 It is 8.30 and everybody is here. We've done our sound checks, so I'm gonna kick us off. So good morning to everybody who's listening. My name is Jessica Holmes and I'm currently serving as the interim chair of the Green Mountain Care Board. Today's day five of our hospital budget review process. So we're gonna be hearing from North Country and Gifford today. Just as a reminder to arrive at decisions for every hospital, we look to our statute, we look to our hospital budget rule for guiding principles. We have to balance several competing factors. On the one hand, we need to work to slow the growth and healthcare expenditures. On the other hand, we need to ensure that our hospitals have the resources that they need to recruit and retain healthcare workers and to provide the care that we expect in our community's high quality care. So as we attempt to balance that cost containment, access quality and health system sustainability, we have to be mindful of this year's significant headwinds. We have historically high inflation rates, we have workforce shortages, we have provider burnout and we're still facing the impacts of COVID-19 at all of our institutions. We've been hearing a lot about that through all the budget hearings that we've had so far. So both nationally and in Vermont, we know that hospitals are facing unprecedented financial challenges as our businesses, families and individuals. So over the next few weeks, the board is gonna be working to approve fiscal year 23 hospital budgets for the 14 community hospitals that we regulate. But I just wanna remind everybody who is online today that the board is working very closely with the agency of human services to begin the work that's outlined in Act 167, which really aims to move us closer to a sustainable hospital system that ensures that remoders have access to high quality, affordable care. That work is gonna involve extensive data analysis and community hospital engagement. But the hope is that the end result is a more sustainable path forward. So as we turn back to the hearing today, I just wanna extend a thank you to both North Country team and the Gifford team for the time and effort that they've taken to submit the documents for our review. We know it takes a lot of time and we appreciate the effort there to help us understand your budgets. There's a few housekeeping notes about the hearings today. This presentation is a public meeting. It's being recorded and transcribed. So there will be a publicly available record. If at any time a hospital's leadership team believes there's some confidential information that the Green Mountain Care Board should consider, either as part of your presentation or in response to board or staff questions, just let us know. Because if needed, we can go into an executive session and review confidential information from hospitals. Executive sessions will be limited in scope as defined by the open meeting law and limited to information such as contracts and information that will be considered confidential under the Public Records Act. So if an issue of possible confidentiality arises, I will call on our legal counsel to determine the scope of what could be discussed in that executive session. And then if it's deemed appropriate and at the appropriate time, I'll just ask a board member for a motion to go into executive session. So with all of that said, I think at this point we can proceed with North Country's presentation. I'm gonna hold all board and staff questions until the end to allow you to kind of get through the presentation. And with that, I'm just gonna ask our legal counsel, Russ McCracken to swear in North Country's witnesses. So anybody who's planning to present or even answer questions today, if you could participate in the swearing in process. Great, thanks very much, Chair Holmes. This is Russ McCracken, attorney for the board. For the North Country team, who is planning to be speaking today? Yes, it's myself, Brian Null, Tracy Paul, Megan Sargent, Paul Giordano, and Dr. Steven Perlin. Great, thank you. If you would all raise your right hands. Do you solemnly swear that the evidence you shall give relative to the cause, no under consideration shall be the whole truth and nothing but the truth. So help you God. I do. Great, thanks very much. You're sworn in and I will turn it back to Chair Holmes. Great, thank you so much, Russ. And just my other request is that everybody make sure that their microphones are on mute other than those who are speaking so we can avoid any kind of feedback or background noise. But with that North Country team, Brian, I will happily turn it over to you. Yes, thank you, Jessica. I assume you guys will be able to put the PowerPoint up on screen. I think the hope is that you all can share it, but if not, I think Kara, who's one of our staff, could also staff members navigate that. But if you have- Yes, we presume that that would be easier if you guys did that. Okay. Is that okay? Can you put that? Yeah, Kara, can you pull their presentation up? She is right on it. All right, thank you. And we'll just tell you next slide. Let me know when you need me to advance. Yeah, we'll just, we'll say next slide. So, and you can go to the next slide. So thank you all for meeting with us today. Again, this is as we go through the budget process. Our presenters today are myself as a CEO. I've been here for four years. And Tracy Paul, who's our chief financial officer and does manage other departments in the hospital. She has been with the organization for 26 years in the CFO, the VP role for three years. Megan Sargent is our VP of patient care services. And she's been with the organization for 16 years and in her current position for two years. Paul Giordano, VP of human resources has been with the organization for one and a half years. And then Dr. Steven Perlin is our radiologist and has been serving in that capacity for nearly 15, if not more than 15 years. And we've created this, the chief medical officer role for the first time within this last year. So he's been serving in that role for under a year. Next slide. So just a review of our mission and it hasn't changed. It's to provide exceptional care that makes a difference in the lives of our patients in our community. And we have been here in the Newport area for over a hundred years and continue to evolve and adapt with technology, the service lines that we offer and intend to be here for a hundred more years. And so we're happy to share our story of what's going on this year and what we project for the coming years. A reminder of our next slide, a reminder of our next, of our service area is what's unique in Newport is we're really, we serve like a half circle because we're right at the Canadian border. So one of the few places in the country that has this dynamic, our service area is somewhere in the vicinity of 30 to 35,000 residents. And it's 45 minutes to the closest Kirkloxas hospital, two hours to the tertiary care facilities being Burlington and down in Dartmouth and New Hampshire. We do attract staff from Canada, but we have very little healthcare provided to Canadians. It's really just in the emergency care setting that we seek Canadian residents, mostly because back in the 70s, Canada does not extend, stopped extending their healthcare coverage going into the state. So that's a little different flavor than some other areas of our state. And then the next slide, and I'll be handing this over to Tracy in a moment. When we submitted this overview of our projection, it was July 1st and our net operating income loss at that point was $1.1 million projected for the remainder of the year. We started our integration into our new EMR service, our new EMR system on mid-May. And so we've been 90 days in and it's been very difficult and challenging navigating that. You'll hear about that story a little today and its impact on our short-term situation here. And so we've had really little access to solid data on our performance. And unfortunately, I need to report to you today that after closing out through the month of July, we now project a loss of $5 million. So we've had a terrible last three to four months on our operations and our operating margin is not projected to be a minus 1.2 but instead a 5.25% loss operating margin. And reflecting back on our budget asked for last year for the 2022 budget, we had asked for a operating margin of 2% and our rates were adjusted to where our operating margin be 1%. And so you're gonna hear through today the stories of it doesn't take much on the critical access hospital and perhaps other hospitals in our state to swing that operations to the negative. So although we've had a couple of years of good performance and even navigating through the pandemic, we have a lot of more pressure points on our system that weren't anticipated for the current budget cycle. And we've tried to anticipate that in the future budget cycle, but even since submitting the budgets from projections in earlier in the year, everything is changing so fast that we continue to be challenged with projecting out towards what the future will look like. And it seems to be in some circumstances, day to day, week to week assessments of what's going on in our current state and the environments that impact our operations. So with that, I'm gonna pass it off to Tracy to share some. So good morning everyone. As Brian mentioned, later in this presentation, we're gonna cover a lot of the changes between our original projection and our new projection and for a budget next year. So next slide, please. So for the 2023 year, we are asking for a overall fee increase of 12.4, excuse me, 12.45%. This is to cover the large increases and expenses that we have occurred through FY22 and that are gonna continue to occur, we're projecting into FY23 and to allow for a 2% operating margin. The net revenue NPR is an increase of 12.5%. This is basically made up of two different components. One is the rate increase and the reimbursement paramix change, which accounts to about 34% of that 12.5% increase. And the other majority of it is utilization increases from budget 22 of 7.4 million dollars. The major increases are in the ER and also in some of our ancillaries, lab, radiology, specifically in the area of CAT scan. Next slide, please. Continuing on the revenue side of the house, basically for FY23 proposed budget, our other operating revenue is decreasing $500 and $3,000. That decrease is directly attributed to decrease in our 340B revenue. We've seen a decrease in 340B for the last three years. We're actually engaging an outside consultant to evaluate us and evaluate us becoming part of the 340ESP program, which would help us to hopefully recapture some of that revenue that we're losing. The non-operating revenue shows a decrease of $849,000. Basically, we showed gains in last year's budget and we're showing a small loss for this year. As everyone knows, this is very, very difficult to project. So these numbers could come out basically anywhere, but this is what we have in our budget. Next slide, please. So let's move on to talking about the expenses. This graph shows what North Country Hospital's expenses growth have been from 20 into budget 2023. Basically, it's a 10% increase from budget 22 or $9 million. Next slide, please. So the major expense drivers out of that $9.6 of that is actually inflationary increases and 3 million of that 3.6 million is compensation and benefits. Locum and travelers are up $2.2 million. Supply costs are up $1.5 million. Costs we've occurred during this year and also projecting further increase in costs for next year and also an increase in our provider tax. Next slide, please. Now I'm gonna turn this over to Paul, our VP of Human Resource, who will discuss the slide. Good morning, everybody. North Country Hospital has seen an increase month over month in certain areas of metrics as far as vacancy and turnover. As far as vacancy, we had a high of over 11% for vacancy for all positions within the hospital. Our end bedside nursing vacancy was as high as 27% earlier in this year. We are currently at 16 to 17%. We anticipate that will normalize a little bit over the next several months as we have several new grad RNs and orientation that will come off in probably about six months. Everything maintains the same and we do not have any more high turnover. We should be probably closer to 12% in the nursing vacancy at that point. As a critical access hospital, we have to understand that we have a smaller pool of employees to draw upon. So in some departments, if one person leaves, it could be a 25% turnover or vacancy rate. We do not have the resources to move back and forth between departments or shifts or have per diems or part-time work additional hours because they have been working that. So we have experienced some work of burnout in which we've had to address through that. Our turnover rate for this year for the first six months is 13.8% just in comparison to last year for the overall hospital, it was just under 10%. So as you can see this year has been more of a challenge than last year was. Our turnover for nursing in bedside, our rents is a little bit over 22% whereas