 This is all a group of us, I can do that. We need it, so I can see from here. We will take it. We'll see you in a minute. Is there one next to Sarah? He took the mute off. I was checking to see if he took the mute off. OK. He's the closest to that. Welcome, everyone. The first item of business on our agenda is the executive director's report, Susan Barrett. Yes, thank you, Mr. Chair. I have two updates for the board and for the public. First, I wanted to report back that yesterday the board held our data governance council meeting. This is a revamp of the data governance council that the board put in place in 2014. And the meeting went very well. You had approved the charter of the data governance council a couple of months ago. So we're off and running. We will conduct meetings pretty much bi-monthly. But if we have a need to schedule a meeting, we can do that ad hoc. And Tom Pelham is one of the council members. So thank you, Tom, for participating. And if you have anything to add, you can. Just thank Kevin for having me participate. Thank you, Kevin. And then the other announcement for the board and for the public is that the primary care advisory group will be sunsetting July 1st. This was a statutorily prescribed group that was looking at administrative burden for primary care providers. We have decided to continue the primary care advisory group as a technical advisory group to the board. And applications are now being accepted. We have contacted the DMS, Spice State, VAS, other groups to solicit applications. Those are the application is essentially why a provider would want to be on the primary care advisory group and their CV. And those are due to the chair by July 15th. We will have a posting on our website as well. That's all I have to report. Thank you, Susan. And the initial response to people showing interest in the PCAG has been quite robust. So it looks like we'll have plenty of candidates to try to choose from. OK, the next item on the agenda is the minutes of Wednesday, May 30th. Is there a motion? On to the FIVA. It's been moved and seconded to approve the minutes of Wednesday, May 30th without any additions, deletions, or corrections. Actually, I think there is a correction, which is I was I'm listed as in attendance and I was not in attendance. That's pretty amazing, Robin. I'm good, but I'm not that good. And so the vote likewise as Maureen just pointed out to me should be 4-0. Yes, I'll abstain. OK, so it's been moved to approve the minutes of Wednesday, May 30th with the corrections of removing Robin as an attendee and changing the vote total to 4-0. Is there any other discussion? If not, all those in favor signify by saying aye. Aye. Aye. Any opposed? Thank you. I abstain. I abstain. But let the record show that it was a 4-0 vote. And now we can get to the business at hand. And it seems like an overwhelming number of people. But in reality, we're actually taking a lot of flak for not having more people on the panel, if you could imagine this. But this is an ongoing discussion and it shows the importance of this topic to this board and also to the monitors. And just as a way of announcement tentatively on August 9th at Castleton University, there will be a workforce summit that the Nurses Union is coordinating with the faculty down there and others. And so this is not a one day on, and then we're done with this discussion. This is a continual discussion that we continue to have. Our statutory work on workforce stems from 18VSA Chapter 220 that talks about the board having to approve the health care workforce plan. We have the author of the last workforce plan as a member of the board now, Robin Lunge. And of course, she'll quickly say that it was a whole team of people. But is the, in statute, is the, help me with the correct title. Director of health care. The director of health care's reforms responsibility to put out the workforce strategic plan and also to work with the working group that's still in place to have modifications. We haven't had any modifications since 2013, so it has been five years and maybe it's time that we take some look at that. But this today is meant more of having the discussion, trying to bring people from different areas of health care together to talk about what we continually hear about as we're out in the field. It doesn't matter which hospital that we're visiting or which budget we're overlooking. We hear about shortages in the workforce and it changes from geographic regions of the state. Some regions are truly struggling in the specialties. Other regions are struggling with primary care. We have a common theme throughout the state of a shortage of nursing. And we know that whenever a traveler is hired that the expenses to the budgets are much higher than if they had a legitimate actual member of their workforce. So everyone wants to hire Vermonters. These are good paying jobs with benefits. And so I know that we're not gonna solve the problem today but I think if we can help to have this free flow of ideas between all of you on the panel we can start to get there. And it may require some steps that end up in failure. I'll point to what happened at the College of St. Joseph. Everybody knows that we need more primary care providers and yet one of the reasons why the college almost closed is they spent half of their endowment on trying to start a PA program and could not get it off the ground. So there may be mistakes that are made along the way but that doesn't mean we should stop trying to improve the workforce, especially when you're at a hospital and the people that are around you are older than you. And they're saying that they're the average age that they see at their workplace. And I know at least personally I'm starting to look as I'm getting older to try to find my doctor retires next year, trying to find somebody that's a lot younger than me. And I think that it would really give the existing providers a ray of hope if they saw that there were efforts put into making sure that somebody can actually replace them so that they actually might be able to retire without having the burden of guilt of leaving their community behind. And so I'm gonna ask each of the members of the panel to briefly and I'll say in two minutes or less introduce yourself and what your role is. And then we're gonna come back to you and just ask you to start to frame it through your lens of what you're seeing as far as workforce shortage, what you see as possible solutions, what you see as possible barriers to solutions and so on and so forth. So I guess we'll start and go from right to left. Okay, well, thank you all for really sharing with you all and having so many of us here and working towards addressing some of these issues. My name is Sean Tester. I am the CEO of Northern Canada's Health Care. We're the FQAC serving all of Vermont's Northeast Kingdom as well as California Health and Hospice at Columbia State University. So I wanna start by sharing Tom just mentioned to me last time I had the pleasure of presenting to you all in February in St. Johnbury. I opened with a little anecdote. So I'm gonna open with another one that kind of highlights kind of the challenges around out-migration and finding that special kind of person who's willing to live in the long, cold, winter, the ghost kingdom. There was an island in the Connecticut River at the top of the Somson River and an old Vermont is with the operation and a couple years ago, I'll come back to ways now, he was resurveyed and it was discovered that that island is in fact in Hampshire and when they let the Vermonter know that he was in fact in the future resident, he said, thank God I couldn't stand another Vermont winter. So, you know, I wanted to open my conversation about demographic change and I think you all may have seen these slides. The first couple of slides I stole from John Freeman of NCIS who stole the data, I believe Mark Wolfe, but it really talks to what I call the demographic change that we have in the Northeast Kingdom. You know, if you look at this first slide, so you see this total workforce of 125,000, we don't have that size workforce in the Northeast Kingdom. This is data for the Northeast Kingdom and Northern New Hampshire, so co-ops in bracken counties, which we also pull, draw from, as a potential labor pool for our communities. If you go back to 2010, the total workforce for Northern New Hampshire in the Northeast Kingdom was about 125,000 people. Fast-forward to today, as a population's age, we're down to around 111,000, that's a drop of about 13,000 people out of the labor pool. And as you look at the cohort of people in the younger generations coming up, those cohorts are simply smaller. The final slide that I wanna leave you with around demographic change is the projections of average age for monitors across the entire state. We're all seen as, okay? If you look today, and I leave the slide down there, we're at about 15% in 2010, being 65 or older. 2020 is projected to be over 20% and just as it works. Now, what I'd like to say of us in the Northeast Kingdom is we are on the leading edge of that program. So the communities we're taking care of are patients by the oldest, sickest, poorest, remote. So we're already feeling the impact of this demographic shift within our population. Now, that has another challenge. So one is who's gonna do the work, right? Where is our workforce coming from? But the other problem here is that those cohorts that are aging for monitors, the people that are aging in place, what happens when we get older? We need more health care, right? So the demand on services for the organizations that are struggling to find the workforce is just relevant and that is contributing to a whole whole different problem. So when you look at our system, what we need today in our system, I think this is what I'm speaking about my experience in Northern counties, this is really universal for the most reason. Probably for the rest of the state, but the types of health care workers we need, we need primary care physicians, okay? We, the average age of my primary care physicians is over 50 prime, and we struggle to find people to bring to the area who want to grab this primary care physician. Physical therapists, we really struggle with physical therapists in home health, right? So what's happening is our population's aging, people are getting a lot more ortho care, they want to get to the place in the home. Physical therapy is an important component of helping people successfully navigate that. And last year, we had to rely on travelers to do that. Mental health professionals, we talked about that a lot. The state of crisis, you know, across the board usually is there. But I also, I really want to speak specifically to nursing and nursing professionals. You know, I brought, this is the ad running in the Caledonia record right now for Caledonia Home Health and Hospice in the positions we're seeking right now today. Physical therapists, we're looking for a high-tech pediatric home care nurse, we're looking for a couple community health staff nurses as well as maternal child health staff nurses. Those are just the needs of my organization in home health. We are also looking for nursing staff for primary care. And I know for a fact that NBRH is looking for staff as well. Dentists, you know, if you look, I think the standard of care is, you should have about 1200, 1500 patients per dentist in the area. I think areas like Chittenden County need that. In the Northeast Kingdom, we have something like 3,400 to 3,600 patients per dentist. There aren't enough dentists to care for our population of this condition. And again, we have a challenge that only 80 work tools. Many of them are in this area of order. They are able to make retirement. Many are hanging on because there isn't someone to replace them, but that's a challenge. The other thing, you know, we talk about healthcare in the healthcare workforce, but for us, we also are strained to find other professionals to support the systems, whether that's information systems professionals to support our EMRs and our networks and our communication systems, but also our managers and administrators to help support the complex healthcare system so that our providers can be at work. You know, I think especially in the Northeast Kingdom, there are some different headwinds that make the workforce challenge even more challenging even with things a lot. The first one of those, I kind of like just culture and community. People like me, I was born and raised, well I was raised in Northeast Kingdom, I was a brother. I love the Northeast Kingdom, but it takes a special kind of person to live there. You know, you don't have access to the same types of cultural opportunities you have in a more urban area. And that makes it hard to recruit people from other areas like that, so you can come in and see them. Another problem is housing stock. I think in the Northeast Kingdom, what we see is there's a lot of housing that's under $200,000, but it tends to be housing that's in decline in the need of serious work. And then there's a lot of really expensive housing, kind of houses over $400,000. And the type of feedback last winter, I was trying to recruit the dentist to my area and spent a lot of time trying to recruit the dentist, but he spent time with his wife looking at housing in the area and he came back and said, we're going to live. I mean, we're paying under these times, like I can't afford a nice house here. So that's a huge problem. The other issue, which is getting a lot of, you know, press right now, but the challenge around the trade is fast. And how do you, you may find a great healthcare professional, but you also need to find work, employment, meaningful employment, and your spouse department. Huge challenge for us in the Northeast Kingdom. Another problem that we face as an organization is wage inflation as compared to reimbursement wage inflation. So, you know, home health and prospects, we really rely on a talented, just dedicated nursing staff to provide quality care. But if you look in our area, this is a rough guess, but I would say that wage inflation for nursing professionals is running at about a 5% increase annually, but we struggle to get reimbursement to come in and hear that. So, and over years, that goes like this, and we can no longer afford to pay for care for the staff. And then finally, I can't stress this enough, but it's provided burnout. So, we've talked a lot about burnout with primary care physicians and the administrative burden that they have, that makes it hard for them to do their job and feel like they're doing meaningful work. But what we're really starting to see is burnout across the system. You know, and again, home health and prospects where we really have to rely on travelers last year, you know, we struggle upon staff, we ask for the new more, we stretch everybody really thin, and that contributes to the people just knowing about the community, again, so for us to talk a little bit about what the recruiting experience at Northern counties is like, you know, I know that health care reform and payment reform is on top of most health care administrators' minds, but it's not the thing that keeps me awake at night. The thing that keeps me awake at night is trying to figure out where our future workforce is. And we really take, we've decided to make a conscious decision to take all hands-on debt approach to solving the problem. It really takes all, the entire team, all of us working together within my team and with our partners to try to refine and recruit professionals that come from different areas. I'll give you an example. The last physician I recruited here in Anapagos, Guy mid-30s has three kids, they're about my kid's age. When we were recruiting him to the area, his wife spent an afternoon with my wife, driving around the area and showing to different communities and neighborhoods. And his kid's plate was my kids. We had them over to dinner at my house and with a bunch of other staff to make him feel well and comfortable here. Because what you're doing is, you're selling a lifestyle. You're selling the people that, when you join us, you're joining the family. That's really what it takes to, you know, another example, the dentists that I tried to recruit, the failed wife that already been in the area. We had her over my house with Anastasia and we get the issues along with Anastasia. You know, it's those kinds of, like it feels, it makes you feel crazy but that's really what it takes to find the right kind of people to join the organization. I also want to stress, lonely human, that is like the second question that potential candidate asks when they are inquiring about a job opportunity or either the first question is, how does it pay? What does it work like? And then the second question is, what would you offer for all of them? And if you don't have a good answer for that, then the next step is a hand up with the phone, right? Because we are competing, these people have such great opportunities nationally that we need to be better than that environment. And then finally, I kind of touched on this briefly earlier, but you know, you're recruiting the whole family, not just the person. You know, you have to convey that this is a lifestyle choice that the entire family is making and try to find ways to engage in the kind of family in that process. And then finally, collaboration with your local partners is key because you are trying to find a job for that kind of spouse. You end up being a part of that conversation no matter what. You network hard to bring that person to the board. So, there you go. Thank you, Sean. That was quite eye opening. Dustin. Thank you. I want to thank the chair. You must be as happy as I am to not be getting petition signed right about now and staring at a pile of signs you don't have to put out any more. And what a thought we'd have retired the same year. I'd love to find a way to recycle them. That's a good point. So, my name's Dustin DeGree. I'm a former state senator from Franklin County. I live on the pretty side of the mountain from Sean. And in November, I left that seat in the Senate to come work with Ms. Buxton as part of Governor Scott's workforce and labor force development team. Part of the eye opening things that you're seeing in the