community and here's what we came to agreement on. The patients who had an acute mental health crisis and came from the community would wind up coming into our EDs and we were kind of including them. They either found their way into inpatient psych. They came to the EDs and were admitted for an acute condition and we will be talking about them in a minute. Or they were already included in this piece of the ED population analysis in the unmet need group, if you will. So we felt that there wasn't a special piece of analysis that we had to do for these direct from community patients that we were picking up on the other parts of our analysis. That concludes the current state piece. So again, to summarize, what we did was we said, okay, we've got patients who wait in our EDs for a long time to get placed in an inpatient psych unit either at our own facilities or someplace else around the state. And so that's the delays group, if you will. And then we have a number of patients who come to the ED and had an inpatient psychiatric bed been available would have been admitted to the inpatient psych unit. And so that's the second group. We call it the unmet need group. And then the third group is our expected growth rate where we apply our forecasted growth for inpatient psych. So we're going to go start with the delays. So back to these ED graphs. I'm on slide 20 for anyone who can't see. Again, we took away the people who came to the ED and were discharged and we just wanted to take a closer look at these patients who come to the ED and do get an inpatient psychiatric bed and they have to wait. So you can see again the number of hours that some of our patients have to stay. And many of our patients are admitted within a pretty reasonable amount of time. The black bar is the eight-hour bar, both for CVMC and UVMC. But you can see we can still do a lot better for many other patients who have to stay in the ED and wait. So this formed the basis of what we looked at. We actually built a model that said, well, we know that these patients are arriving at the ED. And so our model said, how many more beds would we need to have an inpatient bed available for them within a day, or actually within eight hours of their arrival in the ED? And so let's use a simple example to try and show you how the model worked. So if we had a patient who arrived on July 3rd and they waited in the ED for two days for an inpatient psych bed to become available and were admitted on the 5th of July, and then this is an actual patient. And this patient stayed for 12 days, had a 12-day length of stay and was discharged on the 17th of July. So what our model did was said, this patient arrives on July 3rd. We're going to take that 12-day length of stay and we're going to start it on July 3rd rather than on the 5th. So this patient gets admitted on the 3rd and gets discharged, I can't even do the math here, on the 15th. And that opens up, by the way, that same inpatient psych bed two days earlier than before for the next patient who comes into the ED. So this is the way the model works and it's a classic queuing theory for people who like that kind of analysis. And the result is that, there we go, that around the state to reduce these delays we actually only need three to four additional beds to take care of all of these patients who are currently getting inpatient psychiatric care but had to wait long times to get it. We did this hospital by hospital. So one to three beds at the medical center to reduce those delays, about a half a bed at CBMC to take care of those delays. We estimated that in Rutland and Springfield did a lot like CBMC, so estimated a half a day for these patients. We didn't have that specific data for Springfield and Rutland, so we couldn't do the same kind of analysis on there. For transfer patients, the same idea, we didn't have these patients' actual length of stay. So we went to the VAWS data and we took a randomly selected length of stay from the VAWS inpatient site length of stay distribution curve and what we got was two to five additional beds needed for those patients who have to wait for transfer. And again, this is around the entire state, EDs around the entire state. So if we add those up, what we get is five to nine additional beds to reduce delays for patients who are already receiving inpatient psych care. So that's the first block. I had a question. Sure. How do you factor in when you go back to the charts that show by month and there are certain months that there were peaks? So that's what driving, I guess what's the factor that's driving the max of the beds? Because some months would need five to nine other months would. That's right. So the model did that and because we used actual arrival dates, we wanted to make sure that we had enough beds to take care of these patients. And so it just adds a bed when you have a peak. So it adds a peak? Yes. Well, we actually simulated it through the whole year, if you will. And length of state factors in there, as you can imagine, very, very well. So we used a lot of simulation analysis, ran simulations a number of times, a thousand times, and kind of looked at the cumulative data there. Does that make sense? It's amazing. We'll actually show you some actual data when we look at the number of total beds for the unmet need and the variation is just striking. And I think one of the great... I'll give Zach Sullivan kudos here who's sitting in the audience. Zach did the live share of the analysis here. But it's really instructive to see the different variation that you can get when you're randomly choosing that length of state rather than taking the average and assuming everyone's at the average. As you go down. Thanks. You're welcome. So unmet need. Again, so we're defining these patients as patients who are in our emergency departments who would have been admitted to an