SmartTranscript of House Healthcare 2025-02-11 - 3:00PM

[Chair Alyssa Black]: Committee, we're back in session. And with us this afternoon is a group of nurses, nurse practitioners, emergency room nurses, people from the a nurse midwife? [Speaker 1 ]: Yeah. As a nurse practitioner. [Chair Alyssa Black]: Nurse practitioner. Okay. And what they're gonna do is talk to us today about their priorities for this legislative session. That will include, and correct me if I'm wrong, workplace violence, certificate of need, and workforce development and retention. Okay. So we are going to start off with Liz Kudo. You just come up right now to see if you can feel it. [Witness Liz Kudo]: I I don't like standing. If I'm gonna stand, I'm gonna walk around. Hi. My name is Liz Kudo. As was mentioned, I am an ER nurse for the past seventeen years. I've worked in ERs at multiple level hospitals, level one, level two, level three, critical access, And I really enjoy what I do, which is being a nurse and taking care of my community members. I am also a director at large for the ENA, which is our national and global specialty organization for emergency nurses, as well as the governmental affairs committee chair. And what really sort of I really appreciate your time. We had a couple of conversations last year, which really led to us meeting for the first time here in November, which has led to the follow-up meeting today, which we really appreciate. So just a little bit of a recap. At least for me, this started at where I am in my career. I currently am also a nurse leader. And what I was watching is where healthcare has gone and where it is going. And for me personally, where do I wanna be in this and how are we gonna survive? I've been watching a lot of my colleagues leave. The lifespan or the burnout timeframe for an ER nurse, physician, NP, PA, anyone in the emergency medicine field is seven years. We are down to seven years. It takes us a really long time to be really good in emergency medicine. And nobody really wants to meet us until you need us, and you want us to be really good at what we're doing. And that's really hard because people don't think about that proactively. You think about it in the moment and reactively. Some big issues that we've all been facing as nurses for years has been workforce. So we're looking at an astronomical amount of nurses being short. We've been looking at nursing shortages for ratios as the patients We have more patients. We don't have an increase in support for nursing, so it's leading to more issues there. And really, that's ultimately coming down to workplace violence. So again, for me, watching the violence in ERs across states that I've worked in and hospitals in this state, It's not something that I really wanted to teach the nurses that I was bringing into my department right now or continue as a culture that's learned to be accepted. So I wrote a couple of letters, started having some conversations with my colleagues, another doctor who wrote a great article and said, What do we do? Doctor. Smith, do we walk away together? Is this it? High five. See you later. I make more money bartending two days a week than I do as a full time nurse. And I think that's something that speaks to what is a problem with workforce retention recruitment, because I have three degrees to be a nurse, and I am none to be a bartender. And nobody really, very rarely hits me as a bartender. And if they do, they go to jail. If they hit me in the ER, there's nothing that happens. So we'll talk a little bit about where we've gone to see where Act twenty four is supposed to help with that, but there was a little bit of a stop gap because our nurses weren't at the table. The nurses that are at the bedside and clinical have not been at the table as some of this legislation is written. So workplace violence is a big one. Again, short term, long term, we talk about how health care has so many issues that we need to look at, transportation, certificate of need, reimbursement, Medicaid. We can talk about all that. And that is so long term, but they all come down to what patients are feeling when they can't get their medication. They can't get access to their primaries. They can't get access to other services they need. And a lot of them end up in the ER. And they end up in the And they end up in the ER and we're already boarding because there's nowhere to discharge these patients to, or there's no resources to get them. And they end up sitting, either waiting for a bed or sitting and waiting until they're clear. So as you can imagine, or as some of you have also shared, it's really frustrating. And after hours and hours of waiting, whether you might have not been able to get in because your kid has strep throat to get to your primary care, you're sat for eight hours waiting to get your kid a strep test. We're doing the best that we can, and we're happy to see you when we see you, but it's not on your timeline. And anyone else that is more emergent, I come up with this little slang. Like, if I'm not running into your room, it's a good thing, but I understand that you're frustrated. That increases the amount of workplace violence that is happening at the bedside for us. And again, that goes into primary care. It's that they've waited five months, six months, seven months. I think one of you guys at our last meeting actually had to leave to get to a primary care meeting because it took them eight months to get to it. And again, long term solutions. But how do we have a little win, which is prevention for workplace violence, to help support us? Because changing the culture and regulating that is really important for right now. So some facilities, it's really wonderful that I've worked at facilities that have put in bulletproof glass. I don't really want to be in a profession where I realize that I need that. I didn't sign up for that, but it is something that was done to protect me for those situations, and it makes me feel better. Some facilities have gotten a metal detector, and that was after a nurse had a knife pulled on her in triaged. A lot of these implementations by hospitals are retroactive to incidents. And to what level of the incident is really how fast some of that stuff goes versus why we can't be proactive. Are nurses willing to strike because they want security in their hospital? They are. That's part of negotiations, is they're saying we want security within twenty four hours. So started having conversations about where to take this and how to make this change. And I realized that I was working in my little county and there were some other nurses and other professional organizations, the ANA, that were working in other counties and the MPA on the same issues. And I said, Why are we all working in silos? We're all nurses and we all want the same thing. So we all came together and we said, Okay, we're not talking about one nurse at one hospital. We're talking