 on YouTube. This is the Vermont House Health Care Committee streaming our afternoon committee meeting. And we introduced all the committee members and staff earlier this morning. I don't think we'll do that again this afternoon. But for reference, we're all, you can see our names, I think, and we're on the Vermont Legislature House Health Care Committee website. Our witnesses this afternoon are with us live on Zoom and I'm going to welcome Dr. Steve Leffler to introduce yourself and then Georgia Meharis. Why don't you both introduce yourselves now and then first we'll hear from Dr. Leffler and then we'll hear from Georgia and then we'll before you sign on, we'll open it up to questions. Okay. Sounds good. So my name is Dr. Steve Leffler. I'm the president and chief operating officer at the University of Vermont Medical Center. Thank you for the record. My name is Georgia Meharis. I'm the vice president of policy and strategy for a by state primary care association. Great. Well, welcome to you both. Appreciate you making the time to join our committee this afternoon. We have another member. I think we're all here now. Yes, I think we're all here. So, Steve or Dr. Leffler, let's start with you. I know that you have been making massive changes in preparations at UVMMC and across the hospital network, generally both the network UVM, UVM network, but also the hospital network in the state. We really were hoping to hear from you to hear about where are we at this point in terms of the hospital and preparations for everything we're in the midst of. I'm going to give you an open ended opportunity to speak to us and then answer questions. That sounds good. Let me also say for both you and Georgia and our other witnesses as you are thinking and talking with us I also any specific asks that where you need further assistance from the legislature that we can offer, we are wanting to know about that as well. So with that I'm turning to Dr. Leffler. Thank you. So at the University Medical Center today, we have 18 positive COVID-19 patients. We have six of them in our intensive care unit and we have another 11 on one floor and we have total right now of I'm looking 14 rule outs for COVID and that's been relatively steady for us over the past week. We've been running about those numbers each day. So at least in the medical center, we haven't seen a huge surge about a week ago. We saw a pickup in cases and we've been pretty steady admitting two or three a day. I'm happy to tell you we've been able to discharge a couple of people who are COVID positive now that we're in the hospital so people are getting better. And I'll just brag for a second on behalf of my intensive care doctors. We've actually been able to extubate three people who had breathing tubes come out and if you get the data around the world, the number of people who get on a breathing machine and then are able to get off is actually pretty low. It varies between about 50%, 80% do not come off the machine, meaning they go on to die, but in Vermont right now we've already been able to get three people off the machine. So that's really good news. Our doctors are following the most current guidelines and protocols and so that's very encouraging for Vermonters that going on a breathing machine doesn't mean that you're certain to die, which in Italy and some other places that it was looking pretty grim. But I'll tell some better stuff than that. But we have good news. We have excavated three people. I will tell you that I've been at the medical center for almost 27 years and I've seen more change in the past three weeks here than I've seen in the other 27 years almost combined. We basically have changed almost everything that we do, how we do it, where we do it, who's doing it. We've changed everything. We've changed, so we have a, we've changed our visitor policies, we've changed how our workers get into the building. Every single person coming in the building now is screened with a temperature check and a quick history of they have a cough or feel ill. We've worked very hard over the past couple weeks to get all of our employees to having on-site parking. We'll have that completed by Monday so that all of our workers will be parking on-site so we're not using buses at all. We've essentially stopped elective everything, which I will tell you is it's been helpful for social distancing and to keep our PPE supply up. But that's a huge, difficult task for our people who are waiting for procedures, who may be waiting for a surgery for something that they have this painful to cancel or delay all those. It's very hard on our people and it's really changed our workforce. We have many of our workers working from home now. We have many of our workers working in different areas than what they're used to. And we have some workers right now that don't have work and are waiting for when the surge comes to be redeployed in a different way. We have spent a lot of time updating a lot of our policies on how we manage everything that you can imagine. So the final thing I'll say is I believe that we're about as ready as we can be for what's going to come. We have good capacity in the hospital right now. The hospital is only about half full. And the reason it's half full is because we've stopped doing a lot of things that we do routinely. Most routine things have been stopped. So that's given us big capacity in the hospital to deal with the surge that comes. And we've done a lot of work with partners around the hospital to have surge capacity outside of the four walls of the hospital. So we have a unit in converse lot on the UVM campus that can manage people who present with respiratory complaints who we think we can take care of without them entering the ER. We're seeing people there now some numbers every day. Most of them are able to be seen in that tent outside of the hospital. They're able to stabilize and then send home and never have to come into the hospital. We're working with the state of Vermont emergency command to stand up a 50 to 100 bed field hospital in Patrick Jim. That's been pretty much built in the last seven days with staff from the medical center. That's pretty close to ready to go at this point. So people who for some reason can't go home, they've been screened. They might go over there and wait for their results. We don't think right now we use that as a positive, a COVID positive space, but that could change depending on what happens. What we're learning over the past three weeks is be flexible and adaptable. Everything changes from one day to the next. And we're working with the National Guard to help them stand up a 400 bed unit at the Champlain Valley Fairgrounds, which at this point is envisioned to be a non-COVID type hospital. So it could manage other patients there who it makes sense to get them out of the hospital to free up capacity. We're going to start putting some, basically we're going to use it for long-state patients who don't really need to be in the hospital, but we have no good discharge place in normal times. This hospital in the short term could take some of them to give us, we'll pick up 15 more beds using that over the weekend. We're also doing a lot of work with our local nursing homes who have had some outbreaks in their areas. And so we've spent a huge chunk of today helping make a plan for Birchwood. So in terms of hospital beds in space right now, we're in good shape. We've also done a lot of work to expand our ICU capacity. We converted a big chunk of our operating room into another 20 plus bed intensive care unit where all those patients could be ventilated if necessary. And we have also adapted other spaces in the hospital that we would normally be using for other kinds of services, and they've been able to put them back into patient care spaces if they should be needed. I'm trying to think what else I could give you a quick update on. Oh, I know, I was going on, we're ready. So in terms of space, we're about as ready as we could be. The second big