inpatient psychiatric bed had one been available. So again, that's those folks on the right-hand tail there in the red. But not all patients who come to the ED. We're not saying all patients who come to the ED with a mental health condition need an inpatient psych bed. That would be crazy. So we'll show you how we broke down this problem. So one is we know that the EDs are an appropriate place for patients who come with an acute mental health crisis. And we're not saying that all these patients need an inpatient psych bed. But there are some patients who stay in the emergency departments for a long time. We believe waiting for an inpatient bed placement. And I think many of them do finally receive, as we saw before with the delays group, many of them do get an inpatient bed or are transferred to another facility that has a bed available. But some weight in the emergency department and are stabilized and are able to be discharged and go home rather than continue to wait. So we're trying to find out who those patients are. Those patients who had an inpatient bed come available and it was appropriate, the appropriate care for them, how many of those patients there are. And here's how we put our arms around that. So what we did was we looked at the, we went back and we looked at the data and by length of stay. And we noticed that, let me fight back up here a little bit, there are some pretty steep drop-offs in the number of patients who wait after 28 hours. You can see it both for the CDMC data and for the Medical Center data. So what we did was we had a hypothesis and we went back and we said, hmm, do we see a correlation between a recommendation for an inpatient admission and the number of hours that these patients are in our EDs. And we pulled 200 charts at random on random days and took a look at that. And what we found was this, that patients who stayed in our EDs for 28 hours or more had a high probability that they were recommended for inpatient admission. About 70% of patients in that group on their charts had a recommendation for inpatient admission. On the other side of things, patients who were in our EDs for less than 12 hours were far less likely to have a recommendation for inpatient admission. Okay, so... You have a question about that? Sure. 85% of those who stayed less than 12 hours were eventually discharged. Do you have to do a look at all that they were re-admitted or returned to the ED like three days later, a week later or something like that to see if, yes, they were discharged for that admission, but we didn't see them again, three suppliers or something like that. We didn't, to my knowledge, that. Do you want to answer that? We really focus our look at re-admission on the patients who were staying for long periods of time, multiple times. So there were a significant number who might have been there for a... Typically, we didn't have patients through there for a short period of time, a number of times followed by a long period of time. They might have one long stay all by a number of short stays. So what we think is happening there is that, yes, we do have these treatment suppliers, but once they've been evaluated, once the staff has figured out this is what's going on with this patient, they do keep coming back and get treated very quickly. So I don't think that's really adding to potential demand. Thank you. Jessica, the other thing we didn't want to do is we kept catching ourselves from making the assumption, particularly since I'm not clinical, that in patients' life it's always the answer. So even if a patient did go away and come back, it may be that it's a different kind of community treatment that might be the answer. So we really wanted to check ourselves from having that hammer, if you will, and finding all the nails that go with it. So I think if anything, we could be criticized for being overly conservative on some of these numbers. I just have a quick question to you. Did you look at if you had four patients come in on the same day, presenting the same way, and they needed to be transferred out? And one's Medicaid, one's Medicare, one's commercial, and one's uninsured? Is there a difference there from getting the placement? So we did not look at that, but mostly because we felt that it didn't matter for this bed need analysis that we were doing. There's other deep dives we could do, right, but we just wanted to make sure we were really trying to get our arguments around how many more beds we needed and not those other drivers. From a clinical perspective, the clinicians are not looking at their source data for insurance. They're treating the patient based on their condition and their presenting condition. I can almost guarantee you that our R&D docs and R&D docs don't have a sense at all of the insurances to that patient that's in BD. I was looking at more ahead to be transferred somewhere else. In our experience, it's not impacting. We don't commonly hear when we're trying to place patients into an appropriate level care setting that they're asking those questions. It's more around the clinical presentation of the individual. They can balance that individual with the milieu that they're being admitted to. Great. Taking those pieces from our exploration of data at UVMMC into account, here's the set of assumptions that we used to identify of all those people who come to BD with a mental health diagnosis, which ones are part of this potential population meeting in patient psychiatric care. And so we decided that everybody who waited in the ED for longer than 28 hours at what were discharged would have potentially gotten an inpatient psych bed and had one then available. For the group between 12 and 28 hours, based on our chart reviews, we decided one out of five of these patients would have been admitted to an inpatient psych bed. Four out of five would not. One out of five