Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Good morning. It is April 8, and this is Caledonia. And we're starting off this morning again, and this I apologize. This morning is going to be jumping back and forth between lots of different bills based upon language you get witnesses in. But we're going to start off with 197, and we have Chris Town with us from North Country Community Health. And you want to come on up?

[Chris Town (CEO, Northern Counties Healthcare)]: Sure. Hi. Hello. Good morning. Good morning. The record, my name is Chris Town. I serve as the CEO of Northern Counties Healthcare. As many of you are probably aware, Northern Counties Healthcare serves Vermont's Northeast Kingdom, the Tri County region. We serve about 40% of the community members throughout the Northeast Kingdom through a network of federally qualified health centers, primary care, medical, dental, integrated behavioral health. We also have a certified home health care and hospice agency. We were the first FQHC in Vermont and we're actually celebrating fifty years this year. So quite a milestone that we are quite proud of. The Northeast Kingdom is the most rural and medically underserved area of Vermont. And in Essex County, we are the only provider of primary care, dental and pharmaceutical services actually. We have a closet in our Iowan Pond Health and Dental Center. And so we're here today to talk about S197. As a network of FQHCs and Northern Counties in particular, we fully support S197 and more investment in primary care. We know that investing in primary care, in particular, saves costs, saves the system money. And for the Congressional Budget Office, they have verified that as well. When we are looking at S197 in particular, there's a couple of things that we want to talk about. We fully support more flexibility and eligibility for participating in Vermont's Blueprint for Health, whether that be currently through NCQA certification. But we do support other avenues in more flexibility inclusive of NCQA. For example, FQHCs have a rigorous set of regulations and quality metrics, access metrics, etcetera, that we do submit to the federal government on a very regular basis, including annually. And I realize there may be other systems out there as well. Is But Vermont's good for health and building on that, I think is a wise investment. Talked about this before, I think, and I know, Chairman Black, you, I think have said similar, reducing administrative burden. There's a lot of administrative burden on primary care. And anything that we can do as we move forward with the design of aligning metrics across the different payers, I think is critically important. We spend an inordinate amount of time on a lot of these various quality programs, access programs, etcetera. That I think is a crucial component as we move forward. And as I started out, it's important for us to continue the investment in primary care. We are currently operating a negative operating margins. We are extremely thankful for the additional investment that was provided last year that corrected years of underpayment in the system. But we're continuing as we move forward, we're in a gap year with the dissolution of One Care Vermont. We're looking at another gap year in advance of the ahead model or whatever is next. And that creates an immense amount of uncertainty and a lack of stability for us. A really difficult environment to provide care, to manage, especially when we are a people driven industry. I'm doing a budget presentation later for my staff. Around 75% to 80% of our expenses are salaries and benefits, and we're only seeing that increase. And so when we are facing uncertainty and instability in our funding stream, What that means is we do have to look at staffing and we have to look at services. So with that, I guess I would pause and ask if there's questions. But in general, I think supporting the intent of S197 and supporting work investment in primary care, we fully support.

[Rep. Alyssa Black (Chair)]: How many health centers do you have?

[Chris Town (CEO, Northern Counties Healthcare)]: So we have five patient centered medical homes currently. So brick and mortar primary care offices that all have integrated behavioral health. And then we do have two walk in care facilities under the Northern Express Care brand, one in Downtown Newport, one downtown St. Johnsbury. Those were set up purposely to improve access to care. So we put them in downtown as part of trying to help with downtown revitalization efforts, as well as put them where people live. In St. Johnsbury, for example, there's a very high percentage of residents that don't have access to reliable transportation. And so we have purposely put ourselves in a place where folks could walk to if necessary. We also have three dental locations. So one in Hardwick, Orleans, and then our location that I mentioned in Island Pond is a combined medical and dental location. And then we serve Caledonia and Southern Essex through our home health agency.

[Unidentified committee member/staff (shared diarization ID)]: Lori, did I see you medical? You mentioned the desire to have reporting be

[Tina Zook (American Heart Association)]: Sorry, just had my copy.

[Chris Town (CEO, Northern Counties Healthcare)]: Mine hasn't kicked in either.

[Unidentified committee member/staff (shared diarization ID)]: Yeah, okay, good. How you would like to have everything aligned?

[Chris Town (CEO, Northern Counties Healthcare)]: Yeah.

[Unidentified committee member/staff (shared diarization ID)]: Reporting wise, I think, is what I heard you say. Yep. I'm just curious, has that had groups outside of the legislature, so you and your colleagues, ever tried to do that? Put a proposal together? I will say

[Chris Town (CEO, Northern Counties Healthcare)]: it's actually, we've been advocating for this for a while. And I will say that actually, think we've made pretty significant strides in that. And so, but one care is the longer bound. But then a lot of the we've worked hard to have some of those metrics align with other programs, too. So yes, we have been advocating that. I do think we've made efforts in that. But when you look at some of the commercials, they may have a surge. Now, there's many different Medicare ACOs now in Vermont that may have their own set of requirements. So more we can do to align it and there has been a lot of progress in that area. But it's a lot of time. So when you're trying to do this for this group, this for this group, it kind of one, you're spreading out your focus. And so if you can have a more we're all rowing in the same direction, you're going make more of an impact.