about an entire nurse organization in a specialty. We're talking about the American Nurses Association, and we're talking about the VNPA. And to be honest, a couple other groups that we're just kind of waiting to pull in, but they're also just as excited about this work, about how do we level the playing field for us? So I don't wanna leave my hospital someday because we move and go to another Vermont hospital. And I have to work all over again maybe to get a different standard because that hospital has even less security than I do. So what we're really asking is a workplace violence prevention program. Betsy's gonna talk a little bit more about what that would mean in regards to regulation from the state to support that and a standard of what is implemented at each hospital. Because right now, the conversations that happen at different administrative levels about who decides, again, what needs to be implemented is not including those of us at the bedside actually being assaulted. And, again, if we're gonna have nurses here to take care of the increasing number of patients needed or maybe one of you someday, you have to change something. [Chair Alyssa Black]: Thank you. Any questions? No. And you or your organization has some advice for us on what you wanna see and how you wanna see it implemented and [Witness Liz Kudo]: We do. So that was some of the great conversations. And I get it. We we wanna be here. My colleagues will speak to that too. I don't wanna steal their thunder. But the conversations have really been also like, thank you. We've started it, but it's not including us. And the last time we sat down, you said, what do we do? And we have drafted something, and we're going to speak a little bit more about what that would look like. Because looking at what other states have done, there's sixteen states that have implemented this, that, from the Emergency Nurses Association. And in the Alliance, I really want to be seventeen. Okay. Any other questions? I'll let Betsy [Chair Alyssa Black]: Thank you. Any other questions? Okay. Thank you very much for calling in. Yes. Yeah. Betsy. [Rep. Mari Cordes]: I have a second running. It's not that. No. [Chair Alyssa Black]: Before you start, Betsy Yeah. If you people have anything written, just give it to our committee assistant. [Witness Betsy Hassan]: It's it's gonna say. [Chair Alyssa Black]: Then we'll have that complete record. K? If you've already done it, then that's okay. Alright. Let's go, Betsy. Hi. [Witness Betsy Hassan]: So I'm Betsy Hassan. I am currently the ANA Vermont president. And in my professional life, I'm the director of nursing education and professional development at the University of Vermont Medical Center. I'm here to talk to you today about what we propose as our solution. You know, we wanna as nurses, we wanna come to the table for collaboration and solution based. So Liz gave the frame of sort of where we've been, the experiences of a number of our members and other colleagues in the state. And you actually asked us what other states have done this. And so we dove in and found some current legislation that actually came out of Ohio, and it's going to it's been signed by governor Mike DeWine and will be implemented as of April twenty twenty five this year. So we took a good look at that legislation. It was also coauthored by nurses, which we feel is really important and that we have a seat at the table. But really, what it does is provide some system accountability for how workplace violence prevention is done throughout the state. Really, the key provisions, and you do have this document, we've sent it along with the additional, draft legislation. It's really about best practices and what we know the literature is telling us to do, to keep our workers safe. So one, key element for that purpose. Is a security plan to address risk assessment for all areas that healthcare workers are and where patients are. The other is to do de escalation and defensive training plans, ensuring that all healthcare workers, whether if they're in a clinic, in an ambulatory setting, doing triage, or in an inpatient unit, that they receive some element of de escalation training, as well as self defense. There also is an element about supporting clinician well-being. This is really coming out of the Institute of Medicine put out a report about burnout and clinician well-being, and there's a whole lot of literature that's all about supporting our health care workers through things like trauma informed care and support. So this also helps victims as they've been assaulted at work. We know that they file a police report, and it takes a significant amount of time to actually get through that legal process. And then you also have to be rehabilitated to come back to work maybe within the next hour or sometimes, like, the next day. And so we wanna make sure that folks are supported and we don't lose them at that five to seven year mark. We also wanna make sure that it's easy for organizations to invest in these either facility updates, training, equipment that may be needed. We know that there are large scale items, but we know that if we need if we need them now, we need to be able to move quickly. And so one of the things that we'd like to do is offer, have an exemption of all of these workplace violence prevention facility updates, things like ballistic glass, doors that lock, a number of elements, have them exempt from the certificate of need process. We also propose, that these items would be safe harbored from any budget line item expenditures within the Green Mountain Care Board at budget constraints. Then we also want to partner with AHS and other organizations to secure funding and find creative ways to do this as well. Hopefully, there'll be grants that could help with this, and that would be able to speak to some ways that we could also incentivize, our organizations to do the right thing. And we know that they wanna support their workers, but oftentimes when you're balancing maybe a new piece of equipment to help with a surgical procedure versus what we can do to invest in our workforce, those are hard decisions to make. So that is our proposed solution for today, and that's what we're really here to discuss. [Chair Alyssa Black]: K. Any questions? I'd love a copy of that. If you can get a It's on there. Okay. Yep. Thanks, No questions? I have one. Thank you for your word. Go ahead, Melissa. [Rep. Mari Cordes]: I'll just just for the committee and the public's benefit, the there is a bill in the works that represents all of the work that you've heard about so far, and it's in the in the legislative Mhmm. Process. It doesn't have an actual member yet. There's we still have some, fine tuning and questions around the certificate of need part and the exemptions. So it's not a bad thing. It's just we wanna make sure that our attorneys that help us draft the bills, even though most of the work has already been