last year it was just under 9% at this time last year. So that's, you can see the struggle that we've had in different areas and it's been across the hospital not just in specialty areas for nursing and reviewing it, we see that med surge has for the first time in many years had to have some low incomes put in in that area. So I will now, I will speak later on some more slides about recruitment or retention. I'll turn it over to Megan Sargent right now. Great, thank you, Paul and good morning everyone. So some recruitment and retention efforts that we're doing specifically on the nursing front, we have a generous tuition reimbursement, we offer loan repayment, we offer sign-on bonus for new nurses to our facility. We offer referral bonus and longevity bonus as well. We here at North Country have a strong share governance model and unit practice council that feeds into this decision-making. We also have a nine month new grad residency program so that we're helping new grads really build a healthy foundation in nursing and supporting them throughout almost that first year where we know that retention is important. We've also invested in bedside unit educators for nurses that are new to specialty and for the new grads coming out of residency again to support them in their efforts in developing their nursing skills. Lastly, we do as a nursing leadership team offer a Rockstar award to recognize at the bedside level when people are doing a good job and that's peer to peer and they hand that out to each other and they look forward to that every month. Next slide. Again, so going back to recruitment and retention, one thing that we noticed was our compensation. We had to make some changes there to be competitive not hospitals no longer just compete with themselves. We compete now with the nursing homes. We compete with the local other industries such as Walmart and grocery stores and even the little stores around town. So we've made the commitment to increase the minimum wage to $15. We have a longevity bonus that we now give to employees every five years they've received that. We also did a comprehensive market rate adjustment across the organization and then the hospital traditionally has given regular rate increases. As Megan said, we do a lot with the employees. We now we do referral bonuses. So if employees refer an applicant and they are hired they receive a referral award. There's a sorted recruitment and retention initiative Megan mentioned sign on bonuses. More and more we're having to find employees outside of our service area so that incurs an additional cost to us. We are paying for relocation expenses. We have started a program in the last several months where we do a search for employees all throughout New England down into New York, Pennsylvania, New Jersey, we've even able enable get some employees from some other states in the Midwest to recruit no longer can we just recruit in our same area. Those are some of the things as a whole host of other activities we do with employees to recruit in to retain them. Next slide. So for the proposed budget we want to again continue to longevity bonus with some additional market adjustments as necessary rate increases, the referral incentives and continue all the programs that we're currently using for that we put into place in the last year to two years to attract and retain our employees to make us the employer of choice within the Northeast of the kingdom. Next slide. Turn it over to Tracy Paul. Yeah, so this graph you'll see represents our compensation benefits and local expenses as percent of our total expenses from FY 20 to the 22 budget. You can see that it's pretty flat. This should continue to tell the story we've been speaking of that we went up to almost 66% and we're seeing this level off for FY 23. Next slide, please. Continuing to talk about local expense. This is a graph that shows the total local expenses part of our overall salary expense. And again, same story, relatively level from 20 to budget 22. You see a sharp increase to 16% per projected and then a decrease to about 9% in budget 23. Just to put some dollars to this in budget 22 we had $2.4 million budgeted for travel expenses we're projecting $7.6 million for traveler expenses and we budgeted in budget 23, we're budgeting $4.6 million worth of travel expenses. And you can see the number of locums at the high point on the bottom graph is 22.75 but as Brian stated earlier, that projection is already too low. We've had to add two additional lab techs as well as four nurses and our ambulatory clinics which is something that we haven't seen before either. Our projected back down to 14.75, how we're gonna get there is really our strongest influx of nurses comes from our new grads. We have a strong partnership with VTC. We're a clinical site and we often see our new grads coming from there. Additionally, looking to continue recruiting for new hires. Next slide please. So this is a graphical representation of our operating margin from FY 2016 to budget 2023. Again, you can see that FY 22, we're seeing a large decline to the $5 million loss that Brian was speaking of earlier. But basically there's three reasons for that loss. Revenue decreases due to specialty provider loss specifically in the area of our general surgery. Revenue decreased due to the EMR conversion and traveler costs. Here to date July, we were at $4.6 million over budget which is something we've never seen before. The supply and pharmaceutical costs increase and among other things. Next slide please. So this slide shows basically in numbers what we've been talking about. As we mentioned earlier, we need to update the 22 projected that actually should say a loss of $5 million or 5.25% for budget 22. We had asked for 2%, we got 1% for $981,000 for an operating margin. For FY 23, we are requesting a 2% operating margin of 2% operating margin of $2.1 million. Next slide please. So I'll cover this slide. I want to point out that I think there was an updated slide deck that we might have sent that has some of this information. So Tracy, do we, do you know who you sent that to? Just so Kasey can pull it up while we're talking. It was uploaded into Adaptive. Oh, okay. All right. I don't know if you can just email it just in case you guys want to see that updated deck but we will talk to some of those variations from this report. So just looking at the marketplace, we're just looking outside Newport area and saying, okay, what's going on with the hospital environment? So this was just a reference to a Coffman Hall study showing operating margins were pretty stable for the first part of the year through December. And that's what it felt like for us too. We were off track with budget, we were still doing okay, but then the bottom fell out with us that needed to get more locums. We had some turnover and specialty physician practices that's impacted our margin as well. And so what we're, and in addition to that, we talked about the Surner transition which has been a continuing strain on the organization. So what we're doing right now is we're getting extra eyes on our operations. So we've contacted and with this formerly known as BKD, our audit firm, and we've asked them to come in with extra eyes to help us to continue to look at validating what we're navigating and also enhance anything that we may not have eyes on that we need to focus our time and attention on. So they'll be looking at not only our revenue cycle side and the Surner transition, revenue capture, collections. They'll be also looking at margin improvements across supplies, group purchasing opportunities, our employee benefits programs, and other areas that may have some opportunity. I feel personally, I feel like we're at the point where we're starting to scrape the bottom of the barrel because we always look for these things and improvements and we always will. But I don't know that there's gonna be, from what I'm looking at today, there's gonna be a huge swing in improvements except for replacement of positions. And that will start to bring things back in mind but the cost of locums in many cases exceeds the normal cost of operations but we need to continue to provide medical care for our community. So it's a conundrum because you need to be here in present 24-7. We don't have the privilege of like restaurants and other businesses that say, okay, we're not gonna be open on Saturdays because staff don't wanna work or we're picking which days we're gonna be open. We don't have that luxury. So we remain committed to staying open and providing exceptional patient care but this is the current cost of doing business. In addition, they will also, and they'll be with us with our board as well, they'll also be giving us a current state of marketplace overview of what they're seeing across the country to give us perspective of what are other organizations doing and how do we pair up with those endeavors. Next slide, please. I'm just gonna switch to your current slide deck. Okay, perfect, thank you. Great, thank you. Sorry for the trouble. Okay, thank you. Yes, thank you very much for doing that. I appreciate that. So obviously this is a balance sheet. The biggest thing to know here is our drop in cash, which I'm gonna discuss in a second. So if you could advance to the next slide, that would be great. So here's our cash flow without the Medicare accelerated payments from 2019 until now, you will obviously see the slight, the major decline in FY 22 projected. Basically it's three-fold on obviously like the rest of the hospitals, we are continuing to pay back Medicare dollars. The also the losses we're experiencing is affecting our cash flow. And one of the major reasons that significantly impacted it is the transition to Surner. As of April, we had a cash balance of $8 million. And now you can see we're down to less than a million projected for the year end. And we also have had to draw $2 million on our line of credit. We did not anticipate such a large decline in cash. In fact, prior to conversion, we put into place a billing company to help with the Surner billing to minimize this. What happened at Goal Live after May was that we realized that there was a lot of setup issues that significantly delayed the start of the billing. And the outside company can't bill until things are set up in internally. The positive news is that we anticipate gaining back this cash. We are working through the billing revenue and volume issues associated with Surner. And we've seen a lot of action on that front. So we're anticipating for this cash to come back. Next slide, please. So to discuss the change in the charge request and how that affects the payers in regards to Medicare, we only received net revenue on the outpatient piece of the outpatient portion of Medicare. Medicaid charge increase does not net any additional revenue. Commercial inpatient and outpatient does net more patient revenue. For North country hospital, 1% of charge equates to about $692,000 in net revenue. About 68% of that or $470,000 is from the commercial payers. And the other 32% is from outpatient Medicare. In regards to bad debt and free care, consistently for a very long time, we track about 2%. And it's usually split almost evenly between 1% of bad debt and 1% in free care of our gross revenue. Next slide, please. Good morning. I'm going to discuss the joint venture between North country hospital and Northern counties health care called Northern Express Care Newport, which is a walk-in clinic, which opened on July 11th and has been quite successful. One of the intents of this venture was to try to shift low acuity visits from the emergency department to the walk-in clinic. One of the advantages of Express Care is its location on Main Street in Newport, which is an aid to our socio-economically disadvantaged patients, because this is within walking distance for many of them and avoids the necessity of having to drive to the hospital to the ER or undertake transportation, say through RCT to get to our ER. So we believe that this is an effort to increase health equity for our patients. I'll now turn it over to Brian to discuss the Wellness Center. Yeah, thank you, Dr. Perlin. And this is just a short list of internal and external things that we're doing to really advance the communities on the community's needs and improving community health. So we're happy to partner with Northern Counties as Dr. Perlin shared that is an operating expense. It is not a profitable venture, but it is something that's right for the community. And it's only been open for probably five weeks now. We have seen, it's too soon to tell, but we've seen some variances in our ED volume. So if we were normally in the 40s, mid 40s, we seem to be hitting in the 30s as far as patients per day. So we also are impacted by the revenue on the ED and on top of the expenses to help open up and operate express care. The Wellness Center is something that we have had for 25 plus years where it offers programs and is really its purpose is to attract those that through our programs and activities to focus on their health and wellbeing, whether it be physical or mental. And so we've been operating