Vermont Legislature SmartTranscripts:

[Unidentified Committee Member]: Welcome

[Alice M. Emmons (Chair)]: back, folks. This is House Corrections and Institutions. It is Thursday, January 15. We are now shifting gears. We're going to be talking with our health contractor, Wellpad, who is where DOC contracts out for our health care systems that are provided within our incarcerated facilities. We have Doctor. Ulicer here, who's the medical director, but we also have the executive director of the whole health, wellness and engagement division or whatever of the Department of Corrections, Director Tibia. I always have a hard time with your last name, even your first name. I think one question before I don't know who we should put up first. I think we need an understanding of what health care what is provided with our WellPath contract. Because I know we've just really been looking at the MOUD, but to provide a lot of other services. So we need that conversation. I think one thing I would like to be a little clearer in is the contract. We have a contract. DOC has a contract with WellPath. But who does the negotiations for when we go out to contract? Is it the 5th Floor? Is it DOC? Who signs off initially? Is it the 5th Floor? Is it DOC? Because some members of the committee have asked that. So I think that's the first question that needs to be answered so that people know. So I'm assuming, I don't think you, Doctor. Youth, you're

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: talking No, it's not about had typically for, I think, the presentation we had in mind to get at some of those questions. The flow might work best if we're able to

[Alice M. Emmons (Chair)]: I think if you could just explain who signs off on the contract and who negotiates it. That's simple terms. Is it the fifth floor, is it

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: DOC, both? Can, to the extent that I'm

[Alice M. Emmons (Chair)]: It's either Caius. Yes, Aviv Vitev.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I'm the executive director of health, wellness, and engagement with Vermont DOC.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: And Jamil Guram, our state medical director for WellPath.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So the initial negotiations are between DOC and WellPath. The part I can speak to less is the broader state contracting mechanisms and reviews that are involved after that.

[Alice M. Emmons (Chair)]: That's another department a mid floor.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: But in terms of the initial, what is in the contract and when we amend it, that's a DOC, the WellPath dialogue.

[Unidentified Committee Member (privatization concerns)]: So if

[Alice M. Emmons (Chair)]: you could just identify yourselves for the record, I'll start.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Okay, I'm Gina Giger. I'm a physician and medical director for DOC through WellPath.

[Alice M. Emmons (Chair)]: I'm Navi Viteva. I'm the executive director of health, wellness and engagement with Vermont DOC. So is this your first page? It is. It is.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Do you want us to just get started? Great. So based on some of the conversation last week in particular, we thought it would be helpful to do a refresher of the structure of the contract. If we wanna dig into certain pieces, we certainly can. So the initial contract is a three year contract with the ability to extend for two years beyond that. The contract And I will add, this is, at least as I understand it, how it's been structured with multiple vendors. It's not specific to the relationship with WellPath. But the contract itself has had a lot of continuity in what's in it with previous vendors as well. The cost is based on a per member per month calculation, which is inclusive of everything that WellPath provides. So that's medical services, it's pharmacy, it's off-site specialty appointments. It's really everything in the comprehensive services that are provided are represented in that per member per month dollar amount.

[Alice M. Emmons (Chair)]: So per member per month, is that per offender? Is that how it's calculated or the number of folks going through the

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: facilities? So it is the amount that we contract with WellPath for their services is a per member per month number, which are those numbers for the first three years, multiplied by an average daily population average. So until recently, that average has been, I believe twelve fifty. And if there are more people in our system in a given month, we don't pay well Path more. If there's less people, we don't pay them less. Every month we pay them the same amount, which is that based on that average daily population times the per member per month cost, which again is a function of the entire budget services based on that average daily population number.

[Alice M. Emmons (Chair)]: Does that answer your question? So what is the average daily population? Does that shift day to day or is that over a period of I think we look at it

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: possibly monthly and quarterly, but the contract is based on a single calculation for the year. And in the contract, WellPath has the right to renegotiate if our average daily population numbers exceed what the contract is based on.

[Alice M. Emmons (Chair)]: So has our average daily population number exceeded what's in the contract?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: It has, which is why the increase That's why Exactly. Got it. Exactly. Awesome.

[Conor Casey (Member)]: That was essentially my question. Like I said, a corollary to that would be if if the average daily population is substantially below, guaranteed is there floor for you and the state disabsorbs the premium?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So we wouldn't need to renegotiate if it's lower because the way the contract is structured, if WellPath doesn't spend the budget, the state gets the money back.

[Alice M. Emmons (Chair)]: At the end of the contract. At the

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: end of the year. So we pay them the same amount every month, but if we, over the course of six months of a contract, had a much lower population and they didn't spend that money on care because the patients weren't there, then at the end, that would be reconciled and the state would receive that money back, which is why I've described that within Vermont, they don't have an incentive to cut any corners because if they spend less, it comes back to the state anyway. There's some additional nuance there, but that's the kind of simplified version.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: And it has recently. Believe Yes. Last

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Brian?

[Unidentified Committee Member]: So two things. One is you just said in Vermont. So does that mean that in other states or with other contracts, if you do underspend, money could be kept or is kept?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I don't know. I just know how ours is structured. So I'm positing that other contracts might be structured differently. To be honest, I've never read another state's contract on WellPath.

[Unidentified Committee Member]: Then you were just talking about that extra can that is charged once you're over a certain population. Is that in the same calculation, the per member per month, or is it different?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes and no. So the way the initial three year contract was set up was based on a certain average daily population with certain PMPM rates, which are those three. With WellPath having the right to revisit the average daily population and the budget if our population significantly goes over what the contract is based off of. So we did that and amended the contract recently, and that's the BAA increase. Most of it, is because our average daily population had consistently been greater than what the population was based off of. And in that process, we also revised the PMPM. It actually went down. So what WellPath did was they looked at the budget based on the previous two years of services, were able to sort of say, this is what we need to serve that increased population. And the budget didn't increase proportionally to the population increase. So the PMPM went down, the average daily population went up. And between those, there was an increase in the annual contract.

[Alice M. Emmons (Chair)]: Around 3,000,000? Was it 3,000,000? 3 or four. Three or four. Yeah, was either the 3,000,000 or the

[Unidentified DOC budget/finance staff]: 4,000,000? It was 3,300,000.0 for the ADP cost increase, and then 1,200,000.0 for the SCD program increase.

[Alice M. Emmons (Chair)]: So it's 4.5.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, total of 4.5.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So there were those two sources of increase, The enhanced SUD was a separate increase, separate population.

[Unidentified Committee Member (budget scrutiny)]: But there's two different increases we're looking at. Yeah,

[Alice M. Emmons (Chair)]: Hang on. What does actually stand for?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Sorry. Substance use disorder.

[Unidentified Committee Member (budget scrutiny)]: I mean, you can ask the question too. I'm just trying to figure out if so because we're looking at an increase of

[Alice M. Emmons (Chair)]: eight million total.

[Unidentified Committee Member (budget scrutiny)]: Close to eight million total. There's the well past staffing invoice for 2025, so last year, is increasing by $3,000,000.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I don't have in front of me what you did. Think have the total CIA.

[Unidentified DOC budget/finance staff]: So there are some other things that were accounted for in that that are not relevant to Wellpass. And

[Unidentified Committee Member (budget scrutiny)]: then the Wellpass staffing contract amendment based on the population Mhmm. Is 4,500,000.

[Alice M. Emmons (Chair)]: And that's what we're talking about for the per member per month amount in the average daily population, that calculation. And it's about 4,500,000.0 above what has been budgeted.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Between the two. Between HUD and per member. Yes. And one additional kind of nuance or detail for your understanding, the increased costs for the enhanced substance use disorder treatment services are majority or all staffing. It's staff positions to provide extra services. On the other side, the average daily population increase is across all of the categories of cost. So it involves some staffing, but it also is an increase in the off-site specialty care costs and pharmacy costs that go up basically per person.

