Vermont Legislature SmartTranscripts:

[Chair Theresa Wood]: Okay, good morning. Welcome to House Human Services. This morning we are going to be taking up testimony on the Budget Adjustment Act from the Department of Disabilities, Aging and Independent Living, and then the Department for Children and Families. So we're joined today by Dale Commissioner, Doctor. Bowen and Padre of Staff. Mr. Kelly is here. We'll do introductions like we normally do. So welcome. So just in case people

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: need a refresher. Wait, this room for three of us if you want. They clearly don't want to.

[Chair Theresa Wood]: Is this someone's stuff? No,

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: that's your spot.

[Rep. Daniel Noyes (Clerk)]: Oh,

[Chair Theresa Wood]: it's Alyssa's.

[Jennifer Garofedian, Director, Developmental Disabilities Services Division (DAIL)]: Yeah. I don't know.

[Chair Theresa Wood]: She'll be looking for it, but not for long because thank you. Okay, so Doctor. Bowen, we'll just do quick introductions to reintroduce everybody. Of us who happy to see you over the Hi, next I'm Theresa Wood from Waterbury. I also serve Bolton Guellscore in Huntington, and I'll go this way

[Rep. Golrang "Rey" Garofano (Vice Chair)]: this time. I'm Rey Garofano, Essex and Essex Instruction. Nice to see you again.

[Rep. Jubilee McGill (Member)]: Jubilee McGill. I represent Bridgeport Middlebury, New Haven, and Wakebridge. Hello. Good to see you. Esme Cole of Hartford.

[Rep. Zon Eastes (Member)]: Good morning. Zon Eastes, I represent Guilford and Byrne.

[Rep. Eric Maguire (Member)]: Representing Hamiltonian, Eric Maguire. Great. Yeah. Bishop, Colchester, and Chittenden, minutes here.

[Rep. Brenda Steady (Member)]: Brenda Steady, Westford, East Milton.

[Rep. Eric Maguire (Member)]: Hi. Good morning. I represent Wyatt Robinson.

[Rep. Daniel Noyes (Clerk)]: Good morning. With Anne Noyes, I represent Wilkie, Hyde Park, Johnson, Belvidere.

[Rep. Anne B. Donahue (Ranking Member)]: And, yeah. From Northfield.

[Chair Theresa Wood]: Can I just ask a question? We have an Angela McMahue asking to be led in. Yeah,

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: it's down. Okay. She'll come back.

[Chair Theresa Wood]: Oh, okay. I'm sorry. Okay. And so now we'll go around the outside.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: On the screen.

[Rep. Brenda Steady (Member)]: There she is. Yes.

[Jennifer Garofedian, Director, Developmental Disabilities Services Division (DAIL)]: Hi, I'm Jennifer Garofedian. I'm the Developmental Disability Services Division Director for Dale.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: And Angela, you on?

[Jennifer Garofedian, Director, Developmental Disabilities Services Division (DAIL)]: I'm on. I don't know if you can see me. Can you hear me?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: We can hear you, but we can't see you.

[Angela McMahon, Director, Adult Services Division (DAIL)]: Okay. Yeah, I'm having some Internet issues in my office here in Waterbury, but I'm on my phone. This is Angela McMahon. I'm the director of the adult services division in Dale.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Gail Zon I represent adult day programs and Amy Johnson, Maguire partners.

[Chair Theresa Wood]: Remorse committee assistant. Great.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Excellent.

[Chair Theresa Wood]: Okay, thank you very much, Commissioner Bowen. The floor is yours. Great.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So I'm Doctor. Jill Bowen, for the record, Commissioner for Department of Disabilities, Aging and Independent Living. So I would begin by describing the department, our mission statement, to make Vermont the best state in the nation in which to grow old or live with a disability, with dignity, respect and independence. Just to remind folks, there are five divisions: the Division for the Blind and Visually Impaired the Adult Services Division, of which Angela McMahon is Director, Developmental Disability Services Division, which Jennifer Garofeden is the Director, Division of Licensing and Protection. Fireability makes up the department. I think everybody here is familiar with the specifics and details, so I won't go into that. So we can get right into the BAA and look at the numbers. So the overview for BAA is the total net increase. All funds combined is 30,313,848. This includes internal service fund increase for Agency of Digital Services at 312,378, Ask Me collective bargaining agreement, bonus and direct care workers. For all of the appropriations combined, it's 2,396,000, and that is broken out in each, many of the divisions. So ASD has an allocation DS, developmental services, adult services, TBI and choices for care, each have allocations, you'll see for ask me. Then we have choices for care. The estimated nursing home pressures is 14,500,000. The choices for care utilization pressure is 2,500,000. The Choices4Care nursing home Medicaid bed day pressure, which is AHS neutral, nine million six hundred and forty two thousand two hundred and two. And the Choices4Care Vermont veterans home cost settlement is 963,267, additional to what's already in the base budget. And that's the sum of what our BAAs are.