that. It does cost us over $100,000 to operate that. We would like to invest more in this, but this is something we can't do because we don't have, we need a stronger operating margin, at 2% or greater to be able to offer this and so we would like to actually infuse more capital and energy into this endeavor and build it and actually see our dream would be that it would be money spent on this and invest in this would serve a greater proportion of our population. And we have some ideas for that, but this, because of our operations, we have to put on pause. We can't get to where we want. And I think this is something that is important because it's something we invest will pay dividends five, 10 years down the road. It's not a short-term thing. It's influencing people short-term and long-term. And then for the next two, I'll just ask Megan to take over. Sure, thanks, Brian. So we also on our online learning platform, we have a mandatory training for cultural diversity at North Country Hospital. We know that showing respect for our patients' cultural, spiritual, our gender identity is part of providing the overall care for the person. And we wanna do that well. Also, we have an initiative, Hospitals Against Violence, which again is supporting our staff and patients to feel safe on our campus. And we know that when our staff feel safe, they're providing better care for our patients. We initially rolled this out in our emergency room with signage and a redefined workflow for our staff who may experience violence. We partnered with our community agencies, with the Newport Police Department, with Human Services to really define that workflow. And now we've expanded it across the campus into our ambulatory settings. Next slide, please. We were asked to discuss wait times as part of our presentation. One point I wanna make is as we've said before, mid-May we did a center conversion. During the first three to four weeks of that center conversion, we purposely decreased our provider schedules by up to 50% in order to help make that conversion more successful. And of course, this has affected our patient access during that time and going forward. And we did engage with 3D Health. We use them every three years to look at our physician needs assessment and help us design and develop our recruitment and succession plan. They forecast that based on our population current demographics and forecasted demographics to help us establish what our community can support across all specialties. And this year within that, we asked them to also do a survey on appointment access by specialty. And we just met with them two days ago. And so I'm just gonna share with you those preliminary results. And I have to say that this is tempered by this process happening during the CERNR go live. So as Tracy said, that impacted our schedules. So these numbers are above average for national. But I would hope that we would be able to throw our recruitment and retention and then normalizing CERNR if these would improve. But this is current state. So for family medicine, we are an average of 50 days wait time for establishing a new relationship with a physician. And that's 27 days over the national average of 23. Internal medicine were 53 days over the national average of 25. And for pediatrics were 40 days over the national average of 19. So we acknowledge these wait times. It doesn't surprise us because we believe we're short about three physicians right now just in primary care. And then in specialty care, we're recruiting for general surgery because of a turnover there. So we're short on general surgery coverage. And so we'll continue to keep our eyes on this but I do acknowledge that another impact of this is during the summer months for the first time people are taking more time off across the organization. So that PTO particularly with providers that paid time off is impacting our schedules as well. And we've had some that have even traveled out of country to visit loved ones that they haven't seen and quite some time. So that's again just news that we were able to acquire just two days ago. Next slide, please. Yes, and to follow up on what Brian was just discussing we have several transitions, recruitment and retention efforts across the physician spectrum in general surgery as Brian noted we are operating under deficit of general surgeons. We have been recruiting vigorously to replace general surgeons that we have lost in the process of doing that. We have engaged a employed per diem general surgeon who's contributing about 10 days to two weeks of time for us and we're in the process right now of negotiating with another general surgeon who would take the same role as an employed per diem also 10 days to two weeks of time. So if we can secure that general surgeon that will be a significant improvement due to these transitions in this deficit we're certainly experiencing a significant revenue deficit from that revenue stream. Cardiology, our prior cardiologist has moved on to another position just within the past few days we have secured a contract with a new cardiologist who will be starting with us in mid-January in the interim. We are engaging two locom tenants who will each work one week a month so we will have two weeks per month coverage which we believe will enable us to maintain continuity of care within our cardiology service and allow our patients to continue to be seen at North Country Hospital rather than having to go to a tertiary center. Pulmonology, we suffered a loss of our pulmonologist last year since that time we had engaged services from Dartmouth to fill in that proved to be an untenable model and at this point we are no longer offering pulmonology services at North Country Hospital. So again, there's a loss of revenue from what is essentially the closure of that service. We are currently undergoing a stabilization in our hospitalist program. We have secured three hospitalists, three physicians as members of our hospitalist team with a one in three rotation to provide work-life balance in that area. We're also attempting to recruit three nurse practitioners as nocturnists in the hospitalist program. Again, three people to provide that work-life balance. The recruitment of those three nurse practitioners will increase the costs of this program but we believe it's necessary to establish that work-life balance for both the physicians and the hospitalists. Other hospitals do have an all physician model so our costs are somewhat lower by recruiting nurse practitioners. However, this is an increase in expense based on what we have been doing in the past. Primary care, one of the major transitions or stressors that primary care is undergoing now as has been alluded to previously in this presentation is the implementation of the CERNR EMR which has proven to be difficult from a primary care standpoint, excuse me, and has decreased on a continuing basis the number of patients that our providers are able to see on a daily basis. So that is one stressor that they are undergoing over the past number of years. We've suffered a number of retirements of physicians, illnesses. Our model has transferred to somewhat more APPs than physicians in our primary care system. We are recruiting vigorously to equalize that. We do have a primary care provider coming on with us in mid-October who's moving here from Cleveland. So we're looking forward to her arrival and as I say, we are continuing to vigorously recruit for primary care physicians. We've had some success recently in orthopedics. We have recruited a second full-time orthopod who will be starting with us in mid-November and that will certainly increase our orthopedic access here at North Country. And we believe that that will be a very vigorous program going forward. Next slide, please. Thank you, Dr. Perlin. And so overall, no surprise here, staffing shortages, I'm sure you're hearing this from the other hospitals, but we're having staffing shortages across all positions, physician, clinical and non-clinical. We're dealing with wage wars across multi-industry, competing with people that are leaving the industry and then also with our hospital settings. And really a lot of changes going on because of work-life balance challenges and we're doing our best to balance that. We had, for example, a provider who had a pending illness of a loved one and needed to be with that loved one. And so we were able to, for a period of 90 days, have that provider work offsite out of the state providing care and that particular specialty at work through telemedicine. So we created that work-life balance so that person can continue working, serving our patients here and also serving the needs of their loved one. But we have a sad story with, we've lost in the last year, we lost an ER and a hospitalist and their early careerist and they have completely exited. In the industry, at least for the time being, we lost an APP just to retirement and we have several others that are approaching retirement the next couple of years, whether this one particularly wanted to transition out before a change of the EMR system. We lost a geriatrician, internal medicine doctor who completely burned out of providing care in the long-term care setting. And I know you guys are hearing about the challenges with long-term care. That was a solo provider in our community. And so immediately jeopardized and has jeopardized the coverage there, which is a challenge not only for our organization, but I know it's, I think the last sector is about 14 different communities having these nursing homes having that type of challenge. We have staff taking medical leave and taking care of themselves. So just as we've heard about people delaying medical care and now accessing medical care, that's the same for our workforce. Our workforce, we've had some that have had to leave for extended periods of time, which has also led to more locums use because they needed to take care of them themselves or family members. And then even when they're returning for various reasons, if they return, they're returning not in full capacity. So they're dropping from a full time to a part time. And so we're not getting that full coverage back. And we continue to look at the challenges with remote work as it relates to a competitive. We've lost leaders and frontline staff, clinicians to other industries where they're able to work completely remote. One more recently has left or is in the process of leaving and will be able to work six months down in a warmer state and six months up here when it's nice in the warmer weather of the opposite part of the season. So those are the types of things and that's not even a healthcare, it's healthcare, but it's not a hospital centered. So those are the things that we're continuing to navigate like many others of creating a work-life balance for our staff, but also being able to continue to meet the demand of 24 seven care. Next slide, please. And our risk and opportunities with our continuing that, these are really our goals for our EMR system. I'm not gonna read through those that I had to highlight one medical record, enhanced patient portal, not on this list is the transition from Athena was necessary. We did not, this was not something we wanted to do. It was something that we needed to do because our Athena product stopped supporting hospitals and we're just decided they changed their model after we were just to just support the ambulatory environment. So our goal as an organization for a number of years has been to have advanced one medical record. And so that was a great deal of reasoning for selecting CERNR. So it added cost and duress to the organization to go through yet another conversion of Athena. We were only on that product for about four years. Next slide, please. So, you know, with the stable operations equals stable environment of care and long-term reinvestment into our infrastructure. So, you know, we don't believe 2% operating margin is a big ask. It may sound like a big ask, but we need a stable of operating margins. We can continue invest in the infrastructure. We haven't poured over a number of years. We haven't actually been able to put money into our investment, our long-term investments because we've had to redeploy it to our immediate capital and operating needs. So we'd like to get back to the place where we can do that. And it's our long-term investment portfolio that will be financing a project that I'm about to tell you about. So our hospital campus here, although we're over a hundred years old and our first main hospital actually still stands. We built things to last, but our current campus and current location, we arrived here in 1973 and has grown over the years. In 2019, we started a facility masterful we conduct every seven years or so to see what are the areas of us high need. This was paused, obviously, because COVID, although we had line of sight to what direction we believe we were going. And then re-agreed, we re-energized this at the board's direction. And later, 2020, as we're starting to normalize COVID. Next slide, please. So I want to, first of all, thank the Green Mac care board for the approval of our certificate of need that