[Rep. Alyssa Black (Chair)]: Along those same lines, so I do realize that you, as an FQHC, have reporting requirements and quality measures from the federal government tied to federal funding around FQHCs. Correct. So I think I'm trying to So you're also NCQA patients that are in medical homes, I'm assuming?

[Chris Town (CEO, Northern Counties Healthcare)]: We are. So we have the seven locations I mentioned. Our two locations are walk in are not NCQA, but the five others that we have been for a number of years now.

[Rep. Alyssa Black (Chair)]: Can you talk about, because we've heard, particularly with the blueprint, about the different payment amounts, and yes, it's cents, but when you start doing cents multiplied by thousands of patients, cents add up. How they're based upon the results of the quality measures. I'm wondering, so you have five different locations. Are you getting the same amount on all those locations or are some locations rated higher than others?

[Chris Town (CEO, Northern Counties Healthcare)]: So I would have to get back to you on specifics on that. And so I can circle back with you. What I know and then my colleague may be able to chime in as well. Currently, it is the same. So there may be other programs that are quality based through different payers where you do get a different quality incentive based on, for example, One Care would, again, it's we're talking past tense at this point, but they did have different pay for improvement metrics that were based on

[Rep. Alyssa Black (Chair)]: outcomes. I'm just thinking that you have multiple locations all over and that the needs and the demographics of those communities are all different. And if you're all being measured on the same thing, and I'm thinking statewide, I realize that you're, but just how different populations are able to access healthcare.

[Chris Town (CEO, Northern Counties Healthcare)]: And I think that's, to your point, Terwin, having flexibility in those payments allows us to address the specific needs of a community, because you're absolutely right. The needs up in Essex County and Island Pond might be very different than those living in Downtown St. Johnsbury. And so we all have to report on the same metrics, but we do get flexibility on how, and I think preserving flexibility to address that. And that's one of the great things of a population model gives you some flexibility to address that.

[Rep. Alyssa Black (Chair)]: Can you speak about the role of the community health teams through the blueprint and how they play with your facilities? Play probably isn't the right word, but I'll get my take.

[Chris Town (CEO, Northern Counties Healthcare)]: Yeah, totally. So we're interesting. Because we have a very large service area, we sit in three hospital service areas in North Country, Copley and VRH. So one of the talking about alignment, we have also worked over the years to try to align to ensure that we have flexibility and also are aligning some of those metrics and reporting requirements through blueprint. But when I think about we employ all of our own community health team through Blueprint. There's different models that are out there, which I'm sure you're aware of. And what I look at is it's really an extension of our provider team. So one example that I like to give and I talk to our new employee orientation is it's not uncommon for a patient to show up for a scheduled diabetes follow-up, for example, and you learn that they've lost housing, they don't have access to daycare, their car doesn't work, or maybe they're newly diabetic and they don't know how to manage that. You're dealing with the medical, but also the emotional, all the other components of a top seed change in medical status or a new medical diagnosis. And our community health team has not only the resources, but that flexibility and time to spend with that patient that a medical provider may not be able to do. One, they don't necessarily know all the resources available. And we often find that our patients want to talk to someone with similar lived experiences as well. And so someone who may have gone through something similar may have a family member who's also had a similar experience and can help connect it. So it's a really invaluable resource in my opinion, not only for our patients and the community, but also for our provider team.

[Rep. Alyssa Black (Chair)]: My last question is, do you feel as though and I realize that you're not clinical. You're not clinical, correct?

[Chris Town (CEO, Northern Counties Healthcare)]: No. I didn't start in as an optician.

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: Do not put hands on anybody.

[Rep. Alyssa Black (Chair)]: Do you feel that the care that Northern County Community Health gives is made better with all the quality measures that you have to report for various different entities? So all?

[Chris Town (CEO, Northern Counties Healthcare)]: I know,

[Rep. Alyssa Black (Chair)]: I do. I

[Chris Town (CEO, Northern Counties Healthcare)]: will say, maybe not all my colleagues would agree, and maybe probably not all my staff or providers would agree. But yes, I do think it's really important to have measures that we measure ourselves against our peers against, to ensure that we are providing a level of care. That I think is critically important. That's why we're in medicine is to improve health and health outcomes. And so I realize that there's a variety of different ways to measure that. But yes, I do think that we have to have standards and a minimum set of standards and then measure ourselves against that. Absolutely.

[Unidentified committee member/staff (shared diarization ID)]: Any other questions? Yeah, go ahead. Hi. Mentioned you received a payment last year, and it sounded like it helped you financially. What was that payment?

[Chris Town (CEO, Northern Counties Healthcare)]: So last year, and thanks in part to this committee, we did have our Medicaid rates adjusted. So there was additional funding through that. So that's what I was referring to. I

[Rep. Alyssa Black (Chair)]: see Wendy, but just on that, can you remind me, are your Medicaid rates in line with your commercial rates or are your commercial rates still lower than Medicaid?