[Chair Theresa Wood]: Before we start asking you a bunch of questions, do you have any explanation for any of the line items? Do you want to elaborate further on any of those?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah, so I can elaborate on $9,642,000 which is there were three nursing homes that had an ownership transfer, and there was a delay in being able to pay them because they didn't have the proper codes in place. It wasn't the codes, it was the Medicaid. What was it exactly? Number. The Medicaid provider. Right, so that is budget neutral, it just carried over, and that's why it is here in the BAA. As far as the EFRs, we spoke last year about the EFRs during BAA. What we said is that there were a number of things that were put into place that we thought would reduce the AFRs, but not eliminate them. And that is, in fact, the case. That we didn't rebase on the two year cycle for the nursing costs that brought it more in line with reality because there's a two year delay. So what we have for requests this year, the $14,500,000 is compared to the 21,000,000 asked last year. And in fact, it's actually lower than the 24 half, which was 17,000,000. So there is some movement in the right direction, in part because of some of the things that we have put into place, the caps, some of the changes that allows for flow on a more regular basis in terms of stabilizing the nursing home. I do want to say that the nursing home system is shaky. It really needs stabilization. It needs attention. We have a growing demographic. The EFR process has been in place for a while, but only more recently has it been at these kinds of levels of need. And the EFR is to prevent closure, and several are at risk for closure. When an EFR is requested, it's quite a deep dive into their finances, and they really need to be on that edge in order to be granted. So it's a symptom of a bigger issue in terms of what the nursing homes need to be stabilized and to be prepared for the growing demographic. We are increasingly filling closer to capacity, we're not there yet, but we need to plan forward. Are looking at ten years forward, we're looking at this year, we have a stabilization and sustainability plan that's formulating. We'll be in the planning stage this year. We'll be finalizing our projections in terms of what will we need between now and over the next ten years in terms of that level of care. When we talk about the nursing homes, they are financially stressed for several reasons, but one of the biggest reasons is still the workforce challenge. Now, is a little bit of closure there, in part because some of what you all provided for the LNA grants is actually having some impact. But we are going from 35% of the staff being traveler or contracted staff, down to 25%. So any movement in the right direction is great. But compared to the nation, they have reduced down to closer to 5% need for the contract staff, and Vermont is on the upper end. And there's many, many reasons for that affordability, housing. There's many reasons why it's hard to attract folks to work more permanently. I have been to the nursing homes. I've talked to travelers. I've talked to permanent staff to try to hear from them directly why they make the choices that they make. And of course, travelers, it's courtlier for us, it's good for them. But those who stay, I want to know why they stay. And those who say that traveling and working here is the greatest experience they've had, why not stay? And the answer to why not stay is, this is like the traveler experience is fascinating. They get to go to lots of different places. They're in places in their life, like they're pre having kids or they're post kids growing up, or there's reasons why for them that kind of lifestyle, this is the moment in time for them. Those who stay talk about the people they work with being like a family, feeling really committed, really just loving the experience that they're having. So we want to understand more about who's doing, where the best practices are, how we can help keep and attract anything we can do to invest in the whole long term care system. It's not just the nursing homes. It's not eitheror. It's both. We need to look at the entire continuum. Our average I think everybody knows at this point, because certainly in this committee we talk about it a lot but a third of the population in Vermont is 60. But there are different groups of older Vermonters. Nursing homes tend to have an average age of around 84. So we really do need to plan for what do people need at different times in their lives. And then how can we invest not only in the available options for people to stay home, but residential care homes and assisted living and all the way up through the nursing home system. So our capacity is something we're looking at very, very closely. It's not just the number of beds available, it's whether they can bring into their beds complex care situations, because those are becoming less of a sort of occasional thing and much more of a regular occurrence. Multiple medical conditions, mental health and medical forensic experience

