Vermont Legislature SmartTranscripts:

[Rep. Theresa Wood, Chair, House Human Services Committee]: Okay. Good afternoon, everyone. We have a pretty packed house this afternoon. Thank you all for being here. So we're switching up the agenda a little bit because the secretary has a little bit more flexibility than we originally thought. And we've invited Jen Carvey from legislative council to give us just a brief review, because it's been a couple of years since this act was passed, about what the intent of the act is and what we were expecting to receive. So thank you so much for being here.

[Jennifer Carbee, Office of Legislative Counsel]: Yes. Thank you for having me. Jen Harvey from the Office of Legislative Council. Excuse

[Rep. Theresa Wood, Chair, House Human Services Committee]: me, just a minute, Jen, I should say. In welcoming everyone here, we have it's a joint hearing between the House Health Care Committee and the House Human Services Committee. And we appreciate everybody's attention, especially as the implications of anything in the Agency of Human Services are very far reaching and impact many thousands of Vermonters. And someone might say all Vermonters, given the public health focus at the Department of Health. So I just wanted to say thank you for everybody who is here, as well as the people who are listening.

[Jennifer Carbee, Office of Legislative Counsel]: Have anything else?

[Unidentified committee member(s) or presenter (diarization overlaps)]: Thank you for having me and thank you

[Rep. Lori Houghton, Chair, House Health Care Committee]: for hosting us. Care Wood. Awesome. Looking forward to this.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Thank you, Jen.

[Jennifer Carbee, Office of Legislative Counsel]: Sure. Again, Jennifer from

[Jennifer Carbee, Office of Legislative Counsel]: the Office of Legislative Council. I will put the ACT language up on the

[Jennifer Carbee, Office of Legislative Counsel]: screen and I'll reading it all to you, but we will just remind ourselves what this ACT was and what

[Jennifer Carbee, Office of Legislative Counsel]: it called for. This was ACT

[Jennifer Carbee, Office of Legislative Counsel]: 119 of 2024, an ACT relating to re envisioning the agency of human services. It started out with some findings and purpose findings about the history of Vermont's agency of human services and then the purpose of the act being to create a meaningful process through which the agency, its departments, and the individuals and organizations with whom they engage can collaborate and identify opportunities to build on past successes and to make improvements for the future. And it directed the Secretary of Human Services in collaboration with the commissioners of each of the departments in consultation with a number of other stakeholders, was directed to consider options for re envisioning the agency such as restructuring it or dividing it into two or more separate agencies. So directed the secretary and stakeholders to evaluate the current structure of the agency, identify potential options for re envisioning it, engage the cost benefit analysis of each option, and come up with one or more recommendations for implementation. Directed the agency to solicit feedback from the stakeholders and engage existing boards, committees, and other channels to collect input from individuals and families who are directly affected. By February 1, the Secretary was to present to various committees, including these committees, an update on status of the stakeholder process and the development of recommendations for the final report and recommendations due by 11/01/2025, including the rationale for the option or options recommended, the likely impact of them on the departments in the agency and the Vermonters served by those departments. How the recommendations would center the needs of and lead to better outcomes for individuals and families and make the agency more accountable. How the recommendations could improve collaboration, integration and alignment of services currently provided by the agency and its departments, and enhanced coordination and communication among the departments and with community partners. How the recommendations could address the workforce and personnel capacity challenges based on the agency and its departments. How recommendations could address facility challenges, how the recommendations could strengthen the use of technology, a transition and implementation plan for the recommendations designed to minimize confusion and disruptions, post organizational chart for any recommended routine vigorations, and the estimated costs or savings associated with recommendations. That is what you were going to hear about