[Chris Town (CEO, Northern Counties Healthcare)]: Yeah, they are typically I

[Rep. Alyssa Black (Chair)]: don't have

[Chris Town (CEO, Northern Counties Healthcare)]: have a code by code analysis, but in general, commercial rates are lower.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: Mine was on that line.

[Unidentified committee member]: So we're just discussing about what the plan itself, so the blueprint itself, if you would get reimbursement from Medicare and Medicaid, those would be adjusted, correct? I'm I'm trying to understand this. So the the the commercial rates, it would only get it would only be adjusted with the with the marketplace, correct? The quality, the QHPs in the marketplace. I'm not explaining this, it's part of my head, but it's not coming out right. It would only be that group of people that this blueprint would then adjust the rates for reimbursement. The commercial

[Chris Town (CEO, Northern Counties Healthcare)]: space, we bill on a fee for service basis. When you come in, we bill for service. When we talk about blueprint funding, so under state statute, the commercials pay into to Blueprint. And then that funding comes typically in the form of a per member per month basis to support some of the activities that we were just discussing. And then through Diva as well. It excludes

[Unidentified committee member]: self funded plans. Is that correct? No.

[Chris Town (CEO, Northern Counties Healthcare)]: Mary Kay, maybe you can chime in.

[Unidentified committee member/staff (shared diarization ID)]: So the QHPs must participate. Some funded plans can opt to participate. And that is part of, when we talk about data for Blueprint, we talk about building the business case for self funded Demarissa plans to participate. And that is then setting that for member per month payment for the TZMH status as well as another member per month that goes into the community. Does that help?

[Mary Kate Mullen (Bi-State Primary Care Association)]: And that would be for the commercial.

[Unidentified committee member]: So it does help, but I guess my question is, it's a better plan if the self funded does participate.

[Unidentified committee member/staff (shared diarization ID)]: The Blueprint has struggled for a long time with this problem of free riders where the community health teams support everyone in the practice. The benefits of being recognized as a patient centered medical home are felt by everyone in practice, but not everyone contributes funding those. And then

[Unidentified committee member]: to the way. That make them, we can sort of walk them through.

[Rep. Alyssa Black (Chair)]: Wendy, can I ask Jen, I think?

[Jennifer Kirby (Office of Legislative Counsel)]: Jennifer Kirby on this legislative council. So this is the issue around federal preemption where we can't regulate the plans, benefits that self funded businesses must provide to their employees. There are sometimes opportunities through third party administrators who administer the programs, the insurance companies and others that the employer funds are planning to make contract with to get participation in certain activities. But often we are looking for voluntary participation in this regard for the anti gender or so.

[Rep. Alyssa Black (Chair)]: Gotcha, okay. Thank you. If I'm understanding from your testimony, are you really just advocating for an increase in blueprint funding? Or are you advocating for different methodology in how the blueprint pays? Are you testifying that you would like to see a capitated more of a capitated model? So I think we're Just increase in the blueprint.

[Chris Town (CEO, Northern Counties Healthcare)]: I think the the testimony in general is recognizing the importance of investment in primary care and additional investment in primary care and open to different vehicles of what that looks like. As I said, we know that investment in primary care reduces costs. And we know that primary care in general is underfunded in the state and across the country. And so additional investment in that is, in my opinion, prudent.

[Rep. Alyssa Black (Chair)]: Thank you. I am so sorry, we are running behind. So I think probably another fifteen, twenty minutes.

[Chris Town (CEO, Northern Counties Healthcare)]: Thank you. Thank you very much. And

[Rep. Alyssa Black (Chair)]: then we have another Christopher, Christopher Chadwick joining us from Community Health Centers Rutland.

[Christopher Chadwick (Community Health Centers of Rutland)]: Yes, good morning. So I was asked to speak about behavioral health services within the FQHC model and answering questions you may have specifics to that. I'll just give you a little context of community health centers of Rutland and we have six primary care locations, one of those specific to pediatrics. We have two express care walk in clinics, two pharmacies, three dental programs, one eye care. We have a building specifically dedicated to behavioral health in Rutland, and we have embedded behavioral health staff in all of our locations. And we also have SNF medical coverage, skilled nursing facilities, the nursing homes in Rutland, And we have embedded behavioral health in the nursing homes as well. Our behavioral health team is about 63 employees. And last year alone, they did about 45,000 patient visits that were billable. That doesn't include care management visits, community health worker visits. These are billable provider visits. We offer psychiatry. We offer counseling and case management as well. And we do service pediatrics, adults, and geriatrics. And we are looking at expanding into a geriatric behavioral health program, outpatient clinic as well in the next couple of months. So that's kind of an overview of what we have done. We manage about 4,000 behavioral health referrals every year that come through our FQHCs that are already primary care patients of ours. So they have to have primary care established within our model Then they can be referred by primary care to our behavioral health program. So that's kind of the overview. I'm sure you have questions so we can do that or I can speak more about what we do.

[Rep. Alyssa Black (Chair)]: I'm sorry, again, the number you gave of 60, is that just sort of your mental health teams?

[Christopher Chadwick (Community Health Centers of Rutland)]: The 60 employees are just behavioral health employees.