would. And then in the big bulk of patients who are in our EDs for less than 12 hours, we took none of those patients as potential driving and potential need for inpatient beds. One quick note on this pie chart that I'm showing you. This is a subset of patients who actually had a psychiatric evaluation at the medical center. This is if we showed you patients who came to the ED with a psych diagnosis, that the pie would be bigger, but particularly for those patients who are staying less than 12 hours, that would be significantly bigger. I just wanted to make that a note. Okay, so we've got our potential population. Everyone who stayed was in the ED and waited more than 28 hours and one out of five of those in the 12 to 28 hour group. How many patients is that? It's about 617 patients from our EDs around the state based on our analysis. All right, so we've got our patients. We know how many we have. We know when they arrived. One quick thing that I'll tell you is in our simulation analysis, we picked those one out of five patients in the 12 to 28 hour group at random. So that's the first piece of randomization we do. Then the next question is, well how long did these patients have stayed in an inpatient site bed? We don't know. They were discharged from the ED. So we went back to the VAAS data and we said we've looked at the inpatient length of stay distribution from the VAAS data around the state and we're going to choose from that distribution curve in a random way. Here's the reason why we do this. This is amazing data from our friends at VAAS. Average length of stay for this group. Oh, first of all, we excluded level one patients. In the VAAS data, the hospitals who submitted the data kind of self-identified level one patients, we're using that as a proxy for the highest acuity kind of patients and our feeling was the highest acuity kind of patients, they're often that delays group. We've already, they found a way, most of them, to get an inpatient stay and we've already taken care of the bed need for them in our earlier delays analysis. So we didn't want to overstate the need for beds here. So we took away the length of stay for level one. These are non-level one patients, but look at the range. Zero to 194 days for the average length of stay of 8.4. So we absolutely wanted to randomly pick from that distribution curve to be able to simulate reality here. So that's how we use that curve. So you get the simulation there. And we ran the simulation a thousand times and then aggregated the results from all of those 1,000 simulations. And here's in short what we get. The census graph on the left shows that most of the time we had, we needed an additional 8 to 16 or 18 beds. But there were times when we needed 24 more beds. So you can look at that. For those of you like me, the graph on the right says, well, what percent of the time did we need 18 beds or less or 20 beds or less? I picked a random point here of the 20 bed mark and saw that at 20 beds we would kind of meet the needs of this census about 97% of the time. So it's about somewhere in the 18 to 20 bed range for this unmet need group is where we're winding up. So here's the fun reality versus the bed thing that I was telling you about. This is nine of the thousand scenarios. I picked the midpoint between 18 and 20 and said, and this is just the scenarios with this unmet need group. And said, okay, let's look at the census and let's draw a line at 19 beds and see how many times we're under that or over that. So I love 737, the simulation in the bottom left looks pretty darn nice. We looks like we never get above the 19 bed mark in that simulation. But if you go to the simulation just above it, 364, far left in the middle row you can see that there are times when 19 beds would keep a bunch of people waiting in the ED for care. So that's how I look at that. One more set of bar graphs for you, sorry about this. So this is 18, 19 and 20 beds and looking at kind of the T's about the bar that really matters is the one on the far right in each of these scenarios and here's what they say in short that at 18 beds we are full, 100% full about 10% of the time. But that doesn't mean because you're 100% full doesn't mean that you hit the nail perfectly. Actually being full 10% of the time said you didn't have anybody waiting about 4% of the time and 6% of the time people were waiting in the ED because you were full. But at least this lets us and you can see with 19 beds we're getting we're full about 6% to 7% of the time about half of that time we've nailed it we're full and nobody's waiting and another 3% of the time we have people waiting in the ED. This gave us another feel that we were kind of in the right ballpark and we think about 18 to 20 beds for this unmetting group. So we'll stop there. Before we go to forecast we wanted to do is go back and say hey, if we re-ran the data for the past 12 months or the 12 month period we're talking about what would things have looked like? So we kind of teased with that in the 19 bed scenario. So a couple of things. So we wanted to look at the wait times for patients prior to admissions in an IP unit and what we saw when we ran it was that we could get patients to an inpatient psych bed about 98% of the time without a wait. So we felt that was pretty darn close to being on the money. And by the way for those of you who think in terms of overall system occupancy rates we're calculating the overall that includes the current beds of all the beds the occupancy rate would have been 88% had we added out of these beds. Oh sorry I should say what I did was if you took the 5 to 9 beds for delays the 18 to 20 beds for the unmet need I kind of took midpoints and said 26 beds. If we had 26 more beds over this past 12 months period re-ran things what would they have looked like? So with those 26 beds 88% occupancy. Are there