[Unidentified Committee Member (budget scrutiny)]: What I'm having a hard time just kind of wrapping my head around is you're talking about it, like with these things, it's a $8,000,000 increase, which is of that 25% ish of the budget for well, am I looking at year three right now, Or is that year two in this year? What of those years is 'twenty four, 'twenty five, 'twenty six?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Are in year three, but it's still 10% because the other 4,000,000 is unrelated to health services. Is that what you were saying? Oh, MBA. MBA.

[Unidentified Committee Member (budget scrutiny)]: But we didn't go up by 25% of the people in the facilities. We only went up by

[Unidentified Committee Member (privatization concerns)]: 10%.

[Unidentified Committee Member]: Well, an increase is 10% also, I believe, is what's being suggested.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Seems like it's more than one It's

[Unidentified Committee Member]: around 40. It's not eight.

[Unidentified DOC budget/finance staff]: Yeah. I think

[Alice M. Emmons (Chair)]: some of this is is really Kevin and Shawn need to work directly with Trevor and you folks in

[Unidentified Committee Member (budget scrutiny)]: that And I'm just trying to square that up.

[Alice M. Emmons (Chair)]: Right. I'm trying to square that

[Brian Minier (Member)]: That's all

[Unidentified Committee Member]: I can

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: We can get you more specific numbers. The increase in the cost is actually a smaller proportion than the increase in the population when you look at the

[Conor Casey (Member)]: Okay, that's good to know.

[Alice M. Emmons (Chair)]: Joe, Kevin, what's your name? Conor.

[Conor Casey (Member)]: And do we have a number for the proposal for when we start 07/01/1926? Because that's the end of this contract, yes?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So we're planning to extend the contract. We don't have those numbers yet. That's underway currently.

[Conor Casey (Member)]: But that's something I would assume that would be draft in the near future, but then it'll be in negotiations. Do anticipate when you may have the number available?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I don't know. We could follow-up.

[Unidentified Committee Member]: I think right now, this is going

[Conor Casey (Member)]: very much affects this fiscal year, but it's just not a complete we know it's not gonna be twenty six, thirty six, seventy four.

[Alice M. Emmons (Chair)]: So year three, I'm just trying to connect with the fiscal years. So it became effective in FY '24. Year three is I first '23. That is f y twenty four. We gotta connect it with our fiscal years. Okay? So year one is f y '24. Year two is f y '25, and year three is FY '26. So it expires in June year. Yeah. Just so folks have that time frame because the calendar year and the fiscal year are different. So when the governor proposes his budget next Tuesday, will be for FY '27, that in DOC's budget, we'll have some dollars there for the extended one year contract with WellPath.

[Troy Headrick (Ranking Member)]: You said two, right? You can extend for two?

[Alice M. Emmons (Chair)]: Yes, it will be for two. It's two years total. Is it one year and then one year?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Anticipate it will be two at once when we do it.

[Alice M. Emmons (Chair)]: Kevin and then Conor.

[Brian Minier (Member)]: I'm not hearing that the contract incentivizes any efficiency improvements for health improvements in the population. Would that be a true statement?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: No, I would say it differently. There's very specific performance incentives. There's what we call pay for performance metrics, where if certain metrics are exceeded that are related to services provided, I would say more than outcomes, there's a relatively small amount of additional payments that WellPath can receive. They're very small relative to the total budget. So I wasn't trying to say as much that there's no incentive for them to perform well as much as there's no incentive for them to provide course services, if

[Brian Minier (Member)]: that makes sense.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: But there are a lot of requirements for meeting and exceeding standards. I would say it's a pretty rigorous contract in what the requirements of the provider are.

[Brian Minier (Member)]: So if WellPath felt that injectables versus application mistaken was better for the inmates and it was lower cost, the contract would incentivize you to propose that and rationalize that and encourage us to do that. Absolutely. As opposed to just to the standard-

[Conor Casey (Member)]: Yes. Yeah,

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: and we actually have some slides on kind of system improvements and some of the ways that we're trying to improve services between DOC and WellPath. But for that example, the prohibitive factor has been cost. And if costs were not an issue, I think we would absolutely be doing that. There's nothing that would prevent us from doing it except for the fact that currently it's cost prohibitive.

[Brian Minier (Member)]: If things change, as you didn't have to have as many PAs or doctors in the med line every day, that kind of thing would affect

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, I did that calculation. I tried to make that work, that if we could have half the med line and half the nurses passing meds and etcetera, and it wasn't even close. You don't know if you

[Alice M. Emmons (Chair)]: can One

[Brian Minier (Member)]: day. I only brought it up because I know it's but it's an example, it's a good example.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: One thing that did happen is that we used to only give, buprenorphine is mixed, typically the community with naloxone, so people can't inject it. And we recently changed, with the mono product, meaning that just buprenorphine is much cheaper, that cost difference went away. And so after a number of years, just about a year ago, we went ahead and went to the community. So we pulled aboard and did because the cost was the same. So we now use the dual product repair.

[Brian Minier (Member)]: I am not pushing for injectables. Was just the easiest example I could give you.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: We have

[Brian Minier (Member)]: have a look. Here that's incentivized you, board's efficiency, and better outcome.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes, and there's many different kind of ongoing processes in place, whether it's a CQI, continuous quality improvement process, or reviewing various types of costs that are recurring and ongoing to make sure we're being responsible. But there's a lot of flexibility too, something What would be the best way to approach something changes?

[Brian Minier (Member)]: Thank you.

[Alice M. Emmons (Chair)]: Yeah,

[Unidentified Committee Member (privatization concerns)]: sure. And I just want to preface this, Doctor. I have the highest respect for you and your team. And when you come in here, all I hear is patient first and it gives me comfort. But I think people on the committee know I have a philosophical issue with privatizing this type of care here. I'd love if you were a state employee. So, it's absolutely not you and your team. But think my question is, as we're looking at contract negotiations, I know in the past bringing this type of service in house is something that's been analyzed and debated. And I requested last year some of the spreadsheets just on the cost analysis of how it compares to privatizing this type of care here. And the reasons I hear that we don't do it is two things, recruitment and cost. And I was hoping you could talk about that a bit. Because when I see the spreadsheets of state employees, the numbers do not reflect the number of staff on the ground for WellPath, right? And I wonder if that's some telehealth issues or But yeah, I guess the question is, I find it tough to have a culture change when we have different contractors every few years here. Hear about state employees that worked before. And there were a lot of problems with that. But you can change the culture when you have it under your roof. But when you have a national company declaring bankruptcy regularly, you're worried about, are they gonna pull back staff? That gives me anxiety. It gives me anxiety the transparency and accountability of a private company generally. So I'll say that, is there a real look at maybe bringing these services in house? And if it's a recruitment issue or a cost issue, why can WealthPath recruit people better than the state can? Because wouldn't you be paying people more in that case? So I'm talking a lot at you, but

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Sorry, so I understand. Paying people more in which case?

[Unidentified Committee Member (privatization concerns)]: So the question I have is, if the reasons we don't do it with the state is because we have trouble recruiting people, but the other reason is it would cost more to do it with the state. I'm having trouble reconciling those two things, right? Why can WellPath attract people that state government could not? Is WealthPath paying people more than state government would? Does that make sense?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes. So I'll start by saying, I don't think I currently have great answers to those questions myself. I think we can certainly follow-up. And it sounds like you already have the analysis that was done and you probably are more- I've

[Unidentified Committee Member (privatization concerns)]: got the analysis yet, but I think I'd love to see that stanked up against the wealth path current staffing on the ground too, maybe.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yeah, we could definitely follow-up. My understanding is that it would, and caveat that I have not validated this, is that it would potentially cost the state more to hire people at a similar level for the person being hired. Again, I don't-

[Unidentified Committee Member (privatization concerns)]: Because of benefit.

[Alice M. Emmons (Chair)]: And he's Benefits and fringe.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Beyond that, I'm not, again, right now myself, very familiar with the details of kind of how that analysis arrived at the conclusion that it would be so much more costly. But I think we can certainly revisit it for better answers to

[Alice M. Emmons (Chair)]: your question.

[Unidentified Committee Member (privatization concerns)]: Is the department looking at an analysis this time to bring it in house as opposed to privatizing it?

