Vermont Legislature SmartTranscripts:

[Rep. Robin Scheu (Chair)]: Good morning. This is the House Appropriations Committee. It is Tuesday, 03/10/2026. It is 10:50AM, and we're just back from a roll call and back to continuing to get an overview of Vermont's World Health Transformation Program. So back to you, Jill. Thank you for your patience.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Of course. Thank you so much. Okay, I'm going to actually keep going. Okay, this is my big picture. Turn it to sky. Oh, It's still wrong. How does that happen?

[Rep. Wayne Laroche (Member)]: You've had all

[Unidentified Committee Member]: this time to

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Goodness. Oh my gosh. I don't know

[Unidentified Committee Member]: how it happens. We just keep pulling to the wrong deck, I think.

[Rep. David Yacovone (Member)]: You can ignore something if

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: The word housing, you can ignore that. We're not able to do that one. I cannot believe that's still in there.

[Rep. Robin Scheu (Chair)]: Which one are we crossing out?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Sorry. Under strength and rural health workforce, we had hoped to do a workforce housing project.

[Rep. Robin Scheu (Chair)]: And I have changed the slide three times. So housing is not right, but training programs. Yeah, I saw it anyway. Okay,

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I apologize. I just I I just don't know how I make that mistake over and over again. So this is a sort of a this is how I like to think about these projects. But since you want me actually go through the list, I'm not going to spend any time on this slide. Okay, let's just I this this grouping works better in my brain. But for what that's worth. I'm going stakeholder engagement. So I mentioned some of this. We have a program page with a public contact form. So people want to reach out to us or let us know about project ideas. That's the place to do that. And then also on that website is our project narrative, literally what we submitted to CMS. A summary of the projects, maybe a two pager, then this list of projects. And if you've downloaded this list before, we made a minor change to it recently. There was one project that every time I read the words, couldn't remember what they meant. And so I thought if I didn't understand them, maybe no one else did either. So we just reworked, we reworked the project set of teams, rewarded.

[Unidentified Committee Member]: Okay. A little more sense.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: And then as I think I mentioned, also, are in terms of our stakeholder engagement, we're leveraging, we have a lot of committees that already exist. We have a strategic plan advisory committee. We have a primary care steering committee. We have lots of work that we've already done on healthcare reform. And we certainly have lots of provider relationships. So we have a lot of ways to gather feedback and information. Think that's my last slide. Yeah. Okay, I'm going to stop sharing.

[Rep. Robin Scheu (Chair)]: Well, I

[Rep. David Yacovone (Member)]: guess you want me

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: to share the list of projects too. I want to actually say before I jump into the projects, a few more things about just where we are in our process. So I think I mentioned that August 1 is our sort of internal deadline for obligating the funds. So we've been starting to think about the work in sort of different kinds of buckets as we think about the deadline. So the first projects we want to get out the door are things that are going to require either a competitive bid, or we're going to have multiple subrecipients. So things where we need to put something out and lots of people, lots of organizations are going to apply because that's going to take the longest to get sorted out. When we have lots of different partners, especially if we're choosing between partners. And so are we have in terms of prioritization, and this is actually different, it's not really by initiative, it's really by activity. The things that require more time we're trying to do first. That is going to, this is why I say that when we got this sort of milestone scoring from CMS based on initiative, I started to think, oh boy, we got to make sure we're thinking about this in two ways. And so we have I believe the very first RFP was released this week and it's going to be brought up on our website, if it hasn't already on the RHT website. So different departments are releasing notices of funding opportunities through their usual channels. And then we're also cross posting on the Rural Health Transformation site. And then we have a listserv that we built that people can actually sign up for on our website just so that they get an announcement. So we'll probably do like a weekly announcement saying like, hey, these grant opportunities have been posted so that our provider community doesn't have to like refresh the website, you know, every day to make sure that they haven't missed something. So that's sort of one we're thinking about it. So we're working on those projects first. And it's not completely sequential. There is parallel work going on. But we're also working on then we think about the projects where we have one obvious partner. So some of our workforce projects, like we might have one obvious partner like VSAC. And so if there's one obvious partner, then there's a little more time to work with that obvious partner to get things set up because we don't have this back and forth of a competitive process or a multiple awardee process. And then we also have some things that are actually payment models. And so those dollars that are going straight from us to providers. And so we're working on those also kind of separately because they're not again, they don't have the same. They just it's just a different way. It's just a different we were operationalizing those differently. So that's how I'm thinking about the work.