standards of bench arms that are not used to be for a system? Is that about the target? This is about the target. We used our partners at HALSA to talk about that. They've got broad national experience in hospitals and occupancy rates. So that's the break down there. So we're not perfect all the time but we're pretty darn close. Then we asked ourselves what would the experience in our EDs have been since we're over the experience in our EDs have been if we had 26 more beds over this 12 month period. What we see is a significant decrease in the number of patient hours in the ED. About a 55% decrease overall in our EDs around the state. This understates the impact just a little bit because we only know about patients who come to the ED and wait and then are admitted to our own inpatient psych units for our own hospitals and the network. That data is not available to us through the discharge data. So it's probably slightly understated but you can see the impact. Notice that we don't solve the problem entirely. So we will still see patients who have acute mental health needs come to our EDs and we said that we weren't taking care of the patients who come and stay less than 12 hours and we didn't include those patients who come and stay or 4 out of 5 of those patients who come and stay between 12 and 28 hours. So we aren't going to see those numbers completely go away but we certainly do a pretty good job addressing the huge amount of hours that those patients stay in the ED. We did have data about our own patients who wait for the ED before being admitted to our own inpatient psych beds. We could actually do a better job of quantifying the impact on our EDs. So again with our access to our own data we showed that we predicted a 58% decrease in patient ED hours at the EDMC and a 64% decrease at the Medical Center. Sorry I'll explain the color coding pink is patients who come to the ED and are discharged are stabilized and then discharges our patients. Green Green is still transferred. Green are patients who wait in the ED and then transferred to another facility to make a decrease in the hours for those patients and then the light blue is patients who are admitted to inpatient psych. And you see the dark blue there on the kind of after scenario this is kind of a before and after scenario you see the dark blue because those are the unmet need patients coming who were discharged in the left in the current state who were discharged stabilized and discharged from the ED and the darker blue on the right hand is those patients now getting the inpatient psych bed that they needed. So just one more thing I wanted to think about how many patients' lives were we impacting with this work that we would be doing and again looking at our own data because it's complete from all of those aspects and with 26 more beds we could impact the experience for about 1,300 patients at these two hospitals and reduce the number of hours waiting in the ED by about 53,000 hours in a 12 month period. So that was the simulation for today now we have to add one more piece which is projected growth rate in patient psych and then we're done. I have a question about whether you looked at the length of stay in terms of folks who were admitted in patient bed but perhaps had a longer length of stay because there wasn't an outpatient placement or some place for them to go because I was wondering if that might impact the numbers and whether you had the opportunity to look at that in some way. We used so we decided to use actual length of stay and hold that constant and ask that question in a second phase if that makes sense. You're welcome. Growth, 5 to 10 year growth we use a partner called SG2 nationally recognized intelligence partner who do a lot of healthcare forecasting and they do it, they have a methodology that takes a number of factors into account so not just changes in demographics but also changes in economic factors in the regulatory environment changes in epidemiology changes in treatment modalities outpatient alternatives you get the idea we looked at their forecast for the growth in adult inpatient psychiatric days for Vermont over the next 5 and 10 years and their estimate is a growth rate of 4% which many of you may find shockingly low but I will tell you that their estimate of the growth rate for patient visits for psych visits or mental health visits actually it's just psych visits on the outpatient side is 10% over the next 10 years and they're forecasting a 19% increase in the number of ED visits over the next 10 years so SG2 I have found is conservative but there are very big believers in treatment modalities they are very aware of many new outpatient treatments and new inpatient so ECT therapy for example that can reduce the length of stay so all of these things are being factored in here in short what I'm saying is this is a group of people who thinks if you can treat a patient the right thing to do is treat a patient in the outpatient setting that's a forecast that says inpatient is the only way to go so so many people who see this growth rate think it's very conservative I'd rather be on the conservative side of this estimate than overly aggressive but again so take that 4% know that their ED forecast growth rate for 10 years is 19% on the outpatient side is 10% so that I think that puts that into context we applied that 4% growth in patient days to all the beds in the system because it's really system-wide and so that translates to about 6 more additional beds for growth and finally we got to the finish line back to the equation so if we take the beds to reduce delays the beds for the unmet need and the beds for forecast regrowth we get a final estimate of the additional number of beds we need 29 to 35 thanks for hanging in there any questions just to make sure I understand this 4% growth rate so I look at the day 2022 