[Chair Theresa Wood]: medical Is it actually those folks?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Mission care, obviously, takes those We're paying them a premium to do so. Well, but others can also use special rates. So there are others who are doing that. But we also have challenges with not only do we worry about closures because it's so costly, but we also worry about being able to find a buyer. Since I'm here, which is only a year and a half, and there's been ownership transfer in just that time, several of them, it's not like they're lining up. So it's really hard to even find someone who is interested in coming in. And so some of the issues around owner transfer needs some attention, too. So either complex care, the stabilizing financially, the EFR report that DIVA prepared from rate setting and DIVA was submitted last month. So it does outline some fiscal stability ideas, some of which still need to be vetted with stakeholders, and we'll be embarking on that with DIVA. DIVA and rate setting put together the EFR report with Dale's insight. From our perspective, we're also focusing on workforce. In addition to the LNA grants. We are also working with CMS on the ability to use the monetary penalty monies that we have, the CMP monies that we have, with their they have some level of matching funds, and they are organizing nursing LPN and RN tuition coverage or reimbursement if they're going to work in the municipal health. So we are all in on that. Really, the ball is right now at CMS's court to come up with the next step in terms of how they're organizing this for other states as well. But we are going to be full on that. So anywhere where we can support folks coming in and working in there. So the training opportunities, the engagement of the ground through the nursing homes themselves, This is having an impact. You can see that it's having an impact, but it's a much bigger issue. And so the EFR money, circling right back to the VAH, the EFR money is still necessary. It's a minority of the nursing homes, but some of the nursing homes are struggling with the PDPM. The change from the RUG IV to the PDPM, for some, that is challenging. In the report, if you read the EFR report that Ziva put together, you will see that some of the suggestions include looking at the smaller nursing homes as sort of a peer group, because they struggle a bit in a different way than a larger So as an example of that would be: you have the same costs for certain administrative tasks, let's say a nursing director, but you get paid less because of the number of people that you are serving. So there are certain groupings. Hospital based nursing homes have higher costs related to being part of a hospital. So there's a couple of places where we can get targeted on addressing some of the challenges. And then looking at doing validation audits and training in areas where there might be opportunity for coding around case mix or understanding how to ask for a mid year or special rate opportunity.

[Chair Theresa Wood]: Thank you. I think we have a couple of questions. Representative Maguire first and then Representative Noyes. Thank you. According to the

[Rep. Eric Maguire (Member)]: last housing report, there's roughly, what do we have, 2,871 skilled nursing facility beds. Currently at this time, there's two sixty three of them that are not being utilized. But throughout that housing report, that number has always been up with over 200 consistently over the last couple of years. What are some of the barriers and challenges that are running on into to why those beds are not being utilized?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah, we watch that really, really closely. So one is the complex care case issue. So some of those beds, they can't take in. And some of those folks that are boarding in the hospital post acute need complex care. And so that's a big focus for us this year, is really getting to what do they need. The Rural Health Transformation Fund has some incorporated into that, where two of the highest concern areas that the providers brought up, which are the need for ventilators and the need for dialysis. And so there is opportunity there through that to increase their capacity, their skill set, their ability, and whatever they need in terms of equipment to serve a population that it can't currently serve. But you'll see that repeated in a couple of different places. And those numbers of beds represent maybe 11 or 12% because we're at like 87.

[Rep. Eric Maguire (Member)]: Yeah, it's probably 10%. I was interested because that this month, that's the highest I've seen it. Last month, was around two eleven. Because you It's been consistently the last couple of years, right around between 200, two fifteen, two sixty three.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah. So Angela, is

[Rep. Eric Maguire (Member)]: I could see the utilization going up and that number going down, it seems like we're now going up, which

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Right. And also just some of those beds just are for short term rehab So you do need to have some beds empty at all times, you can always have some rehabbed beds. But given that you review the weekly report so you can see the fluctuations, do you want to say more Angela Smith Dang, the deputy commissioner for Dale?

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: I would just say yes. What we're seeing is between two hundred and two fifty beds on a weekly basis are considered open. As the Commissioner said, some are short term rehab, some are long term care. Part of the reason, when you look at each individual facility, have 33 facilities, so there may only be less than five or 10 beds available at any given time in a facility. And there are always people in the process of being admitted, as well as people who are discharged. So there's that constant flow. So you do want an element of availability there. That said, challenge with folks who have complex care needs is a barrier to being able to complete these open spaces. So we're hovering around 87%, 88% occupancy, full capacity in most nursing homes at this stage, in most proximity, which is far higher than we were a few years ago. So we've seen a steady increase in occupancy. And at Mission Care, for example, we're at almost 90%. So we are seeing more people with complex needs being admitted into facilities, but we also have more work to do to be able to increase capacity to do that.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: That is a focus for us, a deep dive. We watch that very closely, and we want to fully understand all the barriers. So they brought forward the provider's ventilator needs and dialysis as their top, and that's why it was included in the rural transformation application. But there are other complexities that we are aware of where some say they cannot provide that level of service. And so we have a little bit in that. And again, it's the small percentage, so it's a percentage of that percentage where we're going to be focusing. So we understand the short rehab piece. But to truly understand what the barriers are and how we can break those barriers down, like what do you need at what levels and which kinds of complexities are particularly challenging.

[Rep. Eric Maguire (Member)]: Yeah, because it's evident that there is some level of capacity that's available, but what I'm hearing is it's more of an infrastructure in regards to how can we utilize those available beds to our maximum potential by placing those beds into the scope of practice sex to meet that need? Is that kind of what I'm asking?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yes, absolutely. And we want to use every bed that's available for the way in which it was intended. We track things like, is it due to staffing needs?