just happened a few weeks ago. And just highlight what, again, for everyone, what this project is and emphasize this is a long-term project. So regardless of our current duress, this is something that we'll pause, we'll think about what's going on in the marketplace and how we continue to support this. So this is not breaking ground tomorrow, but we're just getting to the point where we can be shovel ready when the environment's right. So the project is a new addition of 20,000 square feet and a renovation of 22,000 square feet. It's to consolidate and improve the multi-floor inpatient care departments, which will actually help us with the staffing, reduce some staffing. We're not increasing staffing in this new design. It's really to sustain staffing. It provides a larger lab for, in replacement of our lab, to house the modern day equipment and the space necessary so that those larger machines can operate efficiently. And also expands our emergency department. And this may sound counterproductive to our discussion about express care and trying to reduce the emergency department volumes and unnecessary encounters. But we do, in our emergency department, we need enough exam and treatment rooms to spread those patients. We've had instances where we have people waiting in the waiting room and we prefer them to be triaged and waiting in an exam and treatment room where we can help control and monitor them during their stay. And so this is actually to expand treatment rooms and offer some more modern exam and treatment space within the ED and would be built within the existing ambulance bay. So I wanna, again, just thank you for the board's approval on that. And we will continue to look at this as our long-term strategy and really looking at what the environment is. We are pursuing, we met with the city this past week to come together to apply for a community grant up to a million dollars. It's a competitive grant. And then we're also working on new market tax credit strategies all too in the effort to reduce the overall cost of the project. And then last thing about this project is that we use our long-term investments as leverage to get competitive debt on projects such as these. And we intend to use the long-term portfolio to pay for this project so that it wouldn't be coming out of our operations. All right, and now I'll ask for the next slide and turn it over to Tracy. And that hammering sound does not mean there's nothing going on. Well, I'd like to echo Brian's thanks to the Green Mountain Care Board for approving our project. And also, so for FY23 capital budget, we're requesting $3.6 million in capital spend. 58% of that is for medical equipment, includes such things as a new mammography unit, addition sewer orthopedic tower, 28% of the spend is technology, laptop replacements, storage upgrades, and 14% of this is a facility spend. Next slide, please. In regards to our value-based care participation, we participate in Medicaid, Blue Cross and MVP with OneCare Vermont. You've heard a lot about avoidable ED accounters. This was something that actually the Green Mountain Care Board spoke to us about last year when we had this hearing and also the reports that we received from OneCare on a quarterly basis points this out also that we were high in this area. So as you have heard, again, we have been successful in opening a walk-in clinic and being part of that to help address this. Next slide, please. Great, so here is actually the ribbon-cutting of our walk-in clinic that we're partnering with Northern counties with to reduce those avoidable ED visits. As Dr. Perlin had stated earlier, we know that it's early, it's only been open for a few weeks, but we are seeing some, a little bit of decline in our ED visits. They're seeing, the walk-in clinic is seeing about an average of 18 visits a day. So we'll be anxious to look at the data over the next year to see the impact on that. Next slide, please. So we know that value-based care is about right treatment, right time, and right setting. Currently, this slide outlines some of the challenges that we have providing that, specifically in our emergency room. And this is across the state and the country, supporting mental health patients in our ER is often delaying care for other patients and is not really the right setting for the mental health emergencies. We'd love to be able to screen them medically and see this patient population move on to the appropriate care setting where they can immediately receive the care that they need. Transfer volume and delays, we see this again. And what happens in our ER is we end up boarding patients because we're not able to transfer patients out to our tertiary centers because of their backlog of patients as well. And what that happens in our 11-bed ER is between boarding both types of patients, we now effectively have maybe seven beds to see our other ED populations throughout the day, which causes such a bottleneck and delays in care. On the post-acute patient side, as a critical access hospital, I'm sure you're all aware that we're allowed to use our beds as SNF beds, a nursing home level bed. But once again, if we're not able to move those patients into the appropriate care setting in the community, which would be into a nursing home or rehab, they end up spending longer amounts of time on our acute floor, which then diminishes our ability to take care of acute patients because we are held at a critical access hospital. We have 25 beds and that's what we have to offer our community. And we understand that nursing home and rehab are battling the same problems that we are with staffing. There are actually more licensed beds than we're using currently in our health service area, but the facilities do not have the staff to staff those beds, so they're staying empty. So those are some of the challenges that we're facing currently. Next slide. So this is in regards to the supplemental data monitoring that you wanted us to address. When it comes to the market share data that we were given, there wasn't anything in the data that really stood out as a large change. It did show, though, that we did lose a little bit of our commercial revenue from 19 to 20. As far as the reimbursement analysis goes, there wasn't anything from that information that I could really see any differences to know on that. Megan? Yeah, so and on the demographic report, we know that we have a high percent Medicaid population. We also have a high percent of dual eligible patients, so both Medicare and Medicaid. And what that tells us is we have a high elderly population that lives on an incredibly fixed income. And so we also know that from other surveys that we have high rates of obesity, poverty, and high blood pressure in our health service area. When you put all that together and we're making budget assumptions and planning, we know that based on our population here in this health service area, it's going to take more resources to care for this population. Next slide. All right, so in conclusion, you've seen this slide before. We're asking for 12.45% overall fee increase for budget 23. Next slide, please. And basically what that's made up of is the expense increase of $9.3 million, which is 85% of that charge request. And out of that, 68% of that is going to direct labor and 20% of that is going to supplies. And of course, the other 15% is going towards a 2% operating margin of $2.1 million. So that concludes our presentation. Go ahead, Brian. Yeah, that concludes our presentation. There's a question slide, but I think you can probably take that off the screen. And thank you for your... Yeah, go ahead. I was gonna say before, Kara, before you take it off the screen, could you... Sorry, Brian, I just wanted to... Since I know we didn't have the full slide deck, the updated slide deck, can we just go back to slide six, if that's okay? I think that may have been the slide where it's the profit and loss statement. And if it's been updated, I just was hoping you could go through that slide with the updated numbers, with the projections for 2022 updated, if that's possible. So Kara, that would be slide six if it's been updated. Yeah, Tracy, was that slide 17 that you updated? And I think you said that that first slide was active, so it was hard to update. Yeah, so Jessica, the slide that I have as part of the PowerPoint was the slide as of when we submitted the budget as of July 1st. And I didn't know if it was appropriate to put something different on there than what we had submitted for July 1st as part of our regular submission. And that's why I put that slide into the slide deck. But as I spoke to, obviously, our revenues are less than projected and our expenses are higher than projected, basically, which has made the $5 million, but I'd be glad to get you more details and give you an overall profit loss on the projection after. That'll be helpful. That's what I was gonna ask for in my question. So I'll just save that question. I don't have to ask, but this slide would be helpful to have this slide updated for us with the new column for the 2022 projections so we understand what the revenues now are, what the expenses now are, obviously both getting in total and all that. So thank you, I appreciate that, okay. Well, thank you so much for the presentation, sorry for that little diversion. And I think what I'm gonna do now, we've been doing this and I think it's been really helpful, although it's only been an hour. Maybe we should, I was wondering if we, often we take a 10 minute recess that will allow the board to kind of compile their questions and give everybody a chance to stretch and refuel, but we're a little bit ahead of schedule today. So let me ask other board members, do you want that 10 minute recess now or do you wanna trudge forward? I could use the 10 minute recess. Okay, since you often launch the questions, I'm gonna absolutely give that to you. Okay, so everybody, we will be back here at 9.45, give everybody a chance to stretch their eyes, we'll compile our questions and thank you so much for that presentation. So we'll see you back in 10. Well, I think at this point, I am gonna turn it over for board questions and I am gonna start as promised with board member lunch. Thank you, and thanks for the 10 minutes. It allowed me to get a little more organized. So first of all, I wanna say thank you very much for looking at the ED utilization and moving forward with the Wacken Clinic. That's great to hear. And I look forward to hearing more about that and the impacts on the ED avoidable use in the future. So that's great, that's really terrific. I'm also sorry to hear about the headwinds that you've been facing. It sounds like there's been a lot of challenges in addition to what I would say are the challenges that we're hearing from every hospital around. Travelers, staffing, burnout, workplace violence, on top of all of that, it sounds like you also have had EMR issues and a lot of actually more staffing challenges than many of the other hospitals. So I am very sorry to hear about those headwinds. I wanted to dive a little bit deeper into your utilization assumptions that you outlined on page two of your narrative. So, and it's also, I think outlined in your presentation on pages 25 and 26. So, but just starting with page two of the narrative, it looks like you're anticipating overall from the financial sort of a nearly flat utilization but that you are seeing some increase in the ER offset by some of the avoidable use, increase in patient days that aren't COVID related and mad surge and increased volumes in radiology that seems tied to the ED and lab. So, could you just speak a little bit to why you anticipate that these volumes will be maintained and kind of connect the dots for me with some of the vacancies and provider transitions that you outlined on pages 25 and 26 for example, we often see that decreases in access to primary care does have a direct impact on labs and radiology. So if you could just kind of give us a little more commentary on those moving parts, I'd really appreciate it. So I would be glad to start with that and let my colleagues fill in wherever that I'm missing. There's a lot to those questions obviously. So when we work on the utilization basically, we're working on this in March and April. So we're taking actuals and that's always our base stone, right? We're taking it and then we're looking at what do we concretely know from April to the end of the year to get our projections and then we take that and do that again for next year as far as trying to. So for the ER after COVID, our ER utilization came up really slowly but then finally when it came up, it hit and that's what some of the increased utilization from budget 22 to budget 23 is and of course we've seen tracked always that whenever the ER utilization goes up labs and everything radiology goes up along with it. So that's the, I guess the rationale for that. Right now, we don't see that changing. I did make a small, we did make a small adjustment for the avoidable ED visits based on some conversations with people who have had this or CFO that's had the same thing happening in their community. We're not sure if