[Alice M. Emmons (Chair)]: It's been a few years since

[Unidentified DOC budget/finance staff]: I looked at that analysis, I remember the cost being around $100,000,000 which is a very incredibly steep increase that I don't know whether the legislature would be up That

[Brian Minier (Member)]: was a

[Unidentified Committee Member (privatization concerns)]: lot of employees though that I did not necessarily see reflected in the wealth path contract.

[Unidentified DOC budget/finance staff]: I did leave the cost was predominantly staffing. I have to look at it again. I'll have to find it.

[Alice M. Emmons (Chair)]: That was before justice oversight this time. It was last year. It was '24. It was and the question that came up at Justice Oversight is what you're kinda reinventing the wheel because some of this is already in place within the agency of human services.

[Troy Headrick (Ranking Member)]: So

[Alice M. Emmons (Chair)]: commissioner demo came and presented. It was about 90,000,090 million, 100,000,000. And some members of the Justice Oversight Committee says, well, some of these services could be provided in house within the agency of human services. They haven't calculated. So that was part of the conversation, and that's as far as I got.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: So I have just to share the clinical and the financial piece and the philosophical, I'm taking care of patients, I'm good. I appreciate the politeness of the question. The one thing that I do appreciate, especially because I was not, I don't have a long tenure in corrections at all, is that I have a pretty deep well of experience to draw on from my colleagues. I meet with state medical directors from the South, the Midwest, other New England states, and we rely on each other. And we have some infrastructure, for example, some telehealth services that we can share, that we can pool. So I'm not trying to defend one position or the other, but that's something that is very helpful.

[Unidentified Committee Member (privatization concerns)]: Thank you. So

[Alice M. Emmons (Chair)]: any questions further on this particular slide that we can move on here?

[Unidentified Committee Member]: Just one clarifying point. I heard Haley mention 100. I heard you say 90 or 100. Are you saying 90 or 100 delayed for one year is the recollection?

[Alice M. Emmons (Chair)]: We need to start it all up in one year.

[Unidentified Committee Member]: They're a big startup. I don't know. I understand it's all fuzzy.

[Unidentified DOC budget/finance staff]: It's going to be fuzzy now when we find it. I'm happy to share with the committee noting that this was a

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: few years.

[Unidentified Committee Member]: But somehow, some way, it's some multiple of

[Unidentified DOC budget/finance staff]: what we're talking about. Oh, that seems strange. Yeah. Like.

[Conor Casey (Member)]: Yeah. But obviously, since they're they're they're gonna be since we don't have this input, we don't know what what FY '27 is gonna look like on a per head basis. You're you're just kinda flipping in the breeze because you can't really

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: can't get

[Conor Casey (Member)]: a termination on

[Alice M. Emmons (Chair)]: I think we're they may know. They may not be at the point

[Conor Casey (Member)]: Certainly, if other products have numbers, but but for our purposes, it it doesn't allow for testimony that in order to drill down and get an understanding.

[Alice M. Emmons (Chair)]: Yes and no. I'm just wondering. You may be more limited in what you can say because the governor has not proposed this budget in terms of I I understand. Participating in internal costs. That may not be the case, or it may be the case. I mean, it is it is an estimate that you put out there because you don't know what your daily population's gonna be. You just don't know. But we

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: do know that it is higher currently and has been for a while than it was when we negotiated the contract. And if it costs money to provide these services to people, and we try to provide very robust services, we don't want to change the level of service we're providing. And so if the population's increasing, it's a

[Alice M. Emmons (Chair)]: natural, mathematical outcome that the total cost would increase as well. Now really, terms of the VA change, the biggest component of that increase is about population. So my understanding, the question was from a probes was, well, the population's increased by two hundred, three hundred people. Why is it increased by this $4,000,000? That just seems exorbitant. So that's a level that was asked. So it's the average daily population that has figured it doesn't mean that all those daily population that folks are coming in stay incarcerated. It's people working through your system. Correct?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So the average daily population that the negotiations with WellPath are based off of in terms of their ability to revisit is monthly. So it's the people that we see in a month. In a month.

[Alice M. Emmons (Chair)]: And that has increased because even though you've had maybe 200 more people incarcerated or 150, you're seeing them more. So I actually just misspoke. Sorry. I realized as

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I was saying it. So there's two numbers, and I'm just envisioning one of the reports we get every month from WellPath. One number is in a month, the number of patients that are provided any service. So those you could think of as people, combination of new people coming in who are getting, our next slide outlines the different services provided when people come in, but at least that initial intake all the way to someone who is up for their annual appointment. And so that number of patients is currently, I believe, more like 1,800. The average daily population that the contract is based off of is actually an average of the number of people we had in custody every day over a one month period. So it's much lower, right? Because to your point, people are coming in and out, they're not there every day of that month, but then someone else is there the next week that is part of that daily total. And the contract is not based off of the number of people that were ever in our system in a month. It's the average number of people on a day in that one month period. And that has gone up. We were low in our previous contract compared to what our population has reached recently. So the gap is not just from this point today to this point last year, but it's a larger gap and a bigger change because they've actually been serving a higher ADP than the contract for quite a while.

[Brian Minier (Member)]: So, if the population is aging, they're gonna be probably seeing that more often than if they were younger, as an example.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: That would increase the overall spending, but it doesn't change the contract amount. Because the average daily population is not about services being received or the number of services The number and of people.

[Alice M. Emmons (Chair)]: So when you have a lot of detainees coming through, you're doing those initial health assessments that first day or second day, and that contributes to the

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: It contributes to the the cost of And the at the end of the day, when it gets reconciled, it will come out. But the average daily population is more a function of how long those people being detained are with us and how much they're overlapping with each other. Because if someone is coming in every day and also leaving the next day, then your average daily population is lower than if someone's coming in and with us for fifteen days or thirty days, and the next person comes in and

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: It's been a big burden because of ICE.

[Alice M. Emmons (Chair)]: Because of ice. At Northeast I'm sorry, at Chittenden Northwest. Because they're staying longer?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: No, because they're staying shorter. So people are doing oodles of work, we're going to go through the assessment, and then they leave. Then a whole another truckload of 20 people shows up, they do oodles of work, and then those people are all gone. So to get somebody in the system is a lot of work.

[Alice M. Emmons (Chair)]: So does that contribute to your average daily population, the ICE numbers? Only in that those people are counted in the people in custody.

[Unidentified Committee Member (budget scrutiny)]: So it's increasing the

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: And cost, not the average daily population necessarily because It's increasing the cost. But they are part of ADP. I just can't speak to how much that's driving ADP versus

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: ADP, yeah, I'm sorry if you got it. ADP is throughput times length of stay, and so throughput is what drives a lot of the work, But if the length of stay is really short, it's going to make the ADP look lower for any particular throughput. So that's one of the things.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: It might be a good time to go on to

[Alice M. Emmons (Chair)]: what the services are. One question and then we'll go.

[Unidentified Committee Member]: Maybe too hairy at this point. I've gotten a little confused. No, it's interesting. I had been thinking, you said earlier, I believe, that the average population had gone up, but the per member per month had gone down. I was assuming that was because of the short stay, but now I hear from Doctor. Hewlett that actually increases the cost because of the expense of somebody being new there. So I guess one question is, do you have any idea how the per member per month went down? The other is just about that calculation in general. Is that all of the retrospective? Like, here's how much it's been costing. That's what we're gonna adjust it to.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So I can understand which calculation. So my understanding, and we can follow-up with sort of more of this BAA background for those specific numbers, but that the way the per member per month went down in the recent negotiations was a close analysis of the spending to date over the previous two years and essentially identifying efficiencies. So these are the staff that we have in regional office and at each site. This is what it's costing us per person for pharmacy, etcetera. And that in that analysis, they did not feel like they had to increase every single cost across the board. And there were places that the staff that they had didn't need to be increased to serve a higher population. So for example, they did somewhat enhance regional office, but not proportional to the number of people being increased. Because someone like Doctor. Hewletters, his job, he can still do it whether there's 1,200 people or 1,300 people. And so in analyzing all of that, the per member per month when they had the total budget was able to be lower than it is now.