[Rep. Alyssa Black (Chair)]: Okay. How do the community health teams through the blueprint supplement or where do they fit in with your employed providers that have billable services?

[Christopher Chadwick (Community Health Centers of Rutland)]: So we get funding several ways. We get funding through the hub and spoke model to provide support to the opioid use patients that we have. We have about four seventeen MAT patients or opioid use patients in our programs here. So we get hub and spoke money to support the care management and the counselors for that work. We work with, we get reimbursed for care management through the regular core contract with Blueprint that provides care management supports for our patients that are attributed through the Blueprint. And then we also, community health team has three full time employees that are embedded within our pediatric practice that support the pediatric population. Those are community health team employees not affiliated with us, but they service our patients.

[Rep. Alyssa Black (Chair)]: You have one pediatric practice?

[Christopher Chadwick (Community Health Centers of Rutland)]: We have one practice dedicated specifically for pediatrics, but we have pediatrics in our other facilities as well.

[Rep. Alyssa Black (Chair)]: Oh, okay. And those pediatric support team, they support all your pediatric patients, not just the ones at that one pediatric practice.

[Christopher Chadwick (Community Health Centers of Rutland)]: That's correct. And they also, that community health team and those employees also service practices within Rutland County outside of ours as well, if they have those pediatric patients.

[Rep. Alyssa Black (Chair)]: Okay. Any questions? Yeah, go ahead.

[Unidentified committee member/staff (shared diarization ID)]: I have like a page of questions.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: Oh, okay. I won't ask all of Daisy my has a page. I'm very excited talk to you, and thank you for all of your work. I'm really curious, when someone needs well, first of all, is it a federal requirement that someone be enrolled as a primary care patient before receiving behavioral health services with you?

[Christopher Chadwick (Community Health Centers of Rutland)]: It's not a federal requirement. It's an internal requirement that we have because we try to provide the holistic care. And we find that if we just offered mental health and couldn't address the physical health needs, it wasn't in the best interest of the patient unless we were managing both at the same time.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: And then how do you know that that model of integration that you're using is effective at good outcomes for someone's mental health?

[Christopher Chadwick (Community Health Centers of Rutland)]: So we've seen a specific demand in our services. Patients have transferred primary care to be able to access our services. And we have right now a 98 patient satisfaction scores across our behavioral health program, which is tremendous scores, especially compared to national averages. And our no show rates for behavioral health patient visits are averaging about eight percent, which is really low for behavioral health programs. So all the engagement work that we're seeing and the improved health outcomes that we're seeing with our data from improving health outcomes, including physical health improvements is showing that patients are feeling really supported and happy with our services.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: And how about your staff? Are you So checking in on their

[Christopher Chadwick (Community Health Centers of Rutland)]: we did a engagement survey with our employees and our behavioral health team scored the highest in the organization in terms of employee satisfaction. We have diversified how we hire because it's been such a challenge to bring in new talent into behavioral health. So we've actually expanded into three different roles. We started a clinical internship program partnering up with schools and universities to recruit them to do their internship hours through our program. We did a fast track rostered psychotherapy track for them so that upon completion of their degree, they slide right into a salaried rostered position where we provide clinical oversight and on-site supervision and hands on experience with behavioral health patients. And then from there, slide right into a full time salaried license position as well. So we're seeing a boom in recruitment for us. So we have had significant growth. In fact, in the last four years, we've had about 68 growth in our team in the last four years, just because people are excited to be a part of our team. So we're having great engagement with our employees as well.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: I'm curious when someone needs a type of care, like if the acuity of someone's mental health is beyond what your team can provide, How does that referral to higher levels of care happen? And is there any breakdown in that? Do you have any concerns about that process?

[Christopher Chadwick (Community Health Centers of Rutland)]: So that's a really good question. And it's a double edged sword because I'm going to make it sound great for Rutland. And in many ways it is, but I know there are challenges in other communities where it doesn't work as effectively as we have it modeled here in Rutland. But we actually have a really good partnership with the inpatient facilities. And we specifically hired care transitions care manager. And that care manager's position is specifically coordinating with those inpatient facilities and coordinating care with the patient before they're even discharged from those facilities to transition back to our program. So we make sure that when they're discharged, they have follow-up visits and a point of contact that follows them between the transition. The highest risk of relapse, the highest risk of mental health acuity going up is in that discharge period, where they're being released from the higher level of care and going back to the outpatient level. And so we have that care manager who works with them through that transition period. All of the patients try to be, we try to get them scheduled within three days of discharge to make sure that they have med reconciliation completed, a review and fast tracked into counseling upon discharge. So we have worked very closely with our Rutland Regional Medical Center, which has an inpatient psych unit here in town. That care manager is part of their discharge team. So they work directly with them. And we have partnerships with Serenity House and the other clinics around the state that work with us as well. And we work closely with Brattleboro Retreat for those discharges for pediatrics as well. So it's working well for us. We also built a crisis room in our building so that if a patient is experiencing an acute crisis, we have a dedicated room that set up like a living room. It's a living room style crisis room where the patient can be brought there with a family. The crisis team here from Rutland Mental Health will come to our building, do the intervention right in that room. And oftentimes they're sent home and avoiding an ED visit or a 911 call because we have it built the way that it's set up now. If they do need transport, it's in the back of the building where we have easy ambulance transport and they can transport the patient through the back door discreetly and protect the patient's privacy. And oftentimes, the rest of the patients in the building aren't even aware that the patient is being transported out of the facility to the inpatient psych unit at the hospital.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: That all sounds pretty ideal. I wish we could take whatever you're doing and make sure that everyone else knows how you're doing it, because I suspect that this isn't happening around the state and perhaps it should be.