that's the correct adjustment, obviously because we didn't have any data at that time and we're gonna continue to monitor it but we felt that there should be a decrease in avoidable visits and to go to some of the service line impacts with the physicians that we talked about in regard to general surgery. We've had three general surgeons in the past. The budget reflects, one was done in January, one got done in May and basically our budget reflects too. So we have the one who's still here and then we have the, at that time we were thinking it was gonna be locums to basically make up another full time. Since that point we now have a situation that Dr. Perlin talked about that we will have two docs job sharing, okay? So we basically went from three general surgeons to two which is part of the revenue drop because at that time also any of the potentials for surgeons were more likely gonna be someone graduating next July. And again, nothing on a dotted line, right? But we would know that we, chances are that we wouldn't see any new surgery until next July. Things happen and somebody could fall from the heavens but that hasn't happened. So that's what's happened with the general surgery and of course with that, PACU decreases, anesthesia decreases, there's impacts across the revenues. As far as the cardiology goes in the budget I did not budget cardiology for the first quarter of FY23. Hoping that there would be, or projecting that there would be a cardiologist in January and I did decrease ECHOs and nuclear stress tests. We did to offset that knowing that that would be, that's the direct ancillary result of not having a cardiologist. Pominology was completely removed from our budget. So there's no professional revenue in there or the ancillaries are not a high generation but anything that we thought was, we did decrease a little bit in the ancillary for not having a pulmonologist. And the primary care transitions, I think when it comes to access for that, basically we're saying that we need more doctors. So by basing our budget on the doctors we have right now seems like a fair assumption. Like these numbers aren't increased based on knowing we need more primary care to increase access. They're based on what we have right now. So I mean, that's a really good question Robin but none of that it's built in here about having any more primary care besides the Dr. Lane who's replacing someone that has left. And anything else? Did I, any other things? Yeah, that's great. Okay. That's great. I wonder if, do you have a sense of the impact on your revenue from the drop in general surgery, the cardiology and pulmonary issues? Yes, it's all built into the budget. I'd have to go back to my detail sheets to tell you the actual numbers. I will tell you the general surgery impact is a big one. And I'd be glad to give you those actual numbers afterwards because I have it all detailed out. I just don't have it on my fingertips right now. Perfect. Perfect. Always fine if you need to follow up. Yes. We don't expect you to have it memorized. I wish I could. That would be quite a feat. Great. Thank you very much. That was super helpful in understanding kind of the background behind those numbers. Also on the ortho, do you, you mentioned when you were going through your wait times, your wait times for primary care, do you have wait times for ortho? Like I'm wondering, do you have some pent up demand for the second ortho person that you're having start? Yeah, so ortho, so let me also share that the orthopedic that's the addition actually has already been coming to the community. And then when I'm working here part-time and decide to buy a home on the lake, the beautiful lake that Jessica mentioned earlier. And so basically it's flipping from more full-time in the Littleton to our community. So we already have him part-time in the community. So our survey really was really reflective of the existing practice and the skill set of our orthopedics has different expertise. Sure. So that actually felt like it, this is initial, but it looked like it was pretty close to the national average there. And in orthopedics, people are, they tend to go to the specialists where they get that expertise. So we know that there's a lot that lead town that will go to other areas. Does that make sense? Yeah, yeah, you're basically anticipating with additional time, you'll be able to recapture some folks that are leaving the community and perhaps even get below the national average on the wait times. That's my takeaway. Let me know if that isn't right. It's very common for me to be at a community meeting in here, though I'm having a knee surgery or something and they're not having it here, they're having it out of area. Sure. Yep. Okay, thank you. So in, so I wanted to ask a little more detail about the commercial rate increase. So when I look at appendix one in your submission, your narrative, let me just pull that up, which is the reconciliation table that walks us through budget to budget and projection to budget and understanding that your projection has changed. When I looked at this exhibit, in terms of budget to budget, it seems like your NPR is an overall increase of just under 11 million and 8.6 of that is coming from rate. And in the projection, the increase from your old projection, understanding this is old, was 8.9% and 8.6 of that would be coming from rate. So the question that I had about that is related to the critical access hospital status and your cost report. So what we've been hearing from a number of other critical access hospitals is that they, because of the cost-based reimbursement and the ability to file the cost report and get some enhanced revenue from Medicare to reflect the fact that your expenses have increased, that that has given the ability for many of the critical access hospitals to not ask for large rate increases this year because there is that protection. And obviously not all your patients are Medicare patients, but as you noted earlier in your presentation, you're one of the oldest communities with high Medicare participation. So could you please provide some more justification for the rate increase given sort of what you would, or what I would expect the impacts of the cost report might be and also whether the cost report impacts are reflected in the budget or not yet. Yes, I'd be glad to. So about 30% of our gross revenue is Medicare. So we'll start there. And just as a reminder, any additional physician costs for professional services do not receive cost-based reimbursement for Medicare. So that's a piece of the cost that we will not get any increased reimbursement for. And basically what it comes down to for North Ventury is from the allowable cost, which we know was a sugar down of all our total costs. We would see approximately 33% of that cost is what we would get. I will tell you that it is not in our budget. Historically, we have not put it in our budget. We have reserves for these things basically because we have seen these Medicare cost reports almost swing on a dime sometimes for different things. So we do not put those, we do not put that in our budget. Basically, we'll do an interim cost report before we close, we'll have the final cost report will be done at the end of February of next year. And then at some point after that, we could get an interim rate adjustment. But we feel like all of that is too, I wanna say iffy, which is not a technical term, but it's not concrete enough in order to be able to put that in our budget. And we think the rate increase is necessary. There's nothing black and white that shows that we're gonna get that money now and to be able to jeopardize the future from now. And like I said, the cost report won't be even filed till the end of February and we wouldn't even start to see any money until sometime after that. And there's desk reviews and audits and so it's hard to say when our rates would actually change and we'd actually see any kind of pick up on those dollars. Thank you. You're welcome. So in looking at the net patient revenue increase, from, it'll be very interesting to get your updated projection because the increase, quite frankly, from both your budget and the projected number that we have to the 23 budget is quite large. And in the past, what we've seen particularly with critical access hospitals is that it's been difficult for them to span that big a jump. And I think I'm sort of from looking at your materials, it seems to me that the reason why there's more certainty for you in this shift is because of the rate increase. Is that accurate, would you say? Is that an interpretation of the numbers accurate? I'm not sure, Robin, if I completely understand exactly what you just stated could you say that again for me or maybe someone else can help me? No, of course, of course. So typically with critical access hospitals when they come in with, for example, a 12% NPR increase from budget to budget or 10% from projected, like it's been very difficult for them to actually reach that. And so in the past, we've talked about aspirational budgets where the top line isn't really achievable. So you're kind of baking in a loss essentially because you're building your expenses to a top line that's not achievable. And I'm basically just repeating what Maureen Youssefer used to say. I learned this from her. What I'm trying to tease out is it looks like from the reconciliation chart that actually most of that increased budget to budget or projected budget is in the rate, which means it's more certain because once your price goes up, your price goes up. Yes, thank you. That helps me. And yes, the answer to that question is yes, that is why it's more the majority of it is the rate and also the utilization that we're increasing. I mean, I believe it's pretty solid, you know? So it's both. I mean, we do know, I mean, we now have line of sight to when orthopedics comes online and when cardiology comes up back online. General surgery, we have, you know, historical on that as well. So I think that's, you know, when we look at it, that's what we think is conservative. And as far as not jumping too high because we've been there before, just a matter of getting back to there because it only takes one provider to leave and then it's... Right. The provider changes really impact you a lot. A lot, yes, on our ancillaries a lot. Yes. I'm almost done. So in terms of your travelers budget, thank you for providing the information and the presentation with a little more detail on it. Can you talk a little bit about the hourly, a lot of hospitals? It's helpful for us to hear about kind of the hourly assumptions that you're making because a lot of the other hospitals have put it in those terms. So it's good to be able to kind of see what's happening around the state and if there's consistency or not. So could you just speak a little bit more to the traveler hourly numbers? Megan, would you like to speak to that? Yeah, I can. So in actually reviewing the hourly rates of our current nursing travelers that we've had here, I saw as far back as 2013 where we used to have travelers for $70 an hour. I know you all know that that's not the current state. And then, no, the high point of that, we had $200 an hour. Where we're landing right now is our high point is about 140 with a low point of 95. Great. So it sounds consistent with other hospitals like those numbers that are starting to come down. And do you know what you used as the budgeted number? Tracy, do you know what we put in our spreadsheet? Actually, I think we kind of went somewhere right in the middle, Robin, because we were using some of the projected dollars and then on the new dollars of what was coming in. So I think we probably went somewhere right in the middle on those rates to be conservative for our traveler dollars. I don't know if you guys are hearing this, but I've heard from a couple of people that have said, and I don't think we've experienced this yet, but that the rates may go up in the fall because of large systems trying to acquire the talent ahead of time for possible surge, which is discouraging because that would impact our supply as well. But we have the mindset of we're looking at every, in fact, we're talking, we have a meeting later today to talk about what opportunities do we have to lower even the existing traveler rates? But there's a risk reward there. And so for example, if we go, I think this is correct. And it could be contract dependent, but if we say, hey, we have someone in mid-assignment and we say, okay, we want to drop your rate by $20 an hour, by having that conversation, we may allow for the opportunity where they won't need to, even if they say no, they don't have to stay for the remaining part of their term because we tried to negotiate a new term. So we really, we definitely look for at the time of a change at the end of a cycle or we're looking for additional replacements because we know that they don't stay for ever and we have to replace them with new people. We look, every time we look at an opportunity, we post the rate low and then we ratchet it up what that rate we're giving until we get the need met. Great, thank you. And so my last question, it's