[Unidentified Committee Member]: So if I understood, I think then it's most easily attributable to a classic explanation, the efficiencies of scale, as opposed to a different kind of population or they're receiving different

[Alice M. Emmons (Chair)]: Yes, that would have been

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: a better way for me to say. That's my understanding as well, anyways.

[Unidentified Committee Member]: Thanks.

[Alice M. Emmons (Chair)]: Let's go to the next slide.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Sorry.

[Unidentified DOC budget/finance staff]: Follow-up Just on wherever you were.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, no, but I wanted to see how presented. I think understanding this slide, we'll start with understanding the difference between screening and assessment. Screening is looking for something in a population that is at risk maybe, but doesn't necessarily have symptoms or anything, so it tends to be very broad. We might find people that screen positive for depression that aren't depressed, and that's okay, because we're trying to catch everybody who's depressed. So the facility admission is primarily a corrections piece, security piece. The initial receiving screen is done by nursing, and it's big. It takes, I don't know, up to an hour, more if there's language barriers or etcetera. That's

[Unidentified DOC budget/finance staff]: not booking, or do they go to the infirmary?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: That's typically done in booking. And they get depression screening, different mental health screenings, they get substance use disorder screening, they get a once over connection if they even belong in the facility, sometimes they're sent to the hospital straight away. I've had some nurses make some great catches recently where somebody caught the appendix out, I'm going to misspeak, but there was something big that somebody caught that was pretty subtle, pretty impressive. So that screening is a big, like, what are the big things we have to deal with?

[Alice M. Emmons (Chair)]: Just to be clear, anyone who's coming into booking gets arrested and comes in, even if they're there overnight, one day, they are screened.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: That's correct.

[Alice M. Emmons (Chair)]: So just keep that in mind.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: And that drives a lot of the nursing volume.

[Alice M. Emmons (Chair)]: And what about in caps? Are in caps screened at all?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: I'm sorry.

[Alice M. Emmons (Chair)]: Incapacitated. Oh, yes. They're screened as well. I haven't seen as many of those as kids.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, so you meet if somebody's on campus. Nibra. Yeah.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: The people that aren't different.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: I see, yes. Thank you. The nuance of that, I'd have to ask our nursing team exactly how they handle that. People are looked at, everybody's looked at. If somebody's inebriated or whatever, they may not be appropriate for our facility, so they do get looked at. They don't sit down and do an hour interview with them, though. But yes, there's a pretty thorough nursing screen. The next two thing, and that says within four, and I think the standard across the country by NCCHD standard is actually twelve hours, I think, so four hours is aggressive.

[Alice M. Emmons (Chair)]: That's by statute.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, and fair enough. Yeah, I think that may be true.

[Alice M. Emmons (Chair)]: Seven days is

[Unidentified DOC budget/finance staff]: Yeah, I can check.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: And I'm not saying that's We're just on the more aggressive side, which is fine, happy to be. The initial health assessment is that's a provider, a nurse practitioner, physician, or a physician assistant. That's physical exam that's done within seven days. We do, if that needs to be People are regularly being triaged if they're sick, we'd see them in a day or two or right away, but within seven days is the goal. Then there's the additional mental health and substance use assessment. So here's the importance. The initial screening was a screening by a nurse. The assessment is with a mental health professional, non prescriber, but somebody who could say, Okay, you screened positive for depression. Do you have depression? Do you have trauma? Do you have something else? And that's within seven days.

[Alice M. Emmons (Chair)]: And can I ask a question?

[Unidentified Committee Member]: Yeah,

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: please. Is that dependent on the outcome of the initial screening? Someone wouldn't get that if there were no flags whatsoever

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: That's right.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: In the initial.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Thank you for that clarification. Yeah. I appreciate that. And then a dental exam within thirty days. But that first seven days, you see a lot of different services.

[Alice M. Emmons (Chair)]: So this was also done for detainees who a scenario, they come in on a Friday, They would receive that initial screening. They go to court to be arraigned on Monday, and they all are set, and they come back. And they're there for two weeks. So within a week, they would have a health assessment. And then they could go in for an additional mental health or substance use assessment. And then they may bail on the third week they're there, but you've expended all of this. Okay. Just so people know. Brian?

[Brian Minier (Member)]: Can we just follow-up on that? So if they show back up in four weeks, will you go through all of this again? Yeah.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: But there are records in the system.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, so we can build off that. Yes, we can review previous. Sorry.

[Unidentified DOC budget/finance staff]: Sorry, Mike So

[Troy Headrick (Ranking Member)]: we heard testimony yesterday pertaining to ICE detainees that's especially concerning. That doesn't necessarily align with what we're seeing here or what we're hearing. I'm not doubting that this doesn't happen. But testimony indicates that by the time this is testimony from the Vermont Assassin System Project, the folks who are probably frontline providing due process services and legal services to ICE detainee. And they're hearing constantly, from my interpretation of their testimony, it's not at all uncommon for them to learn once they meet with these folks and sometimes that's incredibly delayed that plenty of health concerns are going unnoticed or un cared for medication, diets, necessary diets. So I'm wondering, I'm really wondering about that gap in testimony we heard yesterday based on how clean the protocol seems to be laid out here.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah. Well, so I have a few answers, and none of them is sufficient. But one is that so this is how it's supposed to work. Does it always work that way? No, it doesn't. But it should work this way all the time. The second thing is, I can tell you, because I'm not frontline and I have a respect for my people who are, the one who I've talked about this most is our frontline nurse practitioner at Chittenden, the hardship facility, the women's facility, and it's interesting the way she's able to enumerate the many barriers. I wish I could think of, and I probably couldn't even share it because of privacy, but a barrier for one person is the barrier for that person, somebody else is a different, and it's amazing. One common one, though, is often a language barrier and trust. So of course we have interpreters, and we absolutely work with interpreters. It's challenging, it's challenging for the patient, it's challenging for me. If I went some other country and was trying to go through it, and they were taking a detailed sexual trauma history. How do you think that goes? We've had many times when that nurse practitioner I'm talking about is trying to take care of somebody, and then days later, a staff member who shows up who's fluent in Spanish, and the whole story comes out. So that's just one example. I'm not going be able to satisfy the gap, and I'm sure there are good reasons and not good reasons for that gap, but I see the pain, the staff is working on meeting that gap.

[Troy Headrick (Ranking Member)]: Yeah, I don't doubt that there's intent to provide services. I'm just really worried about

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: the reporting. No, me too, and I think reporting is a challenge in any setting, and not all reporting would even catch some of those things. Because we can do this and it can look really tidy and there's unmet needs, and if we never know what those unmet needs are until it comes out in qualitative sets afterwards. I totally respect that.

[Unidentified Committee Member (privatization concerns)]: Sort of piggybacking off that, it was a heavy testimony yesterday. One of the things we heard was it's not uncommon to shift detainees for ICE from facility to facility to sort of disrupt, make sure they don't get legal representation. But could you talk about the continuity of care? Say somebody's transferred from an ICE facility in another state to Vermont. What sort of information do you get? And likewise, when we send somebody out there to New York or Louisiana, what are we sending out with them? And how does the communication work with the medical staff at these other facilities?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, and I can give you some qualitative testimonies that I didn't prepare rigorously for what's required or exactly what we do, so forgive me, but sometimes it works really well. Sometimes we get

[Unidentified Committee Member]: a

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: full, here's what's going on, here's their medications, and there it is. It's true that they're not with us very long, so sometimes you get somebody who is, and I'm generalizing very much, somebody who's picked up in Massachusetts on her way home from work, and her kids don't know where she is, and she lands at Chittenden, terrible, it's and then she's with us for four days, and then all of a sudden she's gone, and that's a challenge. One of the biggest challenges is methadone. The Feds won't transport people on methadone, and so we get asked to taper people off methadone. Now, of course, we don't manage methadone. Our opiate treatment plans do, they help us with that, but it's a very common thing that those opiate treatment programs will say, Well, it's not medically integrated. So we're in a little bit of a bug between the hammer and the anvil there.