healthcare workforce are not unique to this industry. You go and talk to any manufacturer around the state, any small business looking to grow, any, you know, any job that really requires some sort of skill other than a high school diploma. You're gonna hear the same exact things that you hear from hospitals and home care providers. And the one major difference we might see is the fact that healthcare is one of the few industries that we're seeing a greater use of, right? So, as that, as Ramon gets older, we need more docs and we need more PAs and we need more folks really in the system because we even with a stagnant population, the population that acts as a healthcare as well. So that's something that's really unique to this sector. I think Sarah and my strategies have been a little more holistic. When I came on in November, she was well on her way to developing a workforce expansion plan that we put basically all the best ideas that we had, things like enhancing money for CTE, creating a program called Return Ships for 55 plus folks who are looking to re-enter the workforce after it out into some reason or another. And we're really at some of that past. So what I'm really interested in as we go back to the drawing board after this legislative session is how we can focus on healthcare for the next year by the apple that we have. And certainly the people here are the experts. I'm not an expert on healthcare policy. Turns out I didn't spell it right because I typically use two words. But I'm happy to be here to listen and certainly anything that we can bring back and try to put in legislative form and convince our former colleagues that it's the right thing to do. Happy to help. Good afternoon. Thank you also for inviting me. My name is Sarah Buxton and I'm the director of Workforce Policy and Performance for the Department of Labor. And I'll just sort of briefly describe my area of activity and then I'm sure we'll get into some of the details as we circle back through. But my job is to, is a unique position that was created to develop and implement strategies in the state that both expand the labor force and strengthen the workforce. And I just wanna pause for a moment there to make sure folks understand that those are two different things, expanding the labor force and strengthening the workforce. They require different sets of partners, different types of strategies, different types of investments from all over the place. The other thing that I've worked a lot on in the last year and will continue to work on, as Dustin mentioned, is trying to steer an interagency comprehensive labor force expansion plan. And so there are a number, probably at least a dozen or so strategies that inside of state government, we're trying to work on to better align and coordinate what we're doing around workforce. Again, both to expand the labor force and to strengthen the workforce. Major partners there are the obvious ones, Agency of Human Services, Agency of Education, Agency of Commerce and Community Development. And then finally, within the Department of Labor, I'm really focused on, excuse me, if you didn't know this, Department of Labor is about 98% federally funded. So the way that we use our dollars and the way that our labor funds are used to support Vermonters in accessing employment services are limited somewhat to the federal guidelines. But my role in the last six to eight months has really been to dive into some of the federal funding streams like WIOA, the Workforce Investment and Opportunity Act. Our apprenticeship grant programs, our dislocated worker grant programs to see where there are opportunities for us to reinterpret what the federal guidelines say. We have been asked to submit applications for waivers where we think that's appropriate for the state in order to make those federal dollars a little bit more flexible for us here in this state. So I'm spending a lot of my time trying to pick those pieces apart and work with partners to come up with some options for all of us to look at as time passes. So Sarah, before you pass that on, you mentioned the agency of education. And I'm just curious, so often we hear Vermonters complaining about our number one export is our children. And yet it seems to be a conflict with the fact that we know there are all these really good paying jobs with really good benefits. Are you reaching out to guidance counselors across the state so that they can get information to kids as they're trying to make their career decisions so that they know that these opportunities exist? Yes, and actually beyond just reaching out and doing an information exchange, we're funding one and about to fund another variation of pilots, one is in Rutland County, where we've hired, we're working with Reddick and with a local workforce investment board to hire a position called a job coach working in Mill River and in Otter Valley. And this individual would be the person who's connecting not with the students who already are working with their guidance counselors to go to college, not with the really at risk students who are working with guidance counselors on a number of other areas and just sort of keeping in school, but with that middle segment of Vermont students to help them plan for what comes next. So Rutland County is one area where we're using a model that's been used in other states of job coaches. And then in Wyndham County, there's another model that the VRCC, Brattleboro Regional Credit Corporation is using. It's a sixth high school consortium with a career counselor as opposed to a guidance counselor. And again, a very designated position that has connections with employment as opposed to student success within the school system. And so in the next year, 18 months, I'd like to see if we can do another pilot of some other variation in another part of the state and start to figure out what really works for Vermont in helping those students be connected the day after graduation to a plan. Okay. Are we passing the mic as we go? No, didn't know there was one, but we can use it. Someone help. Could you hear everything I said? We could. I probably don't need it either. I'll talk loud. My name's Julie Tess, so I work at Vermont Care Partners for over 21 years now. Vermont Care Partners is both the provider network and the trade association for the designated community mental health centers that provide developmental disability services, mental health services, and the majority also provide some use disorder services. We serve over 35,000 Vermonters each year, but we touch the lives of more because when there's things happen, like a crisis in a school, we're serving the whole school. We serve whole communities. So we really reach more than just the clients we serve. We see ourselves as part of the healthcare system, but our work is very expansive. So some of the work we do is helping people become employable and actually developmental services. We have some of the highest rates of getting people back in the workforce or participating in the workforce of any state in the country and we've gotten international recognition for the work we do there. And that's actually a very important part of recovery in both some use disorders and mental health is to have an active job as well as to have housing. So we really look at the social determinants of health. We employ over 13,000 Vermonters. We're actually a very large employer. Unfortunately, because of our funding levels, a number of our employees are only contract employees because we mostly, because we can't afford the health benefits. Those contracted employees are often directly employed by the people they're serving or by shared living providers, also known as foster care. So they're not all direct employees of the agencies that I represent. I know some of you haven't heard much about our services and this isn't a good time to give you the whole overview. There's not time to do that. But what I brought is our outcomes report and maybe you can take a look and we'd love to have you come and visit our agencies because there's so much we do and the best way to get a sense of that is to come out. And I know that Robin's done that. She spent more than a day, I think, doing that. Jessica has two and we really appreciate that. So we welcome anyone to come and see the work that we do. And I'll talk more about employment as we go around and continue. That's a good idea. I don't have a very loud voice. So my name is Dr. Jean Marie Havener. I am the director of the nursing program at Castleton University in Castleton, Vermont. Great school. Thank you. I think so too. I'm a nurse. I'm a nurse practitioner. I'm a clinical nurse specialist. I have my PhD in nursing with an emphasis on rural health and health policy. I've been engaged in practice since 1981. I know what it's like at the coal phase. I know what it's like to be feeling and experiencing shortages. I'm also a donor. The daughter of an 87 year old mom who is struggling right now to find good healthcare, to experience a good quality of life. I'm the director of the nursing program. We serve over 200 students, 85% of them that come from Vermont. I feel pretty intimately engaged and involved in what it is that we're talking about today. I want to echo everything that Sean had to say. I think that I'm also a person who serves as the chair of the board of trustees of a small rural hospital with a rural critical access hospital under its corporate umbrella. So I know all of this from pretty much every angle. And I'm very glad that you're convening this today. I think this is an important discussion to be having. I think that the models that we currently have for financing, healthcare, healthcare education, and for workforce development and the models for education and training are broken. And that we really need to seriously reconsider how it is that we're doing things so that we can better serve the public. So I thank you very much. Jim, could we pass the mic? Is there a way for Castleton to expand the number of graduates in the nursing program? Expansion of graduates, the numbers whom we serve are based on a couple of different things. So one is the availability of faculty. So we need to meet certain regulations in terms of faculty qualifications. So that's one aspect of things. So you need to have that workforce. The other thing is that when we look at how it is that we pay individuals like myself, so I'm a pretty darn qualified person in my field. Yesterday on the phone, I received an offer for a different position in a different state from a person whom I had worked with before for $172,000. I have no shame in telling you that I make $85,000. As a nurse practitioner, I made $110,000. In my previous position, I made $120,000. The reason that I'm here is because I believe in role and I believe in helping to be a solution and it's not all about money. But I work with a faculty who maybe don't have the same privilege and support that I have at home to be able to afford to make those sacrifices. Last year, I spent a good portion of my summer writing a report to the chancellor about nursing workforce, nursing faculty workforce issues, our salaries and our workload. When you take a look at what a nursing faculty member works compared to a regular faculty, it's pretty awe-inspiring. We do not get compensated at the same rate as those individuals who work in the classroom. Yet, we're taking care of human beings. Their lives are in our hands. We're overseeing groups of students. God bless them who are newbies, willing to take the chance and try. But it's high risk taking work. So there's that challenge. There's the challenge of trying to find clinical placements. So right now, we are situated pretty close to the border of New York. We have for 60 years used as one of our learning laboratories the Glen's Falls Hospital, which is a wonderful facility. About 10% of our graduates end up working there. And this past year, because of legislation in New York State, we are being asked to apply for permission to continue to operate. The cost for the application is roughly about $20,000. We will pay about $7,500 a year to be able to continue to have that privilege. In five years, we have to reapply again. And we're not doing the same thing for those agencies that lie on the border between New York State and Vermont who are coming into Vermont and working. So we have a problem, particularly in the specialties. So in the areas of obstetrics and pediatrics, psychiatric mental health, those are real issues for us in terms of finding what I would say are good training laboratories for our students. So in Vermont and across the nation, we're not alone in this. What most regulatory agencies have said is that you can substitute some of what it is that you are doing in clinical settings with medium and high fidelity simulations. That requires having a lab. That requires having lab space. That requires the ability to purchase simulators. The simulators themselves cost $60,000 to $100,000 a piece. They break down. It requires having individuals who have the training to be able to teach students and use this equipment. And those people are a rarity and those people can earn incredibly high salaries. So those are our challenges. We would love to be able to expand. I sit on our Student Affairs Committee and we look at the applications that come through. And currently, because faculty are only hired on a 10 month salary, I have to depend on people who are willing to come in with no compensation over the summer and spend time with me every week or every two weeks to look at these applications. Right now, I can tell you I have six people sitting in the queue waiting for me to tell them, can you come or not? The university is being hit right now. There's a deficit there. We're having to write size and realign and whatnot. My department has been hit by those changes. So these are all things that impact on the ability for us to be able to expand. I know how to do it, I've done it before. I know what needs to be done. I just need the tools. I really need the tools. I've got the toolkit, but I need the tools so that I can do this. Thank you. Thank you. Good afternoon. Steve Gordon, the CEO at Barlow Memorial Hospital and the banana belt of Vermont. It's a pleasure to come up here and not have to present my pleasure. You get the award for the farthest. I'm not sure if you get the award or if Trey gets the award for the farthest driving. I think Bennington. It was a beautiful day and there was no snow on the road, so it made it even better. You know, I guess from my perspective there's not an easy solution to this. And I look around this table, whether it's Liz or Candace or others, that we have partnerships with. And we're gonna solve this issue. It's about breaking out of our silos, linking up the educational institutions with, in my case, the hospitals and developing programs to meet our needs as opposed to just generating degrees. And I think we have a great example of that which when we come back around, hopefully we'll have time to do that, about a relationship we've had with CCV for medical assistance, which are really critical to our operation. And it's in its third year and it's been a great program for us. And I think it can be an example for the rest of the state. But it's gonna be about partnerships that we develop amongst the higher education institutions, the hospitals, home health care to really meet those needs. And there's some really interesting programs out there. So I look forward as we come back to talk a little bit more about it. Hi, I'm Liz Cody and I'm the director of the UVM Office of Primary Care and the Area Health Education Center's program, AHEC. And we are a healthcare workforce development organization. And we've existed in Vermont for 22 years. I've worked with this organization for 13 years. In your packet, there is a visual of the work that we do and the pipeline, how we pursue healthcare workforce development. It's a pipeline that starts with Vermont's youth. We have programs for middle school students, high school students to get them interested in health careers and inspired and to give them hands-on opportunities. We continue that work through the undergraduate years and then into health professions training programs, working with nursing students, medical students. And then we continue that pipeline to work with medical residents and to help recruit and retain the current health workforce, particularly primary care. We administer the state's educational loan repayment program. Many of you are familiar with that. That program currently exists for primary care practitioners, physicians, nurse practitioners, certified nurse midwives, PAs, psychiatrists, dentists, nurses, LPNs and RNs. We also have a position in our office called the physician placement professional. And this person works with the recruiters, the hospitals, federally qualified health centers and private practices around the state to understand their primary care and other medical physician vacancies and works to match UVM College of Medicine graduates and UVM Medical Center residents and fellows with those vacancies in Vermont. So we're trying to keep them here in Vermont. So we start at the beginning with the kids trying to grow our own. And then once they're here in training, we try to match them with an appropriate site in Vermont. Currently we have 99 physician vacancies posted with our office, 44 of those are in primary care, 55 are in specialty care. Of the 55 in specialty care, we have five in psychiatry, five in orthopedic surgery, six in emergency medicine and seven hospitalist positions. We have additional data that I've shared with you in your packets about the counties that those positions are located and then the type of practice setting where those vacancies are. In this work, educational loan repayment is a big factor. And I would like to just read a quick statement about educational loan repayment. And then I will pass the mic. I also hope that when later in this program we can get back to talking a little bit more about the mental health workforce, particularly psychiatry, substance use disorder professionals, and also dental. Those are two things that I really hope we can get back to. Increasing educational cost and the corresponding increasing educational debt are very concerning. Each year