question we're getting all the time is, do we have personal protective equipment? And that's a tough thing to answer. I will tell you that we are really, really trying hard to conserve our supply. So we're doing things different than we do in normal times. I'll use the emergency department because that's the place I'm most rooming with and still work there a little bit. You get one N95 mask in the morning when you start work. And you keep that mask for the whole day. That's very different than how we usually do it. And for my entire career, if I needed to wear an N95, which is unusual, I would wear it in to see a patient come out, throw it away. We're saving them now in a brown paper bag to potentially be able to sterilize and reuse them in case we get short. And for a lot of our equipment, we're re-sterilizing it to be sure that we don't run short. We have, every day now, we have a committee that manages our PPE, that's a mixture of clinicians and supply chain. And they are keeping track of how many days of inventory we have at our current use rate. How far out we think the surge would be. And then is there new supplies coming? Are there new ways to potentially safely reuse equipment? So right now for our PPE, we're in reasonably good shape using, I would say, non-normal mechanisms to manage that, but we are in pretty good shape and we're much better off than our colleagues and friends in New York City. We have a reasonably good supply to get us through the short term. And our staff is tired. They've been working hard, but they're ready for what's to come. So I honestly think that we're ready for what the near term brings us. And we've worked hard with our state partners, including hospitals, other providers to have the state be as ready as they can be. So I'll stop there. And I'll let Georgia go. Thank you. I think I'm going to echo some of what Dr. Lefler said. So first, from a, so I don't forget. We have been working very closely with our hospitals and other community partners as well as Diva and VDH. So to the extent that we are generally collaborative in Vermont, I would say we're in an even more collaborative space. And so that is really heartening and appreciated. I know that other states are not, not able to pull together in times like this. So we are appreciative for that. The other appreciations actually to you, because one of the things that you did before you adjourned was H742. And so that law, I think is really helping with some of the emergency powers and authorities that enable Dr. Lefler to do some of what he described doing and enable my folks to do what they're doing, not the least of which is licensure and credentialing rules so that our workforce can go wherever they are needed. So thank you for that. In terms of what our health centers are doing, like Dr. Lefler, I have been blown away by how fast these practices have flipped. So we had practices that went from, you know, predominantly in person, perhaps some home visits to, you know, 60, 70% telephone, telemedicine, tele-anything types of communication with their patients. Again, reducing the well visits dramatically to free up capacity for other things. Things like this location is where you are sick. This location is if you are well, because some well visits do have to happen. We still are immunizing babies. We're just newly born. We're still taking care of, you know, various individuals who need to come in. So splitting those people apart. We have sample collection at a lot of our health center sites. And we've been working with the Department of Health to set those sites up in locations that are strategic. And then we don't have any testing capacity. So we send those samples to places like the medical center or the state lab, so that those can get processed. Additionally, many of our practices have dental capacity at the direction of the dental society and the governor. Those dental practices have closed except for emergency purposes. And we're working with the dental society and others to make sure that those individuals who have emergent dental issues that those are managed in an appropriate way. Finally, to the point of PPE, there's never enough. So similarly to Dr. Lefler, we are doing what we can with what we have, you know, similar behaviors of you get one, not use it and dispose of it and trying to work with the state. And also frankly, a recognition that given that there's not enough PPE, the state will distribute the PPE they get in a certain way. And that might not always mean that every site for one of my members gets PPE as the first priority. And that is understood and recognized as one of the contributions we're offering to the system. I think the other thing that I would note is we are also engaged in surge planning. And I guess we're the givers in this scenario. So our health centers are working with their hospitals with the different setups that the state is engaged in. I think for those of you who saw the press conference yesterday with all of those various locations, you know, where is it best to send our workforce, you know, they need to keep some, right? Because part of the role of primary care in a surge is to keep people away from the hospital who don't need to be there, right? We want to, I joke that I'm making sure my son doesn't break a limb so that we don't have to end up in the ER or urgent care. But kidding aside, we really need to keep as many people out of the hospitals as we possibly can. So that's, I think, a key role that we're serving and planning for and prepping for. I also wanted to address a couple of questions that I got in advance. And those relate to community health center and FQHC. So not to go down a word salad rabbit hole, but a federally qualified health center is designated and regulated by the federal government. It is federally qualified and obligated to do certain things. I won't go into all of those details, but it is defined in statute and in agreements that these organizations have with the federal government, along with the regulatory burden that they bear and the obligations such as taking care of everyone, regardless of the ability to pay, having a sliding fee scale and 92 other obligations. They do get grants from the federal government. So they kind of have this base amount of money that comes into them that is intended to help support the discounts that they give to patients from their sliding fee scale and other administrative duties with compliance. In addition to those organizations, there are things called rural health clinics. A rural health clinic is also defined in federal statute. And those are entities whose parent is a hospital. So we have many rural health clinics in Vermont as well, but those are different and regulated and governed differently than federally qualified health centers. So for example, getting to the second question, the federal government in stimulus three, the CARES Act has an appropriation for federally qualified health centers that will go to the federal regulator at HRSA that only benefits federally qualified health centers and does not benefit rural health clinics or other non federally qualified entities. The, to put a fine point on how much Vermont would get for its health centers from this funding and how those dollars are likely to flow. Those dollars, as I said, go to HRSA, which is the federal regulator. HRSA then historically and by historically, meaning in the past year, they will give the money to the health center, put it in, there's this kind of electronic reporting system that they use and say, the money is now available for you health center to draw down. And then they require the health center to give them a budget for how they're going to spend that money. They have to report on how they spent that money. They have to do a work plan for how they're spending that money. And depending on the rules that HRSA applies to any given dollar will dictate how those dollars can get spent. So for example, HRSA in this case could say this money is for