[Rep. Theresa Wood, Chair, House Human Services Committee]: from the agency today. Great. Are there any questions for Jen about what the intended purpose or the purpose of the Act? Great. Thank you so much, Jen. Appreciate it. And then we're very fortunate to have the Secretary of the Agency of Human Services here, Denise Samuelson. And welcome to the table. And if you have more people you want to bring with you, then we have spare chairs. Members of the public or members here, you can find testimony of Secretary Samuelson on, probably on both committees' websites, but I know it's on the House Human Services and is on the House Health Care Committee if you are looking to follow along.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Chairs, thank you for having us here today and the committee and the Austin group. This is a really exciting opportunity for us. As you've heard, the Act 119 report, and again, I'm Jenny Sandison, I'm the Secretary of Agency of Human Services for the record. I'm joined here by Jacqueline Coleman and Ted Fisher, both from the agency. Both of them actually did the research and the work on the report. So this is a really exciting opportunity for us as an agency, for an organization that strives to continuously improve, to grow, and to evaluate our organization. And we use this as an opportunity to really dig in, both as you saw here, to structural changes and other programmatic and operational changes that we could do to improve our agency. We're going to walk through the methodology in detail, so folks understand how we work through this, and we're going to walk through the recommendations. This report was just completed. Today, we're not really in a position to walk through the implementation and next steps, but we would be happy to take questions and come back with the appropriate departments. I am say speaking on behalf of our entire executive leadership team at the agency, which includes myself and the six commissioners and the deputy secretary. This was an all agency effort in an all agency report. So again, to revisit the purpose, it really is to create a meaningful process which the agency and its departments and individual organizations with whom we engage can collaborate to identify opportunities to build on past successes and to make improvements for the future. As I mentioned, we really took this very seriously. We went in-depth. We tried to ask a lot of questions, starting from a very open ended perspective, and getting them into the details with our departments. We wanted to make sure that we really heard from a lot of stakeholders, community staff, the people that we serve and the agencies that represent them, and the organizations that really deliver services on the ground in Vermont. So, a broad threat. And as you can imagine, there were many areas where we heard consensus, and there were some areas where we could hear broad set of goals that people wanted to achieve, but lacked full consensus on actually how to achieve them. And so, we will point out those areas, but overall, it was a really good process to help identify how we continue to improve as an organization. As a reminder, the Agency of Human Services is the largest executive branch agency. It represents more than 40% of employees and has one of the largest budgets. We serve hundreds of thousands of Vermonters through direct service, and we provide services and support for all Vermonters across as we really have both the health and the public health mission across the agency, not just in the Department of Health, but across every single one of our departments. IHS directly serves and oversees contracts. Much of the work of the agency is delivered by valued partner organizations on the ground and in communities. And so, a lot of this work and the work of the agency isn't just from the 4,000 employees that we have within the agency, but really represents many, many more people on the ground working with clients. It's home to programs that directly serve Vermonters. As I said, hundreds of thousands of Vermonters and families statewide, and has significant impacts, and that I don't want to minimize on their health, well-being, economic vitality. And so, it was really important for us to really look across the breadth there. One of the things to acknowledge, and I believe that this is why over time, not just this time, but many times, we've been asked to continue to evaluate us as an agency and it's in the codifying legislation, is that we've changed significantly in both our charge, our mission, and the depth of our programs from 1970 when we were created. That represents the intersect between health and healthcare and human services. Many of you have heard me talk about health related social needs and the impact of housing on health and the impact of food on health, and that's why we were put together as one agency. But again, that has evolved significantly. There's also been a significant increase in not just the scope, but complexity of the work and the systems that do that work on the ground. So, I do think it's important for us to iteratively evaluate our structure and our purpose. So, at this point, I'm going to turn it over to my colleagues, both of whom I just want to say led this work with the whole team, but I just want to congratulate them for a job well done in terms of the depth that they went into, particularly because this wasn't a funded initiative. And so, stepped up and they stepped out of what they usually do and really, I think, did a robust process. So on that, I'm gonna turn it over to Jacqueline. Thank you, Secretary. Hello, everyone.