[Rep. Wayne Laroche (Member)]: That strategy. Think that strategy also gets the most money obligated as fast as possible.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I think so because we're trying to do the hard to get the heart, give the most time for the hardest stuff to obligate. Yeah.

[Rep. Wayne Laroche (Member)]: I'm thinking he's looking at it through the lens of, you know, how do we get money on the store if Yes. So it's through the other months.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yes. Yeah, that we felt like some of these awards really are gonna require more, just are more complicated to get finalized. We want to do the hard stuff as fast as we could. Yep. But there's still plenty of work to do. So, okay, I am going to see, I think if I just I think I shared my screen and I just

[Rep. Robin Scheu (Chair)]: yeah, okay. All right.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: This is impossible to read on the screen. It is not impossible to read if you print it or if you go to our website. Copies. You all have copies. I actually think I'm going go from I'm going to work from the copy. Maybe I'll just not share my screen because it's not helpful to anyone in the room. Anybody who's watching. Oh yeah. Okay. I like it. Yeah. Okay. I'll do it.

[Rep. Robin Scheu (Chair)]: Don't worry about the size they can do with it. Bring your watch.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Okay.

[Rep. Robin Scheu (Chair)]: Yeah. Okay. And people want to see it and get their own paper copy. It's on your website and they on our website here and it will be posted if it hasn't already done. Yeah. So lots of places people can find it.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Great. Okay. So the first seven projects all fall under the regionalization initiative. And so regionalization is really thinking about how we provide care in the various regions of Vermont and some care we want to make sure we have in all regions, right? So there's some care that you need really close to home, like primary care, you want really close to home. Some care can be provided in regions. And then there's some care that we would probably expect to only provide on a statewide basis. So like tertiary, like complex hospital care. This is these are initiatives that are related to what we think of as regionalization services in various regions of Vermont. So one is, and I'm not going to go deep into any of them or we are going to be here all morning. I've done this. I've done the whole thing a couple of times and it does take a while if I go deep. I'm going say hi. And if you want me to go deeper on what I will, but I'm going to.

[Rep. Robin Scheu (Chair)]: Right, we'll try to keep ourselves at a high level.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Okay. So there's a and again, this is why I say that measuring these all together is going to be a little hard to work and it through. So we've got community paramedicine or mobile integrated health. So that's using our EMS workforce in a new way. There's a pilot happening now in the Brattleboro region where essentially EMS is providing care in people's homes. And that the EMS workforce, and this is how I think about it, is a workforce that actually sometimes has capacity in a way that a lot of the rest of the healthcare system, nobody else has time on any time that they're not already engaged in clinical care. And so using our EMS workforce in a new way is a strategy to bringing more care closer to home. What we don't want to do is we do have a course home health. And so there's, we got to make sure we don't have an interplay there or we want to sort that through. I used to work for home health. That's important to me. But I think there's plenty of opportunity for care at home. So that's gonna be a pretty significant project once it gets fully underway, but quite a bit of work to do because there's policy work as well as just, it's not entirely straightforward on the policy side. There's some legal framework work to do. Facility upgrades, we've now actually moved all, this is a change from how we originally applied, but there's also a facility cap. So, there's both the rules about facility upgrades, meaning minor renovations only. And then there's also a cap. The cap is pretty high. It's actually, I can't think of it now, but it's, I think it's higher than the provider payment cap. Okay. And that was 30,000,000 ish, but we probably won't be able to spend it all just given the restrictions. We used to have a facility upgrades in multiple projects, we had them in different projects. And we realized with the cap that was going to get really confusing. And so we changed it with CMS and we put them all in this bucket. We didn't change the dollars of any of the projects. We just changed the words so that all so that some for some projects, you're going to see me talk about projects that have a facility implication. Some projects are going to require to grant applications, for the main project and one for any facility upgrades. So they're not we're gonna have