really a sort of a, trying to put your CON approval and project for the ED into context for really your patients and others who might look at your budget and say, hey, you're asking for a big increase in price and you have this big project out there that you're saying you're gonna spend millions of dollars on. How would you answer that new port resident who was wondering about what I think to most people would see as kind of a, you know, inconsistency? Yeah, yeah, it's a very good, very good question. And one we would have hoped not to have to even respond to because we would have a stable operations. And so try to break it apart for, for example, just on the ED utilization, for example, if I can start with that, the ED utilization is a factor in our model and we do wanna drive down that, but we have, when we say 11 beds, that's not 11 beds in rooms or it's not a, so we have people that are in the hallway within the ED and they're not in an appropriate care setting that we would like to have. So we're stretching our existing space to accommodate. So some of this growth would just say we're putting people in a room than in a hallway and there's just a whole host of reasons why that's good. And then, so that's on the ED utilization side. The overall project is a long-term need and we have said from the beginning that this would be funded through our operating through our long-term investment portfolio. We would leverage that as that debt for debt. So we have, I think, well, the market keeps changing. So we had at $1.60 million there. So on a $28 million project, we just seek to use that leverage to cash out. We use that as leverage to pay for it. So then that's not affecting the current operation of the hospital because that's being financed through that mechanism. And that gets back to why I say it's important for us to have a operating margin year after year because that allows us to reinvest into our ongoing capital but also into that long-term because if we disintegrate that portfolio, it's the beginning of a crisis. And it's just punting forward and then we're gonna have a crisis where we don't have any cash to invest in our infrastructure and make sure we have appropriate care environments. So this, I hope that gets us on the, helps at least have a conversation and on the right track of separating the two. That's long-term what we're talking about is current state. Thank you. That's it for me. Thank you, Robin. Great. Thank you, Robin. I'm gonna turn it over to Tom Pelham. Well, good morning still. I've found myself a couple of times looking at the screen here and seeing a TP and the lights blinking as if I'm talking and I'm not talking, it took me a minute to realize that's Tracy Paul. That's not Tom Pelham. So there's two TPs up there. Nice initials. Yeah. TP. Kind of following up on a couple of areas, Robin touched. One of them is Medicaid, the NPR revenues in Medicaid. And in both your payer mix table and your reconciliation table, you have a fairly large increase, $3.9 million in Medicaid revenues, not attributable to the rate but attributable to utilization. And that's a third of your overall NPR increase. And so I'm just wondering, you're also kind of looking at Medicaid across all the hospitals. The projection increase is just 1.4%. Most hospitals I find don't expect much additional revenue from Medicaid. So I'm just wondering kind of what's your thinking behind the Medicaid number that you're proposing for and that the difference from 2022 to 2023. Okay, so as far as the actual reimbursement for the net for Medicaid, I was using when I went from the budget, it's based on what we're actually receiving. So that was, I didn't put any increases in there. It's the combination between what we're getting from traditional Medicaid and what we're getting from the ACO for our Medicaid. Medicaid is about 25% of our population. So there are no increases built in over and above what we are actually seeing here today. So I did not build any increases there. I'd have to go back, Tom honestly, specifically look at what the assumptions in 22 were when that budget was built. But again, this budget was built on what I was actually seeing for what I would call traditional Medicaid and what I'm actually seeing for the FPP from the Vermont OneCare. And that's how that that's where that percentage came from. Well, that might be helpful if we just could get a little window on whether or not this increase and, you know, it's obviously the right thing to do is to base it on what current revenues are or the current experiences. But just to see what if this current experience is, you know, has a longevity to it over time because it's a big number. It's a 30% increase and it's totally independent from the rate increase. I'd be glad to show a crosswalk across, Tom, of how that came out. My next area has to do with travelers. I guess, I mean, it's a topic with all hospitals. But there are a couple of lines that kind of caught my eye in your narrative. One is I'll just read a couple of here. Expenses from projected 22 to budget 23 are forecasted to decrease by 1.1%. This is due to the projected decrease in travel users because of the new graduate nursing hires and other staff hires. So that's one. And then later on, you have talking again about the overall increases decrease. The new grad residency program mentioned above has filled many positions beginning in May. So I'm just wondering if you can tell us a little bit more about this new grad residency program. Absolutely, I can feel that. Thanks, Tracy. So yeah, our new grad residency in the presentation talked briefly about. We offer a nine-month program. And if you've seen any stats on nursing, you know that there's a high turnover in the first year. If they come into the profession, they're unsupported, they're highly likely to just turn around and leave. Forget about the rest of the years in nursing. So it was about five years ago that we really invested in this new grad residency program. Our education department, they run that nine-month program. It's heavy on the front end providing support and training and then tapers off towards the end of the nine months. And what that's done for us, this is previous to this year, we typically see I think the lowest amount that we've seen come through our seven new grads. And we've had classes as large as 12 new grads. As I said, also, we partner with VTC as a clinical site so that we have that feeder line. We also offer externships to nurses in bachelor programs heading into their senior year. We often see them come back in the spring to participate in the new grad residency program. So how that impacts this year is looking at our increased traveler usage and then in those opening positions where perhaps in specialties, we might not have filled new grads before. We adjusted our new grad residency program to really support new graduates going into specialties. That is coupled with the support from the unit-based educators so that they're really we're trimming down our orientation time in order to move those travelers out and move the new grads into those permanent positions. So is it fair to say that this program is one that's kind of locally based? It's something you folks have put together and made real. Yeah, other hospitals have new grad residency programs. And I'm thinking of the critical access hospitals throughout Vermont. Ours is the longest and the most time-intensive. So later on in the narrative, just to kind of continue on this thought a little bit, in the narrative you listed, you say North Country Hospital has implemented numerous programs to attract and retain qualified team members to provide the service to the community. And then you list a few signing bonuses, referral awards for existing employees, relocation assistance, loan repayment, et cetera, and then conclude that paragraph by saying, unfortunately, there are no outside funding sources for these additional expenses of higher salaries and other programs. And so I'm trying to get a sense of the kind of state strategic plan workforce development program, which they came to the board and presented last October. So it was like nine months ago. And I think we all thought it was a very good profile of opportunities. But what I'm trying to get now is a sense is any of that's filtered down to the local level, where these programs are the ideas, the recommendations of this workforce group are becoming real opportunities for hospitals. I'm not aware of any of that. I don't know about anybody else on the team. Yeah, I've been part of, let's go ahead, Paul. I can't hear you, though. Nothing has been brought up to us about funding sources on that one. Paul, I can't hear you. I'm sorry. Yeah, I'm on the HR Directors Committee for Vermont. Can you hear me now? Fairly. Paul was saying, I think, Paul, I'm going to give me a thumbs up if I capture this. But he's on the HR Director Committee for the state. And they digest these things. But I don't think there's been anything as far as actual dollars flowing through. And Tom, I think even the challenge for the state will be having that set at something that's competitive for everyone. So for example, if a nurse is going to get a loan repayment of, I'm just making this up, but $2,000 a year, we may have to be at a $4,000. So we still probably would have to supplement it. So anything that would flow through to help the organizations. We also participate, Paul participates in AHEC. And that also provides loan repayment that we participate in for providers. And a lot of those times, if they don't get it through that program, we still end up covering it. So we try to say, hey, one way or another, you're getting the scholarship. We have actually this weekend on Sunday, and there's still time to come. But we have a golf scholarship that raises, I think, $30,000 to $40,000 each year. And we give out scholarships through that. So we do supplement it with these types of fundraisers. But unfortunately, it's just the competitive nature of things. We just continue to have to find ourselves contributing or from our operations. And that scholarship program, by the way, is scholarshiping people that are in school. And we don't even have a guarantee that they're gonna come back here. We try to build that in, but it's sponsoring people that are four to six years out as they're in med schools and nursing schools. So I did have a balance sheet question, but Jess has already kind of hit on that. And it's a moving target. So we'll talk about that some other time when we get the updated balance sheet. And I think finally, there was one more. So when I first came on the board, it was probably in 2018, I came up to North country and visited with you a couple of times. One time with Kevin, where he tried to convince you folks that he was really from the Northeast Kingdom because he was from Rotland. And I was from Arlington and that's part of Massachusetts. So we had that conversation at your board meeting, but just when I first met at the hospital, one of the comments that struck me was obviously recruiting has always been a problem for North country. And it's obviously just being exploded with the pandemic. And so we were talking about some ideas about you're trying to get new staff to come and stay and maybe mortgage subsidies or some housing programs and things of that sort. It was just a general conversation. And one of the comments was is that there is a tension in the community between the folks at the hospital that have great jobs and get paid well, set out relatively to the underlying employment base of the area. And I'm just wondering if that still exists and has it changed given that we've gone through a pandemic and the relationship with the hospital and the community is tightened rather than still a bit fractured? So unfortunately, none of us were here during that visit. So I can't after that perspective, but I don't hear that sentiment in the community. The sentiment in the community is, we need more physicians. I don't think they're going around saying we need more nurses, but they acknowledge that we need more of those. We do try to do incentives for or we have and we've done some stuff with that. We have a couple of condos that we own to help out with housing needs. And that's been helpful even in our locum setting, but I don't get the sense and I'll turn to the team here or just be looking at you if you feel like that there's anything of that nature. I don't think there is. No, Tom, I've lived here my whole life and worked here for a good share of it. And I don't believe I've never felt that way. Here at North Country, people usually are very appreciative of having this hospital in their backyard per se versus the option of traveling at least 45 minutes. So that's kind of the under, that's the kind of take-eye gap. Well, I'm happy to hear, go ahead. I was just gonna say from the perspective of, over the last couple of years, like you alluded to, things kind of leveled in the playing field. Nurses at the hospital don't make an absorbent amount of salaries versus nurses in the long-term care. Actually, some are long-term care places around here paying better than the