done by this amazing group, the coalition, the legislative council is currently working on it. So hopefully, we'll wrap it up soon and get it actually officially introduced. [Speaker 1 ]: Thank you. [Chair Alyssa Black]: Thank you. Other questions? Okay. Thanks very much for coming in. Catherine Mears. By the way, we're very informal in this committee. We go by first names. [Rep. Mari Cordes]: Okay. Good. Especially with your family. That's wonderful. Thank you all. Such a great day. [Speaker 1 ]: Great. Alright. Well, I'm sorry. Disclosure. [Chair Alyssa Black]: Yeah. This is my oldest daughter. Is this a conflict of interest? She's a nurse down at the dot. [Rep. Mari Cordes]: Right. Thank [Witness Catherine Mears]: you so much. I'm so honored to be here, and thank you all again for the work that you're doing for workplace violence and for act twenty four. We're really excited about that, and you heard from my colleagues how we're gonna move that forward. I'm here to speak a little bit about, workforce development retention. And, mostly, if you take nothing away from what I share today, is to make sure you have a frontline nurse here giving you testimony about anything with health care policy. And that when you develop you're in health care, but when you develop policy, have health in all policy. So speak to the nurses who are in the ERs. I am an RN case manager. I've been a nurse for thirty five years. I, work in the ER. I also have been a school nurse at Waitsford Valley School in Topsin, Vermont or Corinne, Vermont. I've lived in Vermont, all my life, and I live in Bradford, and I work closely with Monique Priestley. She's our representative, which is wonderful. But you need to have a nurse that works at the front line who is currently working, and it's kind of tricky for us. Someone's covering my role right now in the ER, so it and and that's wonderful, and I got that time off, but that's that's how tight things are. In regard to workforce development retention, I just wanted to share some, information with you, which I'm sure you know, but I want to say it out loud and have it here. With our nurse faculty issues with getting nurses who can educate other nurses, to be nurses, we need to have some competition competitive salary. Excuse me. According to the American Association of Colleges of Nurses, nursing schools are turning away more than ninety one thousand qualified applicants from nursing programs, and this is from twenty twenty one because of an insufficient number of faculty. The most common issue schools reported related to faculty recruitment were noncompetitive salaries. According to the Bureau of Labor Statistics, the median salary across advanced practice registered nurses is around one hundred and twenty nine thousand dollars By contrast, in twenty twenty three, the median salary for a master's prepared professor in schools of nursing is ninety three thousand dollars So as a nurse who's been working for thirty five years, why would I leave to earn less money? Today, we had the Vermont State Union Vermont's, State University nurses here from Linden, and they have a fantastic, educator, Carol Hodges, who brings them every year to see us. This is actually our second year. We have had nurses in the past for Legislative Day. It's really important that we think about how we're going to retain nurses and recruit them into education, to be faculty. And and that means competitive salaries, and that means money, and I don't have a good solution for that for you. But the other piece that, again, I just wanted to leave, to share with you again to have a nurse that's currently working at the frontline to come in anytime you are developing some policy. So thank you very much. We've got a great coalition. The other big thing I wanted to share is just to introduce that we have this great coalition with ANA Vermont, the Vermont, nurse practitioners, and, the, who am I forgetting? ENA. [Rep. Mari Cordes]: How could I forget? [Witness Catherine Mears]: I'm emergency nurse. ENA is is all. And we hope to be bigger next year. And, every year, we are getting bigger. And, and nurses will make a difference, and we care. And we're so grateful for all the hard work that you're doing in health care for our nurses. [Chair Alyssa Black]: Thank you. Sure. Questions? Yeah. Go ahead. [Rep. Mari Cordes]: A comment. Just a gratitude. I when I first ran for legislature, actually, before that when I was president of our nurses' union, it was really I I led work, to make sure that nurses were our our voices were heard in the in the statehouse. And it was really frustrating Yeah. That, so few people so few nurses were interested, in in being in playing that role. So it just makes me so happy to and I I crossed the line multiple times in this committee of turning from a legislator listening to testimony to testifying myself because I'm a nurse. [Speaker 1 ]: Yeah. [Rep. Mari Cordes]: It's much better. I'm not the one doing that if it's all of you. So I'm just really grateful. [Rep. Leslie Goldman]: And thank you. We want more nurses. Yeah. Very good. [Rep. Lori Houghton]: So on a similar note, I'm gonna expand on what Laurie said. This is my fifth year. I am a nurse practitioner, thirty seven years in primary care, and I've been sad at the lack of voice of nurses at all levels. We know the physicians have a very strong voice. We know the hospitals have a strong voice. And now I'm really excited to know that you are going to have a strong voice. So thank you, and I hope you keep building. [Witness Catherine Mears]: We will. Thank you so much. [Rep. Mari Cordes]: Thank you. It's crucial. [Chair Alyssa Black]: Other questions? Okay. Thank you. Yeah. And Mary. [Rep. Mari Cordes]: You just did a good job, dad. [Chair Alyssa Black]: Well, I'm gonna have an evaluation. Wait a minute. Is [Rep. Mari Cordes]: that what you say when she's in trouble? I like the discussion. [Chair Alyssa Black]: I said Okay. Bridgette? [Speaker 1 ]: Oh. Oh, I know we said [Witness Brigid Nienbries]: we were informal, but I'm going to use my honorific. My name is doctor Brigid Nienbries. I'm a doctorally prepared nurse practitioner. Currently work at Gifford Medical Center where I oversee a primary care panel of more than a thousand patients. I work in two rural communities. One of those communities is very isolated, that requires driving over one of three different mountains. I'm the only provider in the area when I'm working. One of the things that I wanna talk to you today about sort of ties into all of these themes. As nurse practitioners and working with the Vermont Nurse Practitioner Association, we really wanna be at the table and have a voice in helping advocate for our profession, for our patients, and for the Vermonters that we have the privilege of taking care of. One of the themes that I think that has been brought up is access to care can be a tremendous challenge. [Chair Alyssa Black]: And [Witness