you help federally qualified health center to pay for COVID response preparedness and recovery. You cannot use it to for general operations. You can only use it for COVID-19 related expenses. We do not yet know what the regulator is going to say those rules of the road are. What I can say is the financial fragility of our health centers and other health care providers and our hospitals is pretty severe when you get rid of all of your well visits and elective procedures. Your revenue goes down pretty precipitously. And our health centers have lean budgets and lean margins to begin with. So I do not think the federal money that is coming will come anywhere close to filling their need. Either from a cash flow perspective or from a, you know, come out on the back end completely. That said, I think they are unfortunately similarly situated to so many Vermont health providers where, you know, bottom lines are lean. And we've got a lot of folks working really hard right now. So I will stop there. I think before I open it up generally to questions, Dr. Lefford, I wanted to ask you to, but we heard this morning from Vicki loner at one care. And I wanted to ask you to share your thoughts about that process with one care as well. So it's actually interesting that the all pair model and fixed perspective payments could actually be one of the things that are most valuable in this time because having a guaranteed predictable revenue stream through this over the next three, four or five, six months as this goes on, could be critical for keeping us able to function normally. So I think that's one of the things that we're going to be able to do for keeping us able to function normally. So just like Georgia told you, we think we're predicting that we think about half of our monthly revenue is going away. And I hate to tell you how big that number is, but it's giant. And so having fixed perspective payments from Medicaid from Blue Cross and from Medicare that would be based on what March 18 look like would be incredibly helpful to the hospitals that are participating in that system. And I actually think in many ways that Vermont could set the course for the country on a model to get through this, meaning if we got those dollars, even though the work that we're doing looks quite different, that would allow us to pay our staff to keep things going because that revenue stream would be the money we need to do those things. Exactly as Georgia said, Vermont, you know, we're a very regulated healthcare system. That's not a bad thing, but that means that our margins on the best of times are very thin and every health part of the state right now has to be losing money. Some of it incredibly lost is because the parts of the business that we do that actually are burners our margin. We've stopped all of those. We're not doing anything right now that earns margin. We're only doing the things typically that we would do because you do them because it's part of your mission. But most all those things were losing money on. So I think one care is a huge opportunity to use that for the good of the system. So Vicki mentioned, I don't want to just dwell on this, but she mentioned that they are working with. The agency human services and the. I'm spacing out here and the signatories to the all pair agreement to approach Washington to get further waivers on parts of the waiver, if you will, really so that my monies can flow more easily or so that some of the advanced payments can even be advanced. And while that hasn't been responded to, we look forward to seeing if that's possible because that could enhance the. Ability of one character and the all pair model to be responsive. Once again, I think it could be a great model for the whole country. If those dollars could flow with all and Vicki and I, and she's been talking to all the different hospitals, if the waivers that she's asking for came through, that would have a huge stabilizing impact for the hospitals. Okay, I think I'm going to open it up to questions at this point, because there's lots of different directions that folks might want to want to ask questions about. And I see represent. Cortis, who of course is also a. One of one of your staff at the hospital. So represent Cortis. Nurse Cortis. Hi, Dr. Leffler. Thank you for joining us today. I want to thank you for the hard work that you and the rest of the network have done. My own unit and cardiology. We can feel it. And even though our unit is not an identified COVID unit because of community spread, it's still. As I know, you know, incredibly nerve wracking for staff. I am. And it's hard for patients to not have any visitors at a. A critical time in their lives, but I thank you for that as well, because it's protecting everybody. Thank you also for the addressing the bus issue that was a huge concern. And I'm glad that we're able to park on site now. So my question has to do with the. As the hospitals, but I'll just speak about ours, because that's the one I know prepare for the surge. We are redistributing beds and not actual beds, but opening up beds, for example, in, in our unit. To take patients from other units so they could be COVID units. This is causing downstaffing. And so that's what we're trying to do. And that's where staff can either use their earn time off or. If they don't have her in time off, they can go into a negative balance and pay. Pay that back later. They also can't be. Some people are being laid off, but people that don't want to be laid off. They don't want to be laid off. Particularly per diem. So the paid sick days that came down from the federal government. Apparently according to UVM health or UVM. Medical center HR department. People that are per diem don't qualify for that program. So I just want to toss that out to you. And if you, if that's something that you need to answer later, that's fine. It's not about how you're paying the care to the health care. When they're advertising, not getting laid off, they're just not getting paid. And it sounds like they might not qualify for the federal. Two weeks of paid leave related to COVID or child care closure. Thanks for the question. It's really important and we are understanding and sympathetic of the impact it's having on many people in Vermont whose work looks different or may not have the same amount of work. So when you stop everything that's elective on that has an impact on your workforce. And so we're trying to like everyone else to balance dollars coming in with expense. We did do a couple of things to try and blunt some of that impact on our staff. Everyone within the UVM health network makes $99,000 or less out of weeks pay. Across the board, that was to help people who are working very hard at this time be rewarded. And that was to help everyone who might get furloughed, which is what we're calling it to survive that. We're letting everyone go up to 14 days negative on their CTO. And we have a sign up program so that people who want and are able to work can be redeployed into different jobs. And we have every day now more opportunities for people to do something different. But everything Mari said is true. We are moving people around the floors. We're trying to keep a floor ahead. So every time we start putting COVID patients on to a new floor, they're on three of our floors today. We're trying to have the fourth floor ready so that if tonight or tomorrow morning, we had a big surge of patients, we'd have a place to put them and we have staffing there and ready. So I don't want to minimize this has had impact on our staff. But we've tried very hard to make it as soft impact as possible. And we're working on some more things right now. But like every other business are revenue is way down. And we're trying to at least manage our expenses to some extent the ability that we can. And that means that some people are not working right now using their CTO, using their extra week of pay if that's how it has to go. And you're right per diems are tricky. We don't have a full