hospital and the prison likewise. So it seems like maybe the disparity is somewhat equal now, but I also have been in the community for a long time and I haven't heard anything recently to that effect. Well, it wasn't a big deal. It was just kind of an off-the-cuff discussion. And I'm just glad that you're just disabusing me of it. I think that that was it for me. And I'll throw the ball back at Jess. Great, thank you. Board member Walsh. Thank you, Jess. Good morning, Brian. It's nice to see you again. Thank you. I'm Stephen, Paul, Megan, Tracy. It's nice to meet you. Thank you for, you did a really thought a nice job outlining the headwinds that you're facing. It was very clear, very transparent, honest, and I appreciate that a lot. I don't have any real questions per se. I just wanted to say that I appreciate your effort focusing on primary care and the urgent care and ED development and trying to decrease the avoidable admissions through the ED. I think that that's a really wise area to focus. And I say that based on experience from other places in the country with rural settings where sometimes the choice is to try to grow out of the situation, a similar situation to yours by focusing on bringing in one or two specialists. But the cycle that tends to happen then are prices rising to try to make up for revenue, but the community can't pay. And they then choose not to have elective procedures or not to go to the doctor, but they still get sick and have accidents. So they end up going to the ER, right? Then they're sicker than we would hope and they're admitted. And then in our current setting in Vermont, there's a log jam, right? Where people are in and overstay their diagnostic code so the reimbursement from Medicaid Medicare isn't sufficient. Patients, I don't know specifically about your policy, but often patients are still billed for those extra days. That becomes medical debt, right? And then the bottom line looks worse. And so the choice is to raise prices and you can see this cycle that can be really detrimental in a community. The way through it, the places that I've seen go through it, the focus is on strengthening primary care and urgent care and affordable access. So I liked hearing about your focus on that area. I think that's spot on. So again, thanks for presenting to us transparently and forthrightly and helping us see the situation you're in. Back to you, Jess. Thank you, Tom. Thanks, Tom. So this is the question I've been asking all the hospitals, so you probably had a foreshadowing of this, but trying to get a sense of the historical relationship between change in charge and what really is the effective rate change for the average commercial patient. So you're asking for a 12% change in charge. Could you translate that into what the effective rate increase will feel like for your typical commercial patient? Realizing that obviously, I think you've said this somewhere in your narrative, but there is that different payer contracts mean that that change in charge will be implemented differently. So for the average typical commercial patient, what is that effective rate increase gonna be? I guess I should have had a better foreshadowing, Jessica, because I'm not quite sure how to answer that question. Okay, well, here's what I would say is that if you could, obviously that sounds like a number that you can't off the top of your head, compute totally understandable. If you could follow up with Sarah, that would be helpful. And other CFOs are tackling this. Some of them had answers right, prepared, others didn't. So maybe understanding how some of those calculations are being made by other hospitals, that would be helpful. We're trying to get a sense of that effective rate increase because from all that would be helpful. It does seem like there is a deviation and we understand that there is. So it's just understanding that would be helpful. And then this is just a slight addendum to Board Member Lunge's question about kind of unpacking the revenue losses that you've experienced. I just would add, could you also add to that list quantifying what was the fiscal year 22 revenue loss that was associated with the CERNER conversion, increased PTO time loss of providers? Basically some of those reduced patient appointments that potentially are short-term. Although I guess I'm not sure about the PTO time that may be a summer event every summer. So really interested in some of these one-off CERNER conversion reduced patient appointments impact. Jessica, we will do our very best to do that estimate. It's easy to, not easy. It's easier to do it, but direct effect from in the practices. The harder part is to try to figure out what the ancillary effect of that will be on, right? On the labs and the radiology and stuff. And so that's where the challenge is but we can definitely provide some estimates that we can come up with. And then again, we're thinking we're gonna recoup that at some point, right? But with the access, that's a challenge also. Understandable, yeah, thank you. My next question is actually around in the narrative. This was in the section around average daily census and occupancy rate. I noticed that your average daily census was pretty stable at 16.9 in 21 and 16.8 in 22, projecting a 16.8 again for 23. Very, very steady and stable. It surprised me a little bit. We've seen from some, at least from some other hospitals a little more variation in average daily census from year to year. But the other question related to that was you listed your occupancy rates and your occupancy rate for fiscal year 22 was 44.1% per licensed bed. It was also 44.1% per staffed bed. Typically we see there's a deviation between licensed beds and staffed beds. There wasn't one for North Country. And the 44% would imply that you license and staff for 36 beds, which didn't sound right to me at all. So I guess I'm just trying to understand those numbers. I think we'll have to go back and do that math because I agree with you. Cause it should be, you know, there's a difference between the 25 bed critical access hospital and our license of 30, you said 36. So it really should be on that 25, not the 36. Okay. Yeah. That's what I thought. Yeah. Okay. Yes. Should be a higher number. Yeah. Okay. Thank you. That's helpful. And we, I mean, although that's normal, you know, you said, you know, you read that 16.9, you know, I think you understand that we have fluctuations where, you know, in flu and COVID season, if I can say all that, we've been, you know, 25, you know, 25 patients for a period of time or 22 plus is really where we start to say that's, you know, that's really high census or maybe it's a 21. And then you have some lows from time to time where it's like, well, we had a couple of weeks where it was down below 16, which was actually refreshing. So it's a lot. Shortage, I'm sure. No, it just seemed like it was so solid and steady with literally no deviation over these years, particularly in a pandemic when there is so much fluctuation that it honestly was just a bit surprising. And even the other piece I thought was interesting was, you're projecting that same average daily census for 23, the 16.8, but you're at least from some of the materials I saw, you're expecting 17% fewer admissions. You're projecting, you know, 1600 admissions versus the 2000 that you've had in the past few years. I recognize average length of stay may contribute to that. I just, if you all could just help us unpack some of that, some of those numbers a bit more because I think that would be helpful. And certainly if you have answers now, that's great. But if you need to follow up, that's fine too. Yeah, we'll follow up. Okay, that'd be fantastic. My next question is just, or my next comment really is just around wait times. You know, I fully recognize that you did a EMR conversion. I, we've heard over the years have challenging and difficult that can be. So I understand completely that the data collection around wait times was challenging. And I really wanna thank you for sharing the 3D health assessments data that you do have and for attempting to try and get a handle on those wait times. My request is simply that as you're thinking about your new CERNR system, if it's possible to think ahead for next year and make the necessary IT changes in the system to allow you to track both referral lag, which I think is an important metric to track. That's the time between when a referral is made and when an appointment is scheduled. And then the visit lag, which is the time between when an appointment is scheduled and when the visit actually happens. You know, we've heard from primary care providers across the state that that referral lag is the source of major frustration for patients and for the providers themselves who are waiting to hear what an appointment will be scheduled for one of their patients. So we're trying to track both of those metrics. And if we don't measure it, we don't know whether there's a problem, we can't fix it. So now that you have a new EMR system and maybe there's a long enough runway to think about next year, my request is if you could make those adjustments in the system now. Yeah, great. We're looking to do it. Yeah, we're looking forward to that tool that Cerner, you know, we're obviously in a high anxiety environment right now, but we're looking forward to the tools that we should be able to turn on and then the metrics because of Cerner. Fantastic, yeah, thank you. And then my last request, there's not a question here either, but you know, to the degree I'm asking every hospital to the degree that any known or likely changes to federal and state payments, any relief funds, any unexpected increases in Medicaid and Medicare rates, if you would share those with us, if they, you know, you've learned about them since the budget submission or you learn about them in the next few weeks, if you would just update us with an email with Sarah and team. Okay, fantastic, thank you. I'm gonna kick it over to Sarah Lindberg to see if there's any questions from our hospital finance team. Sarah Lindberg now off mute. No questions from staff, just thank you for your partnership and clarity and all this. Thank you. Great, okay, thank you, Sarah. At this point then, then I will turn it over to the HCA for any questions. Thank you, apologies. I decided to take the exceedingly generous tact of relieving Sam from doing all 14 hospital budget hearings and generously taking two of the 14. So I questioned my decision only to take like 6%. So my first two questions are about Starner and one is that, so you might know this but the Health Network, UVM Health Network purchased and implemented EPIC a few years ago and is kind of currently rolling it out. One of the selling points of switching to EPIC was that the network would offer discounted EPIC licenses to Vermont hospitals that are not in the network. And I was wondering, did you have the option of obtaining a discounted EPIC license from the network? So we traced in, I don't know that you can answer this because, but we would need our CIO to help us answer that because we did go through a process and we did get EPIC. And I can tell you that when we looked at EPIC and that, so this was probably a year and a half ago. So I have to believe that that conceptually that that was on the table, but the EPIC cost was EPIC. Yeah. And so that was the thing. Yeah, so when I'm thinking about when we, our top three were Starner, Meditech and EPIC and EPIC was the most expensive. I can't remember Meditech about how it was, it was the closest to being competitive with Starner. So we're really looking at the top three players at the time and Starner was the more from operations standpoint more effective for not impacting our financials that is deeply. Yeah, if you could look into whether you were offered a discounted EPIC license, that would be really helpful. Cause I do know for a CAH, you know, a full price EPIC license is, I would agree that it would be an EPIC cost and perhaps totally unreasonable. Yeah. So staying with Starner, you mentioned that a substantial portion of the decrease in cash was due to issues related to the Starner implementation. I'm just wondering when Starner comes online, is that going to drop down to your operating margin? So are we going to see in 2022 or in 2023 that the operating margin would look better than it does currently potentially? Yeah, Eric, I would love to say that's what's going to happen, but it's not. Basically what's happening is we're capturing the charges. So we're capturing the revenue. So the revenue is going into our financials. I mean, there may be a little bit out there, but not anything of consequence. The real issue here is the cash, right? We're not able to get the bills out the doors and the cash back in the door. So it'll affect our cash balance, but it's not going to affect our total revenue so it won't hit the bottom line. That's really helpful. So I'm going to switch a little bit. We'll switch very much. So I'm just a little, I wanted to understand the change in how you book bad debt. So I'm looking at 2021 where bad debt drops precipitously, almost so low that I thought it was a typo at