Brigid Nienbries]: it can be a tremendous challenge in a rural state for a lot of different and complex reasons. Some of those are holes in primary care. Some of those are transportation issues. And I think that we all know having had a recent evaluation of the system that's been done that we have a lot of work to do to make the health care system sustainable. Additionally, some of the barriers that we have are difficulty with workforce retention. So the clinic in which I work in when I started two years ago, I was without RN or MA support for a total of eight months. So the patients that I was caring for had myself and a office manager who were able to provide support, and it was simply because we could not find staffing to staff that clinic. So developing our nursing workforce is essential, and having that nursing perspective at the table that looks at people in a holistic way is also absolutely vital to the health of Vermonters. Some of the things that VNPA has sort of identified that we would like to be interested in helping shape going forward. If we move ahead with the AHEAD model, we wanna make sure that we have the correct waivers in place so that nurse practitioners are allowed to work to our scope of practice and to be able to care for patients as we have been taking care of them in in practice norms. So that's important. There are a couple of waivers that we've asked that the Green Mountain board consider that I would invite you to take a look at and see if we could consider. Just generally, we'd wanna be a voice at the table. Other things that are really helpful for us are reducing administrative burden. So I know there's a prior authorization bill that's being worked on that's going to be vitally important to primary care in particular. And so we wanna be able to to work with you and and be at the table. [Chair Alyssa Black]: Thank you. [Rep. Leslie Goldman]: Is there any other policy changes that would really address administrative burden, will you please send them to us? Absolutely. Glad to be. One prior auths bill last session. We're doing some adjustments to it that you mentioned this session. But I think many of us in the room are big fans of continuing to improve that. It's tremendously helpful, and [Witness Brigid Nienbries]: it frees us up to be able to care for patients, which is really what we need to be doing. K. [Rep. Mari Cordes]: Okay. Make sure you understand [Rep. Lori Houghton]: the process. We have no input. [Witness Brigid Nienbries]: I know. Just I know. But if anything comes your way Yeah. [Rep. Lori Houghton]: Just so that you talk to the right people [Speaker 1 ]: Yeah. [Rep. Lori Houghton]: People at AHS, people at the Green Mountain Care Board and the governor's office, That's where the pressure needs to be. We're we can do what we can. [Witness Brigid Nienbries]: But Yeah. If anything yeah. If anything comes your way and you see any language, we we really wanna be able to take care of our property. [Rep. Lori Houghton]: I'm just saying that. [Witness Brigid Nienbries]: Thank you. I appreciate that feedback. [Chair Alyssa Black]: Anything that following up on that, anything that you would like us to look into, then we do have the power to look into it. Perfect. So you send that to us. [Rep. Lori Houghton]: Thank you. I'm sorry. I didn't hear what you just said. I was so sorry. [Chair Alyssa Black]: Following up on what you said, I'm I'm asking them to send to us anything that they think would be helpful. That we do have the power over that. We can Do we? I mean, I I think it's only about [Rep. Lori Houghton]: I think it's worth the conversation in this committee to really think about where our voice is in this negotiation. [Chair Alyssa Black]: Yep. Yep. [Rep. Lori Houghton]: That's all I'm saying. [Chair Alyssa Black]: Okay. K. See, we all have a little, you know, finger and and have a pen in our hand. So we can do stuff. [Rep. Lori Houghton]: Convince it. Well In this arena. [Chair Alyssa Black]: I will convince you. I'm waiting. You watch. [Speaker 1 ]: I just What? [Chair Alyssa Black]: You already signed one of the bills. [Rep. Mari Cordes]: There's actually additional waivers [Chair Alyssa Black]: that you [Rep. Mari Cordes]: receive to the Green Mountain Care Board grant. [Chair Alyssa Black]: Do you [Rep. Mari Cordes]: you don't have the power to do any of that? [Chair Alyssa Black]: Pardon me? [Rep. Mari Cordes]: We we don't have the power to ask for additional waivers from the Green Mountain Care We [Chair Alyssa Black]: will ask for them. [Speaker 1 ]: We will? [Rep. Mari Cordes]: I mean, we can talk about that. [Chair Alyssa Black]: We can suggest it. No. We do. They will ask for it. [Rep. Leslie Goldman]: So you don't sign off on it? [Rep. Mari Cordes]: No. I know. But I just You you can't [Chair Alyssa Black]: Okay. One at a time. Daisy. [Rep. Leslie Goldman]: I think you're talking about Medicaid waivers? Yes. With Medicare [Witness Brigid Nienbries]: Medicaid waivers. [Rep. Leslie Goldman]: They wouldn't they wouldn't request [Chair Alyssa Black]: it at the [Rep. Leslie Goldman]: care board. They might ask them to make the request of AHS, but we wouldn't grant that. It would be through AHS. And, yeah, we can have the offline conversation. It's nothing that we would need to put in legislation or anything like that. We would just say, hey. Are you thinking about this? So, yeah, we can be part of that conversation through the relationships and partnerships that we have. But isn't it things like that group offline. Things like that do not take legislation. They take an email to say, [Witness Brigid Nienbries]: you know Just an understanding of that this is something that might help us provide just support would be right. Ish. Yep. [Chair Alyssa Black]: Mary? [Rep. Mari Cordes]: I just really easily looked up the under the AHEAD model and found your letter really quickly. You're passing a waiver. So and I sent it out to the committee. And just a reminder that we have legislative liaison Diane Lanfer to the Green Mountain Care Board, so we can always talk with her about issues like this. And we can support the the request of the Vermont Nurse Practitioner Association about the waiver through Diane. Okay. [Witness Brigid Nienbries]: Thank you. I really appreciate your time. Thank you so much. [Chair Alyssa Black]: Thank you so much. Thank you so much. Thank you for coming in. Anybody else around the outside while I have anything to say? [Speaker 1 ]: I'm, number five. [Chair Alyssa Black]: Oh, excuse me. [Rep. Mari Cordes]: You and that's [Chair Alyssa Black]: I'm sorry, Janet. I am sorry. [Speaker 1 ]: I wasn't really expecting to be number anything. [Chair Alyssa Black]: So this is number five. So you're doing well. [Speaker 1 ]: Oh, hi, everybody. Hello. I'm here not because I have a specific piece of legislation I wanna advocate for or educate you about even though, nurse midwives as nurse practitioners are affected