answer for that. There's not an easy federally answer and there's not an easy HR issue to how to deal with that but we are, they are able to sign up for different work if they're able to do that. So we're going to do more. I want you to know that. Thanks. I just want it sounds like you got the per diem question and Yeah, let me know if you get an answer. Thank you. Yeah. Sorry, I have to represent. Hi, Dr. Lefler. And as you know, I represent as extension and we're just a couple miles away from Fannie Mae or Fannie Allen. Sorry. I'm just posting in one of the local torch forums here and I just want to make sure that I have the right information so I can share it with our community but the posting indicated that if you don't have a primary care provider and you feel you need to be tested you can walk into Fannie Allen. I want to be clear that what what the truth is my understanding is we're not recommending people walk into anywhere. So the last part of your statement is true. We're asking people not to just walk into anywhere. The system works best. If you have a doctor that you can call to help you decide. And the next hour talking about testing. I should highlight that there's been a great collaboration, a really good Vermont collaboration between the Department of Health, the UVM Medical Center, and the medical school to keep us having enough testing to keep us going. So, without this collaboration, we will run out of tests in the state of Vermont last Wednesday. But our researchers at the College of Medicine and the Medical Center, our research are actually able to build test kits, build reagents test test them make sure they meet quality standards. And our researchers have actually added 4000 tests the capacity in Vermont. And through that collaboration, we've really been able to speed up the how quickly we're getting results back so we're getting almost all our results back now in within one day, which is much better than many other places. It's been it's taken a lot of work and money. We're flying some of those on a charter every day to Rochester Minnesota to Mayo to do some of them because we can't do them all in house but we're improving on that on a daily basis. So to answer your question specifically. If you don't have a doctor, but you think you need to test. You should probably call walk in first before you just showed up there. Most people do have doctors though. And we are not testing on demand yet. We do not have enough tests to test anyone anywhere shows up. And we're honestly probably still at least a month out from that. Because that requires many, many, many more tests than we have and increase testing capacity and while our testing capacity is improving on a daily basis right now. It's far from testing on demand for anybody who wants one. Okay, thank you and just one other quick question with the changes that you've made within the hospital. How many ICU beds do you have Normally have 43 ICU beds split evenly between our surgical intensive care, which also has a couple pediatric intensive care beds in it in our medical intensive care. We added on 26 more yesterday. So we have 70 that we could use tomorrow. And we have 70 ventilators. So that's why the numbers the same. We ordered more ventilators states trying to get ventilators in a worst case scenario. We could probably manage around 100 ventilated patients. The truth is at that point it would be staffing that would be as much of a limiter as ventilators, because you're going to need a lot of people to manage that population. But we think we could do around 100. But that would put Vermont in the New York City type of situation just. Yeah, so we think we've got about 100. Okay, thank you. Representative Murphy. Yes. Dr, you mentioned the good news that the hospital has discharged two or three patients. Is that right. Yes. In thinking about capacity for the system or for your hospital in particular. Wondering, is there any way to get a handle on or quantify what the average length of time is that a patient who's going to recover will be in the hospital. That's a fantastic question. And I think that's how sick you were. So, we've been able to check discharge people who are moderately sick. We didn't require reading a ventilator. And so they needed some oxygen for a short period of time or some fluids, and they'll probably be go home and they'll probably feel sick for three or four weeks, not up to themselves but most likely after that get better. The ventilator, meaning their lungs were much more affected by this will have a very long course to getting back to some someone's a normal is this virus is particularly hard on people's lungs if it gets in there, it causes a lot of damage. And I'll be honest, we don't really know yet how much of that will be long term permanent, but it's not insignificant what it does to your lungs which is why it's so hard to get people off the breathing machine because if your lungs are hurt enough, need to go on it. It's hard to heal. So it's a great question. I would think for this is a guess. So please take it as a guess for most people that come in that are, you know, moderately sick but require hospitalization, probably a seven day stay. And if you have to be on a ventilator it's probably a 20 to 30 days day, but those are, you know, best guests. Good thank you. Dr. Rogers. Yeah, thank you. I have a question I'm not sure if you would have the answer to or not for Dr. Lechler. I have a constituent who would like to donate a CPAP machine and he heard on the news that they could be used as a as a respirator in an emergency. I'm just having the most difficult time ever figuring out what to recommend to him as to how and where and if to donate this. Do you happen to have any insight on that or are you not the right person to ask. Well, I shouldn't be the right person I should have an answer. Do you have my email. I'm sure I can get it. If you send me an email I'll figure out who the right person to take that is a generous offer and we can figure it out. Another communication about in 95 masks has been all about donating through the local state police. And I, and I haven't found anything about whether that extends beyond in 95. CPAP machines are interesting and they meet, we may not be able to take them because they sometimes harbor bacteria in them, but it's worth looking into. Okay, thank you. Okay, represent Smith. Brian, you need to unmute yourself Brian I think you're muted. Brian you're muted. Can you hear me Dr. Lechler. I would like to compliment the hospital there. Before I ask you my question, you saved my brother's life 20 years ago and that that left a lot in my heart so thank you. My question to you is, how many how many people have died from COVID-19 in the hospital in Burlington. Two. Two. Two. And how many in the state right now is it seven 60 to 17 I believe. Did it go up again. I think it's 17. How many people died from the flu, the regular flow. Significantly, significantly more. So in a typical year Vermont will have 500 to 1000 something like that. I was just curious because I think this is a very serious virus, but the flu is also a serious illness as well, isn't it. So, I will tell you that we get that question a lot. But what you have to realize is the way the flu hits an area and the way COVID virus hits the area are vastly different. So, with the flu because many, many people get vaccinated, and many people have some immunity from last year and other years we've had the flu. The flu kind of comes in and we get a number of cases starting in November, we get a couple in December we get some in January, and Mario knows this and we'll have the flu from November to like say around May, we get a sprinkling of cases. Every month and a couple of those people get very sick. So our intensive care units could certainly have one person who has bad flu that's get on a breathing to rarely to never 10. Because our immunity from vaccination and from having it before spreads it out it's naturally like a tool of social