[Christopher Chadwick (Community Health Centers of Rutland)]: Yeah, thank you. I do believe that's true. And that's one of the challenges with this testimony is I think we're doing a really good job in Rutland. But I know that there are health centers that are struggling with this and dealing with those and have backlogs for admissions as well. So our representation isn't always a good indicator of the rest of the state because we are doing well. But we are working with other FQHC partners across the state to help tell them how our model is set up and training them in exactly the model that we have.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: Is there anything that you're doing that we need to be careful to preserve with any new funding changes that we make to this model that would impact

[Christopher Chadwick (Community Health Centers of Rutland)]: That's

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: what

[Christopher Chadwick (Community Health Centers of Rutland)]: you're doing with behavioral a great question because a lot of the work that we're doing is on our shoulders. We really only get reimbursed off of the provider visits that we have. But as you can hear from what I'm testifying about, there's a lot of support that goes into that's not billable visits. So it's, So we have to absorb the costs of that, but it's in the best interest of the patient care. And so that's why we do that work. So I think if there was any way to get more funding to support those additional services that we don't get the fee for service reimbursement for those provider visits, that would be helpful specifically around case management and care coordination, because that's so pivotal to this experience and this model is having that care management and we're not getting reimbursed fully for the work that we're doing for that.

[Rep. Alyssa Black (Chair)]: Thank you. That's helpful. Thank you. Any other questions for us? Thank you so much for joining us and thank you for the work that you are doing and your whole team is doing.

[Christopher Chadwick (Community Health Centers of Rutland)]: Yes, thank you. I'll pass that along to them. And thank you all for the invitation.

[Rep. Alyssa Black (Chair)]: Thank you. Alright, moving to a different topic. Tina, did you were you going to come up and was everybody going to be together? Do you want to work this? One at a time, but we have three in person, one in one. One. Okay, alright. We'll go ahead and start and I will let you all

[Unidentified committee member/staff (shared diarization ID)]: choreograph. Face? Yeah, I don't if we talk about this a little bit later, but I just want you

[Tina Zook (American Heart Association)]: to see it while I'm talking to you, know what a CSA is. And that's why it smells

[Rep. Alyssa Black (Chair)]: like onions in the ocean.

[Tina Zook (American Heart Association)]: So for the record, I'm Tina Zook from the American Heart Association, and we're talking about food as medicine today. Thanks so much for making time. We don't have a specific ask this year, but we really just wanted to let you know about all the good work that's being done, and we may ask for something next year. So food as medicine, what is it? It's a covered medical benefit when a healthcare provider prescribes healthy food to help patients treat, manage, or prevent chronic conditions. And it's needed because 90% of the 4,300,000,000,000.0 in annual healthcare costs in The United States are spent on care for chronic diseases. And for most of these, diet is a major risk factor. So in Vermont, there are six healthcare CSA agriculture share programs. This is an example of a CSA community supported agriculture that cover eight of Vermont's counties. And working with healthcare providers to prescribe healthy food, their efforts impact diet related illness, food insecurity, and farm viability. So it's this wonderful mesh of interest in organizations. Though providing promising results and unmet need analysis of the efforts by Culinary Rehab in August, found that sustained funding was needed for this program's long term success. The report pointed to Medicaid reimbursement and funding via the eleven fifteen waiver in Vermont as a priority. Currently, are 13 states that have approved such waivers and three others have pending applications. So that's the next year side of things. But in terms of outcomes, health outcomes and healthcare savings, researchers found that medically tailored nutrition interventions could save Vermont $53,000,000 in healthcare expenditures annually, and also translate to a net savings of about $2,700 per patient in Vermont. Participation in the Massachusetts Foodist Medicine pilot program was associated with a twenty three percent reduction in hospitalizations and a thirteen percent reduction in emergency department visits, so significant. And in Vermont, there are three federally qualified health centers who have seen decreases in blood pressure and cholesterol through the programs that are underway or were underway in Vermont. One of those is no longer doing it because of what we talked about with the sustained funding issue, a grant that is gone, right? So we need to find some long term source. So I will let the experts who've been doing this work talk more about it, but I really want you to see, you can physically see, this looks healthy. And if you have something like diabetes or high blood pressure, this is great medicine. This is an example from Root five Farm, and the Vermont Youth Conservation Corps also has a healthcare share downstairs. You can take a look at that too, root vegetables, but also spinach, and as you can see, other greens in the wintertime. There is a Food as Medicine Task Force that is comprised of numerous organizations across the state that's looking into this issue now. It's not legislatively created. It's by state hospitals, insurers, a lot of people that are part of it, trying to find the best avenue for Vermont to move ahead and make some recommendations. I think we're hoping, Mary Kate will probably address this one. We're hoping to gel around recommendations in the summer to come back to the legislature next year with some thoughts on this. But we wanted to see, you to see, some of this good work already. So thanks for having us, and I'll thank Mary Kate.