[Alice M. Emmons (Chair)]: We're dealing with detox.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: And we're dealing with detox, and then there's ways to I'm getting into the weeds a little bit. There's these crosstakers with methadone and buprenorphine that you could do, but they require cutting the buprenorphine, which actually we're not allowed to do. But

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: if

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: the patient was at home, they could cut the strips into this size and that size.

[Troy Headrick (Ranking Member)]: We're not allowed to do

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: that at a healthcare facility. And there have been, and we've heard some of them in the news, there are situations where and what's funny, there's different levels of veracity when I see what's in the news and I see what we actually get. Sometimes it's very reflective, and sometimes it isn't, but the problem is real, and I don't I would be happy to prepare better for that question.

[Unidentified Committee Member (privatization concerns)]: No, are we having conversations with medical staff at other facilities when they're transferred? And do those feel meaningful? Like, how's Anthony Doyle at Mono, you know that? And they know when he gets to the other facility?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Sometimes. I've had some conversations that were concerning.

[Unidentified Committee Member (privatization concerns)]: Okay, thanks.

[Brian Minier (Member)]: Is there blood work associated with this or not?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Not necessarily, but there could be depending on the health conditions you have, your age, etcetera. Okay. So we do, but there are some lab testing. We screen all of our women of a certain age for chlamydia. We offer HIV screening. There's some It varies. Yes.

[Brian Minier (Member)]: And that's on a voluntary basis or Absolutely, always. Never force that.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: There's also urine drug screening with this too. One of the challenges I'll point out, we don't have fentanyl urine drug screening at point of care. That's a big problem, and I've been advocating. This is not a thing for you, but I'm working on that. With With WellPath, well, part of it's WellPath being responsive, there's classically not been a things have to be clear waived, there's some red tape in terms of us being able to allow to use the test, and that's cleared up in the last year or two, so I'm going to try again.

[Alice M. Emmons (Chair)]: Troy?

[Troy Headrick (Ranking Member)]: What would make your translation services more consistent?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Having a bilingual or trilingual medical staff, I don't mean that to be a cheeky answer, but it's such a medical encounter, especially this is such an intimate thing anytime you have somebody. I have heard some complaints of IT the infrastructure not always being a barrier to a clean translator line. And I don't know how

[Alice M. Emmons (Chair)]: That's what you were talking about. The IT.

[Unidentified Committee Member]: The other day in here, I don't know if it was you, Shawn or somebody. I'm going show my apron here. Brought up the ability of phones now to translate. Does it have a lot of languages? Is it totally ineffective? Is it bad at doing medical stuff? Is it just a technical feeling when you're asking?

[Conor Casey (Member)]: Yeah, so

[Troy Headrick (Ranking Member)]: we're not allowed to

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: have our phones in the facility. Oh, that'll hurt. And when you do have your phone, you can't really get reception in a big concrete bunker. And then the third thing, and I don't know, I'm kind of always a very practical, you know, I follow the rules, but I'm kind of so I don't know if we're actually allowed If we were sued because Google Translate did it wrong, I don't know what kind of coverage that would be. I've done it with people.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: We're very much supposed to use the interpretation services over other ways of translating, lest they introduce inaccuracies.

[Unidentified Committee Member]: Yeah, I understood. Was just thinking about it's vague.

[Brian Minier (Member)]: I didn't hear what you're opposed to.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I was just saying that the go to is the interpretation services as the mechanism versus individual tools that people might try to use for consistency and reliability of the accuracy of what's being translated, including not relying We shouldn't be relying on bilingual staff who aren't trained as interpreters. Obviously, sometimes that does occur, but that's not a best practice in language access.

[Brian Minier (Member)]: But just pushing back a little bit, isn't something better than nothing?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Well, something should be the interpretation services. I think the challenge with that is often the dynamic you were describing where having some third party on a phone who's not a medical provider changes the dynamic of the interaction between the patient and the doctor. But there shouldn't be nothing. The something should be interpretation services. The classic example in the community, this is not in corrections, many patients request we're not supposed to do is having the English speaking children of immigrant parents,

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: and that's often what the parent wants. A lot of times it's not what the child wants, and it can lead to difficult dilemmas. So that's an example, something better than nothing, yeah, and even if the patient prefers it, it's still not a good practice. Very nice. Anything

[Brian Minier (Member)]: else? Just keep going.

[Conor Casey (Member)]: I think I have some questions later, but we have to get to that part of

[Troy Headrick (Ranking Member)]: the presentation Do then,

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: you want us to keep Okay.

[Troy Headrick (Ranking Member)]: Yeah, there might be a side of play thing for time.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, okay.

[Unidentified Committee Member]: It's great.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Without trying to speak to the bigger picture philosophical question of public or private, I have seen a lot of improvement in working with the current provider of our medical services. And my experience has been that we're always between DOC and WellPath, just trying to solve problems and figure out what's getting in the way of providing better services and which problems can we solve and how are we improving care. So some of the current priorities I wanted to highlight for this committee. WellPath has a strategic action plan. So this was developed, I think at this point over a year ago, and was really an assessment, including from not just the Vermont team, but from some corporate and other folks involved in contracts elsewhere, of how services were going, how contract performance was going, and identified kind of big picture things that they wanted to improve to ultimately improve services and repair and outcomes. Some of that work is, a lot of it is around organizing and tracking major system changes, standardizing, which I know Doctor. Uehler can speak to if we're able to get to it today, Redesigning operational workflows. So there's a way a thing has been done. It's not the optimal way, but redesigning it takes a lot of work and planning. It takes reconfiguration in our electronic health record. It takes staff training. It may affect other workflows. And so there's a lot of that happening right now, and it's a huge lift to do that for those reasons I just mentioned. We're also working on enhancing the analytical capacities or capabilities within electronic health records. So being able to better analyze the health data, including being able to do population health analysis that right now, the way it's set up is challenging or impossible to do. The Medicaid reentry project, we also wanted to give you a little bit more detail about today because we're now live after many years. Some of the highlights of that are enhancing release planning, which I know this committee cares about a lot, as do we, and enhancing continuity of care and collaborating with other agencies, including the Vermont Chronic Care Initiative. We also are standing up claim submission to Medicaid, which we've never done as a department. Another priority for, I would say, DOC and WellPath is improving trust and communication with patients. So this is an ongoing strategic priority. My team surveys patients every year on their experiences with health services and how they feel about their health. So we have data from patients about how they feel they're treated by medical staff. And we actually just conducted a survey recently in the fall and should have that data soon. Other initiatives in service of improving trust and communication with patients or that we think that will be a byproduct. One is streamlining medical records request processes, which are very burdensome right now, not deficient. And we're fixing some of those issues. And also we will be implementing electronic sick calls. Not exclusively, you will not have to do it electronically, but that should be a much more efficient system of communication between patients and medical staff.

[Alice M. Emmons (Chair)]: They can do that through their iPad? Would that

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: be In the future, they will be able to. So it will be easier hopefully for the patient to do it in the electronic system. It will also on the back end organize the requests better so that the staff reviewing them are reviewing them more easily, more quickly, and more effectively getting to the more serious symptomatic ones first. I think I may previously have shared sick call numbers in this committee and they're very large, but most of them are not actually symptomatic. So being able to split the communication that patients need with medical staff, that it has nothing to do with being sick in the moment, with when it does is assisted improvement as we get better at it.

[Troy Headrick (Ranking Member)]: How far into the future?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: It's hard for me to say because we're so immersed in the Medicaid work right now, and that's a big lift for staff on the ground. And so hopefully the next couple months, but I wanna caution a little bit because we're so focused on something else that we need to focus on first. And because it involves the tablets and systems, and so how quickly we can design them and then implement is a little bit to be determined. And then the last priority that I wanted to highlight is the enhanced substance use disorder treatment, which is you're building on the services that are already provided and available by offering more counseling and therapy services alongside MAT in particular with piloting that at two sites, which are Chittenden and Northwest, currently in collaboration with the CAC court, which stands for Chittenden Accountability Court. Three Bs or that. Three B Court. At very high level, the next slide, I think, is some of the indicators of improvement, which maybe are even better to share than just telling you what we're trying to do. So these are all from about two years into the contract. So really over the summer, two years into the three year contract. So one indicator of improvement, just a place we've seen positive change is staffing. And as of the summer, the staffing rate was at almost 90%, which was a 10% increase year over year. As you can imagine, staffing issues on the medical side make everything else we're trying to do harder. And there have been a lot of challenges with medical staffing, just like on the security side.