distancing you think about it that way. COVID is completely different, because no one that's up in this call right now, as any immunity whatsoever to this virus, when it hits our area it hits all at once, and it makes all of us sick at the same time. And so, if we all got sick at the same time and a couple people here for five of us got very, very sick, we wouldn't have this, our system is not designed to take care of a surge of patients like that. So social distancing in my mind is it works sort of like vaccination, slowing down the number of people who catch it at any one time, so we can care for all of them. So you are exactly right in any one year, who does kill oftentimes more, but the number of people you look in your city today with their health care system looks like it's completely crippled by this virus, because so many people are sick all at once. So it's not exactly a fair comparison, although I understand your numbers. Thank you very much. Give up the great work. Thank you. Representative Houghton. Georgia, I have a question for you actually going back to the concept of someone doesn't have a primary care. Could someone in our community call not walk into the Burlington Community Health Center and become a patient. It's a little complicated whether they become a patient. But yes, they because they have to willingly want to become a patient of a practice, but, but yes. Any of our health centers actually, you can call and be triaged and screamed, regardless of whether you're insured or uninsured. I believe that it may, there might be some centralized call center right so some physical sites might be only doing, you know, well visits or telecommunication right so you can't always go to every door and knock on it. But my understanding is that you can call all of them. And in terms of weekend coverage because COVID doesn't wait for a Monday. All of our practices do have their usual on call emergency triage systems over the weekend. And we have found that that so far has been manageable for the folks who've been calling who needs services. Thank you. You're welcome. I'll just add, I'll just add to that that was a, I should have thought of that our FQHC in Burlington has been a great partner on this in they are able to see and screen patients down there and get them tested they need to so that's a great option, Lori. And thanks for reminding me. Yeah, anytime. I'm going to jump in here with a question I see there's several other hands but I'm going to jump in with one from of my own which has to do with access to what in other times we would also consider critical care but non COVID related such as friends who have needs for oncology, who are really seriously ill with cancer and require treatment of various types and concern for whether they can access that care in the midst of us changing our healthcare system around to respond to COVID-19. So that's a fantastic question. And I want to assure everyone on the call that we are absolutely still here for other critical health needs. So our operating rooms are still open. Every day, doing cases for people have cancer, getting car accidents will fall and break their hip who have need heart surgery or neurosurgery we're still doing all of that. We're doing less than before because we're only doing the emergent and urgent cases, we're protecting some of our floors to provide care to those people who need it because your question is a good one. COVID virus doesn't protect you from cancer, or from a car accident, or many other things we're still delivering a lot of babies, babies are still coming. And so we have built that into our plan. And we have surgeons and specialists on call, including a three day call schedule for everybody for some are very, very essential and rare providers think like a pediatric surgeon. We're keeping one at home and one here so they don't both wouldn't get sick at the same time if that if that happens. So we have extensive call schedule to manage that we have parts of the hospital that we're going to keep COVID free. And we are well prepared to take care of people who have all the normal health needs that happen anytime. Thanks for asking. And I would just add to that. Again, also appreciation for our local hospitals and other independent specialists that our primary care network is working really closely to manage everyone they can manage because to your point yes, things are happening every day medication does need to be refilled. And also we are anticipating that we might have had a lot of people with some of these chronic conditions that are that are managed so intensively are not seeking services right now, but that can't go on forever those services will need to happen. And so we're working with our colleagues around the state including the medical center to make sure that access to those specialists happens that we can get those prescriptions still going that we can get in if we need certain urgent or emergent hospital care during a time of surge so. So just to say that I think the healthcare providers are working on this and continuing to work on it because it. Because everything else does still have to be taken care of. And the last thing I'll say is that we have plans for people who are COVID negative who have all the things you listed, and we have plans for people are COVID positive. So we can, we can provide surgery. If you're COVID positive and need it. We can provide cancer care if you're COVID positive and we have built that all into our search plan. It's there. And does this include the hospital continuing to provide inpatient psychiatry, psychiatry, psychiatry services. We have inpatient psychiatry patients right now and we will have them throughout this event. Thank you. Representative Donna here. Thank you. This is something that came up actually in testimony to a different committee, I think, yesterday. From someone from Green Mountain. Advocates just folks with intellectual disability. And this was I know based on some actual written policy that had media from another state about protocols, if triage became necessary in terms of access to respirators. And then identified lower priority group. Are there any policies in Bermont or EVM MC that protect against that kind of policies. And we're finishing our policy right now on for a worst case scenario. And it's been actually built through our ethics committee. So we've had our ethicists completely involved in that and work to be certain that it's completely fair and balance and offers the same level of care for everyone and use the same guidelines for how we manage it. Thank you. Representative Cordes. Okay, with my headphones on. Okay. I'm wrong. I don't think we can hear you, Mari. I'm not hearing you. I don't know if it's the headphones, but now I think maybe you can hear you better. Yep. Dr. Lefler, please correct me if I'm wrong, but on the question of people that don't have primary care providers. Health network UVM medical center on their website has an option for when you're looking, searching for primary care providers. You can click something that will filter in all those providers that are currently taking new patients. I've been sharing that tool with constituents looking for a primary care provider. It's another great option. Thank you. Yes. I don't see any other hands right now, but this is. So, again, maybe we're asking Georgia, you and Dr. Lefler to go a little beyond your immediate responsibilities, but I heard the other the other day in response to a question that it was like, well, if you don't, if you need to have find a primary care provider called 211. And I'm concerned that I felt like I thought that I heard previously that our 211 system was fairly overwhelmed with the range and amount of questions being directed. Either you have experience with whether one can successfully find a way to primary care to 211. Georgia, do you have any idea? Yeah, I've not heard of anything positive or negative about going through 211. What I would say is, I think we heard a