[Rep. Robin Scheu (Chair)]: to keep them separate. So that's going to

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: be a whole range of stuff. Urgent mental health and substance abuse, urgent care expansion. I'm going to skip number four for a second mobile units for integrated mental health and substance use treatment and mobile units for dental care. Number four is transformation integration and regionalization support grants. That is a sort of broader bucket. These dollars have not been approved by CMS for release. We need to give them more details about how we're going to do this. But the idea is that we wanted to leave room for our provider partners in particular to think about ways in which they might do transformative work to change our system, to move care out of hospitals into the community that we couldn't think of in the small amount of time we had in which to apply for this grant. So we kind of left this open on purpose, but we are going to have to nail it down in order for CMS to release the dollars. They have not released these dollars yet. They're not authorized to do an RFP. Oh, sorry. Thank you. So that is Oh, there's one more regionalization. Number seven, high acuity services in nursing homes. So dialysis and ventilators in nursing homes. That's equipment related. Yeah. Okay. Liz? Specifically on

[Unidentified Committee Member]: maybe generally as well, facility upgrades and maybe even number seven. How does this all work with CLN, with our existing regulatory framework for approvals? Nothing changes there. They don't have a conflict between

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: No, I mean, if it's something that would require a CLN to over fire a CLN. Thank you. Yep. Okay, so that's regionalization. And then there's a series of shared services. So the big idea behind shared services is essentially like back end operations to allow organizations to share administrative and other kinds of things together, which hopefully to reduce costs and complexity. So we have a number of those that are already planned. And actually, we've heard some ideas from other provider types that we hadn't contemplated that we are also thinking through. So that is, there are some interests from some hospitals in having a shared human resources information system and also a shared electronic medical record. So that a shared electronic medical record will essentially sort of more quickly improve interoperability and allow for more information to go between hospitals around patients who might move from one hospital to another. It doesn't negate the work we need to do to make sure that all of our provider types can communicate because we also want hospitals to have information from home health and vice versa. So, still need health information, but that's a strategy to kind of get us a little further, a little faster. There are some limits on how much we can fund hospital EMRs based on there's previous federal funding to help with EHRs. So And there's a limit, if possible, to receive that funding. Every one of these activities, you open it up and it's just lots of little pieces that you got to untangle. Okay. So we also want to have a statewide e consult. So this is really a platform. This this one, I think needs some more. We're doing some more thought on this because this is both a platform, a tool for the work, but also, thank you, but also, sort of like, how does this, how do the conversations happen? But the idea is to bring expert consultation that we might only have available in parts of our state to rural communities and help physicians in those rural communities to have access to expert advice, specialist advice. Grants to providers for remote patient monitoring. So remote patient monitoring is equipment in the home, home health agencies and some primary care use this, it just looks for sort of key data, blood pressure, weight, various indicators of exacerbations of chronic diseases. And sometimes what we find is that if you are tracking those things, you can sometimes a hospitalization or an emergency room visit if you're able to sort of watch the changes. This is really especially useful with people who have multiple chronic conditions who are living at home. So that's dollars for some providers for that. Grants to This is really for rural independent practices to adopt telehealth technology. That's another piece. Grants to providers for AI transcription, which some providers are finding really, really helpful, but it does cost money. So this would just bring it to more practices. That's our shared services bucket. Then we have a primary care bucket. I would say this whole thing is mostly about modernizing the blueprint. So it's about supporting primary care and modernizing the blueprint. What that means is we call them capacity payments to primary care practices to have things like longer hours, care coordinators. So to have additional services in primary care, It also will support mental health integration into primary care teams. It will support our community health teams, which is a longstanding blueprint strategy where we have teams of other types of nutrition and other kinds of services to wrap around. But it's essentially all the way through the 'eighteen is modernizing the blueprint. Actually 'twenty also. 'nineteen is particular to supporting expansion of FQHC, we had an idea for this is coming out of a particular project that seems to have is not on the same course that it was on, but the idea was to add new FQHC capacity in another in a part of the state that doesn't have it right now. Back '20 goes back to primary care, moderate blueprint. So this is that that PMPM payment. So on some of these like '20 and '21, this is where that provider payment cap, these are dollars that have been released by CMS. These are payment models. And it's Are you on '20 still? I'm on '20 and '21. Okay. Yeah. So there was two incentivizing access to specialty and primary care performance payments, which is essentially incentive payments to help primary and specialty care work together. It goes with the e consult to help support the incentivize the consultation. So, is