which is probably when everyone hopes that you're opening your doors that we've done through this process and it's been built in over 4 years down the road from here and we're opening the doors so is this flat assumption from 22 to 27 is that our demographics etc have are constant off of 2022 or what is in that assumption that it's flat from 2022 to 2027 great question so I think there's a combination of factors with SG2 so I'll walk you through some of them so one is that our population itself is growing very slowly at all so we've got some aging factors that contribute to the analysis but they their forecast is very driven particularly in the 2022 to 2027 period and some major benefits from new treatment therapies on the inpatient side and ECT as one of them and I'm not a mental health clinical expert by any means but they really do believe that there's some new therapies coming that are actually here newish today that will become more mainstream in another 5 years they've done a pretty good job of predicting some of these things by the way in other areas like cardiology etc so I think we're going to see some new inpatient treatments that will help reduce length of stay and they're big believers in outpatient outpatient therapies as an alternative to inpatient care and so I think that you'll see a lot of that influence driving what's happening in that second 5 years of the 10 year growth rate now that we have all this data can you just outline for us the next steps moving forward turn it over to Anna Anna so now I could keep telling everyone that probably as hard as this was to do this analysis this was probably the easy part and that identifying a number is pretty concrete the next piece of really understanding programmatically how we would operationalize a facility like this and what that facility would be those sorts of things is really more almost a little bit of a qualitative type study now that is underway so we're pulling together teams not just within the network but from other organizations to start to inform what the program would look like for care and treatment of this patient population that in turn informs the design of the facility and how it is operationalized so that's really the next heavy lift and we're in that process right now there's also the moving target that we talked about at the beginning of the presentation and that's understanding the IDD rules and the actual number of beds that we can build on the Center Vermont campus because those rules play in the percentage of the overall beds on that campus that can be for inpatient psychiatric services is formulatively derived but it's as lots of things a gray zone so we're doing again under Eric Miller's direction some analysis on what if any limitations that brings to building on the Center Vermont campus so further refine that 29 to 35 to what we actually can build and maintain the kind of funding that we need. So one of the things that you made clear the last time you were here is that you were also taking a broader look at the overall facility of Center Vermont Medical Center and trying to determine if there were changes for updates that needed to be in there so as a master plan. Am I correct in that? Yes and Hulsa is working with us on that as well and the absolute is that we have to be absolutely certain that we don't do something with this facility that will encumber us to make wise decisions and investments down the road and conversely are the things that we can do that are a better use of capital dollars up front if we did something in combination so that will certainly be part of the analysis but what absolutely is aligned in the same is as we design and bring forward for a certificate of need this facility we want to make sure that we're not putting shackles on our ability to do the right things on the Center Vermont campus. Is there anything in the early stages of this analysis that would lead you to believe that there will be an increase in other beds or a decrease in other beds? Our early analysis has us estimating 232 bed and surge units for what we need projecting forward into 15 years but again that's a preliminary analysis point and essentially the services would stay the same. As an example we do not have inpatient pediatrics at CBMC we have obstetrics and the infants that are delivered through that process but we do not have a pediatric inpatient population and we don't foresee having that in the future. Those patients if they need that level of care go to our network AMC that has a children's hospital so we're keeping some things calm. I'm not using the glass at full I'm encouraged because I think even if you had no change and no waiver was received you still could build up to the midpoint of the range that you targeted so I think that's very very encouraged. Yes but we need to complete the analysis on the IFD and remember that the number of inpatient psychiatric beds can exceed a 50% of the overall beds. And Chair Malin it's if we were only charged with looking at the number of med surge beds versus the number of inpatient psych beds that's a pretty easy analysis to do and it would lead you to conclude pretty quickly that you could come somewhere near the midpoint unfortunately as many things having to do with federal funding of healthcare it's not quite that simple and instead of looking merely at the number of beds you're actually looking at the number of patients who are in the facility not in any given month, year or week but on any given day and so it becomes a similarly data driven analysis where you're looking at not an average daily census but a daily census and where it rises and where it falls in order to determine what your true denominator is and looking at that ratio of inpatient psychiatry to inpatient med surge that you cannot go above without risking your federal funds participation. So I