[Rep. Eric Maguire (Member)]: That's what I was going to get to next. Is it a regulatory and staffing Not

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: much. It's a

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: small There are only about 23 beds that are closed due to staffing, so they're not available, they're not in that delivery category.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: But

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: still, a facility might be able to admit someone with sort of a regular amount of meetings with the staff that they currently have. If someone needs one to one support on a more regular basis, they might not be able to do that. That's an example.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So, but because they're using that contract staff so heavily, so they do have staff at the levels that you would want them to have staff. But it comes with other I don't want keep using the words complex but other challenges. Because sometimes when people are coming in and out, it's harder to maintain the quality, and you're constantly needing to train up new folks. The contract staff stay only so long, so we also have a strong eye on quality. Dale is also the regulator, so we do the licensing, we do the quality compliance partnering with CMS. We look at to what extent is that turnover a challenge. So that's another reason the grants that you all provided is so key. We need the nursing and the LPNs also to stay, but the LNA is the backbone.

[Chair Theresa Wood]: We have a few more questions lined up here. Representative Noyes, Garofano, and then Steady.

[Rep. Daniel Noyes (Clerk)]: Yeah, just quickly, thank you so much. You were talking about the travelers in Vermont are in the 20% ish, 25%, but on a national average, it's five. So

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: we went from 30 to 25, but we're still way above the national.

[Rep. Daniel Noyes (Clerk)]: What percentage of the cost drivers is that for the EFR? Is that a majority of why people are coming to us for EFR?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: It's a huge factor. It's not the only factor,

[Rep. Daniel Noyes (Clerk)]: but it's a majority of the EFRs are directly related to the elevated travelers. And I know, is there a way that in the future we can I mean, you going in and saying, Okay, here's different ways you can reduce your travelers so that you don't come back looking for EFR? Is there some support that Dale can offer around trying to find better models for reducing the number of travelers that we could implement tied to receiving the EFR. Like, hey, you're gonna get this EFR money, but here's some things you can do to reduce your travel so we don't see you back in the same boat.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So, yes. And in part, that's what led to the 5% drop. Do you want

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: to say more about that? I would just say also that's exactly what the LNA grants, the 500,000 for LNA grants, is designed to do. The goal is reduce the reliance on travelers and increase the person and retention of permanent staff. And so we have 17 facilities this year doing projects to meet that goal, trying out different models, different ways of recruiting staff, increasing onboarding support, mentoring and training and supervision, bringing more in house training into the facility for that. A number of different projects to try to really meet that goal.

[Rep. Daniel Noyes (Clerk)]: So we're seeing success in that investment to

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yes, absolutely we are. Was the second year, and so we have more information about the impact of the first year. Still in it for the second year, but the reach is there, the outcome is there. And there will be a full summary report in our budget document that we will be submitting to you specifically on the LNA grants.

[Rep. Daniel Noyes (Clerk)]: I hope to see that continued in the proposed budget that we're going to be seeing then, or maybe even because you're going to be coming forward with another budget for the next year. If this is showing return, I hope that that's continued in the future budget when it comes to us to get started. Along with I'll

[Rep. Eric Maguire (Member)]: be quick.

[Rep. Daniel Noyes (Clerk)]: Along with inverse No. Report

[Chair Theresa Wood]: You're fine. I just I just was I'm I'm not sure. It seems like there's some questions.

[Rep. Daniel Noyes (Clerk)]: I'll just be quick. Along with implementation of steps that are in the report, I hope those are included in the budget. Some of this might be helpful. The increase for the small nursing homes to make sure that they are able to meet their There's three things and one of them is to the per diem limits. I just would hope that would be reflected in the upcoming budget. The implementation of- Oh, yeah, yeah. Continue to see this. Although it's great to see it going down. I'm just always nervous also about the last bullet point in there around private equity coming in and getting into nursing homes. It's just something that

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: So that was

[Chair Theresa Wood]: think about a

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah, you're talking about in the EFR report. Yeah. Yeah. That's what I was saying about ownership and having little competition, you know, for owners coming in, and there's been quite a bit of transition. You probably saw the paper about Genesis and their bankruptcy, and they were going to sell it to, and then that's not right. And we still have several nursing homes here that they operate. And then just in general, the amount of ownership transfer. And so part also will be what can we do in that space to be Every piece of this is either a stabilization opportunity or a destabilization risk. We're at a level where we need to be able to stabilize and then sustain. And it's not an easy or a one and done. The multiple issues that affect what the nursing homes as providers can do. And many of them do try to do it. Like 17, last year it was 11 facilities that were involved in the LNA grant implementation, and it was successful. This year, 'seventeen. So they are trying to utilize whatever is available, but some of it just comes down to challenges around the same challenges you're seeing in other workforce issues in the state you're seeing here around housing and affordability and things like that that people speak to.