[Rep. Robin Scheu (Chair)]: all going

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: to be dollars that come from HS2 providers. Some of them are going to be defined as provider payments potentially. So, they're going to be subject to the cap. These dollars have not been released by CMS yet. There's more work to do on those.

[Rep. Robin Scheu (Chair)]: So on all of these particular projects?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: 2021. 2021

[Rep. Robin Scheu (Chair)]: is still waiting to get. Wayne, did you have a question?

[Rep. Wayne Laroche (Member)]: Yeah, so incentivize consultation for how you're going to incentivize, what's mechanism for you to do?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: It's really, people need to be paid for their time, essentially. So figuring out a way to create that incentive. Like I said, more work to be done to develop how that model is exactly going to work. Okay, and then, now I'm on '22, recovery housing for individuals with substance abuse, substance use disorder. So we have recovery housing in Vermont already. This won't pay for what we already have, but it will pay for us to expand. I think this is the first RFP that's out, actually. So

[Rep. Robin Scheu (Chair)]: have you already sent out notice of funding opportunity?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I think this one just went out and it's going to yeah, I think this is the one that just went out. Okay. And then we get to workforce. So, the housing program number 23 is no longer on the table. We should probably just update that. Or just

[Rep. Robin Scheu (Chair)]: cross that off. Just cross it off. Yep. Yep.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: And then we have various other work. David has a question. Oh, sorry.

[Rep. David Yacovone (Member)]: Just a quick question. On the recovery housing, you mentioned earlier that you're limited in terms of buildings and such.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: But we can lease.

[Rep. David Yacovone (Member)]: Is there an exemption on the recovery housing?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: No, it's often those buildings are often leased. So, yeah, so we can- Those are permitted?

[Rep. Robin Scheu (Chair)]: Yeah. Thank you.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: At least if we

[Rep. Robin Scheu (Chair)]: increase the grant list, it's just a business transaction. Right. Okay.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: And then there's also operation. We can also We can't necessarily fund the clinician salaries, but there's also operational salaries that we can fund, especially to get them off the ground. Yep. I just want to be clear, I'm not a subject matter expert on every single project. So we do have, I mean, that's being run by the health department.

[Rep. Robin Scheu (Chair)]: Thank you.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: So a whole bunch of workforce. So LNA training, tuition assistance, critical occupation tuition program, Maple Mountain Family Medicine Residency. So that's essentially a rural primary care residency for physicians. Pharmacy test to treat, you're actually going to see this later. I think today, we need a little bit of additional scope of practice room. And so there's actually an amendment to an OPR bill that I think you're going

[Unidentified Committee Member]: to see later today. Which one is that?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: That's the 28 pharmacy test to treat. So the idea there is to allow pharmacists to test for say strep and provide treatment on-site instead of people having to go to the doctor and then the pharmacy.

[Rep. Robin Scheu (Chair)]: Oh yes, Test to treat. Did you skip over all those other ones in workforce?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I went through them. I just said it really fast. I can pause. I can go back.

[Rep. Robin Scheu (Chair)]: I just wanted to point out, I'm glad to see about the Maple Mountain Consortium. Yes.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: That was the only named subrecipient in our grant. We could have named more. You were allowed to name subrecipients in the actual application to CMS. That was the only one that was so big that we felt

[Rep. Robin Scheu (Chair)]: like we did do that. Wayne, that was actually the odd required people to answer. Thank you.

[Rep. Wayne Laroche (Member)]: Now is probably not the time to put it, but we need to know eventually more about the tuition and what could be done because We'll talk about that. Because we

[Rep. Robin Scheu (Chair)]: have other places. Well, we'll talk about that. Yeah. These are some different programs.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yeah. Yes. Conditional financial assistance. That's essentially tuition assistance with a five year work, five year residency requirement. So that's different than anything we have right now.