by everything that's been discussed so far today and other things that could be discussed today or another day. My goal is to increase visibility of certified nurse midwives as nurse practitioners because we are just a sliver of the workforce of the APRNs in the state of Vermont. So to introduce myself, Janet Kaplan. I'm a certified nurse midwife. I've been a certified nurse midwife for thirty five years, and I've been living and working in Vermont for twenty two of those years. Currently working full time at NVRH in St. Johnsbury for the last eight years. I did not start when I was ten years old. So No. No. No. [Chair Alyssa Black]: No. You [Speaker 1 ]: can do the math if you wanna bother, but I wouldn't bother. That's awesome. I hold, a master's degree in nursing. I hold a master's degree in public health from Emory University, and I'm currently a doctoral candidate in midwifery at the Thomas Jefferson University in Philadelphia. So when I finish that in another two and a half years, I will be doctor midwife, which I think is hilarious, but I Thank you. Love it. So what I just wanna make sure that everybody here knows about is that certified nurse midwives are advanced practice RNs. There are other types of midwives out there in the United States and in Vermont, but the certified nurse midwifery, APRN, with prescriptive authority is the largest group of midwives in the state of Vermont. We are trained in the two disciplines of nursing and midwifery. Midwifery does overlap with medical model obstetrics, but is a separate and distinct profession. We have different skill set. We have our own professional organization, peer reviewed journals, and so forth. You have to be a graduate of an accredited education program certified by the American Midwifery certification board and licensed by the state where you are working, which in this case is Vermont. Essentially, we're nurse practitioners because we are APRNs. We are as if women's health nurse practitioners who also provide prenatal care, labor delivery, postpartum care, and newborn care. We are trained to be experts in normal labor and birth. So we take care of the essentially healthy, normal labor and births independently to our scope of practice, and we are capable of collaborative service with physicians in higher risk cases. I wanted to mention that that sliver of the APRN workforce. The last info graphic that I saw from a workforce survey a couple years ago indicated that certified nurse midwives are about seven percent of the total APRN workforce in the state. There's, sixty to seventy actively working nurse midwives in Vermont. And in the United States, nurse midwives are doing about eleven to twelve percent of the deliveries nationally. In Vermont, it's more than thirty percent. So we have this tiny little workforce of very busy midwives doing probably more than thirty percent because, typically, birth certificate data is underreporting. You know, the people that report it saying, oh, the doctor admitted patient must have delivered it even though the midwife did. So thirty percent has been documented. It's probably more than that, and that was in two thousand twenty two. So I don't know what the latest, birth certificate aggregate data shows, but that was what is available on Google. So you can see it and do the math if you wanted to. There are eleven maternity units in Vermont, as you know. Ten of them have midwives actively doing deliveries there. Ten of them. Some of them have twenty four seven midwifery service. I work in one of those. So UVM has a group of midwives. If you see the midwives, you're gonna get a midwife to labor with you and hopefully deliver with you. NVRH, the same. Some of the Copley, the same. Gifford, the same. But Rutland and, some of the other hospitals, they have midwives on call, sharing call with the doctors, so you don't necessarily know who you're gonna get when you come in in labor. That's just the model of care that they're using. And in addition to midwives doing, deliveries and doing things that people think typically midwives do, the certified nurse midwives are also working throughout the state in reproductive health, GYN primary care, family planning, and, all all of the things that you would associate with women's health care, in Planned Parenthood and offices and clinics around the state. So we're a very industrious group of people. The workplace violence is something that we deal with. Just imagine the complicated family dynamics we get when nobody knows who the father is and there are several candidates and they all show up at once. Sometimes this spy, and we have to call security. And so, yeah, workplace violence and protection, not just in the emergency room, but that is the front line, but, throughout the hospital and including, obstetrical units. Also, retention and salary. The average retention of midwife now graduating and working is fame, seven years, and then they're like, this I'm out. You know? I can't get paid enough. I'm up all night. People throw up on me. This is terrible. I'm done. And there isn't really a reason to make them stay. And just like an emergency room nurse, in order for a person to get really, really good at being a nurse midwife, you need that seven years just to get to the place where you are thoroughly competent and able to function at three AM in the middle of the night in a critical access hospital during a snowstorm and not panic. So retention is an issue for us. There is upcoming birth center legislation. I'm sure you are all aware of that. It's been in the works for a number of years now. I am in favor of it. I am also, I've been following act one sixty seven and the Oliver Wyman recommendations, and I think that in order for us to be prepared for any potential obstetrical unit closures, we need to have birth certificate birth center legislation in place so that women can have a place to go without having to leave their community. So the women who would qualify for delivery in a freestanding birth center is a very small percentage of the women having babies in this state because they have to be normal, healthy, not diabetics, not hypertensive, not twins, not breech, not preterm, and they also have to not want an epidural. So this is a very specialized group of people that don't need a physician. They don't need a hospital. They can deliver safely in birth centers outside of hospitals. This has been shown in the research, and it's all documented in the the legislative proposals. I just want to reiterate that we need it at this point, given the financial situation that all the hospitals are finding themselves in with their obstetrical services. It will replace not enough. It it won't take patients and midwives away from the hospitals, but if the hospital closes, it gives an alternative. And I think that a coordinated effort around where birth centers ought to be would be the next conversation once we have the capability of