the cost of higher education becomes less affordable for US individuals and families. Federal, state, and private financial aid programs contribute while students are enrolled, then contribute again after degree completion through loan repayment and loan forgiveness programs. As a consequence, high educational debt is shifting more of the cost of higher education to future employers. In this example, the healthcare sector. In the context of the current educational financing system, the need for educational loan repayment assistance becomes more evident every year and plays an important role in recruiting and retaining the healthcare professionals Vermont needs most. Thank you. Hi, my name is Alan Rogers and I serve as the academic dean for Vermont Technical College and I'm responsible for our 38 programs and approximately 130 full and part-time faculty members. Among those 38 programs are seven that are related to nursing and healthcare. They cover four different disciplines. This year we'll graduate over 300 in those various disciplines, over 90% of them are Vermonters and most of them will continue to stay and work in Vermont. In terms of what our small window is on the universe, based on our conversations with advisory board members, so every program has an advisory board. The greatest workforce needs include radiologists, nurses, particularly long-term care nursing, EMT and paramedics and of course docs and dentists. And I guess just to tell you where we are in this process, recognizing these various needs, we're hoping to open a dental therapy program in the fall of 2020. So this is a new statutorily licensed position that sort of is the equivalent of a registered, a nurse practitioner in the medical field and we would be, if successfully it'd be the first state to be able to have that particular licensing available. We're also hoping, given the closure of Champlain College's respiratory program, we're hoping to open that program at Vermont Tech in the fall of 2019 and given, I appreciate the comments about the other parts of healthcare, we're looking at opening up a healthcare management track in our business program. My name is Candace Lewis and I'm an Associate Academic Dean for the Community College of Vermont and I work with our science and allied health programs. I see CCV as kind of a conduit that helps students who are in secondary programs in the medical professions and otherwise to start gaining some college credit and some awareness of healthcare opportunities before they leave high school. But we also provide entry level programs for those positions in healthcare that truly do require a year or two of education and not much more. And in addition to that, we also provide programs that help provide a springboard into more highly skilled degree programs at the associated baccalaureate level. One of the things that my counterpart at VTC shared with me was that over 70% of the applicants for the LPN program at VTC have done prior coursework through CCV and I think our role as being an affordable and accessible throughout the state educational provider is one of the reasons for that. I do think one of the challenges that we have is or that our student body has is that the flexibility that they find at CCV sometimes in order to meet some of those program prerequisites, then they don't find that same flexibility in terms of trying to complete specialized programs in healthcare and I know that for all of the reasons that Jean Marie just stated, there are a lot of barriers to providing that kind of flexibility for nursing programs but that's something that I think as a state we might wanna think about. I also think one of the challenges that we have is keeping pace with some of the innovations that our healthcare partners are making so as organizations are trying to better figure out how to more efficiently use those highly skilled providers and what kinds of positions are they going to bring into the workforce. CCV can play a role in providing some of the educational opportunities for those new support positions. We've been hearing a lot about population health workers and people that can kind of do some care coordination pieces or preventative care measures and so those are some of the opportunities that we look for in the future. In addition, as Steve mentioned, we have the partnership with Brattleborn Memorial Hospital and I think for the Met Assisting Program, one of the things that we are trying to get a handle on is exactly what is that level of education that students need in order to find employment in the field because I think we don't wanna overshoot and ask more of our students than is necessary for employment but we also wanna be sure that we are providing students with the skills they need to be successful. Good afternoon, my name is Nolan Atkinson, the Chief Academic Officer at Northern Vermont University and I'm just gonna take a second to explain what that is. Northern Vermont University is the merger of two of the other state schools that actually we're all five represented here. The merger of Linden State College in Lindenville, Vermont and the Northeast Kingdom and Johnson State College in Johnson, Vermont. Back in September of 2017, the Board of Trustees approved the merger of these two institutions and since then we've been working very hard to unify both institutions to become this one university. We are regionally accredited as of July 1 of 2018, three and a half weeks from now to operate as this institution and in the next two and a half weeks we expect to have approval from the US Department of Education to award federal Title IV financial aid funds as well. So that is in a nutshell what this institution is. So I'm here really to share with you the healthcare related degree programs that we offer on both campuses. So starting with the Johnson campus and actually also on the Linden campus both have pretty robust programs in psychology and human services and many of the students that come to these programs come from Vermont and they stay in Vermont and enter many human services related fields and professions here in Vermont. On the Johnson campus there's also a program in wellness and alternative medicine and probably the most robust program on the Johnson campus that really has a pretty firm imprint here in Vermont is the master's program in clinical mental health counseling. A couple of years ago the president commissioned a study just to look at the impact of that program here in Vermont and in the decade from 2006 to 2016 they estimated that about 10% of the licenses issued in mental health counseling those folks actually were enrolled in the Johnson program. To Sean's point about what's happening in the Northeast Kingdom we do plan to in the fall of 2019 offer that program on the Linden campus and so that program will start up there and hopefully we'll begin to address the acute need for mental health counseling and addictions related services in that part of Vermont. Additionally on the Johnson campus there's a health science degree that offers areas of focus in exercise science, pre-physical therapy and physical education and a number of those folks particularly in the physical therapy concentration will go off to graduate school and I would have to say that many of them don't stay in the state of Vermont. On the Linden campus an additional program in exercise science has concentrations in strength and conditioning, athletic training and other concentration in pre-physical therapy and I'm quite familiar that many of those students do go on to graduate school and do leave the state. And finally it's not really a program but we have a feeder program in pre-nursing that feeds the Vermont Tech nursing program on the Linden campus as well. So just a quick overview of the types of programs that are offered on the two campuses that comprise Northern Vermont University. I'm surprised you didn't have a new hat or something for the brand. I have a new name tag. There you go. You can get to a tie in about two weeks. Okay. It's a good looking name tag I can see it. Nice logo. My name is Jim Yolger. I'm a family physician in Hinesburg and I'm vice president of operations for the medical group of the University of Vermont Health Network. I'd like to make some connections because I came mostly prepared to talk about our recruitment of providers and I will but it strikes me that almost everything everybody's saying resonates completely even though as an organization certainly we have a little different scale. The issues are really very much similar if not the same. One of the features was and it's brilliant that we're thinking of much more than the provider workforce here because the practice of medicine and healthcare has always been a team sport but it is that so much more now than it was even five to 10 years ago. The things we are asking. So if we're gonna use our physician workforce well and our nursing workforce well they need to be doing things that physicians and nurses are uniquely qualified to do and the number of things there are to do as our patients get sicker and our payment systems get more complex there's just more to do. So that relies on having a very skilled and reliable workforce to support all of that. And for a lot of those positions I mean the things that we used to ask our medical assistant they put you in the room they took your blood pressure and they may have drawn your blood. We have particularly in primary care it's very complex we have a number of protocols we're asking them to follow. And to great success I had a patient that I took care of for a long time who is declining colon cancer screening and I forgive me I may have told this story before. My kids would say I have because they repeat stories but declining colon cancer screening I had stopped asking her. My medical assistant was following the protocol she came in she said hey you know she's here for whatever but is ready for colon cancer screening I set up the order you just have to sign it I didn't think there was nothing I did I pushed the button I signed it she had an early colon cancer and that high school level or maybe associates degree person saved this individual's life. And it's very profound and it's not necessarily the skills that we're looking for are the ability to follow a protocol to show up on time to do to take care of people in difficult situations and smile on your face. So that's a very important thing is how we leverage the team. At the medical center in terms of providers I was also struck it's important to understand that as physicians and other providers even though patients experience are experiencing us as individuals it's very much a collegial field. People do well they perform better they're happier when they have a number of colleagues. So when I was thinking of North Country Hospital I trained with the good Rachel DeSanto who I think is up in your way. So and she's tried to get me to come your way many times. She's great yeah we'll meet afterwards. You'll be invited to the next barbecue. Yeah right that's right good my boss isn't here so we're good. But if you're say trained in Burlington and you're thinking gosh I have 40 colleagues here all in family medicine I'd be practicing with nine or 10 of them in my site I have residents I have all these things. You know it looks a little different when you go out to North Country in many ways maybe for the better but you're giving up a couple things there too. We get that same experience from a neurologist finishing his or her movement disorder fellowship in Boston or New York City is looking up here in Vermont saying gosh lovely quality of life we love the place a lot of our successful treatments are because of Vermont but you know here in New York there's five fellows that do all the work and there's you know 40 colleagues right in my specialty and there's one other one of me in Burlington and so it's the same issue it's a little bit different but it's the same too. Burnouts also been a big issue. So how are we addressing some of these things? So with one of the things that helped is the network that is helping us the network. There are certain positions one of them is in psychiatry that we'd a lot of our psychiatrists they really want to work for an academic center and there are clinical positions here in the capital region that had a difficult time being filled when we changed those to academic positions that were reporting to our chair of psychiatry all of a sudden we were able to recruit some psychiatrists so people were connected to the family even though there are maybe only three or four psychiatrists I don't know how many particular psychiatrists are in that practice but all of a sudden they have 30 or 40 colleagues because again it's a collegial practice so the network is helping. We are looking at burnout and wellness we need to be able to you know as you know we're putting an expanding and upgrading our electronic health record that is key to recruiting physicians not just because we're putting it in because that new record is able to do things more efficiently than we've been able to do in the past it's much less of a burden there are efficiency tools we're also investing in the training of new providers that's a medical center board meeting tomorrow I have to advocate for that so I'm confident we'll be investing in the training of our providers which has been linked to provider happiness with their electronic health record not just one year down the line but if your initial onboarding is good it improves your happiness with your electronic health record five years down the line not just one year down the line so we're doing a number of these we're setting up mentors I have to check my list oh and then the other thing that both helps recruiting but it also helps us make really good use of the providers that we have are some innovative things we're starting to do and would like to do more of around innovative access so asynchronous visits or electronic consults you know if I'm concerned about I think that mole's okay I don't think you need to see a dermatologist well I don't really want to type that dermatologist's time and we only have so many but if I could shoot them a picture they can in less time than they could see that patient they say you know what that looks fine or hey why don't you biopsy that which I can do in my office and what's making that possible is payment reform going to fix payments and value based care is absolutely what's allowing us to do that because those are entirely unreimbursed services or at least they were traditionally in a fee for service and now you know if the payment is fixed whether that specialist sees the patient or not it allows us to be a lot more innovative so if I think of things that you could advocate for as a board is as new and innovative things come around like that it may take I think fixed payment is gonna cover a lot of them but it may not cover all of them so we need to be innovative and when we do, when we talk about those types of things the particularly the younger providers that are interested in doing things a little bit differently than they've been done they get really excited and if we can offer something a little bit more cutting edge then they perceive even in Boston, New York because we have this fixed payment system that's something that's something uniquely Vermont that we could offer them so this is some of the things so I enjoyed it. Before you pass to Mike James he's hoping that you might be able to address you know so often we hear through emails and letters and phone calls about problems with wait times and some very dramatic stories where people feel that in some respects it becomes life threatening wait times and so I just wanted to since you have members from the education community, the administration and others on the panel up there with you maybe you could talk about the correlation between someone's ability to access care which is part of our triple aim and the workforce dilemma. Well that's the connections between the workforce dilemma and access it's really in those most difficult to recruit specialties and I have a list of our recruitments that are currently open I've highlighted those that have gone over six months or so and they're mostly in psychiatry neurology or two ones that if you ask around the country when you go to conferences they say oh yeah psychiatry neurology you know everybody starts nodding their heads so there's national issues with these specialties but there's also some that are just we only have a couple of them or they're very the medical education system may only produce a few of those specialties a year and again we don't have so many colleagues et cetera so from a physician workforce in those higher end specialties that's oh gosh as a primary care provider I shouldn't put it that way in those more nuanced specialties that can be a challenge so you know and there are things particularly that we don't offer training for so they're just we don't have the patient work the patient's population that it would take to support a pediatric cardiothoracic training program just we don't have that we have invested in some training programs that we didn't have previously child psychiatry is a good example we've had three or four successful accruements from our own child psychiatry fellowship which is relatively new so to the degree to which we can offer those training opportunities to providers it helps us train our own and I think particularly some of the you know Castleton I had a you know one of our great success stories we had a medical assistant came right out of high school she took a love to it she went to the Castleton program and now she's one of our great RNs on the floor you know those success stories are wonderful but it took a few rounds to get into Castleton maybe because yeah right but she did she's doing great but it's really that supportive work for most of the people here at this table it's really helping us with that supportive workforce because the more we can get our support workforce to function the higher we can have our providers so I'm Trey Dobson I'm the Vermont Medical Society president for this year so I get to hear from a lot of physicians and physician assistants around the state mostly via email sometimes through calls and I'm also the chief medical officer at