[Rep. Robin Scheu (Chair)]: Right. Yeah. Which I like that idea of people committing five years from off.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yes. And if they don't commit, then the tuition assistance becomes debt. And then healthcare professions residency. And so this one is really to help new students. So it's not tuition assistance, it's helping new grads transition into the workforce. And so, for example, a home health example, it used to be that home health agencies would say that you don't ever hire a new nurse into home health because home health requires high degree of experience. You're alone down a long dirt road, knocking on a strange door, And then you're by yourself in the care setting. So you really need to be an experienced nurse. And home health used to really not hire new nurses into home health. Now they're trying to build these residency programs because we have such a workforce shortage in Vermont and other places that will happen. And what no one pays for is for a new nurse to go into the field, say with an experienced nurse, there's no payment for that. We only pay for the service once service gets paid for one time, it doesn't pay for two people to provide care or to train. And so the idea of this is to create these residencies, these preceptors, to help just bring along a new workforce into various settings and help them transition and hopefully help retain them in healthcare. Okay, that's that one. And then, so those were all, I just will say this, those were all grant, things that are going become subrecipient grants, following the rules that we follow around grants. There are also going to be some consultants and contractors, and these are going to follow our procurement rules. And so we have a statewide healthcare delivery strategic plan, and we would like to use some of these dollars to actually hire some help to get that developed. We have the statewide assessment to improve health coverage affordability, there's really a couple of particular things on the table like reinsurance for the healthcare exchange that we can pay for with these dollars, we think. Then contractors, we have to have an independent evaluator for the entire project. Transformation analytics and support. So this is analytics to hospitals and non hospital providers to help support transformation. So that means giving them assistance to think through how they might change, what services they provide and how they provide them. So for example, a hospital is thinking about giving up a service, which can happen or sharing a service. The hospital gives up a service. One question that we immediately ask ourselves is, is there anybody else who's going to be able to take that service on in the region? So even if there's another hospital that provides that service, they might not have any capacity. And so there's various analytics work and also to really look at efficiency and whether air can be delivered more efficiently. That's actually probably where I think we're going to see some actual savings. Inter facility transfers, I would say this one is something where we understand the problem better than we understand the solution. And I think this one might take us longer to get through. What we do know is that we don't always have good information about where beds are available, which takes providers a lot of time as they need to try to get people through the system. Statewide closed loop referrals And, oh, oh, I know this is a shared services, but it's it's because it's a contract. It's in a different bucket. It's in a different part of the document. And then,

[Rep. Robin Scheu (Chair)]: has that been approved to do yet? Or is

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: that that one is that? Yes, that one is released. Yep.

[Unidentified Committee Member]: Okay. Yeah.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: We need it. We're going to need to make a new numbering system because the grants are numbered one through whatever. Then the contracts are also numbered one through whatever. And so can't just say project number, blah, blah, blah. Is there.

[Rep. Robin Scheu (Chair)]: You just need a bigger spreadsheet with a line that says no full release.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yeah. So they get their selected. I do have a spreadsheet. So I have other spreadsheets. Yes. This is my project. This is the first one. I do have. Yes. We have one that is like this, but goes keeps going. Yes. And then this is a number five is a it's essentially a tool that the Green Man Care Board asked us to apply for. Yeah, which we did. That's

[Rep. Robin Scheu (Chair)]: on the accepted list.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yes, that one's just going be an MOU between us and the Bluemacare board. I mean, there's other rules, obviously, to follow, like procurement and ABS, if it's a Vermont system, it incates that too.

[Rep. Robin Scheu (Chair)]: But Good data. So, can buy good data. So, this has really helped Toll. Thank you. I know you are One of the things you're doing is going to be hiring a project manager to help you with this. Where does that stand right now? You in your We're close. Okay. So you've started the process and you're hopefully close to making an offer is what you're saying.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: We're even closer than that.