expect that when we're next in front of you we'll be able to come back with a deeper analysis of that. I just wanted to address my thanks personally as one board member I think that you very seriously took the challenge that we laid out last spring and more than we met in my expectations somebody who loves data this is a very sophisticated analysis I recognize that I recognize all the simulations that we've done all the inputs and all the assumptions that have been made and tested and robustness checks and all of that very very sophisticated I really appreciate that I also really appreciate the community engagement that clearly took place and continues to take place and it realizes a piece of a very large puzzle this is just a built-in patient that we're looking at but the numbers that you put up there of the potential to impact 1,300 patients and you know 53,000 ED hours strikes me as hugely impactful and particularly think about the care that those patients that we're seeing in EDs and recognize that hospitals are doing the best they can but that is not an appropriate care setting for those patients and you know there's tons of data out there about you know the impact of boarding patients on agitation and anxiety on increasing their mental health status on even cell harm and suicide so this is hugely impactful the analysis is fantastic and I really appreciate it. I have a question I would just second which it just says so well but thank you. So at this point we'll open it up to the public for comments and if you could start by standing up saying your name what town you're from and address your comment through the chair. Go ahead. I'm aware that on occasion there have been people who make commentary and they criticize the Green Mountain Care Board and I'm also aware that there have been people that criticize aspects of our hospital system including UVM Medical Network but I think today is you know an important day because we do have to recognize that it was the Green Mountain Care Board after a new number of years that took on a leadership position on this issue and in some ways looking at it from a period of years this may be one of the best initiatives that the board has promoted of course we're just at the beginning not at the end so we should be careful not to go too far but I think it's appropriate to express that appreciation to the board today on this issue. It took the leadership that stood up and has really promoted an important discussion. I do have to say that I think the initial work in the project has been quite good. I think there's been a real attempt to exclude people which was a commentary I made a number of months ago of concern and I think the actual analysis whether one agrees with all of it or part of it still is so much more thorough than I think the mental health field has experienced over the years that gives hope that we can come out to an accurate resolution that will lead to some services. Of course you don't want me to be too positive all the time so so I did want to ask the board a question but I do have a question really for the presenters but the question to the board is since 2011 to now excluding this initiative how many of our 14 hospitals have come forward with any projected plan for expanding inpatient bed capacity since 2011 and I'll exclude the battle war retreat because they're not regulated by the main amount of care boards that understand it. I'm thinking just one but I'll defer to Robin who has a little bit more. I would defer to Jess who's been here longer. I think I'll defer to the staff who could probably actually look at that for you. I pose the question because I hope that the board and others who are here today will also ask the question of why you know and I think it's important to at least think about that a little bit and I'll give sort of four issues that I've identified there were more I'll do it real quickly. The complexity of the health care issue is profound. This is a complicated medical issue but I assume that medical people here would agree that over the last decade or two decades treating cancer or heart disease is also very complex with a lot of challenges. Just to be scared off by the fact that it's a complex issue is not acceptable and there's a difficulty with acuity levels. I think over the years there's been a hesitancy on the part of hospitals perhaps engage patients who have this level of acuity and I think that this project has the potential from my point of view to be a major breakthrough and I would call it a parity enhancement of treating all acuity cases. I think the third issue which I think is a great concern is the lack of adequate community services which I think would give pause to any hospital for really pursuing this if the community system includes our designated agencies and a lot of other programs if they are as undefunded and as inadequate as they may be there is the potential of just continual gridlock no matter how good the treatment may be with let's say 35 new beds or 45 or 20 whatever the number is unless that issue is also dealt with there's going to be this sense of gridlock in the system that ultimately suggests great issues to having the project be successful and I think that that's something slightly different than perhaps other health care conditions look at today and it's already been said that many people in some ways get stuck in the hospital because there isn't any or there isn't enough capacity but I think the fourth issue and this is my question is the fact and I won't say it in the most politically correct way that's okay in some ways inpatient psychiatric care has less potential as an economic money maker as compared to orthopedics that's just a general commentary I may be wrong but that's my assumption my assumption is partly because of frankly discriminatory and lousy reimbursement schedules both