[Troy Headrick (Ranking Member)]: Do you know? Are you hiring primarily Vermonters or are those recruited from other states?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: I don't know. Mostly Vermonters, and most of people who are Vermonters are from Western New Hampshire. But some of the staffing is also done. WellPath has a travel nurse program that we have corrections trained nurses that can require.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: And then filling with some agency, some

[Alice M. Emmons (Chair)]: And travel

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: then some agency, yeah.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Extra traveling that aren't the law policy. But the more long term staff we have, the less we have to rely on other Generally

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: speaking, though, and I appreciate where that question is coming from, also the workforce and Vermont, just generally speaking, there are some challenges, especially in southern rural sites.

[Brian Minier (Member)]: Just to clarify, I didn't hear you right. So did you say most of them are from Vermont, but most of the Vermonters are from Western New Hampshire? No.

[Unidentified Committee Member]: You say Most of

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: people recruiting are from Vermont. Most of the people that are not from Vermont are from Western New Hampshire.

[Unidentified Committee Member]: Okay. I was like

[Alice M. Emmons (Chair)]: At your Springfield facility.

[Unidentified Committee Member (privatization concerns)]: Okay. I gotcha.

[Conor Casey (Member)]: We were annexing part of New Hampshire. Those are

[Alice M. Emmons (Chair)]: It's a region around Springfield.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Right. There is a yes. We hire a lot of New Hampshire needs.

[Brian Minier (Member)]: Yeah. It is a tangent, but are you gonna speak to the difficulty of finding staff from Vermont at some point in this?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, well, other than that, I don't know. Again, I'm not prepared necessarily for that, but it's hard.

[Alice M. Emmons (Chair)]: It's hard everywhere.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: It's hard. We have had some luck with collaborations with nursing schools. That's actually gone really well. The problem is those folks are brand new when they come out of nursing school, so we've had students rotate with us. It's been great, but they also haven't been at it for a long time.

[Alice M. Emmons (Chair)]: But corrections nursing is very different than nursing in your local hospital. It is absolutely. It's a different world.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: It's a different world. If you want to be a tough, independent, smart nurse that's on your own, Corrections is awesome. But it's different.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: But I think we have the sense that a lot of people never even know there's an opportunity to be a correctional nurse. And so we're really trying to be deliberate about exposure to people in that medical workforce pipeline for the ones for whom it's a good fit so that we can attract them, even if not immediately after they.

[Brian Minier (Member)]: The reason I'm asking medical staff seems to be difficult to find if all medical applications are And in I don't know whether that's legislative or pay or both, or they just don't like the Green Mountains or whatever, but if you had some insight into that, I would be interested.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: It's also a corrections thing. I could speak a little bit more qualitatively for the provider community that we're trying to make similar for nurses. A lot of our residents, people who are finishing their training in medicine, don't understand that this is even an opportunity. So I'm working with the Luneau College of Medicine. They've asked me to speak at some study of things, and I'm going to do that, and we're talking about just talked to Aviva about this. So it's uncensored information. But they'd like to do some rotations and what that even looks like and bring them on-site. There's lots of barriers. However, the intention is to let's make this a neat thing, not just behavior.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: The opportunity to impact people positively is so vast. I assume there's people that once knowing it's an opportunity will be interested. We also wanted to highlight backlogs. There's been an almost eighty percent reduction in patients past due to see the medical or dental provider since a high of last February, and a ninety seven percent reduction in patients past due to see the psychiatric provider in between previous January and the summer. And looking back to January 2024, that improvement is even greater. So you get very regular reports on the number of patients that are past due for their appointments. They're due at a certain date and they're past that by dental, sick call, all different types of appointments. And those numbers have dropped incredibly dramatically, which is really important because the people are getting care more quickly and not waiting to see the professionals they need to see. We have very structured continuous quality improvement practices in place. And in particular, this is referring to well paths, which are in association often with National Correctional Healthcare Standards and CCHC, Correctional Healthcare, which says these are all the things you have to look at and measure and track continuously, certain thresholds for those. And those studies, which are done on a cyclical basis across all facilities have shown consistent improvement really across the board in the first two years of the contract. Just

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: to build on, Adeeva talked and you went through expertly and a little quick, and so I just want to, on the previous slide, we talked about standardizing processes. And I talked about this a little bit a year ago, which is understandable if you don't remember, but healthcare very much in the modern era depends on a standardization of practice. And the quality of care is no longer you show up and your doc makes the right decision or the wrong decision, and there you go. It's how are the records kept, how can we manage the data? When you call to make an appointment, what is the whole experience from that to your pre visit labs, to all the things? So it's a much more complicated thing than we once considered. So Avita mentioned in the previous slide that we're trying to do an improvement process and a half processes. Every site does things differently. So it's hard to do continuous quality improvement if the workflows are different at every site.

[Alice M. Emmons (Chair)]: Every site being every facility?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Every facility has their own workflow, and that comes from a very genuine way. That's been a coping strategy for years. You make the central office happy, and we'll do our work around and get the work done we need to. That's a survival skill, but now we all have to do it the same way, because then we can standardize, we can cross train staff, we can do a better onboarding, and when we have low numbers in CQI, if you don't have a standardized way of doing things, you can't train to a new way of doing things to improve your CQI numbers. So this CQI goes hand in hand with developing standardized processes, and it is a lot of work, And we're just starting to see the fruit of it, and I'm really passionate about that. So thank you for indulging me.

[Conor Casey (Member)]: What would be an example of an inconsistent process that really is an impediment for you? I'm sure there are many, but just one.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, there's a facility that isn't recording the blood sugars in the right place, and so when we go to look at I was telling my providers, You're not managing insulin right. And they're like, Well, how should we do it? I said, Well, go and look at the blood sugars. They're like, Well, there aren't any there. The blood sugars are supposed to be recorded in the same place at every site. And correct tech and I, well, we beat up a lot of correct tech, this one I'm going to exonerate them a little It's not uncommon for there to be more than one place to record something, but we all have to put it in the same place every time, so I can tell all my providers, you look there, that's where it is, then you adjust it. So I can't teach them to manage insulin the same way until we have measured blood sugar the same way.

[Alice M. Emmons (Chair)]: Where in the chart you enter.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: That's right. So I'll be like, show me what insulin I should use. Oh, okay. Oh, I can't. I don't know. I should change the insulin too, because it's not there.

[Alice M. Emmons (Chair)]: But they know at that facility where to look. It's just

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, well, this nurse on this shift likes to put it there, and that shift nurse on this shift likes to put it there, and the other facility prefers to put it there. And I'm not blaming anybody, this is just, it got this way after years, and we can't tolerate that anymore.

[Alice M. Emmons (Chair)]: Did you have your hand up? No, let's see.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes. So the last thing is enhanced release planning, which we can cover when we cut off the Medicaid project. So moving on to the Medicaid project. So there's really three significant components of what is new in the state of Vermont in the Medicaid and reentrycorrections space. And we refer to this sometimes as the eleven fifteen waiver, which is a bit of a misnomer, because you are probably aware that's way bigger than corrections. But in corrections, we are referring to our part of it. So the three parts are two for everybody, regardless of whether they're enrolled in Medicaid or sentenced or anything like that. And then one, just for people who meet a certain eligibility criteria. So the first two things to be aware of, which have been huge lifts with a million people involved and where I'm just thrilled that they're now actually happening. One is suspension versus termination. So previously, if someone was incarcerated and already enrolled in Medicaid, their Medicaid could be terminated because they were incarcerated. That is no longer possible. Instead, systematically, people's Medicaid, if they're already enrolled, will be suspended after a certain number of days. What that enables is that when they get out, it will also be automatically reactivated. That should happen within twenty four hours. So people should have much fewer gaps in their Medicaid coverage upon release from incarceration.