[Rep. Robin Scheu (Chair)]: I don't want

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: to say anything. No, but I'm glad to know that we're close. Yes. And then we had two positions that were approved early on that we moved through the process quickly, the project manager and then a finance person for the business office. So essentially the lead programmatic person and the lead business office person. Those two positions we put through the process earlier. And then the other positions, including deputy and various project leader positions, those are making their way through the process now. So those haven't been posted yet. Those two positions are, I think actually the finance manager has been filled. Great. Dave, question?

[Rep. David Yacovone (Member)]: Yeah, this probably will sound naive, but given all the demands you have, do you think it's conceivable that after those October deadlines, if across the nation, likely there's gonna be money put back into the table because people just couldn't make it happen. That as you're working through these projects, you might say, number 17 or whatever number, we learned a lot, that's not gonna work. We understand that money will go back, but could you still be in a position where you might be able to apply for some of those unused funds for things that you learned while you were doing this and thereby increase your percentage, 15% on provider reimbursement? Or is that just, you got so much going on in year one, likely to happen?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I think it's hard to predict what our year two award will look like. So whether it'll be more or less than $195,000,000 we know it'll be 100, we can be pretty certain of that, but we don't really know beyond that. I do think that we are going to move back into a creative space about thinking about year two and three. We're not in a creative space right now. In like a what we already promised. That's going to be enough as it is. Yes, it is going to evolve. I expect it to evolve.

[Rep. David Yacovone (Member)]: That's an opportunity.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yes, that's yes, definitely expected to evolve. And Yeah, and our thinking is already evolving. We're already looking at certain projects where we think we might, we're saying, we think it might take longer. So we may not be able to spend all the dollars we dedicated to it in the first year, but we might want to say, okay, in the second year, actually, want to, that's the amount we'll spend. And in the first year, maybe we'll dedicate those dollars to a project that has room to spend more dollars. Okay. So where it's easier to spend it. Right.

[Rep. Robin Scheu (Chair)]: So it's still your intent to spend all the money. It just may not

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: be all of it in the funding. They move things around. We are trying to spend it all.

[Rep. Robin Scheu (Chair)]: You have the ability to move some of that money around within the projects that have been approved.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yeah, this is where the cooperative agreement comes into play, that we do have that flexibility. That's the good part of the cooperative agreement. High degree of oversight, but also that ability to make some of those kinds of adjustments with CMS approval, of course. There is opportunity to make adjustments with our budget. I mean, when I talk to our business office, we have thought that as this gets going, we might be submitting new budgets to CMS as often as every week. For specific projects. For overall, because we'll make gen up changes that will lead to say, this project changed in this way. These words have changed in this way. Yeah, building a house and you

[Rep. Robin Scheu (Chair)]: have a general contractor and the person gets in and they realize they want the light switch over here instead of over there. They need three more in the bedroom than they thought. That's kind of what you're hearing.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: It does feel like that a little bit. Yeah, because we could only predict, well, we had so many unknowns. And so as more unknowns come into focus, it is changing how we're thinking about it. Mean, didn't know how much the award was going to be. We knew it would be $100,000,000 We didn't know how close we could get to 200. So there was a lot we didn't know during the application process. And it comes into focus for all the states and for CMS, we expect changes.

[Rep. Robin Scheu (Chair)]: Well, I'm glad you can work with them to

[Unidentified Committee Member]: have some flexibility around that. That's good.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Tolerance for ambiguity is an important skill.

[Unidentified Committee Member]: I missed it, Lynn, because I asked her if she

[Rep. Robin Scheu (Chair)]: had a question, and then you raised it.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Go ahead. Understand where

[Rep. Robin Scheu (Chair)]: you're coming from. More coffee.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: I am assuming that since the global transformation, that we're really looking at sustainable change that are supportable through our regular budget. That is exactly how we're thinking about it. Or supportable say if we get the ahead model. So I think I talked about this with some of those payment models. They were like, we did have a Medicare component funded by Medicare for Blueprint. That's no right now we're funding this year. We have one time state dollars that we're using for it. The RHT has dollars for that. That could be in the second year. The idea though, the sustainability plan is if we get both say to the AHEAD model or some other federal agreement where we would get Medicare back at the table. Right now, Medicare is essentially not at the table on healthcare reform with us because we're between models. So some things might continue, but with different supports. But yes, we're thinking about it, I think, as you are in terms of really thinking about being careful about what we add to the base.