SVMC and the director of our Dartmouth Hitchcock group and I spend almost 50% of my time recruiting which is not what I imagined when I took my role and I think many of you do the same whether you're a CEO or a vice president I'll just echo some of the comments real quickly Sean well out you know well outlined in the very beginning all the stressors Steve talked about some approaches that we have to do with partnerships with education and that's actually very important we're trying to do the same thing we should learn from each other but I guess I'm very interested in moving towards solutions not necessarily today but developing those James used the word innovative I'll start using the word novel I think that we need to do three things one is we need to figure out how to better target people around the United States who want to live in Vermont versus just blanket recruiting type efforts because that's a lot of waste the second is I think we have to be more immigrant firmly and find ways to get more immigration into this area and third I think we have to be very novel we're novel in a lot of ways in healthcare but we're not in workforce development we offer the same things sometimes less than other parts around the country what could we do to be novel I don't have the answer to that but I'll throw some things out could we develop tenure tracks for nurses and physicians where they are sort of held here and then they get a lot of benefit after a while including sabbatical time things that decrease burnout at the same time as maybe increase retention I don't have the answers to that but I very much appreciate this forum but I'd like to start developing some committees to look toward solutions of course we have to figure out how to pay for that and we'd also have to be novel in that response as well so I guess I'll start off the question right here and I'm gonna throw this out to Liz because we just heard what Trey said and one of the conversations that I think back about many times is the conversation that I had with you in my office about how it seemed to me to be simple this is what we need to do we need to offer a scholarship where they have to work in Vermont when they're done so it has to be flipped and then you gradually ease me into your discussion of how it becomes an arms race and I thought maybe if you could share that discussion with others here today that it isn't always as easy as doing something because once we do something that's not the be all and end all because it may work for a short period of time so everybody else copies you and so on so could you just elaborate a little bit more on that? Sure, so the arms race is because we're competing nationally for these highly trained, highly skilled professionals and we, 25 years ago Vermont was one of the first states to offer educational loan repayment it was an innovation, it was novel we had a leg up and it was great and we offered scholarships with future service commitments through funding from the Freeman Foundation again, it was with a leg up now almost every state has an educational loan repayment program for health professionals and for physicians so it's no longer a leg up it's the new baseline, it's expected those conversations with recruiters and employers if you don't have it, you're at a disadvantage but if you have it, it's just the new baseline it's equalizing the footing so we have to keep those things going or we have a disadvantage scholarships for future service commitments in Vermont we relied on private funding for that that funding has now ended we also, one of the challenges with a program like that is that many of these folks have many more years of training to go, whether it be through medical school or residency or fellowship so their decisions as far as which specialty of medicine that they might want to practice in the future changes and we're committing early in their training sometimes maybe unfairly early and then their personal lives change they go on to residency in another state and they meet somebody, a new partner and they have new considerations and so getting them back to Vermont even when they have those future service obligations can be a challenge so I think we need to think more creatively and I believe that we need to maintain many of these programs that we have to keep that baseline but new things, since you gave me the mic can I just add preceptors Jean Marie talked about this and I heard it a couple other times the clinical sites for trainees whether it be medical students or nursing students PT, pharmacy any of the training programs that require clinical training and out in the field and medicine is the third year of medical school where it's a series of clinical rotations and different specialties some of these rotations are for six weeks we want to get those students out into the field and experiencing all of Vermont not just Burlington or Chittenden County so we need to place in this example family medicine students medical students on a family medicine rotation or clinical clerkship at a site for six weeks so we need a practice to be willing to take a student and help train that student and that affects their care delivery time their productivity their whole team to be involved and so we ask them to do this as volunteers it's a big ask but it's also an opportunity for those practice sites to meet these students and to develop long range relationships long term relationships so it's that cultivation but sometimes it's so long range that they can't see the benefit when they're already understaffed or overburdened with paperwork so I think we need to spend some time thinking about how do we address preceptor development and clinical site development so that we're not sending students who are training in Vermont to other states to get these experiences currently we send some students to Maine, Florida, New York, Connecticut because we do not have enough preceptor sites we compete with other programs that pay preceptors Dartmouth for instance will pay the clinical site to take students so preceptor development is a big piece of helping students connect with practices around the state and then also housing for those students when they're on those rotations so if a student is in southern Vermont for six weeks the AHEC program works to cultivate community based housing and housing volunteers people from the community willing to house a student for six weeks other states have come up with creative solutions and offering different kinds of tax incentives tax rebates, tax credits for preceptors as well as for housing hosts so maybe those are things that we can look at in the future is there any empirical evidence over which of these strategies seems to work best for the most cost-efficient dollars? I'm going to say no as far as empirical evidence there's a lot of anecdotal one of the challenges of the evidence that we all want to see is the longitudinal tracking that's required to determine did that work and how much did it cost so longitudinal tracking of participants and all of the programs that we do is really necessary in order to assess outcomes and success many of our funders want that but they don't want to pay for the work that goes into the longitudinal tracking we also work with many partners in governmental organizations licensing who have data that would help with that process but because of privacy laws or just red tape it's very difficult to access that data in the education world we deal with FERPA the Family Education Rights and Privacy Act as far as limiting sharing of data about students and where they are and even how to contact them long term in health care it's HIPAA so HIPAA FERPA so if we can figure out better ways to share information and data that we have in this workforce development effort that would be really helpful. Thanks, Dr. Holmes is gonna ask the next question and just so I prepare the other board members after that I'm gonna start with you, Robin and work the way up the table and alternate and then after that I'm gonna ask panelists if they would like to ask the other panelists a question so Dr. Holmes. Lots of prep time. Yes. If you wanna advise on data sharing I suggest you talk to Facebook they seem to have figured out how to do that but actually and I was gonna say Trey you mentioned something about tenuring nurses or providers in some way I would say there's lots of lessons to be learned from academic institutions on golden handcuffs to so to speak and I could just say from things like tuition benefits for dependents to help with down payments and mortgages to escalating retirement. I mean working at an academic institution I can tell you that there are a lot of golden handcuffs that keep us there. Lessons learned from related work but I guess one of, I actually have two questions and I'll try and make them quick and open them up and maybe some people can answer one or the other but my question is is the issue more recruitment or retention because I would imagine that the strategies for solving that would be quite different. So is it the problem that people don't enter the workforce because of all the host of reasons or that they stay calm, they're here for a little while and then they're lured away by larger salaries from other states or from other places and so obviously one has implications for turnover costs, constantly turning it over and having people training them and having people leave or just not even able to get people into the pipeline. So that would be the first question and then quickly a second question would be I imagine for some areas when you were talking about the Northeast Kingdom that the population mass is small there so I imagine that there's a critical mass needed for a specialist to want to move into that territory or even primary care to some degree, moving a new practice in. There needs to be a population base to support that so I'm wondering what role technology plays in telemedicine and or mobile units like you were talking about dentists per capita there and I'm wondering is there an innovation where there's a mobile dental bus that drives to the Northeast Kingdom and is there for two or three days and then drives to other, I mean, what can we do if we can't get people to move and reside in a particular community? Can we use technology, mobile, telemedicine to do that? So my first question, recruitment versus retention and my second question, how can we use technology and mobile resources and move the providers in and out or move patients to those practices? I don't know but I'll throw those out there. One advice that I did in the recruitment versus retention says, it's both. I imagined it was, but I mean, is there one weighted more than the other? So I would say that for us, the honors and challenges on recruitment, that's what we really start with, workforce, our workforce is major. Nurses are older, physicians are older and so that gets to the retention piece which is that we're not seeing people really clean because they can buy higher-paying jobs elsewhere. We're seeing people retiring that for the course and we're seeing providers, especially in primary care and permanent. So they're retiring early or they're changing their career so they're going to primary care and work at the hospital this year and the other. So I think that the opportunities around that are how do we get back to quality of life, right? And it's leverage technology to make that work easier. It's finding ways to make it work on them. Those are things that we start exploring as an organization which help keep people clean, right? You know what I mean? And again, we just updated our contracts and we added, I think it wasn't in there, we added the opportunity for our physicians, anybody who's been 45 years or more, every five years taking a system-based pathway. So it's doing those things. We're going to have to go to that cross. They're taking us to where we're soon, but we recognize that in trying to use strategies like that to help people remain clean for it. But it really adds to the bigger problems that we're in and it's not, and we have great patients here and we have great partners who are trying to support us. And sometimes people just don't have to even talk to you. That's, you know, nursing, I like to use the, there are this many nursing opportunities in there and there are this many nurses. You know, it just gives, you know, so that's a challenge that we have to do. As far as technology, I would say all of the above it is hard to adopt new technology and leverage telemedicine in meaningful ways within our practices, especially in the medical field. But I think that especially moving forward with public reform and payment reform, the opportunities are starting to open up and that's where it ends up. Yeah, and I know. Hard why? Sorry, you said it's hard to leverage technology. So why is it hard? So a couple of years ago, there was a pilot actually moving before going to the clinic. I've heard a lot about it because it was an epic fail around my trying to provide it, it was a telecephaly. So here's an example of the problem. At that time, you needed to have a monitor and a special connection, you had to make sure it was secured and then you had to schedule that. And then you had to figure out how to coordinate the schedule with the provider remotely with the patient when they came in. So by the way, a third of our patients, no judgment, a third of our patients are living in the clinic, right? Their lives are chaos and we have a very high nose show rate. So how do we deal with that, right? So that complicates the challenge of the people who need to care the most and that man are the hardest ones to connect with remotely. It's a lot easier to open up to your opponent when he grabs the person next door. And so those are all very real barriers that we have to figure out how to overcome. It's not, yeah, those are, plus, plus, again, no judgment, please, but my workforce, average age of decision, 55, 56 years old, right? They didn't grow up in a YouTube iPad world, you know? So the idea of interacting with people that way is also a cultural shift. I think as a younger generation of providers who are much more comfortable with technology coming into it, that's going to be easier, but that too is a very, very important. Yeah, I mean, I just happen to have the mic here, so I'll say I agree with all of that. Recruitment seems to be, I mean, retention's always a problem. People are going to leave anyway because they're leaving for other reasons. They're leaving because they're distraught or recruitment's the big thing. On telemedicine, I know all of you and us included are working very hard on it because that is very helpful. I have a presentation, it's not a panacea, because their biggest concern is workforce. They don't have it either. There's not just all these physicians and nurses sitting around saying, oh, I would be working, but I'm not, but if I could do telemedicine, I would do this work. They don't exist either, so it's a combination that'll be there. Oh, I had a similar, so it's recruitment except in the highest burnout specialties, which are primary care and emergency medicine for us and for there, it's retention. We're definitely seeing early retirements. For the technology, it's not as simple as having the technology because even for our pilots that we're doing for the e-consults, I heard that, I got excited that I said, wait a minute, are we setting aside time for that dermatologist to go through those? And it's that dermatologist's time, which is extraordinarily valuable. So if we were to provide telederm services for all of Vermont, which would be beautiful, like how do we, and then how do we schedule that? And then we're going outside of our fixed payment area, which is fine, but then how do we fund that? So all solvable, the technologies have to be compatible. And by the way, hiring a technology workforce is becoming harder and harder. And IT workforce is very difficult. I mean, that's the, they're being, and we're competing with, I mean, talk about competing for doctors, we're competing for IT salary, you know, IT salaries all across the country. In the recruitment work that AHEC has involved in working with candidates, we always hear about pay and compensation package and benefits as being a huge concern. But we also hear a lot about the workplace environment and the management of the workplace. So sometimes we refer candidates to practices and we've screened them and worked with these candidates for a while. So we believe the geographic location, you know, might work for them and that it's a fit. It's a hot lead, at least a warm lead, not just a lead. And then we get the feedback of, well, the site is very outdated. It's old, they don't have current technology. Even spotty internet sometimes. And then just how the electronic health record, which record, how that's managed and the general management of the site. These are things that incentive programs like loan repayment and workforce development programs cannot solve for. So these are other kinds of things that need to be addressed or self-assessment as far as employers and practice sites and what they can do as far as putting their best foot forward when they're working with recruits in addition to the hospitality of barbecues and things like that. So if I could just frame the problem, especially on the primary care side, because as you all know, when we did our budget review, we had three full-time primary care physicians that retired. And that's about 6,000 patients that need to find a home. When you look at the data, and this was a study done by Merritt Hawkins, one of the big recruitment firms, that of all the primary care residents that come out of their residencies, only 4% are even interested at looking at a rural or semi-rural area. They're much more interested in a suburban or urban area. So the numbers out there that are even interested in coming to a place like Vermont, whether it's Southern Vermont, mid-Vermont, the Northeast Kingdom, whatever, is a very limited number. So one of the questions that we had was, how do we differentiate ourselves when we're out recruiting for these three new physicians? Well, one of the things we did, and we've talked about this at the hospital association, is at Barbaro, we've established a scribe because we know how the