[Unidentified committee member/staff (shared diarization ID)]: I'm hungry now.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: That looks so good.

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: It was just very Emily moves walking into

[Rep. Alyssa Black (Chair)]: the State House with a box of vegetables. Good

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: morning. My name is Emily Perry. I'm the Food as Medicine Coordinator at Little Rivers Healthcare, a federally qualified health center serving the rural communities of Bradford, East Corinth, Newbury and Wells River, Vermont, and bordering New Hampshire towns. Thank you for your time today to talk to you about our food as pharmacy and our food as medicine initiatives. And thank you for all of the work that you do to support the health and well-being of our communities. In our communities, nearly one in five patients who come through our doors have a chronic condition such as heart disease, hypertension, or type two diabetes. These conditions are directly affected by what they eat. Years ago, Maureen Boardman, a nurse practitioner and the director of our clinical quality, started doing something simple and radical. She partnered with Willing Hands, a local nonprofit leaning and food recovery organization, and once a week began to fill her car with produce to distribute to her patients. This was outside of what her job entailed, but she did it because she knew that her patients needed healthy food to improve their health outcomes. From her understanding of food as a key social driver of health, our food pharmacy was built. Ashleen Buchanan, our grants and programs manager, who's here with us today, worked really hard to earn a grant through Bi State Primary Care Association, and I was hired as the program coordinator. We have since worked with Bi State on multiple grants, as well as Dartmouth Health and the Vermont Department of Health to build and fund our current programs. We work with Dartmouth Center for Advancing Rural Health Equity to develop a strategic plan, which largely focused on our continued struggle and need to secure funding for our growing programs. Through community needs assessments, food insecurity and the barriers that our communities face to assessing the food they need to maintain their health was highlighted. And in 2022, we expanded our hunger as a vital sign screening to all annual visits and well child check system wide. Currently, we have upwards of eight percent of our patients screening positive for food insecurity. We are now working with BiSAID to add a nutritional screener that was developed at Tufts University to better capture not only food insecurity, but nutrition and security. We have developed workflows into our electronic health records so that patients who screen positively are connected to our care coordinators who work with them to sign up for WIC, SNAP, commodity boxes, and other food resources that are the first line of defense to those in our state facing food insecurity. Our first goal is to connect our patients with the agencies and organizations that are already doing so much work to address food insecurity. Our care coordinators also identified chronic conditions such as diabetes, hypertension, or cardiovascular disease, which were the conditions our grant funding allowed us to focus on before referring them to me for food as medicine supports. The foundation of our programming is our food pharmacy, where we offer fresh boxes of produce and other staples like eggs every three weeks. We operate on a three week basis because of the limited capacity of myself and our volunteers to serve all three of our primary clinic locations. We are now distributing about a thousand pounds of food a week donated to us from Willing Hands and the Vermont Food Bank. And we additionally have secured some grant funding to purchase shelf stable items from the Vermont Food Bank and to purchase CSAs like this one through the summer from Route five Farm in Fairley, Vermont. We also work with Cross Molina Farm and other local farms and are dedicated to supporting Vermont agriculture through our work. We provide recipes and other educational materials, and we have some kitchen items that we can provide. We have developed a survey that can track dietary habits and program effectiveness every six months through enrollment. I believe that one of the most important parts of this program is the personal relationships we build as we work with our patients and empower them to make changes to their diet that improves their health. We are expanding our eligibility to work with our OB patients and, through a collaboration with Dartmouth Health, now offer prepared nutritional meals to our new and expecting mothers. We have gardens at two of our clinic sites to support our in house food shelves, which are set up to support our patients' needs while promoting our messaging that healthy food is essential to health. In 2024, we partnered with Hannaford's and they donated a cargo van to us so that we could scale up our operations and transport more food to our patients. Sometimes it's easy for me to get caught up with all the work that I see needs to get done. And I'm thankful for this opportunity to reflect on the tremendous amount of work we have done so far. Our enrolled patients show statistically significant reductions in blood pressure and cholesterol. We have seen a decrease in missed doctor's visits. And most importantly, we hear over and over again how much of a difference our food as medicine programs make on our patients' health and well-being. Our patients report that they are able to eat more fruits and vegetables, cook more meals at home from scratch, and have a reduction in stress due to our programs. We are so excited to be working with the Food as Medicine task force to define the work we are doing and find more sustainable ways to reimburse our work because we know that it is an integral part of our mission to continue providing these necessary and needed health supports to our patients. We have always known that depending on a myriad of grant funding to support our programs is not sustainable. We've seen other programs that we've worked with close because of this, as Tina had said. It has been our goal from the beginning to build a replicable model so that when we do find a way to sustainably reimburse this much needed work, we're able to support other health care agencies by sharing the foundation we have worked so hard to build. Thank you again for your time today and your interest in the food as medicine work that we're doing collectively.