[Unidentified Committee Member]: Lynn? Yeah. This is really interesting. It

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: really is. I have

[Unidentified Committee Member]: not been bored since September 15. No, transformation is necessary. Yes, it really is. Having gone through five years of transformation at the state colleges. Right, Yes. And looking at what we're trying to do with the K-twelve. Yes. And seeing the problems with our health care, having been involved in other issues. It's harder. I mean, I think this is good.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Yes, it is good. And it's also hard. It's both. And we do have a really great transformation team. A transformation leader along with our Blueprint team is sort of our transformation leads sort of group in agency. And they're working really closely with hospitals, in particular, about how they might transform the services that they provide. And it does get really layered really fast because there are some services we want, we really need and want that don't necessarily meet the financial needs of the hospitals. And yet there's other services anyway, it's

[Unidentified Committee Member]: complicated. Yeah. Thing that I see, this is just like, just came into my head is that this is, they've used this phrase in the tech industry. I'm not sure exactly how it starts, but it's like, start off and fail fast. Then learn. I mean, that's what they do. That's their business model. And this is more of that than it is like what we did with, I'll say the ACO, where we put a lot of money in, we did a lot of things, some of that essentially fit. And we had to regroup after five, ten years, or whatever it was.

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Well, this is definitely, I think the projects or the activities are somewhat more discreet. Think many people could read this and many of these things have a face value sense that they may.

[Unidentified Committee Member]: Yeah. The other thing I'm going to ask you, do you see any danger of execution, the risk when you start to go into hospitals or into provider situations or any we've talked about all kinds of things here. Yeah. Insurance. I mean, there is a lack of willingness to change. How is that going to be addressed? Or have you even thought it's going be a problem?

[Jill (Agency of Human Services – Rural Health Transformation Program lead)]: Oh, no. I mean, I think that, yeah, this is sort of getting beyond the scope of rural health transformation itself. And so we broader health care reform goals to transform our system. We're using this as a tool to support that. So just to be clear, this isn't our healthcare reform plan. This is a tool that helps support our reform plan. Our transformation team is working really closely with hospitals, with analytics, with technical assistance to really try to think through what makes sense in what needs to be delivered locally, where could we have centers of excellence, what can be delivered regionally. There absolutely are risks. I mean, we are now I remember when we were trying to move care out of nursing homes and into the community, which we did really successfully, we are now definitely short nursing home beds. We probably we don't have enough nursing home beds down. Once you close capacity, you have to be careful about thinking about capacity and what we keep open and what we close because it is hard to build it back. And so you do need to really think it through. And yet, think there are real opportunities that hospitals are talking about and looking at for sharing specialists. Mean, sometimes that's just like they have to because the oncologist retires and you can't recruit another one into the community. And so you have to about a different way to make sure people are getting served. So we're always thinking about cost and affordability, that's critical, but also access, because that matters too. And of course, quality. So it's trying to keep all of those things in the mix. Yeah, absolutely.

[Rep. Robin Scheu (Chair)]: Jill, I want to thank you so much. Yeah, sure. And if people have questions, this is high level, so if we have more details, we can grab Jill offline and ask her questions to clarify any other things. But it's just helpful to see this in the picture of all of what we're doing in AHS and state government and the budget and everything else. So that's been great. So appreciate it. As long as you continue, I hope you have a project manager on board really soon. Me too. We'll keep our fingers crossed for that. We are going to meet at one we have a bill. A different bill, 67. This was here for a little while last year, and we sent it back to government ops, and it's back. It's government accountability. We weren't able to get some of the other ones in, but then we'll have a committee discussion about the budget and I kind of have a process of a plan for how we're going

[Unidentified Committee Member]: to do our priorities. It's a little bit different than we did last year, but we'll talk about that this afternoon. So you have a nice rest of

[Rep. Robin Scheu (Chair)]: your