electronic medical record can sometimes be a barrier between the physician and the patient because the physician is entering in the information. So now we have a scribe, and we offer that to every new recruit. And that has made a difference because most other places aren't at that point. And actually now we're starting to leverage technology in having a virtual scribe in the room, where now a scribe is on the internet via, and the patient knows this, obviously, but the scribe is remote. So leveraging some of that technology now to differentiate ourselves in the marketplace and create a better environment for primary care physicians to bring back that jewelry medicine that we sort of have lost because of all the bureaucracy and the regulatory apparatus. But I don't want to leave you to think that it's all equal in terms of recruitment. And that 4% is competing throughout this country for jobs. Since we're moving down the track here, I'll take my few moments. So I just completed a research study with a number of my colleagues at a rural institution where we had 600 nurses from rural healthcare organizations. And we were looking at intention to stay and what it was that kept people in place. And I will tell you that our findings, by and large, very clearly said, it's embeddedness. It has to do with being able to develop some roots in a place. So much like what Sean was talking about, the laugh about the Thanksgiving dinner, it is those kinds of things because we live in a world where people are so, so busy. And while they may be enjoying what it is that they're doing at work, work is only one aspect of an individual's life. And so that individual themselves needs to feel connected within the communities in which they live, as well as their partners and their children. And so I think these are important things for us to think about. It is not just, as you said, it's not just the things that are sort of obvious to us from the standpoint of creating a good job and a healthy workplace and providing people with supports and giving them the golden handcuffs. It's these other things that I think that we have to really be thinking about as we try to find solutions. The one thing I also know from looking at today's post-secondary demographic that first of all shrinking. So that's one aspect of things. So I think as you had mentioned before, we're not talking just about expanding the labor force. We're talking about creating new opportunities for individuals who are at a different point in their career. Maybe they've discovered that they're not so happy doing what it is they thought they would be happy at doing when they were 18 or, you know, whenever they made their choice. Maybe they've been displaced from the economic marketplace. Maybe they're not able to make a living wage. And so one of the things that I've seen in that literature is that only 13% of individuals in that post-secondary demographic choose to go to a rural place. So when I think about this from my standpoint and I think about the solutions that we need to create, one of the things, my message is to everybody whom I encounter is that just as we have a bi-local movement when it comes to our food sources, I think we need to have a bi-local movement when it comes to education. That we should really be encouraging the people who already grew up here, who live here, whose families are rooted here, who have connections here. I think that we need to be thinking about how it is that we grow our own. As you mentioned, Mr. Merlin, that our biggest export here is our offspring. I think we need to think about how do we shift that? How do we do something different? How do we keep people here? What are the financial disincentives to go into school outside of Vermont? What are we doing here that's wrong? Why do they want to go elsewhere? You have a pretty healthy and robust pipeline system here, but they're leaving. And I think that we need to think about that as well. So it's retention and recruitment and your recruitment could be resolved pretty easily. Thank you, I agree. It is both recruitment and retention and the Johnson State program and a number of the programs here really have helped feed people into employment and community mental health. So we're really appreciative of the resources that we have that have fed people in. Let me give you an example though, like of what happens when we can't recruit. I have a colleague whose son uses augmentative communication to communicate. They haven't been able to recruit a staff who will be paying $14 an hour for three or four months now. So during that time, the mental health center puts in subs when they can who has the skill to help them communicate. But very often he's stranded in the home that he lives in, in a rural environment. He can't get out, he can't communicate. And in the past, when he's been in this situation, he's exploded in violence to a very dangerous degree. She's very worried about him, and yet there's no concrete action that can be taken. We can't increase our salaries with higher payment rates that agencies doing the best they can. But in the interim, someone is there not getting support and getting an increasingly difficult situation. However, retention is also equally important. When you think about going to psychotherapy and talking about very painful personal experiences, for instance, childhood sexual abuse, domestic violence, addiction that you can't get over and you keep relapsing. Those are really hard stories to have to tell to a new therapist several times in a year. And we've had turnover rates of about 30%. So that's a real issue in community mental health. And I really hear my other healthcare partners talking about the issues they're dealing with. In our situation, we're just looking at the Vermont labor market. We are so far behind the other players in the labor market, whether it's hospitals, other healthcare providers, schools, or the state of Vermont that also provides mental health services that we're struggling just within our own labor market. So we've done comparisons with state employees doing similar work and found that our employees literally make $20,000 less a year doing exactly the same job at the same length of time. So if you'll see on the reports that I passed out, our employees love their work. They feel good, it's rewarding. It's just wonderful work. But many of them leave to other healthcare employers in Vermont because they can't afford to stay. And when it's that much of a difference, and we're paying people with master's degrees in $30,000 range, you really can't blame them. And we do have some good luck in terms of recruiting the master's level because they can work for us before they get their license. So it takes about two years of supervision. You get your license and then you leave. But at least we get them for the two years. So we're appreciative of that, but we really need support from the Green Managing Care Board to help us look at pay parity, funding parity. How could we really pay for the costs of services adequately? Can we use value-based payments? Can we work with the ACO to find a way to fully fund the work that we do? Because when people experience trauma, they're more likely to have healthcare issues later in life, whether it's related to addiction and behaviors or other cardiovascular and other issues that occur because of the experience. Our work helps people with resilience, helps people with recovery, helps people to have healthier behaviors, but we need the staff to do the work and to do it well. And so without having a consistent quality workforce, people don't have access to good quality care that's really gonna make a difference in their lives, whether it's employment or healthcare or any aspects of their life. So glad to be part of this panel today and be able to present this. I don't have any comments on this question, but I can't wait for the point in this conversation where we can look at the opportunities that we've already discussed, points of connection. Robin. I'd be interested in hearing a little bit more about substance abuse and the substance abuse issues and workforce around the state. I'll just start by telling you we have an opportunity in front of us and then I'm gonna listen very carefully for what others say. The federal government has put out an RFP for states to apply for up to, I think the application we're working on right now is for about $2 million to combat the opioid crisis and we can apply in two ways. One is employment services for individuals who are addicted and right now we're thinking about employment services for those who are in medically assisted treatment and looking at expanding apprenticeships. The other opportunity is for us to use a portion of the money to try to build the workforce that supports the opioid crisis and so we're working with our partners at ADAP and Voc Rehab and others and so I'm gonna listen for even more opportunities as we're writing this grant and what your responses are. That's wonderful and also there's funding in the appropriations bill that is progressing maybe to do some more workforce recruitment and loan repayment looking at different opportunities. Also psychiatric nursing programs so that's exciting but we also need to go back to the reimbursement issue. The reimbursement issues mean that again master's level individuals who have license and alcohol and drug counseling are making in the 30s. The Petster owner in Montpelier, she has the license, she could do the work but when you get paid so little people don't stick with it or they and some people don't go into it and I also know if people have picked engineering in other fields because they know why invest in an education where you're not gonna be able to pay your bills when you get out or even pay off your loan. So we need to really look at our ADAP and diva payment rates for some use disorder services. Our hubs and spokes are wonderful but the focus is actually on the medication administration. Again those counselors working those programs are not making adequate reimbursed salaries to really stick with it and people aren't getting the level of support they need. A hub is required to give a half an hour of therapy a month if that's not enough. People need more support, their lives are in chaos, they need a lot of support. So we need to develop this workforce but we really need to look at the funding levels and not just at developing programs and loan repayment. We need to look at how to re-support the services so people get access to quality care. At Casselton we do have an individual in our social work department who is part of the governor's task force on the opioid crisis and one of the creative things he has done is that he has developed a course within the social work curriculum for students to become certified as an addictions apprentice which don't ask me all the ins and outs of that but I think that we can also guess at what that is and my understanding of this work is that the students are then able to go out and to work in communities assisting those people who are the professionals to reach and access the individuals who are having problems and it's just that hubs and spokes I think but I think that's just a small, minor example of things that can be done and that's being done without any funding. I think there's a lot more that can be done from the standpoint of education. Certainly we could be doing a nurse practitioner program if we had the funding. Let me just say one thing. So Robin, I just had a meeting today before I came to you up here from Brownabarl with HCRS which is the Community Mental Health Agency and Chief of Police and our time manager in Brownabarl because of our opioid crisis and especially as it hits the emergency department and we've just hired actually at the end of last week psychiatric nurse practitioner to be placed in the emergency department to help our physicians who are not trained as psychiatrists to assist folks with mental health substance abuse issues and which represents now 10 to 15% of all of our ED visits at the hospital. I constantly approach Al Gobey and Melissa Bailey about funding for the position but I don't think it's gonna come so you'll hear it during the budget process in our healthcare reform part of it but it's placed a lot of pressure on the hospital but also on our medical practices so we've embedded mental health counselors in some of our larger practices as well as SBIRT trained individuals. So but there is no real reimbursement on that so it's either from the state or we're looking for grant money but and I do want to, I do think the community health team and the blueprint and the hub and spoke have done a phenomenal job in our area, very, very active and we do have now Suboxone treating physicians and nurse practitioner now with the medical staff because one of the things the new nurse practitioner can do is start folks on Suboxone with a referral in the ER with a referral into the community so it's a great need. I'd like to echo what Julie said about master's prepared counselors and the pay issues, the wage issues. We do a lot of work with undergraduate students who are thinking about what's next for them and their pursuit of graduate level training and I hear over and over again folks who are interested in social work or counseling type positions but when they realize the amount of training that's necessary, the increasing their educational debt for that training and then the wages that are on the other side, they find something else to do so we're losing them in that pipeline because of that future earnings issue. I would pass but I would say that it's not, even more tech it's not in the area of our expertise and so we stick to close to our game and try to do what we do well, well. If there are areas that need to be developed we're happy to take a look at them, keep in mind it takes two, three years to develop a program and then you have those years thereafter before you have your graduates. So two things to consider that I've seen in our own family medicine department is it's become a bit of a, it's an unwritten standard I guess I would say for recruiting that we ask our candidates are you willing to prescribe Suboxone in our family and I don't do as much recruiting as I used to but I can't think of anybody that I've met and interviewed that said no so whether that's just the new culture of people are being trained in that environment and we're setting the expectation, that's gone well. The other thing that I've noticed because it's nice to focus on some things that are working well is that the Hubbid spoke model has provided for some family physicians and I could think of two off the top of my head and there may be more, a specialty if you've been a primary care provider and a good one but it may be burning out on the breadth and really need to focus a little bit. I've seen people have some second careers working in the hub and retrain themselves and reinvent themselves and it's been both a victory for the community as well as that provider because they have now a place where they can really have their career furrow so that's been lovely reimbursement as a problem. I'll just share, just to make sure everybody can hear me. Okay, can you guys all hear me? I'll just share what I consider a success or even around bringing people with opioid addiction. One thing is in FQHC we often have access to federal brain opportunities that allows you to really innovate with things in our communities and one thing I'm proud of at noise and county is we've gotten really good at leveraging those federal resources to support our mission. A couple years ago we had an opportunity to apply for a grant to expand MAT services within our community, specifically around supporting mental health, behavioral health professionals between the practices. We looked at the grant and we were really struggling with whether or not to apply and how we would leverage those dollars because we can't find the professionals and it kind of struck on really, I feel like it was a really innovative solution that really addressed the workforce challenge because when you go through a program to become a mental health professional to then become licensed you need was a 2,000 hours of supervision, right? Now here's the problem with mental health provider. When I take a master's prepared mental health professional and want to hire them but they are not yet licensed I cannot bill for them, right? So what do we do? What we were able to do is crack this grant in such a way we said we're going to hire master's prepared unlicensed professionals who are working towards their licensure. We will provide the supervision so that they can get licensed and they will support the expansion of our national program. Okay, so it was really innovative for paying these people a decent salary while they're becoming licensed and then ultimately they become licensed and can become billable professionals. To this day, in about a year and a half we've had at least three people become licensed through that program. We've hired two of them. One of them is working elsewhere in the community and we're able to continue to replicate that through those grant dollars. So we're helping people with opioid addiction. We've been able to expand our MAT program and now have nurse practitioners who are providing suboxone support. And we're building our workforce in a community. Thank you, Sean. Tom. Thank you. So I'm relatively new here. I won't be able to say that too much longer but I'll use it as much as I can for a while. But I'm spending quite a bit of time on the road and getting to know folks out in the field. Sean was nice enough to show me around his tour for a while back and pretty soon I'll be after our budget season is over, I'll be heading south. But one of the things that everywhere I went I hear about this recruitment issue and when you kind of begin to look at hospital budgets you see the travelers budgets going up and up and up. And so when I discuss that with people what I find is that it's almost a two to one ratio in terms of the expense to get a traveler versus having somebody on staff. And that to me is an immense differential. And so I'm wondering as you folks and we develop strategies, recruitment strategies which I'm sure being good remoders we will figure this out over time. That