[Alice M. Emmons (Chair)]: So that information, the triggers, is with Diva? It's- because Diva administers more than Medicaid. Yes.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: So it's built into the IT systems through a lot of painful work over the past many months. But yes, so there's DOC information because the incarceration information is DOC. Diva's very involved. Gainwell, who manages the MMIS system, is very involved. And it's all been built to be automated going forward. The next big piece, also for everybody, regardless of legal status or Medicaid eligibility, well, yes, no, is that DOC will much more systematically review when someone comes in. And actually I should say DOCWellPath, what their Medicaid enrollment status is at that time. If they're not already enrolled, we will be enrolling them in the same coverage that they would be enrolled in if they went to an assistor program in the community and got assistance enrolling in Medicaid. If they're with us long enough, that will then be suspended and reactivated when they leave. So between those two things, the hope is that many, many more people are leaving our facilities with very rapid active Medicaid coverage shortly thereafter. So what percentage of folks who

[Alice M. Emmons (Chair)]: are coming who are on a press rate would be on

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Medicaid? We will have to see by doing the applications, but we anticipate almost everybody will be eligible. What we did find looking backwards or a moment in time prior to these kind of policy changes was that about half of the people in our custody in mid December were already enrolled, were active at that time. And then the other half potentially were never enrolled and just came in, or have been with us a long time and were maybe enrolled at some point. And all of those people we will be enrolling as long as they're eligible. So we'll be doing the application, submitting it, and then we do expect almost all of those to be approved. We'll have to-

[Alice M. Emmons (Chair)]: So is doing this, or is there other staff in DOC? Long term,

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: it will be WellPath doing the checking of coverage and enrollment. In the short term, DOC and WellPath are doing it together because we have to learn how to do it and because we have a backlog of people who are currently in custody who need to enroll before we start picking up enrollment as people enter facilities.

[Conor Casey (Member)]: Would some of these services then will be performed by WellPath in the facilities before an individual is released?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes, so we could actually get to that in the next slide.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Can talk a little

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: bit more about service if not. That's a great question.

[Brian Minier (Member)]: No, I'll

[Troy Headrick (Ranking Member)]: stop there. I probably read that a few minutes ago. Almost

[Brian Minier (Member)]: everybody's eligible because of lack of income. Right. Yes.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: And so those are the two policy changes across the board for everybody, regardless, again, of legal status or eligibility. Then there is, in addition, a separate new set of enhanced case management services through the Vermont Chronic Care Initiative, which is a program of AHS, specifically for people who are within ninety days of being released, sentenced, and enrolled in Medicaid. And so for those people who beat that very specific eligibility, we could go to the next slide. There's a set of pre release services that make up this brand new reentry Medicaid benefit. A lot of those services we already provide, it's just that the state will be able, they will become Medicaid billable. So things like MAT, health screening, medications at release, anybody is going to get these services that won't change. But for people who meet certain eligibility, those costs are billable. What is really new is the enhanced services through the Vermont Chronic Care Initiative. So we have spent many, many months designing what those services look like and how the Department of Corrections staff, WellPath staff, VCCI staff, and eventually other partners will collaborate to support people's reentry planning and then post release. VCCI is the lead care coordinating entity. So they will have their staffing currently. There will be six reentry care coordinators working across the state who will be thinking of them as lead reentry case managers working in collaboration, again, with DOC caseworkers, with probation officers, and with nurse discharge planning staff at WellPath, which we're also expanding to plan for people's reentry. That includes medical health considerations, continuity of care, but it's also much broader and includes other social supports and really anything that could affect someone's successful reentry and long term outcomes.

[Alice M. Emmons (Chair)]: So Medicaid can kick in to pay for some of these services? Yes. Three months prior to the person reentering? Yes. So while they're incarcerated, Medicaid will cover some of the costs for these folks who are on Medicaid.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes. So Right

[Alice M. Emmons (Chair)]: now, when a person reentered to this 11:15, when a person reentered the community, that is the time when they actually leave the door of the correctional facility and enter our community back in the community. That's when they could apply for Medicaid. Yes. So this is a three month jump while they're still incarcerated, set them up for reentry, and their insurance will be taken care of. And they would provide services. And Medicaid would pay for some of those services, health services are being provided while they're incarcerated?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes. So the DOC will be submitting claims for people who meet these eligibility criteria. After incarcerated in that three month window. Yeah. So we have to submit the claims after people are released because then we'll know exactly when they were ninety days pre released. We can't know until they're post release.

[Alice M. Emmons (Chair)]: So James and I have to leave because we have a meeting, but we're gonna continue this meeting. Troy is gonna run the meeting.

[Troy Headrick (Ranking Member)]: Sure. You better keep them in line to rest.

[Alice M. Emmons (Chair)]: I hope. I hope.

[Conor Casey (Member)]: It's a good thing that he's here. Know that could be a wrestling match.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Succession becomes

[Alice M. Emmons (Chair)]: And Troy, behave yourself.

[Unidentified Committee Member (privatization concerns)]: I'd like to make a few more options.

[Alice M. Emmons (Chair)]: That has happened, let me tell you. But if you could continue this conversation.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, I have a

[Troy Headrick (Ranking Member)]: hard stop at noon.

[Alice M. Emmons (Chair)]: But don't get to throw. And we will see the committee back at once.

[Brian Minier (Member)]: Thank you both.

[Conor Casey (Member)]: I think I corollary here to Alice. So the COB submitting the Medicare eligible claims once we know an individual has left because of the ninety day window. So how does that money flow? Is the reimbursement made to WellPath or is it made to the state of Vermont?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: It's made to the state of Vermont.

[Conor Casey (Member)]: Okay. That's probably cleaner, actually, because then you have your same revenue stream and the state has some kind of offset.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Yes. Our payments to WellPath aren't changing. It's money coming back into the state. You would have to ask the finance people for a more nuanced description of this, but of the primary reinvestment is in those VCCI services. So the way that we are reinvesting the funding we're going to recoup because some of these services will become eligible and billable is through the enhanced reentry support of the VCCI partners. And we'll have to wait

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: till the budget to come

[Conor Casey (Member)]: out and see if that looks like, probably. It'd be interesting what that number is. It sounds like it could be a very substantive number. If you're talking about three months of billables, and say even two thirds of the billables were available, that would be somewhere around $6,000 ahead of time. So however many people are released.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I think the Medicaid policy office and AHS finance are best positioned to speak to that. If I can just describe the general flow. We also are cautious about our estimates until we really see it start playing out.

[Troy Headrick (Ranking Member)]: I think we have BCCI coming in before soon. That's a giant storm.

[Conor Casey (Member)]: Sounds like potentially that's a big number.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I think this was our last Medicaid slide. It would be helpful to know a little bit more about what the committee is interested in connecting with BCCI about so that we can think through and prepare for a follow-up if you want to dig further into

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: this. I

[Troy Headrick (Ranking Member)]: think, because I played a role in getting them in here or making a request, my intent was to just start introductions and making sure everybody is communicating about, does BCI have everything they need? How's that partnership looking? That was it.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Do you still want to

[Troy Headrick (Ranking Member)]: Yeah, think they're coming. I think it'll be helpful for this committee to know who those people are and to start seeing faces.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: One thing I'll add just to give you a little bit a different way of picturing what some of the new enhanced services will look like and how it will play out. There will be, I mentioned the six reentry care coordinators that are BCCI staff. There will also be a nurse discharge planner at every site who's part of the Wellcraft team. That's a role we've had, but it's gonna be enhanced and expanded, and we will have more people in that role. And we also have DOC case workers involved at every site, as well as reentry probation officers. And so all of those staffing types from the DOC side, the well cost side, and the BCCI side, excuse me, will be collaborating to provide support around a person if they opt into the program. And so to me, that's really exciting because it's a set of staff dedicated to this and to working together in a coordinated fashion across these different agencies that have a role that I think will be really impactful.

[Conor Casey (Member)]: Great.

[Troy Headrick (Ranking Member)]: Yeah.