having birth centers. And then there's other laws. I'm not sure if it's senate or house. This is my first experience here in the state house, and I'm kinda like feel like a a mouse in a cookie jar just trying to understand everything and get everything I can out of it. But I know that there's a number of Medicaid eligibility expansion, proposals. I think they're in the senate. They might be in the house. I'm not sure. But there's one expanding eligibility for pregnant, people for Medicaid, and that would be something that I would also encourage a development of. I know it's financially crazy right now, but pregnant women, I think we're running about forty five percent in Vermont are Medicaid supported, and the low reimbursement rates are then made up by the high re high premiums and bills that are coming to the private insurance. So one way or the other, everyone is paying for somebody else. We just need to rearrange how that's done, where it's coming from so that we level the playing field and give everybody the same access to the same level of care and then utilize midwives and maybe birth centers to provide that low cost, high high value care that could be reimbursed properly through Medicaid. Anyway, that's all I wanted to say. [Chair Alyssa Black]: Thank you. Thank you very much for coming in. Are there any questions? [Rep. Mari Cordes]: Of course. Thanks, Mari. I I already know the answer to this. We're not supposed to ask questions if we know the answer to it. But But you're not. At the end of the hour. We're I'm personally also interested in Medicaid coverage of community doula services Mhmm. And, daily or breast milk. Are those two things that you would support? Absolutely. [Speaker 1 ]: I've I've read the Sunrise report. Can anyone here tell me why it's called a Sunrise report? Because is [Rep. Lori Houghton]: it as opposed to a Sunset report? That would be bad. Sunrise is No. [Speaker 1 ]: Sunrise is just the first evaluation. Oh, okay. Okay. It's very poetic. Yeah. [Rep. Mari Cordes]: Yeah. Yeah. I was hoping I [Speaker 1 ]: was hoping that was true. Yeah. So the Sunrise report looks like it's trying to create sort of two tiers of doulas in the state, one not regulated, not licensed, and not mandated to be reimbursed, and the other regulated, licensed, and mandated to be reimbursed at the Medicaid levels, specifically to address community health based supports. Population. Yeah. And I think in new I'm involved with a HRSA grant funded project called RMOMS. I don't know. It stands for rural maternity obstetric management strategies. I don't know if anyone here is familiar with that. It's spearheaded by Dartmouth, and it's meant to cover the maternity care deserts in Grafton County and southern Coas County of New Hampshire. And because NDRH is right there on the Connecticut River and we get twenty five percent of our patients who are New Hampshire residents, we got pulled into the grant. So New Hampshire did that. They have mandated Medicaid reimbursement and insurance reimbursement for doulas. And the RMOMS project has created a doula slash community health worker program. So all of our patients who live in New Hampshire are eligible because they're pregnant and having a baby in an RMOMS facility, And so we are actively now referring pregnant women to these doula community health workers that are interested. It's free for them, and I'm hoping that it's gonna yield healthier families with access to resources they might not have have knowledge of or access to prior. So, yes, I support whatever we can do in Vermont to move in that direction. We don't have to reinvent the wheel. Once we have Medicaid reimbursement and let you know, regulation of doulas, we can just adopt what New Hampshire is doing or some other state that's doing something similar that feels comfortable for our particular situation. So yes to that. And then the other thing you were saying was breast milk. I would love to have a breast milk bank, MVRH. We are a breastfeeding friendly facility. We were the first breastfeeding friendly facility in the state, and I think there's one other facility now, and that's a World Health Organization designation. So we have very high levels of breast breastfeeding initiation. But when a baby is having trouble, when the mom is having trouble and they wanna go home and they want us but they need to supplement until the milk comes in or the the nipples heal, pardon the explicitness, but it would be nice to be able to give that baby human milk because formula smells bad, tastes terrible, and doesn't have all the things in it that a baby needs, especially during the first six weeks of life. So if we had access to breast milk banks easily in this state, it would help all the babies. We would get much faster weight gain, wouldn't have to supplement as long. But it's expensive to buy it from the Colchester place nobody can afford, So we end up giving babies for me. Okay. Thank you. You're welcome. Anything? Oh, yep. [Speaker 9 ]: I'm just curious. K. Is breast milk tested [Speaker 1 ]: Tested? [Speaker 9 ]: For, I don't know, for, you know, bad things to be in it. [Speaker 1 ]: Like like like drugs and No. No. What viruses and Drugs. [Speaker 9 ]: Nothing more viruses we've been talking about. Bird flu. Bird flu. Bird flu. [Chair Alyssa Black]: So so I [Speaker 1 ]: will tell you that the the health of the mother or the person producing the breast milk is tested. And so anything that, might end up in the breast milk would first have to be found in the mother or the the breast milk producer. So breast milk is tested when it's going to a bank because then it's not identifiable to a person, and it is being processed and stored. Whereas a baby going to breast, the transfer is immediate, and the milk production is specific to the baby because that's what the human body does. If you have a one week old, the breast milk content is for a one week old. If you have a six month old, the breast milk content is specific to a six month old. It's all hormonal mediated. But in a breast bank breast milk bank situation, you would have to test the milk. You'd have the moms have to, you know, go through health certifications and things like that. [Speaker 9 ]: And I don't know anything about this, so that's why I'm asking questions. How much do you get it by? This is gonna sound ridiculous. [Speaker 1 ]: You get it by I'm a bit Ellen? I think you're you're so brave. You are so brave. [Witness Betsy Hassan]: How much does a woman produce? [Chair Alyssa Black]: Well, no. I I don't need to know that. But, I mean, when [Speaker 9 ]: you purchase it, is is it free? Is it what's what's the cost? [Speaker 1 ]: Yeah. I don't know. Buy it, you know Exactly. [Speaker 9 ]: A finder or or what? [Speaker 1 ]: It's by the ounce. [Speaker 9 ]: The ounce. Okay. [Speaker 1 ]: By the ounce. And it's I don't know. Do you know the price at Colchester? The one called the there is a milk bank in