couple better options up just on the committee call. Our community health centers typically are fantastic about getting people in. Mari gave a good opportunity. I agree there's ways to get people plugged in and we have room right now at the medicine for telehealth visits so we can get people plugged in, I'm pretty sure. Another place actually that I do know is a very good source for getting folks in is some folks are calling VCCI and Medicaid if they're uninsured. And that actually is a really quick, you know, warm handoff type of way for folks to get connected as well. I'm confused by VCCI. It's Medicaid's remote chronic care initiative. I don't think it's an acronym that most people are using every day. Sorry, I'm trying. It's Friday though. Yeah. Okay. Great. Not seeing any other hands. I'd like to raise another question. I think it came up earlier and that is access to end of life care and hospice and whether the respite house is, which I think is affiliated to the network. It is. And through the, well, what we used to call V&A. Can you give us any sense of what's happening in terms of access to hospice care and end of life care? Yes. So I was actually on a call this morning with Home Health and Hospice, which is what the V&A used to be called. And the respite house and the respite house is actually pretty full right now with their routine patients. We had an almost an hour phone call trying to decide would we try and keep it COVID free or would we shift it to being a COVID site. And there's a little more work to do on that, but the general feeling on the phone call was that if we kept it COVID free, that'd be a little easier to manage. And that would give our patients who didn't have COVID virus their normal opportunity to use the rest of the house if necessary. Like every single other thing we've talked about today that could change depending on what the next three to four weeks brings. But it's there. It's available. It's accepting patients. It's providing exceptional end of life care. And we also do have other options for people who are COVID positive to get good end of life palliative care if they need it. We have our palliative care doctors who are providing it both through telemedicine and even some on-site visits when that's appropriate. Representative Christensen. Along the same lines, but even deeper than that, if someone refuses to be intubated, an older person, and if they knew that this was, they were probably going to die if they weren't intubated because they were older, their chronic conditions. Is there the death with dignity pill or how do you, because I understand it seems like it's a very uncomfortable way to die with not breathing. Is there, I know there's usually such a long, a longer process for death with dignity, but what's with that? So this wouldn't be a typical death with dignity type of patient because it's going to be much more acute and quick than that. But I know that the nursing homes like Brogdon and rehab have had a good mechanism for making sure people aren't uncomfortable at the end of their life and are managed well. And so we have specialists and experts, we have medications, so if people make the decision that they don't want to be intubated for this, we have very good tools to keep them comfortable to help them not suffer at the end of their life. And if someone was in that same position and was wanting to die at home, would hospice also have access to making them comfortable to such an extent. So my understanding is that hospice right now does have capacity for home visits for palliative care that could change but right now as of today they do have capacity. Okay, thank you. Thank you. I'd like to echo what others said and thank you both for all the hard work you're doing right now, responding to things under pressure. I have a few questions people were talking a little bit about people choosing to go off of life support, but we're seeing in some places in the world situations where providers are being put in a difficult position where they actually have to choose who gets life support or not. If the patient doesn't have an advanced directive or some kind of guidance, then it's going to be up to the providers to decide whether who gets who gets the resources and it sounds like you've done a lot of work you in the plural like the community to prepare for a surge and hopefully we won't get to that point, but we have heard that there's around the world and different settings different processes in place with ethicists to just to talk about how you'll make those difficult decisions and I'm wondering if you could share a little bit about the process locally. The first thing I should tell you is that we do mass casualty drills, once or twice every year, just as part of normal course of operations, and sometimes the mass casualty drill is a pandemic. Sometimes it's a plane crash or a train wreck or other things, but we do one of these every every at least twice a year. And part of that drill is how you manage with scarce resources and you don't have enough of something. How do you make a decision on who gets what we're in that situation now where that could become reality. I mean, I've personally done those drills for, you know, many, many times but now we're in a situation where we are seeing in some places now, they have to make those kind of decisions. So we took the policy that we have already had to pull out. If there's suddenly a plane crash and you wanted to put that policy in place, and we've made sure that it fits well for the current situation that we find ourselves in. So there are clear, but the tricky part is that it looks different minute by minute. So if you know what's going on upstairs and how many ventilators you have in use, and you have 10 people sign up to show up and you only have two, that looks a little different than if 10 people show up and you have nine. But we do have a very clear plan for how we would go about that, both if you have no time to make decisions so you're asking your ER doctors to be out there doing it quickly. And if you have more time where you can actually pull the ethics committee together and work through the process. We have it fully laid out. It doesn't just up just to follow up like, and I don't necessarily expect the detailed answer now but is there in that in that in the process that's used to make those decisions is their transparency, like after the fact will the public be able to know why you chose this person over that person. And I only asked because there might be people out there who, after the fact wonder, you know wonder why things happen the way they did. It's a great question. I think it sort of depends if we're in scenario a or B. So in scenario scenario a when you have 10 people showing up and they're all out, maybe out in the parking lot of the easy could be in that situation. And you're literally asking your providers and we're trained for this emergency medicine physicians are trained to make a rapid triage decision on who appears to be in a situation that they can survive or not, and how to quickly start that out. That might be an on the fly decision as you're running down through 10 people. If the data around that might be thin, but the second scenario where we're going to take some time and pull the committee together and ethics is going to work through that. That will be all be completely documented in the medical record with decision making and reasoning and how the decision was made. So that would be our goal every single time, but I want to be realistic if it literally we're out in the parking lot and we're overwhelmed with cases. You might be making decisions so you're not even documenting them until later that night or when you can represent Rogers. Thanks. Yeah, I just wanted to briefly follow up on that that's helpful information and if one of if a member of our committee were to want to kind of go a little deeper into understanding what processes are being talked about right now and where the status of all