first and we reached out to you. And then it bounces back up in 2022 P and 23 B. And I'm not understanding the change in booking because I guess conceptually I would have expected it to remain low in 2022 P and 2023 B if there had been a change in accounting practices. Like I wouldn't expect a one-time change is what I'm saying. Yeah, Eric, you're absolutely right. And I did look into that about what the reasoning behind why are bad debt? I know it went up into our contractuals in 21. And that's why you saw the big difference. The free care remained basically the same but the bad debt went up into our contractuals but then since then the bad debt's back down into its own category. So I'm going to have to do a little more research on that. I'm not sure if it's just a matter of where on the adaptive reports this is being put or not. So I guess I'm going to have to take do a little more research for you. I mean, I will tell you overall for the most part besides for 21, we always hover around the 2% where half bad debt and half free care. So I'm going to have to look at that and talk to my accounting team to see if that was a matter of which box they put it in on in the adaptive world. So I could definitely get back to you on that. That would be super helpful. And adaptive is kind of what everyone's pulling up. But so historically it creates this very strange line that I don't think is true in the sense that we mean it. So that's only why I bring it up. So staying on bad debt, I'm just wondering about what's driving the bad debt in commercial and self-pay. So this was in your answers to our question one C. So bad debt for commercial went from 72,000 to 1,249, and self-pay went from roughly 111,000 to 900,000. And so I'm trying to, I think that's because of the issue we were just talking about. So, you know, you go through perhaps. Yeah, I'm going to have to, yeah. I think the answer to that will be once I untangle the other piece of it, it'll all kind of fall into line. All right, and then the last two questions for me, and then I think Charlie has a few questions was, so I want to switch from the budget to a little bit to the community health needs assessment, which was quite impressive. But I wanted to ask you about, so you reported that like 48.8% of respondents to the survey, so they took illegal or prescription drugs in a way that was not recommended by a doctor, and that this kind of issue was the, they get one of the biggest issues in your service area. And then you stratified it by income level and it persisted across income levels. So other findings and that in your report talk about how illicit substance use has been normalized due to financial hardship and poor mental health in your service area. And I was wondering if you could speak a little bit about how you're addressing this kind of pervasive problem around illicit substance use, whether it be prescription or illegal drugs. I can speak to it and then if others want to chime in. So one thing that we are working on with our Journey to Recovery, which is the local center here that works without population, we've had them, we have 24 hour access to their case workers essentially, so that as someone presents to the ED, we can really give them that real time response, someone saying, hey, I'm ready to get help. We can do it real time because we all know that that's a short window if we don't access it then. Historically, our emergency department has not participated in RAM, which is the rapid access to medication treatment. I'm not sure if you're aware of that, but we are currently on track with our medical director and ED staff to look at that, get the training for the physicians. There's some licensing training that goes into that so that we can start prescribing that. We did have a meeting and talking with Journey to Recovery and also one of our areas with Savita on how we would bridge that. So the RAM, you get a one or two day dose of medication. If you're saying you're ready to detox and then we link you with Savita or Bart in our community. So those are some really tangible things that we're doing to help support that population. But that's wonderful. And as you know, the substance abuse is kind of a crisis statewide and nationally. And I sincerely hope that we can share some of the learnings that you've garnered around your project in the system as a whole. And that's kind of a sharing of systems knowledge as a constant refrain for me. But I really do hope we can understand how that works at other hospitals and perhaps use what you're using. Also related to the CNHA, I really appreciate that you were clear about the limitations and challenges of the survey and outreach methodology and that the sample resulted in respondents that were disproportionately female and higher education than the community as a whole. I'm wondering, and this is really a pervasive problem with outreach and surveys is what steps you're taking for or have you thought about taking for future community needs assessments that try to get a better representation of community members with diverse backgrounds regarding race, ethnicity, class, education level, gender identity, sexual orientation, et cetera. Yeah, I'll respond to that Eric. You know, I think our window of time of doing the survey was just unfortunate because you know, it's required every three years. And so we do this when they were right in the middle of COVID when people weren't actually weren't able to get together. So that's what led to a different approach. I think we definitely will have a different approach to the next go around. We did on board with UVM on this project. And so I think we've established a good consistent process we're moving forward with some population health influence a part of the survey, some leadership in that aspect. And so, you know, just the fact that you saw that we acknowledged it, I think shows that we acknowledge we got to do it differently next time. I agree. I mean, that self-criticality is refreshing to say. And so I really, I bring that up to, you know, applaud that recognition and to also legitimately because of curiosity to ask about how you're dealing with it again with the hope that what you learn can be shared across the system as a whole. So I'm gonna pass it off to Charlie who I think is on and he may have a question or two. Thank you. Hi, yep, I'm on. So this is Charles Becker. Everyone calls me Charlie. I'm a staff attorney with the HCA new this year. So it's nice to meet all of you. And thank you for your presentation today. I just wanted to ask, and really it's we. So this is, you know, we worked on these questions together. So we wanted to ask you about your diversity, equity and inclusion efforts. And you spoke in your presentation to some of those efforts, including I believe some training for staff on the opening of a new walk-in clinic. Certainly those are both really good things and you're to be commended for those efforts. But we wanted to challenge you a little bit on a response that you gave to one of our written questions about health equity. And specifically we asked if North Country had a funded DEI position and the response that we received was, we have no current plans to create this position at this time. We have very little racial diversity in our patient population and have received zero complaints related to racial discrimination. And so just first of all, acknowledging the reality that the counties you serve are predominantly white and non-Hispanic, there could be multiple interpretations for why North Country is receiving zero complaints about racial discrimination. And it could be, for example, that people of color don't feel comfortable making complaints. So to turn this into a question and maybe it's a rhetorical question, we're not intending to put anyone on the spot, but is there more that North Country could be doing short of funding a DEI position to make it clear that DEI is part of your hospital's mission and culture and to ensure that the small portion of your population who are black, indigenous, or people of color feel welcomed at your facility? Thank you for pulling that out and sharing your response to that narrative. I think narrative can be difficult and being transparent of where our plans are and what our market is was not intended to be abrasive. So I apologize for that. I think this is an area where it's difficult for us to be breaking the ice on and be the standout lead. So we're looking for help and would ask for HGAs help in this regard, acknowledging what our market is. Internally, we have taken steps in the last four years or so to continue to advance diversity within our hiring practices by taking initiatives. I've said this the last couple of years of hiring international nurses, which does bring in people of color and different backgrounds and have even resulted in very small micro groups of people that are now living in our community, getting into our school systems. And so that's gonna take years. We have, so trying to continue to cultivate those types of opportunities. We have had most recently, we were very pleased to sell our Derby Green long-term care property that was vacant to an organization called House of Mercy that is bringing in European refugees. And we have people of special needs coming in through that program. The hospital's not directly ingrained into that work, but that will be in our community, which will, again, offer in some more diversity. So we're open and receptive to it. Glad to hear ideas. We do work with Northern counties and NKHS to continue to say, hey, what can we do to continue to serve our community in all aspects, regardless of faith, background, gender? And we have a ways to go, but it's just difficult to break ice in an area that's not very diverse and so welcome your help. Well, I say I didn't wanna put anyone on the spot, but that was a really great answer. So I'm glad I gave you the opportunities to say all those things because you're right, it's hard to put all of that into a narrative. So I appreciate that response. And I think you made among the better points you made there, two of them were the hiring, bringing in people from out of your area, but that could increase the diversity of your community and also that you're open to receiving help. And so I can imagine that the HCA would be eager to speak with you about what you could do along those lines. Thank you. Can I just jump in real quick, Charlie? So Brian, we have a few parental leaves happening right now, so it's a rough time for us because we're wildly understaffed. But I think come November, as you are, come November, I mean, depending how the fall plays out with a potential surge, I think getting North country, I'd be happy to get you in touch with our, connect you with our outreach person, connect you with Sam, a health policy analyst, to do some conceptual work around DEI initiatives, and then also any stats or mapping I'm happy to help you with. As you know, numbers are pretty hard to come by in Vermont, especially by county. So unfortunately, it's probably gonna be me saying we can't get the numbers, but I'll try. If there are numbers to be found, Sam will find an Eric will find them, so. Great. Thank you. Yeah, thank you, Charles. Eric and Charlie, is that it from you all with questions? Yes, it is. Okay, great. And I just want to say I love the meeting of the minds and the potential collaboration on these important issues. And I just appreciate, we just saw right before our very eyes some great work that's about to happen. So I appreciate the willingness to help HCA and willingness to receive help North Country. So at this point, I'm gonna open it up for public comments. So if there's anybody from the public that wishes to comment on this particular budget from North Country, if you could raise your hand using the raise your hand function in Teams, we'll see that you have a public comment to make. Okay, I'm not seeing anybody raising their hand. I just want to also offer it to anybody who's on the phone who would like to make a public comment and can't use that function. You just can start speaking now. Okay, again, I'm not hearing anybody. So I don't think we have any public comment today. North Country, I want to thank you again for your presentation. I think there's a lot of great work going on up there. A lot of headwinds potentially maybe more than most faced in the state this year. And I think we can acknowledge that and appreciate your hard efforts there to overcome them. You must be exhausted. So I'll just acknowledge that you and your teams. But thank you to all your workers and everybody who's trying to overcome the struggles and make an effort in your communities to provide access to high quality care. At this point, what I'm going to do is we're going to recess for the rest of the morning until 1.30 when we return and hear back from Gipper. So North Country, you'll hear from our team about some follow up questions. I think we hopefully just so we can all be on the same page for what those follow up questions are. But in the meantime, thank you again for your presentation today. Yeah, thank you. Yeah, and I'll see everybody back here at 1.30.