[Chair Theresa Wood]: And we've actually seen hospitals actually have significant decreases in the use of travelers.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: They have. They have. And a couple of

[Chair Theresa Wood]: them Increasing wages was one of the big factors.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah, it was increasing wages as a piece of it, but some of them were even trying out housing opportunities.

[Chair Theresa Wood]: UVM definitely is. Right. Yeah. Yep. Rep Simmons, you have anything else?

[Rep. Daniel Noyes (Clerk)]: No. Okay. No. But I I would like to see a us dive a little deeper into this at another time.

[Chair Theresa Wood]: Okay. You.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I think the feedback and the We're

[Chair Theresa Wood]: gonna be looking at that report and the recommendations for that. And we'll have rate setting in as well because they're the folks who actually do the financial dives into this, the programmatic stuff that's handled by Dale and the licensing.

[Rep. Daniel Noyes (Clerk)]: I mean, we're investing 500,000 into the workforce, and we're spending 14,000,000 on the EFR. If there was a way to even shift that a little more and save money,

[Chair Theresa Wood]: that would be wonderful. Okay. I have some questions of my own, though. I'm going to defer to other members first. So Garofano and then Representative Steady.

[Rep. Golrang "Rey" Garofano (Vice Chair)]: So I have one question, but now the discussion, I now have several questions. Really exciting about the LNA funding, is that all being used? Oh, yeah. Okay, so we're maximizing that. Oh, okay.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: And

[Rep. Golrang "Rey" Garofano (Vice Chair)]: then what's the barrier to all nursing homes using that? If it went from 11 to 17, why aren't all of them?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So we work through BHCA. They're our partner in this, and that's the Vermont Health Care Association. So they're representing all of them. So they're working with them. And folks who are interested come forward. And I believe that there is somewhat of a competitive process to it. Right? They submit a grant application.

[Chair Theresa Wood]: Yeah. Because there's

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: not enough money to be provided to everyone.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Right. And some facilities, it's about timing as well. If you're in the middle of an ownership transfer, you might not be ready or willing to take on another project like this. So some weren't ready last year, were ready to take it on this year. So four of

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: them came up with a second. Four of the ones who were in for '25 came up with a second project for '26. But if you hadn't had an opportunity, you got, I think, a preferential, right? But there was sufficient monies for those four to also do the second project.

[Rep. Golrang "Rey" Garofano (Vice Chair)]: Then for those programs that are or nursing homes that are implementing some of these strategies to reduce their traveling costs, are you then tracking to make sure that then they're not coming back that That they're not coming back. These are successful. They're not using these strategies but still asking for a lot of EFR.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Well, I mean, the strategy is to not need as many. So we talk about reducing the cost because you can hire a more permanent staff. So the 5% drop is a cost reduction. And I think that's why we have a significant reduction in EFRs this year. It is a nice drop. We're happy to see the drop. It's still significant money.

[Rep. Golrang "Rey" Garofano (Vice Chair)]: There's not a time that's specifically back to the programs that are implementing these, to look at it overall, right? Or are you actually seeing results with a specific program that is implementing some of these strategies to actually prove that they're successful because they're using less.

[Chair Theresa Wood]: Are you asking about cause and effect? Is there a correlation? Exactly. Or is

[Rep. Golrang "Rey" Garofano (Vice Chair)]: it Are documenting that?

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: I will be part of this year's work. Many of the strategies, too, from last year and this year take time to really have that impact. So we wouldn't necessarily see a reduction in EFR right now from those strategies. But in future years, we should.

[Rep. Golrang "Rey" Garofano (Vice Chair)]: And then last question. There's been a lot of discussion about the complex needs of certain individuals. And I wonder if Dale has a definition of what complex needs are. For example, if someone doesn't have housing, is there a criteria? Or can the existing home just say, so and so has a complex need, and I'm just not going to be able to care for them? You know what I mean? Is there some kind of written definition or guidelines around what is a complex need?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I don't know that we have been specific for Dale to define. But essentially, when we talk about complex, we're talking about multiple challenges. And what you're talking about in terms of health related social needs being a challenge. So yes, those who come in, let's say, from the GA system, they do have complex needs. And so they are considered, and that's why we also look So I'm going to use mission care just because there are sort of, I don't know, quintessential complex care. That's why we opened them in the way that we did. Mental health and medical needs coming from a facility that they have some criminal justice experience. They could be coming from the street into the nursing home. Or we also call complexity if you have multiple medical challenges. Maybe you have dementia and you need a ventilator, or you need dialysis and you have a traumatic brain injury. It's not a straight forward simple. And while that's always been there in the mix, it's just that the number complexities you can have, the intensity of the complexities. And we all understand that during the pandemic, people delayed treatment, so you lost something in your ability to prevent and something in your ability to early identify that we're seeing on the other side of that now, and then some of the traumas that you see. So we do understand how we got here. Plus, living longer means that you have potential for multiple challenges. Just natural aging brings with it some of these greater potentials for medical cognitive depression, multiple challenges. So we're just seeing more of it now. So it's probably a good idea to kind of be specific, but it has been defined broadly in the field as having multiple lanes of challenges. Often, the health related social needs do get included in your understanding of what the person's experience has been, as well as what their medical condition is. Does that answer your question?