that is who would be the right person to be So I'm Dr. Tim Leahy is the person who put the policy together. I'm pretty comfortable the policy could be shared I do want to be clear that we don't want to scare the public don't want to have people freak out about this. I still at this point I'm optimistic that the things that we're doing in Vermont are going to help get us through this and we're not going to be in that terrible situation. People burn a lot of energy worrying about something that I'm hoping that we were prepared enough to make less likely or unlikely. But we have written the policy we do have it in place because we have to be responsible. We have to have this laid out so that there is a clear way we're doing this. That's helpful. Thank you. So. Okay, I see representative China has a question. I just want to express a concern to the healthcare leaders who are here that part of one concern I would have and it's a concern I've heard from constituents. It's a concern that we normally have in the healthcare system that gets amplified in a situation like this which is the disparity and treatment for people in the healthcare system based on different factors like we talked a bit earlier with witnesses about the treatment of migrant workers. I'm not talking about the treatment of people of color specifically or people of poor people. So just the concern would be that in in that process that there's some analysis of the implicit bias we have in those moments, just so that we have some confidence that in that moment the choice is going to be grounded in some criteria. It's not something implicit that someone might decide, you know about who they would save over someone else so it's the if you want to speak to you can but I'm not asking for a question as much as expressing the concern that I've heard from others. So thank you for asking. I absolutely promise you that all those things are concerned about. There's no criteria like that in the policy that would make you more or less likely to get a breathing tube or a ventilator. It does occur to me that as we're talking about this. I would encourage you to invite Dr. Leahy to talk to this committee. He's extremely knowledgeable, and I think you would learn a lot from him and I think you'd feel very reassured at the end of that phone call that we have thought about all the different scenarios and so. If you need help with that representative of the product could help you set that up if you like I think the committee would find it potentially very valuable and enlightening. Thank you. We'll follow up represent Houghton. This conversation has been really Chittenden County focused because of obviously where you're located. But I'm curious if you can speak to your thoughts on how the whole state hospital system is preparing. I'm interested in hearing feeling really good about what's happening at UVMMC and I really want to make sure that others can feel the same way about their hospitals and if you can't answer that please say so. No, I think I can give a high level and I think Georgia probably can add to that as well so you should know that every single day at four o'clock we have a health network phone call that includes border hospital center want medical center, UVM medical center in a couple of our New York partners but Roland hospital has been joining that call. So there's every single day, seven days a week now we're coming together to say what we're seeing what we need. How can we share all different kinds of things across the state to make sure people have what they need. So for us, having three calls per week in the morning also share all kinds of information to be sure that we're ready. So, I think that we're as coordinated as I've ever seen and I think Georgia said that in the first part of her call. There's a lot of work going on right now to make sure we know where people are at and how we can help each other and get through this. I'm happy to let Georgia have a couple seconds to but there's a lot of work going on to make sure everyone has. Thank you. Yeah, I think similarly, in addition to the kind of cross state hospital conversations or cross state health center or cross state designated agency conversations. One of the health associations actually get together every single morning to make sure we are connecting sharing information, making sure that our folks all have the up to date information because you know the our long term care facilities are home health right you know, these are critical parts of our system, generally and right now in a very acute way. Additionally, there are local community conversations that I think one of the things that was said to me was, you know, the local fqc in hospital had never talked more they're talking three times a day with each other to make sure that they are coordinating. You know, for example, discharge planning right that's usually a very thoughtful process that goes through normal considerations and now those those normal rules are probably going to change because the environment is changing so much. So I want to make sure that you know someone does get that warm hand off in the end. You know, and I, I can also say having sat on some of the calls with the Department of Health and with some of the hospitals around the state that I have a high level of confidence that folks are communicating, which is the first step to really getting all of this and also, we are making plans to to move things to where the need is most, which I think is a key piece right so chiming County there's a high level of need right now. Because that's where our population center is, you know, but we have the ability to shift things around should they have to and the things being the PPE, the mobile units and the people. And then importantly, and then also with the advent of all of the telemedicine and telehealth technologies, we've opened up the ability to more quickly get our resources where they need to be so you can't plan for anything but I think we're to Steve's point I think we're in a pretty place we've, we've done a lot as a system. We've had the, I guess I would call it luck of getting to see what's going on in New York City and taking every day that we're getting from from that to get more prepared here so I should tell you that we have colleagues down there we talked to them on a very regular basis to understand what they're seeing what's happening, what lessons could we learn, how can we be more prepared and so that's informing what we're doing, I guess, part of the way we knew how to get people off the ventilators we learned from them. And we're learning how to make sure we're as ready as we can be to get the time really we're using it every minute of it. For sure. Any questions represent Christian sin again and then represent page. I assume to since you're such a large hub there and Dartmouth is in the southern part of the state where I live. I assume. I should assume nothing. Are you in touch with Dartmouth and the two states, how do they differ are the big differences in how treatment is given or preparing or so. Dartmouth and the UVM Medical Center are extremely well aligned and how we're managing our PPE, how we're screening people how we're treating people we talk on an almost daily basis. We had two interactions yesterday with Joanne Conroy, their CEO, making sure that we stay aligned and how we're doing that and so I mean Dartmouth cares about a third of their patients they see at Dartmouth or Vermonters. And so we are fully aligned and coordinated and we would share all of our research we're committed to sharing all of our resources, ventilators and so on. The care pathways and plans are similar. Dartmouth's in a little different situation than us because there's a lot of hospitals in southern New Hampshire, you may be able to spread out some of the tertiary critical care needs a little different than us, but the other side is northern New Hampshire. They're it. So there's similarities and differences, but we're very well