[Unidentified committee member/staff (shared diarization ID)]: Must be a rewarding job.

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: It is. Yes. Yes. It is wonderful.

[Rep. Alyssa Black (Chair)]: Stephanie, I think. Stephanie, are you? I looked in the I'm looking here thinking about getting a CSA share from Route 5 far, but I'll do it earlier. Good deal.

[Stephanie Pinard (People’s Health & Wellness Clinic, Barre)]: Hi, good morning.

[Rep. Alyssa Black (Chair)]: Hey Stephanie, how are you? Thank you for joining us.

[Stephanie Pinard (People’s Health & Wellness Clinic, Barre)]: Hi, sure. I'm not sure if there's grass background here. I guess that works with the whole veggie thing.

[Rep. Alyssa Black (Chair)]: My

[Stephanie Pinard (People’s Health & Wellness Clinic, Barre)]: name is Stephanie Pinard. I work at the People's Health and Wellness Clinic in Barrie. I'm the community resource manager here and we serve clients all around Central Vermont. For those of you who don't know much about People's Health and Wellness Clinic, we provide high quality essential medical, dental, and social services for 700 patients a year. Most and many of them who are under insured, uninsured, unhoused, and many suffer from food insecurity. My role here at the clinic is I connect patients with social services, and I'm the coordinator for the Food is Medicine for the Healthcare Share Program that provides fresh veggies on a weekly basis seasonally from the Vermont Youth Conservation Corps farm in Richmond, which is an amazing farm. We match participants that have to meet two eligibility criteria. They have to have food insecurity and they have to have a reason to be able to manage diet related illness. So all 10 of our participants meet that criteria at the clinic. The part of me wanting to share today is I wanted to speak from a participant voice of some of the feedback I've gotten from them. We do survey some of the conversations that I've had with them throughout the season on why this is so important and vital to them to have fresh veggies given to them at no cost. One is barriers. A lot of our participants have barriers that keep them from being able to access healthy food due to their socioeconomic status. One participant reports, I was not at all aware of the vegetables that there were. I did not have access to them as a child. I had no idea there were so many varieties of veggies. Transportation is also a barrier for many of our participants and our patients don't own vehicles. Many are unhoused and they're bouncing from a hotel to another hotel or a tent living outside. One participant said the food pantry is too far for me to walk, but I'm able to live close enough to People's Health and Wellness Clinic to pick my share up each week. So we're able to feed that participant who's in walking distance of the clinic. Some of the participants flat out just had to make trade offs. They might need to pay rent, their electricity bill, potentially they might have a substance use disorder and therefore their priorities are elsewhere. Those things come first for them before buying fresh food. So a lot of them face challenges about running out of food, and there would just not be enough to get them through the next week. During the program, I heard participants speak about their change of food access and their food security. I can seldom get to a farmer's market. I can't afford their prices, but this gives me healthy food just like I'm eating at a farmer's market. Healthcare share introduced me to veggies that I would have never been able to afford to buy for my

[Rep. Alyssa Black (Chair)]: family. Some of

[Stephanie Pinard (People’s Health & Wellness Clinic, Barre)]: them have been able to save money or other alternative things, electricity and rent, because they're able to access fresh food with the increase of grocery store prices. One person flat out just says, I love kale now. I also noticed a large increase in confidence with their cooking skills and their choice of food that supports their health, be it diabetes or any heart related illness that they had. The best compliment that we've ever got is their confidence source when they're reading the recipes that is shared from the healthcare share newsletter that comes every week. And it's really important to a lot of them to be able to eat locally sourced food. They're really excited about telling me week to week what they made from that recipe book. One really positive note that stands out is there's a 60 year old woman that's in the participants program for years, and she's been so grateful that she makes cards, veggie themed cards that she gives to me every week that I pass along to, Grace and Kelly from the farm. And I've been able to go to the farm and see where the veggies are grown. I've taken a tour. I've shared lunch with the volunteers and the staff members. It's really amazing seeing where our food comes from. I've made a little photo album so our participants can see this doesn't just show up from shawls. This is like grown from volunteers and all of these were sort of keeping the circle of sustainability. So this program matters because consistent funding allows us to work with some of our most vulnerable populations that have to choose between rent and food. And I would love to be able to commute accessing and offering food for them. And when we support our local farms, the food keeps the money in the Vermont. From what I see every day, the food is medicine is improving health and reducing stress for our patients and participating members. So my final quote just to end is by augmenting my food sources, I've had less stress in my life and therefore I'm more healthy says one participant who is grateful for having one of our providers sign up for this program. It does make a difference on our 10 participants and their lives and those that they're able to share their abundance of food with.

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: You, Any questions?

[Rep. Alyssa Black (Chair)]: And thank you for sharing about the youth conservation which I didn't know about, and it seems fascinating.