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Represent Steady. I know I'm supposed

[Rep. Brenda Steady (Member)]: to ask a question, but this is dear to my heart. My husband, my brother has been in Genesis Burlington Health and Rehab for thirteen years. They know I'm a state rep. Not one of them has ever complained about their salary. The only complaint I got is they were worried more about their professionalism and how they were treated. I just want to tell you, I've been impressed. He's been treated well. I get calls any time of the night if he falls out of his bed saying, letting you know your brother's okay, he fell out of bed. So I want to thank you.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Well, thank you. I know I'm supposed to ask questions, but I've dealt with this for thirteen years. I do appreciate that. I do want to give a shout out to providers. Do want to give a shout out to the workforce. And whenever we talk about the workforce, I always want to remind folks that a large part of our workforce are older Vermonters. And we could not do this work without that workforce. And I think sometimes when we forget how much of our workforce and our volunteer workforce, that they are absolute like, we would not have the Meals on Wheels, all right. So much of the community based programs also rely on older Vermonters to provide the work and volunteer and the support. Thank you

[Rep. Brenda Steady (Member)]: for call in the morning and say, I'm coming to take him out today. Will you get him ready? They're so excited that he's being taken out. Just love him. Just to let you know, I gotta I know I'm supposed to only ask questions, but I got to give kudos to my nursing home.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Yeah. When I go to the nursing homes all over the state, I talk to the families who are visiting. I talk to the Of course.

[Chair Theresa Wood]: Yes. Okay. So I'm sorry. No apologies necessary. I have a few questions that I am curious about. I'm going to ask this of Mr. Kelly. $9,600,000 the net neutral, AHS net neutral usually means that it's being transferred from one place to another in AHS. Is that is this just is this carryforward from f y twenty five?

[Rep. Eric Maguire (Member)]: Yes. Yes.

[Chair Theresa Wood]: Okay. So it was accounted for in the year end choices for care report? Okay. And

[Mr. Kelly (Fiscal/Budget Staff, AHS/DAIL)]: And it took many adjustments to get that available. We weren't notified from the providers until May that they had this billing problem that started in December. So we needed to obligate funding from a variety of places for that need and carry it forward in a choice for care.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Okay.

[Chair Theresa Wood]: So I just want to make sure I understand. So that's technically an FY '25 expenditure. I mean, a cost, not expenditure, because it's being extended now.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: But It's

[Mr. Kelly (Fiscal/Budget Staff, AHS/DAIL)]: a 25 obligation.

[Chair Theresa Wood]: Obligation. Okay. Then the the 14 and a half million dollars, that I don't I couldn't find the report right away, but that I did not see in the closeout. That would not have been in the closeout because that's all FY '26.

[Mr. Kelly (Fiscal/Budget Staff, AHS/DAIL)]: Okay.

[Chair Theresa Wood]: Okay. Thank you. And then could you is there any information about how Vermont costs compare nursing facility costs compare to other states?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: There is some. If you could provide that. We can provide that.

[Chair Theresa Wood]: That would be great. If you can provide how we look compared to the national average, Or if there's a website that I just don't know about that I can go and look at it, if you can provide a link to that, that would be wonderful.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: We can do that. Yeah, we could also put it into our We are preparing a home report for you. Why don't we just put it in there?

[Chair Theresa Wood]: That would be helpful, just to get some perspective about the cost of healthcare in Vermont, and this is considered part of healthcare. And so I am interested to know, are we an outlier in nursing facility costs? Are we someplace in the middle? Or are we not spending enough in nursing homes? So that would be helpful. We'll incorporate it in.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: And you wanted a whole breakdown of the nursing homes and the for profit, non profit? We will have all of