Colchester. [Speaker 9 ]: I'm just curious. I I don't really know [Chair Alyssa Black]: where it is. [Speaker 1 ]: Answer to that question once upon a time, but you do purchase it by the ounce, and it's serve you know, many dollars. Like, not not, like, you know, fifty dollars an ounce. It's it's somewhere somewhere around I don't know. Does [Rep. Leslie Goldman]: anybody know? [Speaker 1 ]: It's, like, ten probably five to fifteen dollars an ounce, something where it's like that. [Chair Alyssa Black]: It's I think it's not We know it's five. [Rep. Leslie Goldman]: Fifty to five dollars an ounce? [Speaker 1 ]: Four dollars [Rep. Lori Houghton]: an ounce. [Speaker 1 ]: Okay. So I was overpricing it. But a baby, once they get going with their appetite several ounces of eggs. [Chair Alyssa Black]: A lot. [Speaker 1 ]: A lot. Yes. Yeah. The bigger the baby, the more the ounces. [Speaker 9 ]: Well, thank you for that. [Speaker 1 ]: Yeah. You're a very brave man to wade into that. [Witness Liz Kudo]: Okay. [Rep. Leslie Goldman]: Yeah. Those are very good. [Speaker 1 ]: And I do wonder, did I say anything that was new information other than the breast milk stuff? Was I reiterating? Thanks. You have [Rep. Leslie Goldman]: the breast milk right now, but are there other questions? [Rep. Mari Cordes]: It's not breast milk. Just to let everyone know, there's a fundraiser for the Vermont Donor Milk Center on March sixth. And I don't know where it is, but if anyone's oh, Jericho Jericho Ale and Bean on March sixth from five thirty to eight thirty PM. [Chair Alyssa Black]: Nice. Okay. [Speaker 1 ]: Drink beer. Make milk. Yeah. Nothing. [Chair Alyssa Black]: No other questions? Hey. I have one of them. We're gonna wait. [Rep. Mari Cordes]: He's on a roll. [Chair Alyssa Black]: I'm done. I'm done. [Speaker 9 ]: I'm about breast milk. That Copley's birth birthing center [Chair Alyssa Black]: Mhmm. [Speaker 9 ]: Is closing. [Speaker 1 ]: Has not been decided yet. [Speaker 9 ]: That's not. Okay. If it were to close [Speaker 1 ]: Big problems for those birthing people in that area because that creates a maternity care desert there. Women or people having babies would have to drive to CVMC, to Newport, to St. Johnsbury, where I am, and I'm happy to come on down, but it's a long drive. And women don't always make it a two hour distance, if they're in active labor. So then you're gonna have EMTs doing deliveries or dads doing deliveries, or women just camping out in hospitals increasing the cost of their stay at a faraway hospital, you know, because they're too afraid to go home, especially in a snowstorm. [Speaker 9 ]: And and do you know the the perhaps the reasons for the possibility of closure or or is that [Speaker 1 ]: I don't know because I'm not super close to that. Yep. Oh, do you know? That's you. Okay. Go go. [Witness Liz Kudo]: They go it has to do a lot with them. And the ER, unfortunately, is also one of these they are not revenue making. They're revenue losing. We are, like, revenue losing. The conversations at have been with the birthing center first, then the ER is next. Not only are a critical access hospital, and unless there are ways to support health care and the resources that we need to use to support moms, laboring moms, deliveries, babies, the birth center, the [Speaker 9 ]: ERs, the [Witness Liz Kudo]: patients that come in that don't have a, you know, a prior op or that we collect their co pay at the door. It's not equitable for us to stay open and provide these services. But that being said, I don't think anyone in health care that works with patients got into it because we were concerned about where those funds came from or what my salary was gonna be. Most of us are innate caregivers, and we have been doing this for a long time only to end up a little more top heavy in what financing says our health care can provide. So right now, the Kavli birthing center loses approximately three million dollars a year. And, again, it's just it has to do with what is reimbursed. So whether we keep a mom because she's in labor at one centimeter and that's gonna you know, we could discharge her home. Where is home? What is that situation? How is she doing? We may keep her because she's more comfortable here. We don't get reimbursed for that. That is not reimbursable. And again, there's so many services that are provided at the bedside. Full disclosure, I'm an eleven week old. I just delivered theirs, and I worked there in my professional career. So it's really challenging. And and for us in the community, community, it's it's a big topic that we're really nervous about. But also as a health care provider trying to figure out how do I keep my community hospital open, there's no way we can continue to lose three million dollars a year. So where's the middle ground on how we all do this financially, supporting health care and supporting our communities? [Speaker 1 ]: I think you hold on, Janet. [Rep. Leslie Goldman]: Can you repeat your name again for the record? We didn't catch it and where you're from. [Witness Liz Kudo]: Liz, kudo. I'm working under the Emergency Nurse Association for this work specifically, but to speak, you know, as a community member working at Copley and in the community at Morrisville, it's been really challenging to have that conversation. I hear the birthing center is closing. You work at Copley. Is the birthing center closing? You just delivered at Copley. What was your experience, and why are they going to close? And to that point, there would be a that would that would only further impact ERs because people are going to show up in precipitous deliveries, and we're gonna have to deliver them because there's not gonna be a birthing center. And it's gonna it's gonna significantly impact the health of mothers and babies. [Speaker 1 ]: I I think it's really important to speak to the fact that it is a financial issue and not that there was a bad outcome, that the midwives don't wanna be there anymore, that they can't staff it with competent, experienced nurses. All those things are happening and are not the reason why. The community has been very happy with the services there, and the midwives are happy there, and the OB GYNs, I believe, are happy there. This is strictly a a cost saving attempt, which we know doesn't work. It, like, tried that at Springfield. They closed their OB unit, and they're still on the chopping block. So once you start cutting services, you start cutting people coming to you for the services that are then generated by the previous service. So if a woman doesn't have a baby here, then she's not gonna use the pediatrician there and so on down the [Speaker 9 ]: line. [Rep. Leslie Goldman]: When they when these sites are cutting services, we do ask questions and make sure that they are data informed. Mhmm. Because you know that we don't regulate hospitals, but we are able to ask for [Speaker 1 ]: the data. Sorry to offer. [Chair Alyssa