in the insurance industry and the federal government it's really projected poorly in terms of running a financially viable inpatient psychiatric hospital unit so my question is it's not too early just to raise the question is there hope that somehow UVM Medical Center in this model can figure out a way of making this financially not only possible to implement but to sustain over a period of years thanks for your comments Ken is it okay for me to the issue of parity and the issue of sustainability I think is absolutely critical and with our current fee for service system I don't believe that there is any way to get to parity for mental health services in the fee for service system the momentum for doing procedures in high end specialty care to the detriment of being able to take care holistically folks in their population you just can't get there from here and I would say it's not the only driver for why as a health care system the university of my health network we're so help bent and so supportive of the all pair model that moves us to essentially a capitation model were accountable for the quality of services and the cost of services but the ability to appropriately address the needs of the population of mental health issues is a major driver for why we want to move towards that doesn't solve anything or everything because we're talking about the formal delivery system here but it really does allow us to start moving some of the dollars around inside of the health care dollar not necessarily seeking extra dollars but to move those around in a way that we believe is more appropriate to actually serve the real needs of the population and we all know the incidence of significant mental illness I have a very large and expanding family that goes four generations currently and in each one of those generations except for the very newest we've experienced need to access those services the all pair model I believe is not a panacea but it is a critical element to us moving towards parity we then also do I'm not going to sugar coat this when we get to the next phases and we start talking about the financing not so much on the capital side but on the operating side we're going to have some tough conversations with the state and commercial payers about doing their part we're doing redistribution of dollars from the acute care side part of the sustainability equation and this has been done for others that have brought online psych beds there needs to be appropriate reimbursement for these services so it's not a done deal but we're really thinking a lot about sustainability of these services within the context of everything that we're trying to do is that helpful with the next question? I think it was a great summation that all of us were trying to spit out the words all pair model but you did it so eloquently and I just want to say that to your question it takes a leap to faith and Dr. Bromsted and the team at UVM have taken that leap of faith in the same way that Tom Huter did in Rutland when a lot of his peers said that's not a great move putting in patient beds in because sooner or later your reimbursement is not going to pay you enough and it's going to jeopardize other things and everybody knows if there's no margin there's no mission and I think this is a leap of faith that UVM has taken because they understand that between healthcare whether it's physical health or mental health and they're willing to navigate the waters to make sure that they get the sufficient reimbursement the same way that Tom did in Rutland and there are never any guarantees that you're always going to get what you need but this is something that the community needs, the state needs and they've come forward and they should be applauded for the work that I'm coming forward and I would say that a year ago somebody told me that when UVM at this point I'd say you're missing the mark by a long ways and I know that just the work that Jessica Holmstead to convince the rest of the board that this was a movement in the right direction and then knowing the incredible amount of work sense that had to do everything once that decision was made I just want to thank you and everybody that's been working on this I know that Eve and Anna and Eric and Zach everybody have really been working very hard on this I think at the end of the day as long as something doesn't come forward and stop this from happening I think everybody's going to be able to look at themselves in the mirror and say what we really did some good work so thank you thank you for those comments and it is an unbelievable team the rigor that you see here I love my job most of the time because this is the rigor that I get to throw out an idea and then they go and prove it either as a really good idea or a real dumb one so I'm really the great team and this is the kind of work that they produce all the time with all the comments Julie Tester, Vermont Care Partners thank you I learned a lot today and I appreciate the level of analysis and definitely the level of commitment to serve people with mental health conditions I don't think you could have done anything more with the data you had from hospitals but when Vermont Care Partners looks at it as the association for designated agencies we see a bigger mental health system and I realize that we need to push forward so my question is should we do a little more analysis to look at things like those people that are stuck in the beds if you have five people stuck in beds for a year that's a lot of other people who couldn't go through those beds if we developed a nursing home or residential care facility with psychiatric care maybe we could get five people out for six or more we've done some we've just started to have some conversations about who's stuck and what are the options we think there are some options in addition there's some pilots going