whether or not that if these solutions are system wide whether or not there is a reasonable basis to put together a system wide funding system based on the savings of travelers to some extent where the institution that is paying the traveler saves money and gets a staff then as we get more successful money could be used system wide rather than staying in the separate silos. So that's just a thought because I went back and I looked at the State White Hospital budgets they for 2017 had budgeted about 170 travelers but they actually hired a 231. And so when you take 231 multiply it by the average hours of those travelers you're talking tens of millions of dollars that is being spent twice essentially. And the second thing I would ask is that I did hear from time to time that at the hospitals that the issue of incentives in terms of recruitment was sometimes a difficult problem to deal with the existing staff. There's a situation where I didn't get this benefit and these new people are getting this benefit and I'm just wondering if you folks have run across that problem in your travels. So I used to be the nurse manager of a birthing center and we had a sudden explosion in our census because of closures being in a rural place. Loss of obstetricians, gynecologists, shuttering up because they were aging out. So we were faced with having to hire some travelers and let me just tell you a little bit about this whole situation. So just as you mentioned, they're getting paid top dollar. They're coming into your organizations. Some of them can be very talented, very wonderful, very altruistic in some respects. But quite honestly, I think that we need to take a look at people who are doing this traveling as mercenaries. They're guns for hire and from my own personal perspective and from talking to many of my colleagues who serve as managers of units that are faced with having to hire travelers. They're a social contagion and they're a cultural toxin. They come into organizations and they say to them, oh my gosh, I can't believe that you're doing this this way. Really? You guys have what benefits? What are you getting paid an hour? Oh my gosh, well you should become a traveler. I think we have to stem the tide. Somebody who is an educator, I think it starts with education. I think it starts with helping people to understand that part of the role of being a professional is professional engagement. And that means being engaged in the politics of your organization to shape that organization in such a way that is a very healthy workplace for all employees and that you deliver the highest quality and the safest care. So I think it starts with education. I think that much like my colleague Liz had mentioned before, when we think about solutions, I can almost guarantee you that it's gonna end up being a race to the bottom. That we'll create something, we'll say, let's take these monies that are being spent on travelers and let's give the nurses better benefits and da da da da and then the traveling nurse organizations will just up the ante. So I think we can do these things in the short term. We can create some of those kinds of solutions that you're talking about, but I think really it behooves all of us as professionals to be educating the current and the next generations of nursing about what it really means to be a professional and how important it is for you as a professional to be engaged as a professional in the organizations that you work in and engaged in your communities. Thanks, a little bit of my soapbots. I'll take a little different tact. Where are the travelers? And the travelers are in specialty care areas. Critical care in our hospital is critical care and it's the emergency department. I think what we need to do is have training programs with the higher education institutions to take the med surge nurses who are interested in exploring critical care opportunities and create both a clinical pathway and an educational pathway. And that's a challenge I'll give to the educators here because that burden is now placed on the hospital. And the reason why we have the travelers is because we're not getting those nurses trained in those specialties right out of the gate. The other piece is, Tom, you're right on. When I came to do our budget review, we have a million dollars variance in our budget for travelers, 11 FTEs of travelers. Right before us was Rutland and I think Kevin, they were at over 30. 41. 41, thank you. I mean, huge dollars but it's not only about money, it's really not about money, it's about training, it's about education, it's about the interests of the nurses to go beyond that med surge. We don't have a problem recruiting med surge nurses at all where it is in those specialty areas because a lot of those specialty areas are nurses that have trained in those areas and what we're doing now is trying to recruit OR nurses or specialty care nurses out of Keen, out of Greenfield, out of Southwestern. That's not good enough because we're all feeling that pain right now. So we've gotta do something different and that's gonna have to take partnerships with the educational institutions to come up with a training program for OR nurses. We were sending med surge nurses up to Dartmouth because they had to have a training program specifically to take a med surge nurse and give them the educational piece from an OR or for an ER and then they come back to our hospital for their clinicals. We've gotta do more of that in Vermont and that's a challenge I give to the educational institutions here. So where I had been before, we actually had started down the road of developing an OR training program. So there is a woman who came out of Massachusetts. She basically, she has a curriculum. You just need to purchase it. She's got the curriculum that is sort of ready but the problem is adding more time sometimes on to people's educational trajectory so it could be sort of a post certification program and the baccalaureate program that I ran for 10 years, we had a really robust critical care, very robust. Our problem right now with being able to have something that even comes close to matching that is having the clinical site. I have people who have critical care backgrounds but it's really sort of having the clinical sites and being able to have the exposure. So we have started a critical care course in our baccalaureate curriculum. The students take it right before they leave for their senior capstone and they go through all sorts of different simulations and scenarios looking at some of the more common high-risk kinds of things. But it's just the beginning of what you could actually do if you, it all comes back down to resources and for us it's really sort of the clinical resources to be able to do it well. I'll try to be a little ray of sunshine here. So I'm having sort of an aha moment and I think this might be just reconstructing what we think of in our current program. So what I just heard is an employer and an education provider who are describing a situation that sounds very much like a registered apprenticeship and while we typically think of registered apprenticeships as electricians and such, the federal government has because Trump loves apprenticeships, put more money into providing funds for states to expand the apprenticeship opportunities and we've been offered some guidance in looking at Europe and other models and how they are developing apprenticeships at the higher sort of white collar professional level. And so it might be worth having a conversation after to see if we may be able to structure an apprenticeship at that level where the higher education provider can do related instruction which there's funding for on the job training which sounds like it would be the clinical component and you have the employer who's sort of helping to pay while you learn and earn at the same time. So there could be some opportunities there for some innovative or novel approaches to solving this problem. Well we started a program. Exactly, exactly what we talked about. And we had a million dollars range over the years. So several years ago we had a major problem recruiting MAs which are critical for the physicians and nurse practitioners and PAs to act to practice at the top of their license. If you don't have the MAs, who's gonna ruin most patients? Who's gonna take the vital signs? So we had a horrible situation where we had physicians doing that and that way reduces their productivity. So I went to Joyce Judy from CCV and I said, we've got a real problem here. Can we have a accelerated program where we actually provide scholarships, eight students, I think it's around 4,000, 4,500 a piece at that program. We do, you all do a semester of the academic piece. We do the training in our medical groups, in our practices and we guarantee eight of those students who we give scholarships a job when they graduate, whether it is a position or not, but there always are gonna be these positions. And what's beautiful about this program, we're in its third year now, is we have diet texts. The folks that are working behind the trail lines, serving the foods, dishwashers, now progressing into this MA program and now they're going to VTC for their LPN or going on to their RN. So we're starting that workforce development but it takes kind of an innovative, one innovative educational partner to work with and CCV has been that piece. And I think as I keep mentioning, we've gotta get the educational institutions and the businesses and IE the hospitals together to identify these needs and come up with solutions whether another problem we have is RNs where our associate degree RNs, getting them to get a BSN. Right now, we're sending two nurses out of Vermont because the cost is cheaper at Elms and Springfield, Massachusetts. That's crazy. So we gotta look at those kinds of things. The key folks in Vermont, less expensive. We're response really. The Castleton and cheaper than hope. VTC. Okay. Yes, can we just start it fully online? It's both, and Elms is both online, but those are the kind of things that we've gotta get our act together up here. So we keep the students in Vermont and we're not sending, and I'm not sending dollars out of Vermont for the educational piece, but I've gotta have partners to work with like what we've had with CCV. Thanks. So I wanted to, this is a very interesting conversation to take it, to respond a little bit more directly. And I heard you musing about how we could create an incentive for cost savings around travelers, which I really appreciate, though I would, the one thought I'm having is that we have a large incentive already not to use travelers wherever we can. So I think that we use them during big volume surges when we have to and we really need, I mean, the care has to be provided, right? That has to be done. But we have every incentive and we wanna fill those spots with people who are gonna be around, invest in the organization, the community. So just so you're aware of that, nobody's looking to have more travelers than expected. My question is geared to having a few of them. A few of them. Sure. First I wanna say, I think this has been really informative and I think the whole group has really articulated the problems that you face. And I really wanna direct a question to Dustin and Sarah because it's not unique to this industry, as we've said. And, you know, right or wrong, Vermont is not known to be a business-friendly state. And the whole thing with trailing spouse that goes against, you know, that goes throughout, you know, everything, you know, corporate as well as the medical side. So I'm just wondering, and I don't know if you guys did this program, but there's been a lot of headlines lately about this $10,000 people can get for, you know, working remotely in the state and, you know, people joke that if you have to buy clothes, we'll cost you that $10,000 in what qualifies. But my point was gonna be, you know, how do you decide where to put that type of funding? And, you know, why not? It's something like a medical profession. And I understand 10,000 isn't necessarily a ton of money, but, you know, this problem isn't gonna get corrected just by getting more people into jobs in the medical profession, because it's really a statewide issue across all the industries, you know, that just wondering how you guys prioritize what programs can be done. So when we, hey, I don't think that came directly from us, but it was a collaboration with the agency of commerce. Actually, it's senators. Yeah. So, so Senator Soraki and Kevin Goldfinney decided where that money was going to go. And honestly, I think we supported it just because we were looking for ways to get. I think a lot of the conversation that I heard today is fascinating because, like I said before, if you go to global families, you'll get the same exact thing. If you go to my island and said, Almond's is gonna get the same exact thing. And it really is straight up subtraction, right? We have 16,000 fewer people to work towards than we did a lot of that. If not a majority of that is based on requirements. So as these positions leave, it's not that we're not retaining people, as if they're leaving for mocks, that we're not retaining them within the workforce. Sarah came up with a really, I don't know that she came up with it, but has pushed a really great idea for a return shift where investors did money and folks to get back into the labor force. That might be, you know, a nurse who spent her entire career in emergency room and now wants to do two or three days at home health. Might not be the best fit, but we're trying to figure out ways to get people in those skills to stay in the workforce, whether it's a nurse or an engineer. And I think we recognize, I think everybody recognized the concept of living in Vermont, I think, what's going on right now through the legislature and administration is that this kind of brings that whole thing to a head. But we tried to do as much as we could in our original plan, and a lot of the electronic planning on the floor without spending more than that. What I hear from this group is that there does need to be more investment from somewhere into quality employees. And I guess my question to the group at some point would be, what's the most prioritized money that can go with it? I mean, is it the Medicaid reimbursement for places like Franklin Family where the interest is super high? But where can we put the most strategic wedding to make the most difference? And we need to retain people that come here to college. We have that incentive for people that come to UBM and go through their system or come to the state colleges and go through the system so that they actually stay. And we have to figure out ways to train the half of Vermonters that graduate from high school that don't go into any post-secondary education or all that. And all my sisters now at Anne's and all those virtual care partners, you should love them and you can't afford them. How do we help that person who's already in the field create that career pathway so it's not just your job but it's your entry and you're being fastened through that you've been able to grow and be provided with a lifestyle that I think those folks deserve because that's the day of the course challenge, right? I mean, honestly, the day of the course challenge. So, sir, while you're thinking about your response, also, if you could interject into this question, you talked about 98% of your funding is from the federal government. You talked about the opportunities that are there. So, as part of your answer, if you could include whether or not you think there's money being left on the table because we're not getting hospitals or education institutions to step forward to access those funds. And if so, who should Steve and his colleagues be talking to to make sure that we're not leaving money on the table? Yes. No, I appreciate that, thank you. Well, so I'll speak about one aspect of the recruitment and that's not just the recruitment, it's the relocation, but there's something that I know I've learned in the last year or so of trying to tackle this problem is that there is a strategy to getting, to identify a candidate to move to the state in any profession. And then there's, there are all the things that need to happen in order for that to actually happen, you know, for that, whether it's housing or it's the right pay or it's the talented partner, which is a new worker or a traveling spouse, the talented partner supports, all of those pieces make a difference. And for many people who have successfully come back to the state, I myself grew up here, I left for four years, I came back. A lot of what brings people back to the state is a connection through family or through some other institutional social connection. And I think that's a no-brainer for many of us. For those who maybe came here for school and don't have a connection other than their schools to come back, they do need a little bit of that relocation support. So one of the ways that we are looking at money that is currently on the table is this amount of money we have about $2 million to provide employment services through lack of PISA funding. And so some of those career services that we can and are providing to employers and job seekers right now, we are looking to dedicate a relocation unit within the Department of Labor to specialize in some headhunting strategies and some career placements, not just for those who are unemployed, which is typically some of the folks that we're working with right now, but the higher skill-leveled individuals who we can be, other groups like by-state and others are recruiting, and then the state can help provide some of that relocation services and being the conversion funnel. The money that I have to say, we aren't leaving any money on the table, but I think we're leaving opportunities untapped. The one party spoken of is apprenticeship money. The federal government, it doesn't seem to be expanding any of our other pools of money for training and investment, but they are continuing to fund apprenticeship money. I know that New Jersey has developed two apprenticeships related to substance abuse and mental health counselors, and I have one of my co-workers looking into what that model looks like to see if we might be able to go to our friends here at