Black]: I didn't hear you. One of the thing I wanna remind everybody of, we are getting off the topic that we we had. And I'm not against that because I think there's interest. So we have two other people asking questions. Leslie, go first. [Rep. Lori Houghton]: My question is more than a comment. [Rep. Leslie Goldman]: Janet [Rep. Lori Houghton]: mentioned deserts, birthing deserts. Wyndham County is now birth desert, pretty much. Brattleboro, we were talking about this this morning. Mhmm. Brattleboro has a birthing center. The next one is excuse me. Bennington and Rotland and then Dartmouth. [Speaker 1 ]: Can can I just say the term birthing center source is, [Rep. Lori Houghton]: Let me get my language right. [Speaker 1 ]: Yeah. It's confusing. People use it all the time interchangeably, but these are labor and delivery units based in hospitals Okay. Even though they're they could be birthing center ish ish. Right. Early well, [Rep. Lori Houghton]: I delivered at Springfield many years ago. More information about [Speaker 1 ]: When we're talking about freestanding birthing centers as a specific thing. [Rep. Lori Houghton]: A labor and delivery unit. The point being that Wyndham County is now essentially a labor delivery desert. So as we lose more and more services, it's really going to affect women and families and birth a lot. So it's crucial that we have this conversation. [Speaker 1 ]: There are ways to try to make it less of a financial disaster, to run a birthing sent a birthing unit in a hospital. You need to take you need to use midwives. You need to decrease the use of OB GYNs for normal birth because you don't need somebody who's earning a quarter of a million dollars to, you know, come in, catch a baby, and walk out the door unless there's a medical issue that they need to to be managing. So increasing the use of midwives, decreasing the use of the hospital, and moving it into a less expensive setting like a birth center across the street that the hospital doesn't own because it needs to be controlled by midwives so that they can ensure the midwifery model of care is being used there. And then they can go across the street if someone changes their mind and wants that epidural or their blood pressure spikes or they need a cesarean because the baby won't come out. They go nearby to that hospital. But it's a whole lot less expensive. And then you're keeping your OB unit for the OBs to manage complications and higher risk patients or have anesthesia do their epidurals, which can cause complications, which is why they need to be in the hospital and not the center. So there are there are ways of looking at this and not just closing the unit and throwing women out to the To New Hampshire. [Rep. Lori Houghton]: Yes. That's what you told me. You're all going to New Hampshire. Just saying. [Chair Alyssa Black]: That's okay. We wanna keep a little bit of Sorry. [Speaker 1 ]: I can get talk of [Chair Alyssa Black]: Mari, do you have a question related to this right now? [Rep. Mari Cordes]: Yes. [Chair Alyssa Black]: Because what I'm going to do is I am going to cut off the testimony because we have a bill that deals specifically with birthing centers. And the public needs to hear it, but we want to hear them to hear it in that setting. [Rep. Mari Cordes]: So just mine is just a comment, and it's a reminder for some people. Maybe it's a new way of looking at our health care system. But this kind of situation where it may make may be economically rational economically rational to close parts of our health care system, whether it's a dialysis center or whether it's primary care centers or inpatient psychiatry. It may seem if you're only looking at one layer of our health care system, it may be economically rational. But, as we're we're really trying to support and move towards what's best for our communities, how can we increase access. Primary care is critically needed. Serving people who are delivering babies critically needed. Inpatient psychiatry critically needed. But the way that our system has financed health care for a long time, the dollars haven't often don't go to the places where it's needed the most. And so the development of health care systems is driven by what makes the most money. And then everything else is either subsidized by what the current moneymaker is. And we've let go. It's been going on for a long time. And I know there was a situation in one hospital in Vermont where APRNs who worked with women in women's health, because those APRNs were not reimbursed as much as physicians were, they weren't moneymakers for that part of the hospital, and so they let a lot of those women go. And they did ninety I'm extrapolating here, but a huge amount of the the actual labor, the work, the productivity was these APRNs working with these women, and all of a sudden, they're gone. And women had some of them elder women that have been getting well women care for a decade or more suddenly were without their their provider. So I guess that's nothing new. I think we probably all of us know that our health care system makes no sense. [Rep. Lori Houghton]: And is broken. [Speaker 1 ]: Okay. Thank you so much, operator. [Chair Alyssa Black]: Thank you for coming in. Thank you. You know, I'm I'm I'm I'm gonna apologize for something. I don't like to cut anybody off. But Thank you, Jim. The reason I did that is I was reminded by the ranking member here that the public need to hear this. And if we broadcast it, you know, we tell the public what we're gonna be talking about, more of them will be here. And that's why I did what I did. [Rep. Leslie Goldman]: So having you back and listing it as and testing the first interval might be a good idea because it's such a rich conversation. [Speaker 1 ]: Okay. I'm on call on Thursday. [Chair Alyssa Black]: Again, thank you thank you all for coming in. Thank you for waiting till three o'clock. It's just the way it happens around here. Thanks, everybody. And by the way, for my own personal observation [Rep. Mari Cordes]: Get one comment, doctor. Okay. [Chair Alyssa Black]: Okay. Stephanie [Witness Betsy Hassan]: Green from the hospital association has to leave, but she did want you all to know that the hospital association is, supportive of our workplace violence prevention legislation. So she wanted to make sure [Rep. Leslie Goldman]: that the community was aware of that. Thank you. Good. [Chair Alyssa Black]: Oh, yeah. Last year, I witnessed pretty good crowd of nurses that came in here. This year, I witnessed like double the amount of people that came. And that's so important to us to have you here and you representing yourselves and the work you do. So thank you thank you very much for the whole committee. [Rep. Leslie Goldman]: And for your candid stories. [Chair Alyssa Black]: Yep. Yep. [Witness Liz Kudo]: Any of [Chair Alyssa Black]: them. Okay. Thank you. Thank you.

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