on like in the St. Albans area where they the mental health center said let's identify who are our frequent flyers to your emergency room and some of them go to inpatient not all and when they identified them and said okay we need to put more resources into these people and address their needs we're able to get the emergency department used down and inpatient used down significantly so I think we have opportunities and I wouldn't want to go full throttle ahead without exploring those opportunities looking at the system more holistically and seeing where we can make investments both upstream before people get to the emergency room when they get to the emergency room and then on the discharge what we can do and I think there may be some opportunities in IMD to provide a little more support services and housing getting people to stable housing where they're going to be okay is one of the things that prevents discharge so I think this is great I think we need to do a little more work to make sure we're looking at the whole system and really investing resources wisely I have and I have one other question is how many of these beds would be level one beds built or high acuity you can answer it either way so we great comments we are now just doing the analysis on how many beds should be level one versus non level one or high acuity if you will versus non but we for this part of the analysis we kept that off to the side and under other comments much appreciated and back to my beginning comments this is just one sliver of both the entire set of issues that we have around delivering care to those with mental health needs it's very conservatively stated both for many of the reasons that but also for some of the SG2 predictive modeling it's very conservative because we agree with you we think that there are things that we can do much better to reduce length of stay through engagement and collaboration with community organizations and we are doing some of that modeling right now I would just posit that I doubt that we will get below this number when you look at the dynamics because of the conservatism conservatism that's built into the model any other questions yes I am the director in another way and my question is how moving forward you will engage the peer services in Vermont and especially the recommendations by DMH specifically addressing the wait times in the 80s to expand peer respites housing first vouchers and peer community centers and also peer services in the emergency departments so Central Vermont Medical Center by way of example has expanded peer support service, collaborating with Washington County mental health for a number of our populations and the psychiatric population is one of those populations now we are always open to exploring more partnerships so if there is something specific that you would like us to pursue we are open to that and our community is called Thrive and we have a number of community partners that meet monthly to talk about how we can really make a difference around the social terminals that help for the population that we see in the Central Vermont catchment area so I would be happy to connect with you offline to see how we can bring your organization into that discussion okay other comments or questions for the public so with that I want to thank you very much for what I think has been a truly good presentation of the analysis and thank you again for your hard work on this and we look forward to the complete process thank you so is there any old business to come before the board? I have some old business so I was hoping we could circle back to the 2019 Medicare program letter to CMS as you may recall Mike Barbara was here talking to us about it on November 14th and presented some proposed language we had asked the staff to go back and think about some concerns that I think in particular Kevin and Tom expressed about ensuring that the board manager membership on one panel include lobbying presences but that the membership was really focused on care providers in the state in talking to Mike I know that he and the staff have gone back and reviewed the made up determined that currently all of the folks on the board management are provider organizations explicitly to know about lobbying presence this time and so what I was going to suggest to move this forward given that we're getting pretty close to 2019 since we're almost in December is that we my proposal would be that we approve the letter that the language has presented since the language around delegation New York Medicare's current language and is also consistent with our rule but that we direct the staff to teach out to one care to indicate that we had this concern and that should the membership of the board change at some point we would circle back and look potentially to add some requirements for a rule or something like that so I thought maybe we could have a little discussion about that and if it's appropriate to vote today on that to move it forward that would so is there a second to the motion second so it's been moved and double seconded as the person who brought up the initial concern I do want to say that I want to thank Mike Barber for doing the analysis to see the existing makeup of the board managers and I think that member Pelham and I were both on the same wavelength that would ground to see people that are intimately involved in the care that's part of that and I think that your motion covers that so is there another discussion if not all those in favor signify by saying aye aye any opposed let the record shows unanimous is there any other old business to come before the board seeing none is there any new business to come before the board seeing none is there a motion to adjourn it's been moved and seconded to adjourn all those in favor signify by saying aye aye any opposed thank you everyone drive safely