[Stephanie Pinard (People’s Health & Wellness Clinic, Barre)]: Yeah, it's a great program. Introducing

[Rep. Alyssa Black (Chair)]: Thank you Good your

[Mary Kate Mullen (Bi-State Primary Care Association)]: morning. For the record, Mary Kate Mullen, Bi State Primary Care Association. I'm just going to wrap up this amazing work that this group is doing. As mentioned, Bi State is working with several, many, many organizations on the Food as Medicine Task Force. The goal of this task force is really to figure out how do we sustainably support this work. You heard a lot of people talk about, well, we had a grant to do this, we had a grant to do this. Grants are great, grants go away. And so you get up this amazing program. You start to see return on investment. You start to see progress. Communities get involved. Then the grant ends. And all of this work can ebb. And so we really want to get to a place where we have a way to incorporate this into our primary care and community based health. As part of the task force, we are reaching out to and working with AHS and Diva on the Medicaid side of this. They're going to be starting their conversations around the eleven fifteen waiver over the next twelve months starting this summer. And so what can we explore with them? How do we include this either as a demonstration or does it get included in our state plan with Medicaid? Those are conversations we're starting. We're also having conversations with our commercial payers. So Blue Cross Blue Shield is one that we are closely engaged with. How do we get this covered? How does this work as a payment that helps food go from, especially our local farms, get prescribed by the provider and then make it to our patient? And so there's a lot of pieces in that pipeline that we're trying to figure out. And then also, how do we fund those pieces of the pipeline? So that's really what this task force is looking for. We're going be working. We've got our policy group, which this is kind of the key part here is educating right now. We also have a group that's trying to summarize the return on investment for these programs. What kind of utilization are we avoiding by people having access to nutritional food and having food that is tailored to really their dietary conditions, dietary related conditions. And then in the fall, we'll start thinking about, well, what do we need? Is it rule making? Legislation? Is it appropriations? And so that's where we hope to have something ready for you all the next session, assuming you guys are all back here. But that's sort of the overview of what this program is and what it's trying to do. And I do want to make one distinction. There is our food access program. So for example, three squares in Vermont and food shelves, food pantries. Food medicine has a big overlap with those programs in that access to food is kind of your first step to making sure you can get to nutritious food, but it's broader than that. It's really looking at how do you tie the right food to what people need for their nutrition? So it's not necessarily limited to just food access. It can be broader. I

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: am so excited about this program. I love it. Just yesterday, we were talking about gut health and all the different ways that that can impact our physical and mental health, both. So I just think it's really exciting, especially for Windham, my community. A lot of folks live in apartments like me. I don't have a yard. I can't grow food anymore. But that's why I'm salivating when I look at those carrots down I just love this. I think it sounds fabulous. Can you talk about how it interfaces at all with Veggie Van Gogh, is something that we get?

[Mary Kate Mullen (Bi-State Primary Care Association)]: I don't know. That's, I think, more of a food access. Again, there's the overlap.

[Emily Perry (Food as Medicine Coordinator, Little Rivers Healthcare)]: And they don't see that, like the big difference, I think that's what you're talking to, is that there's Veggie Magnum Bill will go to communities and hand out veggies in the same way like a food bank or a food shelf will. And all of our work is directly prescribed by a physician. So the difference is that we're tracking blood pressure and their chronic conditions, we're assuring that they're getting enough healthy foods that match their diet and eating conditions. Whereas Cheshire Gangro is a really great form of food access because we see some not great foods in food security work being private, but Cheshire Gangro is not doing that. So I think that's the best form of food access work that's out there, but it is different from the Buddhist medicine, which is going to happen at your health center.

[Mary Kate Mullen (Bi-State Primary Care Association)]: So I'd say that there's the Venn diagram with the big overlap, but they're not exactly the same. Yeah.

[Unidentified committee member (possibly Daisy Berbeco, Ranking Member)]: And I love that it's locally grown food. Also that it I don't know. When I volunteer at our food shelf, sometimes I see that it's food that isn't it's loaded with sugar sometimes or packaged.

[Rep. Alyssa Black (Chair)]: It's fully processed. Yeah. Shelf stable. I think this is wonderful. We've had a lot of conversation in this building last few years around education. And I constantly hear people like our schools are sort of the heart of our communities and they're a community center as well as just a school. And I often think to myself, why is a community health center not sort of also the center of a community? And having programs like this, having this availability, I think really sort of envisions that your doctor's office is more than just your doctor's office. It's a resource for the whole community.

[Mary Kate Mullen (Bi-State Primary Care Association)]: And I would like to see, and connecting at some of the other work that you guys are really focused on in this committee, is over the next year, we're going be having a lot of conversations around primary care reform. What are we paying for? How are we paying for it? I would love to bring this topic into those conversations because it's really about that primary preventive care to help offset and avoid acute, really expensive care and chronic conditions.

[Rep. Alyssa Black (Chair)]: I'm so sad that Leslie is not with us. Was unable to be with us this morning. This is her jam. This is her jam. Thanks Mary Kate and thank you everybody. Thanks for hanging in and sharing. We'll see you down in the card room.

[Mary Kate Mullen (Bi-State Primary Care Association)]: There's recipe cards. Oh, good. Now we're back to talk bad.

[Rep. Alyssa Black (Chair)]: We can, we're gonna take a break. Our next