the table for both the related instruction and also the support of those employers, because just as a reminder, apprenticeships take an employer commitment and the instruction. So some of the opportunities for funding are in things like apprenticeship funding. The other area that we I think are trying to retool is we have a pot of funds that is for youth services, particularly out-of-school youth. And for those who may not be familiar, youth are up to age 25. And if we can rededicate the way we're serving students who graduated from high school but aren't continuing on in any post-secondary way, and we can bring them into our case workers, start working with them on a plan, we can provide funding for training at tech centers, at CCB, I know CCB, and Lyndon and Johnson have also participated as training providers for some of those educational training services for students. So I think looking at certificate programs with our education partners is something that we have a lot of opportunity to engage in and ensuring that those certificate programs are being provided where the people are. So Northern Vermont University, right, NBU, has some great, I've learned they've got some great certificate programs right now in hospitality. The problem is a lot of the hospitality is in Portland and in Jitney County. And so trying to work with some of your staff to figure out, and I know there's steps being taken already, but trying to make sure that where we're providing those certificate programs and those learning opportunities that they're available to the employers and to the individuals where they are. So there's a few other grants that we're looking at right now in terms of that might be of interest to this group, had a meeting this morning about workers compensation and how some training of some docs, if we could pull down another source of funding, could help people return to work faster if they could begin to do some earlier intervention with the individuals that they're treating. And so we're looking to see what the state of Washington is doing currently in terms of workers comp and their return to work rates. There seem to be some medical evidence that some types of medical strategies are very successful. So if any of what I've said interests any of you, I'm happy to talk and I'll make one final remark about areas of alignment. And that's in terms of longitudinal data collection. The Department of Labor, while very protective of this data, does maintain the wage an hour division. So we already do report on anyone we've served or both rehab has served or agency of education has served and we're going to have to be reporting more where those folks are to four, six years down the road. As ESSA, the Every Student Succeeds Act comes into place and agency of education is having to report on people who are 16 months out of high school. We're going to have to start tracking where they are and who they're, if they're employed, if they're in a training program. So we are at the state level trying to make sure that our data systems are aligned and I could see some opportunities there for us to model and pilot some of these programs to see what works and to create some of the evidentiary trail that might lead to further funding and further development of best practices. Dustin. Really quickly, two seconds. I think also, as we keep in mind, we're having this conversation at a time in Vermont's history where we literally have a diminishing number of Vermonters. So diminishing number of people who are actually paying into the system while costs are going up. One of the things that I think Kevin did a really good job of when we started, instead of the other, was pushing the question to Sarah too, but she was the house owner of the company. How will we pay for higher education in the state of Vermont, right? So we are at last in funding for our state universities or our state university. We have three now with UMM. And while I know it is physically possible for us to cut a billion dollar check, which I would love to do to make sure every Vermonter can go to college, how we provide training might be a way for state colleges and UMM to get more money out of the system so that we're providing that bridge from high school to a two-year degree or a four-year degree. I think if we don't have the conversation about how we fund higher education and training, I think really important is being in training. And I think the state college system and UMM are the obvious place to push Vermonters, then we're gonna be here 10 years from now talking about why we have 50% of Vermonters who aren't going to college and why we don't work for those problems. It's really, we have to build that bridge because we can't get a base job. And back it up to the technical and vocational centers in the public school system. Yep. Well, thank you. I think that, Dustin, I did want to point out that oftentimes I felt like I had more success working with Sarah than I did with some of my colleagues in the Senate. Well, thank you. I think that, Dustin, I did want to point out that oftentimes, I felt like I had more success working with Sarah than I did with some of my colleagues in the Senate. Well, I was 20, so 1919 was our workforce bill and I was sitting at the Senate and she wouldn't pass. I'm thinking to myself, I finally got a bill passed in the legislature and I had to leave. So we do always open up anything that we do here at the Green Mountain Care Board to comments and questions from the audience. But before we open it up to the audience, I wanted to give the panelists an opportunity if they would like to ask another panelist a question. Don't feel that you have to, but I just, you know, sometimes you're sitting at one of those tables and you wish you had the opportunity to ask a question. So if someone would like that opportunity now is the time. Go ahead, Liz. Can I ask you a question? Well, find a way, Liz. So I'm concerned that the lack of attention that oral health and dental health gets in these conversations about primary health care and that it's so segmented. The Health Department recently released its report on the 2017 Dental Workforce Reliciture Survey. And there's some trends there that are concerning. And I'm thinking about vulnerable populations and those served by Medicaid and how access continues to get more and more challenging for them to receive dental health. In the 2017 data, 60% of the dentists, only 60% are now accepting new Medicaid patients. Whereas 97% of those dentists are still accepting new non-Medicaid patients. 33% of the current dental workforce is accepting ages five plus, or accepting five plus new Medicaid patients. Whereas they're accepting 80% of anybody else if they have their full pays or private insurance. And those numbers, those percentages, if we look at the Reliciture Survey since 2011, we're seeing a downward trend almost every survey is going down, down, down. Fewer and fewer are accepting new Medicaid. And that links directly to Medicaid reimbursement. So this is concerning when we look at access to health and also I guess my main plug in this is that oral health and dental health is part of primary care and part of overall health and wellness. And we have to stop segmenting it. Earlier there was a question about innovations and things that we could look at differently. And I think that we really need to look at school-based clinics for ensuring that all children are getting access to dental care. So that is an excellent question, Liz. Oh, and I'm sorry. No, it really is. And it reminds me of a conversation I had just two mornings ago, I think it was with Jess. And we are tasked with updating the Health Resource Allocation Plan. And that's gonna take us some time, but we wanna do it right. And one of the things that we talked about was making sure that dental was included in this next HRAP as we inventory what resources are available now and what is not available, where the shortages are. And we know that so many physical ailments are also linked to barrel health issues. So we're with you on that. We also believe that vision is a stepchild. And especially when you look at the Medicaid program, what they're willing to fund in either one of those two areas, it kinda sets the tone and where that divide first started between certain areas of health and others. I don't know, but it's something that I'm gonna continue to try to research and try to get into. But you have earmarked something that sometimes we get too focused on what we perceive as the traditional healthcare means. And we lose track of other areas that could be creating even bigger problems because who's gonna get a job as Dustin and Sarah are trying to get people in the workforce that has poor dental health or who can't even read the application. So those are things that we're always focused on. Yes. Thank you. So I might like to add that our proposed dental therapy program is part of what we believe is a solution for some of this. We're not adding dentists. A dental therapist is someone who can do the lower quartile of dental procedures, freeing up the dentist to do the upper tier, more expensive procedures. And there are three other rural states that last Minnesota and Maine who passed this legislation in Minnesota. It's been discovered that this is actually an economic benefit to dental practices because it allows the dentist to take Medicare, Medicaid patients and give those procedures to the dental therapist, freeing them up. So it's actually a multiple benefit. Again, that's based on funding from state and sources and will be in place until 2020. We've been seeing some great things from FQHCs, expanding the clinical practice of dentistry from Bennington today. We were very pleased to work as a board to get that certificate of need turned over as quickly as possible so that Bennington could proceed. So, you know, we understand the issue and it's an issue that needs a lot of work. I think one of the challenges, because we went to our local dentist in the community and said we'll pay for a dental therapist once you get your program up. But there's a lack of getting a collaborative agreement, which they have to practice on them, which is a little different than as I understand Minnesota. So that's a challenge. But we've got a group working with United Way that's working on it. But I think if you look at every hospital's community health needs assessment, mental health and dental, it might be at the top. Yep. Okay, who else from the panel would like to ask a question? Nobody has to. Okay, Sarah? I'd like to know more about, in Cassington, you mentioned some money for a simulator or for a lab, and I'm just curious to know if for some of the training needs that you have, if that is, if training tools like that, that might be mobile, could be shared among various institutions, and if there's anything in the state college's schools that would preclude that type of arrangement. I don't know of any rules that would preclude that kind of arrangement. The machinery, the simulators, are fairly delicate. Then, you know, you could potentially, I do know of a place in which they had mobile simulation labs. So I do know of that. It's not on turtle, but you would need to have something that was really pretty heavy duty. I'm thinking the kind of thing that rock stars go around in, you know, when they're on tour. Yeah, you know, one of those release that I, you know, hefty buses that you could, that you could have. Yeah, the ones that we've seen that some call me come up, they're not the $50,000, $100,000 versions. I know. They're the way north of it. But it is an idea that could actually, most simulators, step unused on majority of the time. Yeah, because we're looking at some simulators for CDLs. We know CDLs are also in great demand in the state. And it's much cheaper to buy a simulation or a simulator lab where it can move from institution to institution. And I'm just wondering if there may be some parallels here and some opportunity to make some similar types of investments. The other thing is avatars. You know, the avatars are becoming sort of more and more prevalent. I think you're probably seeing it in medical education. I'm beginning to see that in nursing education as well. So the problem is that the regulations have not caught up with that and don't recognize that as a comparable form of training or education. So I have to admit that you kind of lost me. Being a former movie guy, I know what the avatar is in the movie, but what are you talking about? So I'm talking about, so if anybody does gaming here, you know what an avatar is. But basically, it is a simulated person that is animated, interactive. They are very, very highly programmed, very interesting. They're using them. I see them being used a lot in the training, the beginning training of folks in assessment skills, interviewing skills, therapeutic communication skills, psychiatric mental health, critical care scenarios, these kinds of things. But they're sort of something that has sort of caught on in the last few years. But certainly, if those are developed, that's expensive than having to fix equipment and whatnot. But right now, I think what anybody who has been in any kind of a health care professions training education program would tell you that the rubber meets the road when get your hands on something. That's when a concept becomes alive to you. That's when it begins to make some real sense to you, that you're seeing it sort of unfolding in front of your eyes. So I still think that there's one to do that in your part. And some of it will end up in you guys' private time. OK, great. So at this point, I'm going to open it up to the audience for any public comments or questions. Yes, go ahead, Dale. Speak loud so the camera can get you. I really enjoyed this. It was excellent. And I really just talked as far as how well you all did. I'm curious about one thing that you took for a vote, I took 20 votes. This is the one you were going to ask. When you focus on the workforce and you focus around colleges and their tax workforce, you're saying that we are going to have this many resources from in terms of we are renewing tenants at schools for exporting more than what's needed for them. In that whole conversation, there's another conversation that I'm using at this table. That is the public school system. The students are in those schools right now. They aren't getting advanced courses that we haven't taught. They aren't getting some of these things that I would call crucial to education where if you take time, the schools can support you building and finding out what you're really good at. And it's focused more on special education, getting the person up to being able to do a certain amount of something and stuff right there. You've also got a whole social issue around school shooting. And what is the emotional health of these students that have been exposed to that? Don't think they're quite ready for college yet. I took the main bar. What is this going to be for you in terms of what are you going to be inheriting to educate? Example, mental health as an issue, that could be substantial for not having a high school. It's not already education or either reason. So I'm just curious how this looks going forward. Combined with the social determinants of health, where I read about students going to college, can't afford a meal. They're trying to learn to venture, graduate with a debt ceiling. We need the long-term payment. Before you can live anywhere, it's like, oh, give me a loan. We can forgive this. I'm living there. That's it. That's your choice. It's like, you can't explain here how you can do it. We don't see a freedom again. We don't see a life. I know Sarah knows this one. I was going to say, we act the Department of Labor. We are charged with administering the youth fund. And in 2016, the way that we're allowed to spend the money changed. And instead of spending 30% on out-of-school at-risk youth, we now have to spend 75% of it on out-of-school at-risk youth. And so it causes to approach our work differently. And what is allowed is for those individuals, those young people who have perhaps trauma and have a lot of barriers to employment, we can use that money to provide wraparound services, counseling, transportation, food vouchers, booths, all sorts of supports that I think, as you just noted, are barriers to employment. And so that's been a even, I'll say maybe this is the one time the federal government actually made some sort of smart decision telling us how to spend our money. But it really is probably does make a lot of sense in terms of prioritizing how we're supporting that aspect of the workforce. I'll just add to that from my own perspective. There are doing a normal and generally college opportunities that we try to offer high school students. And I'll give you one other example in Linden. We are partnering with Linden Institute and Impenant High School to offer their seniors, essentially, a year of college while they're a senior in high school. So we have cohorts of 15 or 20 students who will earn in their senior year, essentially a year's worth of college credit. And if they choose to come to Linden in this program, actually those credits are free. So we're really trying to make college affordable for those students who otherwise may not leave that area to go to college because of the cost. Regarding mental health, one of the things that we see in our retention data, two common factors that I see on the Linden and Johnson campuses regarding retention historically have been related to academics and finances in terms of students being able to persist. But increasingly in the last three to five years, this mental health issue is very real and is a challenge for campuses like ours in terms of the acute need that many of our students have. So it is a challenge that we are very in tune with. On the early college, one of the things that, we believe it was just this Sunday that Chancellor Spalding was on, you can quote me, and I was kind of, you know, he mentioned, I think he said there were only 125 students taking advantage of it and I'm sitting there thinking, my God, when we passed this, I would have envisioned that half of the seniors in the state would have taken advantage of it because of the huge financial gain that they would have. Why aren't