[Chair Theresa Wood]: that for you in our budget report. Okay, thank you so much. Just a second. And then, I think you said earlier, Commissioner, that roughly the average age in nursing homes right now, probably not considering rehab, is 80 four I'm just trying to figure out because it seems as though I guess I would think about all the 80 year old people that I know. And by the definition of complex that you said, all of them will be considered complex. So I'm just trying to figure out how do you really make funding decisions if really the whole population is complex? What puts you sort of complex plus, if you will? I don't think that there's I'm familiar enough with how you get into a nursing home that you essentially have to require nurse care, and that usually is a complex thing.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So work your way backwards to what do you need to provide for the care of the individual. Because you're absolutely correct, that there's complexities and there's complexities. The number and the intensity of the complexities and what the care needs are that have ballooned in a way. So people always had something. In order to meet the criteria for nursing home level of care, yes, that's the highest need level in the long term care continuum.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: So

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: work your way back is what the issue is. If you say everybody, well, you may have, but it might be more within what the nursing home system was originally built for, and they can manage that with the skill, the training, the specialties that they have. But when you get into some of the multiple issues, all of which need different level of equipment, skills, specialty training to provide that, So that's what we're doing, is kind of working our way back to what because it's a gap. If the nursing homes could all manage all of those, we wouldn't necessarily be highlighting that. It would be the norm. But because it's exceeding the norm, and nursing homes were built for a certain level, let's say, of complexity, now it's exceeding that for many. That's what we need to address now is what is the actual presentation, and why are some of them not able to be cared for? And that's what we are finding, is the specialty training, the equipment, what they need in terms of how they care for those individuals. There are multiple different scenarios. And so some can like, this is just a small number who can do, let's say, ventilator work right now. Correct. Right. So for example, right?

[Chair Theresa Wood]: And that's very high cost. And so honestly, don't want that in every nursing home necessarily.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: And we may not need that in every nursing home, but we may need something else.

[Jennifer Garofedian, Director, Developmental Disabilities Services Division (DAIL)]: Yes.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Right. And so we need to think about where do we need what. We need to do this strategically, which is why this year is a planning year for us in terms of the strategy around stabilization and sustainability. That's our plan.

[Chair Theresa Wood]: You. And then, Angela, when you were describing when Representative Maguire was asking about the increase in the number of vacancies or whatever you wanna call them, you're kinda describing, like, churn, essentially, you know, needing people coming, people going, people passing away and needing to have that. You know, that exists even at the 200 level. So I guess I'm I'm trying to drill down a little bit further from representative Maguire's question because, you know, I guess what we're not wanting to see is that number increasing, especially with the enlightenment that you provided, that it's only 23 beds that are vacant and not included in that count as a result of staffing issues. So that actually because I had made the assumption, quite honestly, that that was mostly due to staffing. And so that's even, I'll have to say, more concerning for me that there are that number of beds and the number of people with significant medical issues who lack housing right now. And, you know, I I know that Representative Noyes has had conversations with you. I've had we've had this conversation for the last two to three years. Predates you, Commissioner, but we've continued it. And I know we had an interchange this year as well. And I am baffled as to why we cannot make better progress on the older Vermonters with significant health needs who are homeless. It was actually helpful to hear your more dive down about that. Angela might have something to say.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Because she's our rep and part of the AHSDA. So you have some things to say about those, at least on choices for care or choices for care relative.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Right, right. So it's a great question. And there's a lot of work happening, I think, behind the scenes to try to address this challenge. Fundamentally too, think it's really important to remember that we never force anyone to go to one nursing home, right? It has to be their choice. Many people do not want to receive their own alternative services in a nursing home, especially if you've been living in a hotel or have had a lot of autonomy in your life. So often it takes many months of work with an individual to, you know, many conversations for them to consider that as an option for them. Many people would much prefer to wait for a housing voucher for subsidized housing, for example.

[Chair Theresa Wood]: That's not going to happen.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Right, so again, it often takes a long time to get people to that place. And that's where the intensive case management support becomes really, really important in working with folks. Do you

[Chair Theresa Wood]: feel like to that case management support, because I know that that's the link, Do you feel like we have the skill set within the AAAs who are providing that case management to really address that? I guess I'm wondering what additional training that those folks have received in order to deal with more complex, to use your phrase, complex cases. Because it's not something that can be done from an office, sitting in your chair, or talking on the telephone. It's something that's required sort of that one on one interaction.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So I just wanted you to know that we have embarked on it's sort of like a learning collaborative, but it's been we call it a retreat. We've done it now twice with all the triple As, men. It's all of the CEOs of the AAA, the case management directors, and some of the other on the ground folks from every AAA in one big room. And what's happening there is on the ground experience conversations about what the biggest challenges are and how we can close the gaps on those, what the best practices are. It's popping in there. People go, well, here, this is what we do, and this actually works. And this one goes, I'm going to do that. So a lot of that is happening. It's just a really positive experience and absolutely necessary around trying to sort of optimize what is happening on the ground and just to understand what the barriers are for people who are there working at this every day, constantly, in the field, on the ground. I'm not talking about sitting in an office. That's not what we're talking about. Because I know you've talked about that before. You have to get out there and be there, and these folks are. And we are learning together about how to close the gaps. And so that's why we wanted the top leadership, so there would be buy in from all the AAAs as well as the people who are actually doing that work.