aligned and talk at least a couple times every week if not more. Okay, thank you. I would just add that by state being a two state organization focusing on New Hampshire and Vermont. New Hampshire has similar plans to Vermont's they have a lot of regional and county focused efforts so we've done a lot of you know complete state statewide to statewide in Vermont in New Hampshire they've really carved up the state by the different regions. However, you know each of the hospitals is connected and to Dr. Lefler's point, you know Dartmouth is the tertiary care for the North country. And then also I know that there's been good collaboration all along the upper valley with the hospitals and the health centers and other providers that cross over where their population really does doesn't notice the barrier of the Connecticut River. And you know what, what makes me happy actually about New Hampshire and Vermont is when one makes a decision the other state does and vice versa so they've really been in kind of tandem all along this which is just really nice to make sure there's that continuity of care in those states. Okay. The representative page has a question and let me just say that Dr. Lefler and Georgia have been very generous with their time with us. And so I think I'd like to suggest that we, unless there's a burning question that we bring this to a close for them so they can go on about their day with the other pressing work that you're doing. So if you have a, if you really seriously if there's another question that you feel you want to ask before we finish please raise your hand immediately and in the meantime, represent page why don't you go ahead with your question and then we'll bring this to a close if I don't see others. Okay. It seems like the general population is in very good hands with with UVM and our hospital network. But I was wondering what are your plans and how they may differ for dealing with the prison population in treatment. So a fantastic question. I wish I could tell you we have it all worked out. I'm working with that so in a perfect world, you keep as many of them as possible in at the jails and care for them there and only transfer ones who are very sick to the hospital. I think if we do that, we probably can manage the very sick ones like we do the rest of Vermont population. We haven't made it through that plan yet. We are working on it. But I think you have to think about it as right now that's their home, and we have to try and care for them there. That's that we can. We don't have capacity anywhere in our health system right now to totally empty that system out and put them somewhere else. I mean we're tested on that right now the nursing homes. So, work to be done there. Okay. I want to express my appreciation to Dr. Leffler and Georgia, both of you for making time available for our committee today I know you spent time with the Senate Health and Welfare Committee. If I can just say, maybe just pose this question and help you help us think with you for a minute. Our committee is going to continue to meet throughout this going forward because we feel like of all the committees of the legislature the health and welfare and the health care committees really do need to continue to be a point of information for the public and for our colleagues. We're concerned for the financial well being, as well as the physical and mental health well being of all the all the staff the practitioners the health care, the health care workforce we're very concerned about. We were concerned about the health care workforce challenges before we any of us knew what COVID-19 would have meant. And so we have a lot of work to continue to do. My question, both for Dr. Leffler and Georgia is, how can we best in this next period of time which could include a surge, how can we best stay in touch without intruding. So I, because I, we're hesitant to ask for your time. And at the same time, we feel the need to be in touch with people who are leading in this crisis. So if you can give us any guidance that would be helpful and if not, we'll just find our way forward. You first Georgia. Thank you. And I know where to find you Steve. Well I'm at home right now actually so. I'm just joking. You know one thing that could be helpful because I do appreciate the, the need to be able to share information with your colleagues and with the public. One thing that would be helpful is to the extent that testimony can be coordinated so it is to two committees or three committees together. I know that's a lot of pictures on the screen. I think that might be helpful. Just in terms of time commitments, because to your point, there's a lot of, of day of day job work that we're engaged in. I think the other thing that I would offer that I can at least offer from my end is on our buy state website. We're keeping some nice up to date information. One thing is twice a week we're actually sending out bulletins to all of our members with, you know, updated information and guidance we also have special business bulletins we're just really keeping that information up to date so that's a resource to you. And actually when you go to our website you land on the coven 19 page you don't go to our usual landing pages. And then finally, to the extent that we are able to provide information in writing. So I'm not going to talk about peak times. I'm not going to tell you how late I work into the evening but we'll just say, after five. That is just also helpful to know that there's a little bit of, you know, flexibility in terms of deadlines. So those will be the suggestions I would have. So those three are great suggestions. I'm sure I speak on behalf of both of us and all the healthcare providers in the state that we think it's important and part of our job to keep in reminders informed on what's going on and have accurate information. And so I see this as a crucial part of our work to be able to give real accurate information and try and cut through some of the fear out there and anxiety. Please feel free to reach out. I see it as important to hear from your healthcare team. In the short term, all Vermonters right now have a responsibility to double down on social distancing. It looks like it's having an impact. It's helping our hospitals right now. It's tough to do. It's a big sacrifice but right now in the short term, all of us doing that is saving Vermonters lives. And we just have to say that every healthcare provider in the state right now is focused on getting through this surge and pandemic and taking care of these people. But the financial impact is going to have on our system is going to be far reaching. And so we do need people right now starting to think about what it looks like as we do start to emerge from this because it's going to have big impacts. We already had thin or no margins. We already had lots of areas that were difficult and stressful. And so I'm only thinking about it right now about 2% of my time because if I did it would be overwhelming but we do have to start putting some slight energy into what it's going to look like to come out of this. So help us with that. There will be some asks from everywhere on the end of this to get us through because right now we're spending money, however we have to to be ready. Yes, all of us. Well, again, thank you both. We will be putting our attention on how to have this system and frankly tried to help do some of that through 742 to begin with and we will continue to put our attention on how to both get through this as well as to come out the other end on behalf of Vermonters. So again, thank you both. I'm going to suggest that demos. I think at this point. I'm going to suggest that we could go off of our YouTube live feed and that the members could stay on just and I'll share the public this is simply to do a couple of logistical items for our committee we will not be discussing any substantive issues. Off the public record, but again, thank you, Dr. Lefler and Georgia and feel free to leave our meeting.