[Unidentified Committee Member (budget scrutiny)]: Just looking for some more clarity, maybe from DOC and WellPath, but last session, we were hovering at about 1,400 people in our correctional facility ish. That's the kind of number I was new to it, so I was kind of very interested in that. Now we're up at around sixteen fifty ish. Right? Is that number, in your opinions, being affected by ICE people coming in, immigrant you know, people being brought in by ICE? Is that having an effect on it?

[Unidentified DOC budget/finance staff]: We presented this data, I think, last week in the committee. And if you look at the numbers, the most significant increase is in state detainees. So the federal population, which is both immigration detainees and U. S. Marshals, obviously makes up a small portion of that. But for reference, right now there are, I think, 14 immigration detainees

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: at

[Unidentified DOC budget/finance staff]: Northwest from the male population. And then system wide, I think there are around 500 male state detainees.

[Unidentified Committee Member (budget scrutiny)]: Okay. So it is just a small percentage. Okay. That's helpful.

[Troy Headrick (Ranking Member)]: We have to realize too that as the courts get caught up with their dockets, we're gonna a good portion of those are probably going to see some incarceration.

[Unidentified Committee Member (budget scrutiny)]: From the Chittenden and

[Troy Headrick (Ranking Member)]: Accountability Court. In general, we're moving into a higher expectation that incarceration become a tool that we use. That's happening. Right.

[Unidentified Committee Member (budget scrutiny)]: Okay. Thanks. I just needed some clarity on that.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I think you're the last slide. Oh, no. It's not here. Yeah. I think this side.

[Unidentified Committee Member (budget scrutiny)]: System initiatives. Yeah, that's it.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Thank you. System initiatives, yes. So we talked about alleviating backlog and sick call review. Those were two data points that really disturbed me when I was talking about you a year ago, having over 300 people on a backlog list that only had a population of 300 people, so what is that? That doesn't make any sense. So that's substantially better, but we have some continuing work to do on it. A lot of the system improvements we talked about, it requires some correct tech improvements. So for example, if you tell everybody you have to document the blood sugar here, that has to work, and it has to work well. One of the challenges, the formulary was not correct, so the medications that we use for cost containment sounds something too harsh, but to be responsible with cost, what was formulary and what was in the system was not the same, so that recently just got updated. Now, every time you do something like that, we solved a couple big problems and we caused a couple small problems because we changed the formulary and then etcetera, etcetera. So that's undergoing. Improving documentation has been a big Forgive me if I said this last week because I can't remember where I said this, I was telling you, if you use the templates that are in correct tech right now, our numbers look good, but the note doesn't look like anything. If you write a good note, the note looks good, but then it doesn't feed into our data collection system. So we are going to have to redesign our templates to produce both the high quality, clinically useful notes so somebody could read it and know what's going on, and feed our data out, and that's a big lift. And that's not unique to corrections, by the way. I was part of a very similar project at the University of Vermont a number of years ago. Outside of corrections, you're used ahead of this, but that's a big thing. Implementation of new internal MAC policies and procedures, we talked a lot about that last week, I'm happy to talk about it more, but how do we handle aberrant use? We have not been getting people to a therapeutic dose at some of our facilities in a timely way. We've made some changes that are changing that. Likewise, with treating withdrawals with buprenorphine, not letting people withdraw and just be sick in a cell. We should be giving them buprenorphine straight away, and we are more consistently down, though we still have a way to go. And part of the way we did that is having this mini hub and spoke model within our facility, and I think I spoke about that last week, but I'm happy to speak about it more. We had to fully implement and release medications and standardize that across all sites. I got some data from that from our CQI person, Apparently all our sites are doing pretty well, nearly 95 to 100% compliant, except for Southern. We have some challenges at Southern in terms of discharge managers and stuff.

[Unidentified Committee Member (budget scrutiny)]: Just explain release medications to me, not being a doc.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Oh, yeah, I'm sorry. Those are the medications that were required. I think that bill started in this committee that we give them thirty days worth of medicines when they leave. Oh, right, Yes. So from what our continuous quality improvement person told me, we're nearly 100% compliant with that, except at Southern. And so we're still trying, we have some work to do there. It has to do with discharge planners or some HR pieces I'm not fully aware of, but we're on that. And then standardizing and building the release planning through Medicaid initiative, which is what we were Okay. That's a sample. We have more. There's the enhanced SUD model. So I'm pleased that the work that's being done will be a lot ahead

[Brian Minier (Member)]: of us.

[Unidentified Committee Member]: So Troy, can we just yeah, are we

[Brian Minier (Member)]: Go ahead.

[Unidentified Committee Member]: What are we doing? Already make a finger finish. So there's actually a bonus track, a hidden slide number 11, that talks about problems. And one of those in there is technology, not just correct tech, which you just spoke about, I get it, I think. But connectivity, which you'd mentioned a couple of times. And there's a subgroup of us working with next door trying to help with that. And so can you describe some of the common or biggest problems? What does that look like, bad connectivity

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: So for a I spoke to some of our providers that get kicked out of Correct Tech. Correct Tech apparently, and I'm not IT, but there's some when you log into something remotely, there's something that if there's a blip, like a one second blip, that it allows the thing to continue, and my understanding from our IT people is that Correct Tech's not built that way. If it gets a one second blip, it's out. And so it can take a long time to get to, they're seeing somebody, they're behind, but you can imagine a physician's busy day, and then all of a sudden you have to stop what you're doing. So that's one. The other one, and I'm less familiar with this because it's a nursing thing, but it's something I've heard about a lot, is we want to do online nursing med passes. So you're getting meds, here's your medicine, and then we scan your wristband, we scan the medicine, the computer knows what we've done, etc. And that works, I think, most of the time in the places where we do central med lines, but sometimes we go to the patients for good reasons, and the connectivity in those remote places is very poor. So those are two examples.

[Brian Minier (Member)]: That goes right to my question. Last year, I think I recall someone saying that bedwine started at 04:00 in the morning, maybe even earlier because of so many people and this event. Any initiatives to Injectables. Injectables? Well, did we

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: help that with the normalization at all?

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yes, the normalization helped that some. And again, our nursing team would have all the answers about the times of med lines. And I will say corrections, and it's still a bit of a mystery to me, the whole corrections schedule is rotated kind of early in the day, and I don't fully understand that. But I do believe that passing our buprenorphine med at the same time as our regular meds has helped that, at least to some degree, but I can

[Brian Minier (Member)]: sense with it. Because they can't be, what's the word, given out or taken? How does using euthanasia

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: We used to give it differently, and it was an observed med line, and now we give it to you like any other medicine, we crush it. And we went out on a limb doing that because we were treating it like a normal medicine, and so people were like, Oh, it's gonna be diverted more and whatnot, it's helped things a lot, and it's reduced some barriers to people actually getting medication. Because it's crushed? No, because it's without other meds. So you can now get it with your blood pressure medicine and all the other, right?

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: And before you would've gone to two separate med lines. So there was a whole med line just for MAT, not methadone, And then you would have the rest of the medication. As a patient on both, you would be in two lines. And now you're just in one. And it has saved some significant time across But all I think there's still a challenge. The logistics of getting everybody their medications ends up taking a long time no matter what.

[Brian Minier (Member)]: I'm not joking. It's 05:00 instead of 04:00 in the morning now.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Yeah, don't know.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Although KOP should also help, right? We're increasing a Keep on Person program where people have medications that they keep on themselves and don't need to be administered in Medline. And as that expands, it will further decrease the number of people waiting in line.

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: Absolutely true. Increasing the KNP.

[Conor Casey (Member)]: We good? We're good.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: Any other from our secrets, like

[Conor Casey (Member)]: I mean,

[Unidentified Committee Member]: tells me, I don't know.

[Navi Viteva (Executive Director of Health, Wellness & Engagement, Vermont DOC)]: I think they're all real. Just think you found it in the appendix.

[Troy Headrick (Ranking Member)]: Thank you so much, as always. Really appreciate your willingness to be supportive. Thank you. Thanks for

[Dr. Gina Giger (WellPath Physician; Medical Director for DOC contract)]: your question. Absolutely. Have a

[Conor Casey (Member)]: good afternoon.

[Unidentified DOC budget/finance staff]: Yeah, thank you very much.