[Chair Theresa Wood]: I'm glad to hear that because that is, I think, sort of critical. I think that obviously you recognized and people are starting to recognize and understand that it's different than what maybe they perceived choices for care case management to be in the past, for a group of people, not necessarily for everybody, but for a group of people. And so I appreciate that effort that's going into it. I guess the sense of urgency that I feel is that I just have to say this, and I'm not being grandiose about it, but people are literally dying, waiting for people to get their stuff together. Get notices. I have actually in the last month, I've gotten notices of three people who have died sort of waiting. And I'm going to give they probably had some of those same reluctancies to engage as well. I'm not saying it was all the system's fault. I Yeah, I mean, it's urgency. I appreciate that you have that sense

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: of urgency. We do have that sense of urgency. We also talk to the advocates on the ground. But I also want to say that some of the opportunities for people to get from, let's say, GA to a place Money files the person. Know money files. You have to be either in a hospital or a nursing home, basically, in order to be eligible. That's the requirement of that federal grant. So what happens there is when you say to somebody, If you come in short term, that's going to be an advantage to you. They don't always trust that. And we've talked about maybe tours, for people to see what the actual experience would be like for them, or to talk to people who are there and for whom that worked. So we're really looking at and we've been successful. We've had actually quite a few choices for care folks in GA be able to come into nursing homes and other opportunities and options. Because once they're eligible, they have an opportunity that some people who are not eligible don't have. They don't have another option, and these folks actually do have another option.

[Chair Theresa Wood]: Okay, thank you. And we have focused a lot on nursing homes, but I do want to ask about 2,500,000.0 in the home and community based side of things. And it just says pressure. What does that mean? Is that you have new caseloads, you have increased cost of caseload. What's the 2,500,000.0?

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: Well, it's overall utilization pressures for the system.

[Rep. Zon Eastes (Member)]: For full transparency, we began VA early in the fall. That looked like from a community based caseload was increasing to the point that we, as you know, it's been a few years that we haven't needed community based caseload. Since then, the caseload pressure in home community bases slowed down. At the same time we still have nursing home Medicaid ten day, which we've talked about the Medicaid occupancy increasing. So since we put this VA together, two things have kind of shifted. So it's overall pressure and choice for care.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: But the home and community based need is increasing.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: I'm actually glad to hear that,

[Chair Theresa Wood]: to be frank, because as we all know, assisting people to stay in their homes and in the community is cheaper. It's where people will oftentimes prefer. And so I wasn't saying that in a negative way.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: I'm just and That's the thing, right? It's not an eitheror. It's an and. We need the home and community based services to be solid and strong too if we're going to make it through with the growing demographic.

[Chair Theresa Wood]: Yeah. Well, and I guess that's been in this committee, that's been our ongoing concern for the last three years, that the institutional based long term care part of the pie has been sucking up what's not been able to be invested in further expansion and stabilization of the community side. And so because they're linked, because they're all part of the same, Any increases that have happened, have happened as a result of what legislative action has been taken in terms of rates and things like that. So And I just put it out there that I appreciate all the emphasis on nursing homes, and we haven't talked enough about community based services this morning, and we have another department coming in, But not by and, I guess, am hoping when we see your budget presentation that we also see a focus on the community side. Yeah.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: The home and community, I've been watching it, even though the money was there due to the pandemic, so there was significant money in the system. But the home and community base definitely rose, and that's great, right? That's great, the need there. But I'm looking at the whole system. If we don't look at it in one continuum, I push us to talk about this as one continuum and not on silo. In any given day or any given time in your life, you may be in any In any piece of it.

[Chair Theresa Wood]: I'm just going to rip Sam down.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: It was a technical question. Can get it later. Okay. Let's just see it.

[Chair Theresa Wood]: Well, I'm almost done. I think I'll wait and I'll ask during budget. I was just going to ask, think it's this, are we in the second year of the ASCME contract or negotiated agreement, whatever you call it, CBA? Yeah, second year. Okay. Yes. Thank you very much. And thanks all of Sorry, Angela and Jen, you're probably fine with us not asking you any questions. Thank you. Thank you so much. Thank you very much.

[Angela Smith-Dieng, Deputy Commissioner, DAIL]: Yes.

[Dr. Jill Bowen, Commissioner, Department of Disabilities, Aging and Independent Living (DAIL)]: So

[Chair Theresa Wood]: folks from DCF, we're going to be taking just a five minute break in between. So thank you for your patience.