more participating? Any ideas? I think it's a very, I think it's a good question. You know, I come from originally from New York State and my own children were able to avail themselves of what they called in New York State college in the classroom. And so it was all done through distance learning, but you were in your particular school and at the same time, you're taking a class in let's say economics from Syracuse University or intro to psych from SUNY Albany, these kinds of things. So, you know, my own children graduated from high school with 30 some odd credits underneath of their belt and did three years of college and earned a degree. So I do wonder why that isn't so. At Casselton in the nursing program, we are opening up a three year program that is aimed at, you know, those post-secondary students who are coming in with advanced standing, trying to talk to the guidance counselors in our area to get these students to engage and become involved in this program. Because some of them I think get bored in high school, quite honestly, they're, you know, they're really smart kids. They want some more stimulation and whatnot. So, but I think that's a very good question to be asking. Not of us maybe, but somebody else. Okay, other questions from the audience? Yes? So, definitely I'm the psychiatrist in Colchester and I'm also representing the Psychiatric Association. I did email to the board members, thank you. And I also appreciate that you called me last night that you were going to address this issue further, so I won't read my comments to you. The main issues are that our workforce has been designated in allocations to psychiatry so I'll really address some of the enormous stressors when the designated agencies and the ER crisis is only the tip of the iceberg. People just cannot find care. There are a few young psychiatrists in private practice. Child psychiatry was underserved even more than 30 years ago when the rest of the system started to decline, which means we're not investing in our future. Many non-psychiatry clinicians are having to manage very difficult things that they are not trained for, which I can only flip it around and think how good I'd be at managing an acute MRI in my office. And it gives me the willies. There aren't enough of us. The persistently low reimbursement obviously is a huge issue. And for, I came out of medical school in 83 with $5,000 debt, the new people have 100,000 or more. You can't graduate and go into private practice with that kind of debt, it just doesn't work. Our residents are just not seeing it as an option. We were the first to be slammed with the egregious managed care stuff that started in about 1990. The Hay Report in the first decade of that managed care showed that the percent of total health care funding that went to psychiatry was caught by hat in a decade. That's not a very productive behavior on the part of insurance companies. The access was deliberately limited and that discrimination continues in all kinds of areas, which I wouldn't belabor. Managed care and prior authorization are usually or almost always a waste of time and money. And one of the things I'll bring as a suggestion in August is that we get rid of some of the prior authorization prevents that goes on in the Medicaid program. There is no reason under the sun we should have to prior authorize every year for a drug that somebody has already on. That's a complete waste of 20 or 30 minutes depending on how much you start with or whatever. Sometimes a lot of us. So the other thing is that those quality measures, EHRs, it was alluded to about the training, we don't have in private practice, especially in solo practice, the money, the time or the resources to do EHRs, get that data. So many of us are already taking cuts in Medicare payments which are going to escalate those cuts over the next four years. That just cuts in from down further. And there's plenty of evidence that a lot of physicians are not doing well with EHRs and psychiatrists don't like them for good reason that position relationship is also very important in our specialty. As the system unfolds, there has been very little outreach to us as far as sharing digital information. The one time early on when I checked with the state law, the file, they were not able to be involved at all at that point and I haven't heard a lot of outreach. There's also a lot of skepticism about ACOs and it's not even clear whether they wish to engage us and it's definitely not clear that they're saving money. I think we would have done well in view of the recent Universal Primary Care Mental Health and Substance Abuse Bill that failed in this last session. We supported that bill very strongly. We would have done much better to do that first and not do all this Medicare ACO stuff because we know that that would have saved a lot of money. To put more money into primary care, to put more money into mental health, to get those systems to work in a way that allows people to practice its equations and not be spending all their time on computers and basically throwing in the towel because they really need more lives. The two to one ratio of hours on the computer versus hours on the patients, for a lot of people it's a very bad time. So I won't go into all the things but we could have saved a lot of money as a state if we did do the Universal Primary Care. That is not the joint fault, I realized that. I'm going to strategize with my colleagues and see if there are some things we could work with with the board to make some of those things happen indirectly or other ways. And we appreciate the fact that there'll be another one. Thank you. Thank you. Is there anybody else? Yes. Thank you. My name is Stephanie Caldita and I'm the director of our Recruitment Center of High State Primary Care which focuses on recruiting for primary care providers including full health professionals just touching into the field of behavioral health and substance use more recently for the pandemic and so on. And I work with many of your partners for women under rehabs and I just wanted to thank you all for the conversation today for all of the great ideas that you've been raising. There's a lot here that are opportunities that exist right now that we can partner on and take advantage of to attract to women in Vermont and help them become better in our community than we can say here. So I just really want to thank you all for that conversation. I think as we are focused on reaching outside of the state to really think that we either have lived or have attention to Vermont, back to Vermont or those that have attention in our region to consider Vermont as a place for them to live and practice does these kind of conversations where I name a big difference in how we're able to attract them and entertain them. So I thank you all for your comments and I really appreciate the board taking us to do a one-time talk this conversation. Thank you Stephanie. Anyone else? Yes, Walter. It's Walter Carpenter and I'm probably one of the few waiters here. I've been a health care activist but I've been on health care for all of the years in health care I've been. I'd like to start off, I think Dustin made a great comment about the university and colleges and asked us why it is that students graduate with several hundred thousand dollars in debt or if they work in the current grant or journey or any one of these places. And yes, that's how they graduated out of college debt. That's one thing, I agree with Susan on the university climate care problem which is the ACO. And another issue that was not topic by any member is that when you look at health care or health insurance or if you pay a thousand inches to the student, the wage earner to be in blood to death by the people at the top is just making an adaptive salary. And I'm going to use the contracts of the TBO at PGM makes over two million a year in town and promises. This is something we have to look at. The last thing is that I've listened to all of the panelists here talking about all of these problems and the problem boiled down to essentially one. We don't have to put it to the will. We're always, we've got the fight going on the state opposite to what I mentioned earlier. The problem is we don't, we look at taxes as a bad thing, it's like evil. We don't understand their public distance in ourselves. So if we're going to do something, colleges, universities, and technical and all this, we have to look at our taxes. And we worry about for the two millionaires that pay less in taxes, the new classes pay more. So rather than looking at what we can do with them, that's just a few short things, you know. Colleges, faculty, and colleagues today please speak to the graduates of that. Thank you, Walter Ken. I'm Ken Leritov, I was director of the Mental Health Association for 30 years. I have to say, I think as you said before, I think people really did a great job providing perspectives. I have to think Julie Tess is the best. Does that work with her? Relationships. Relationships are important in the mind. The issue that I just wanted to raise is that there are a lot of important health people up here. But there are even more health people sitting over here. And the limit of care work does have enormous power in regulating health care. And it just, again, is something to consider if anything can the remat care board do in taking this conversation and making either sense of it or be prioritized on one or two issues. And should it, I think it should. Just for example, at one point, a number of years ago, the remat care board actually, and this is my recall, it's not exact, but basically voted not to include Dell as a key service. Perhaps the board wants to review that kind of inclination. It was, I think, for the most part, all different members. But it was a very poignant and hard discussion. It wasn't taken lightly, but there was actually this article about whether or not to include Dell as a key part of the health care plan in Vermont. But a number of issues have been raised today and they're not new. And it just occurs that perhaps the board would consider taking after the discussion one topic. Let's just say it's loan assistance and what that might do and what areas of health care that might be directed at. It might be helpful both for the providers and folks in the education field and to the legislature to note remat care board has one or two priorities that's gonna take a look at based on the workforce issue, which clearly is a critical issue. Thank you, Ken. I think you really have summed up the fact that when we're dealing with our triple aim of access, quality, and cost containment, workforce plays into all three of those. And without a quality workforce, we're never gonna be successful here. So I think, at least speaking for myself, I believe that this is one of the most important issues that we have. So with that, I want to thank this panel. There's one more. Oh, I'm sorry. She's not my daughter, she's not my yes daughter. She's graduated from a three-year master's program at New York Empology University. She started at one of the times that she had been supposed to program since she was a little kid, so she made me support her. Since she left, she's started her own private practice and she's married, she's doing very well. She has almost $200,000 in debt. She's long debt. She still wants to get a doctor. She's living at my house happily. I want to have her there. However! People don't have big days. I have a partner up soon, but she's living. I'm not charging her rent, but she can afford it. There's an impact on me that I'm not getting any income, but I couldn't get it. So it doesn't just, because of college, from that, it's ridiculous that it's just, she's a relauncher who can back you up a lot, and it's not that many benefit from doing that. I really feel like those children do come back with some kind of education, recognition, and compensation. It's an extremely good point. She's starting to honor our own nationality. And Dustin, I thought I read that the $10,000 for someone to come here, it was just for someone that had to prove that they could remotely work. So it's a growing sector in the workforce that gets to work from home every day. I want to be one of these people, so I'm not. Basically, what it is, that's 94, I don't know what the answer is. Basically, it's a shot at saying, hey, there's a variety of people who might work in Fort Wayne, Colorado, and live in Fort Wayne, Colorado, and work in Dallas. And I literally never, other than a couple of times a year, have to go to their work site. This is a tool to say, give you a little money to come here and live here. If you don't have to go to work every day, you can do more than multiple here. It has, I think it has its pluses. I think it's Sarah and I could have used that piece of money for something that we wanted to do, but that's just a feature of the money. We don't need assistance in something that we don't have. Moving assistance, we'll pay it. We'll pay it from the service to the laundry department. We don't have a lot of it. And this is the one that's stuck. How many people are actually eligible for that? What is the cap on the? 125,000 I think. Yeah, there's only a certain amount of that appropriation. It begins 2019, so it's 125,000 in the first year. So no one can get more than 5,000 in a given year going to get 10,000. So that's what 250 people could be eligible for in the first year. I would just note that when I first met with my wife- So Sarah, I just want to correct your math. What did I say? You said 250 people? Yeah, 5,000 in there. It would, so sure it is, but... You get 10,000 in there. I believe that 5,000 a year in an appropriation of that, it would only be 25 people. 20,000. Can you do the simple division part? It's 25,000. I'm not getting involved in this. So I believe it's 25 people. Not five state. We were talking about the talented partners, other traveling spouses, and in some cases, you have folks who are researchers and they can do their work from Vermont, but their spouse may have a job in Randolph. And so this would be one of those tools that could support an arrangement like that. So 125,000, I think the first year, it's a little bit more the second year. And then we'll see. And one of the things that we keep hearing about is affordability of colleges. And I know that a few years back, the governor in Florida laid down NEDIC to whoever was running their community college system to come up with a plan for a four-year degree that only cost $10,000. I didn't follow that closely enough to see if they made any progress on that, but. It was Rick Berry when he was governor of Texas. It was, and I think they did it. And state of Tennessee right now, you can get an associate's degree from the college district. It's part of their system. I think there's a lot of ways that we have to compete for people in the future. And it's not just in healthcare, in docs. We have to literally compete for people. Because if we attract 225 people, that might be the difference between our population growing or not growing next year. That's a big deal. Our corporate is really bad right now. So I think we're gonna start seeing more of these creative solutions to getting people to state or come to Vermont as an alternative to continuing to raise taxes and fees and look for more from lefts. I would just caution the conversations around college to I'm in the Public Service Loan Forgiveness Program, which is, so I have $240,000 in debt. But because of federal programs, I can make payments based on my income. And after 10 years, if I make all the right payments, my debt's forgiven because I'm working for the government. That's also eligible for healthcare providers. It doesn't work for everybody, it depends on your debt. But I just caution us when we have a conversation about college and debt to remember that there are a lot of other programs that may be able to support the current issue. It may be just a matter of educating our young people about what they are, what they can take advantage of and it could be some counseling that we need to support. We might also be a really good way, I don't wanna say dissuade because it's not at all what I mean, but to have folks graduating in high school take a look at every option on the table that they have before they commit to $100,000 worth of debt. My brother didn't go to college, has his master electrician's license and might as well be a license to print money. He goes to his life very much. He doesn't have a lot of the state college system, anything. And I still have student debt and that sucks. So there are a lot of options I think for a lot of people in one direction. I hope that we can start to have a conversation about what's the right fit for everybody so that you don't have somebody who's got debt and no grief because that's what we're for. One thing that just occurred to me, my son is graduating high school, actually Saturday. And he did a survey last year of his junior then junior class about whether they plan to stay in Vermont after graduation. And it was shockingly low, the percentage of students that planned as 11th graders to stay in the state even after graduation or return to the state or come and live here as adults. And some of the reasons that we heard that he shared with me is they don't think there's jobs here. So I think that there's a perception problem of the availability of jobs and I think kids are always happy to leave the house and get as far away from their parents as possible when they're 17 years old. But anyway, I think that there's something that we could be doing through the public education system to talk about the job opportunities in the state and to try and change the perceptions about the wonderful aspects of living here as an adult and raising a family here. Okay, with that, we're gonna wrap it up. Again, I just wanna thank this panel. I think it's really been an enlightening conversation. We could keep going probably till the wee hours of the morning, but I do appreciate that many of you have driven long distances to be here and we wanna thank you very much for sharing your time and your expertise and knowledge with us. So the board could give the panel. So with that, is there any 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? So it's been moved in second.