[Jacqueline Holden, Director of Performance Improvement, AHS]: This is my first time. I'm Jacqueline Holden. I use sheher pronouns. I'm the Director of Performance Improvement for the Agency of Human Services and I sit in the Secretary's office. So I will talk about the process that we went through for this report. These were the project phases, broadly speaking. We went from our initial initiation and planning, which Ted and I both were part of starting that in around September 2024. And then we did our broad information gathering phase, which included open comment feedback from both staff, partners, public, and others. And that led into some more focused information gathering through specific focus groups, advocacy groups, groups that are really proximal to the work we do, and others. You can see in there the interim report was during that time, at which time we gave an update on the process through which we were doing this work. After that, once we started to get a lot of the information in, we began the analysis, which was an iterative process. So even before we had a complete set of all of our data and all of our input, we started doing some analysis, which then informed our next steps and what the rest of our sort of feedback and information gathering would be. Analysis continued through about June and we also started to do some interpretation of the information coming out of BETTER. So not just a summary of the comments received, but really what that meant is what we mean by interpretation moving out of our analysis. From there, we did a prioritization process, which included again reaching out to staff, partners, the public, clients, anyone really who wanted to participate. We did just an open survey of people to look at the feedback we had gathered and the broad themes of what we had seen and help us prioritize what was most important to the people that are really involved and impacted by our work. From there, we use those priorities to sort of move us forward to the results and options where we look at what we can really do with that information to put something into action or to make changes and then looking at those, assessing which one of those would be the most beneficial relative to the amount of work, the feasibility, and the likelihood of success and sustainability moving forward. And that led us to our recommendations, which were part of the final report in November. And then beyond, we'll talk about that a little bit later. So then just a little more detail about the process. For outreach and engagement, we did, as I said, discussion groups, surveys, many interviews. We had over 1,000 people who engaged with us and participated in that information gathering. That included staff, that included leaders from the agency, from all of our departments, that included partners that work closely with us, those organizations that deliver the services like the secretary was talking about, advocacy groups that represent our clients, and more public comment was also received. It was generally anonymous. Some chose to identify the organizations from which they were representing or speaking. Some were completely anonymous. So it was a broad set of information that we received, which was really valuable and really, I think the true value of it and what we really got was related to the experience of people. There was not a lot of, this is the solution or we think you should do this. It was more, this is what it means to me to work for AHS and how I experience that as an employee or as somebody who receives services. These are the issues that I see and the benefits that I see. This has been really helpful for me that you should continue to do and the things open here are opportunities that I see in the way I'm enacted by the agency. In addition to sort of that broad feedback gathering, we also included research on the operational data and metrics of the organization, AHS and its departments. We looked at peer states and how their human services programs operated, their structure, the way they put together their programs and grouped them, the way that they delivered them and coordinated between the various types of human services that are delivered across most states. In the organizational theory, generally what's the best way to handle sort of cross collaboration, but also some sort of hierarchy and feeding up so that information and decision making happens optimally and collaboratively. Generally, an organization's design should really reflect the purpose of the organization and the outcome for these desires. And then we also did a historical review of the agency, a lot of which was in the original bill as introduced, which was very informative. And all of that sort of helped us develop and iteratively continue to ask deeper and deeper questions of the people that we engaged with based on what we learned along the way. We got further down into specific interviews with specific groups or specific people who were subject matter experts or a very clear depth of understanding of the agency and the work that's done. As I said for the analysis, it was iterative over time as we got more information. We did a thematic analysis given some of the constraints and resources and also the way that the information would be more useful. We analyzed at a thematic level so that we could see what really the highlights were, what we were hearing most often, and then that could help us be a starting point from which we could look into the detail as far as in this broad phonetic area, what specifically are we hearing as far as what's working well, what are maybe opportunities for us to work differently. And then as that moved forward, we began validating those things with our continued engagement with more and more groups and a little deeper analysis to ensure that the themes that we had come up with really were reflective of the breadth of information and feedback that we received. And then finally, as I mentioned, our prioritization was through a couple of surveys. Mostly we sent one to staff and then also an external survey, which we tried to push out as much as possible to gather as much feedback as we could around, as I said, of those themes, what are really the most important to the people who experience the agency in whatever way that they interact and experience our services, the way we operate. And that really helped us come to the options and recommendations. So from those priorities, we started to look to the options and what we might be able to do to address those opportunities on the ground. We again looked at sort of what those options might be more broadly and then narrowed them as we looked at more research and validated those again, people who were

[Jennifer Carbee, Office of Legislative Counsel]: a little more

[Jacqueline Holden, Director of Performance Improvement, AHS]: intimately involved and informed about impacts through clients and also people who, like the secretary, had served in positions that had a very broad and deep overview of the organization. And then we also looked at those options through a broad cost benefit analysis. You see some of that here, the criteria we looked at to get to recommendations, outcomes, sustainability, impact on clients, alignment with other priorities, and other challenges or opportunities that we know were priorities across the state, usability, resource constraints, and statute, there are regulatory or statutory constraints or things that we needed to be aware of as other impacts. Taking all of these together broadly, it really became sort of a broad cost benefit, including in the cost those impacts, and also the change management costs that would come with broad strokes, large reorganization of an agency as large as ours, potential disruption to services for clients near term and long term, potential disruption to processes, sustainability and organization for staff, and the way our organization operates collaboratively between departments and programs. So all of that together sort of informed where we got to in these recommendations.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So we'll move on to you.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: Good afternoon. For the record, my name is Ted Fitcher. I'm the principal assistant and communications director for the agency of Human Services. Thank you for having us here today. I'm going to go over the findings and recommendations section To with you just start where Jacqueline left off here, we received a really very, very broad scope of feedback from high level conceptual, broad systems considerations, people that clearly have been thinking about things for a lot of time and energy into thinking about their ideas to folks who had very specific and granular feedback. I need this thing changed. This is not working in my specific program or my specific unit or this particular program that I it's not helping the clients that I serve, those kind of things. So they gave really broad brush strokes. And we intentionally asked that when we came out. We didn't say, hey, should we break up the agency of human services? We really asked folks to tell us what they thought the biggest challenges and opportunities were throughout that process, as Jacqueline mentioned. So very specific ideas to comments from maybe small scale teams. So the framework that we're going to go through here in terms of the recommendations kind of reflects that broad scope. But I want to state upfront before we go deeper into our recommendations that much of what we've heard doesn't speak directly to like the structural elements of the charge of the act. We heard a lot of things that was useful in that context, but wasn't, hey, it would be better if we reorganized part of the agency. And so that's where the methodology that Jacqueline was just talking about was really helpful for us to try to put together the pieces of evidence so that we could take the problems, challenges and opportunities in context, the big picture challenges, the more specific and actionable things, sort of feed them all together in terms of what the implications for the organization. Just want to say upfront that everything we heard was thoughtful, insightful, focused on how to improve the lives of our monitors, improve the services we provide or support and empower our agency employees. We work with a really amazing group of people at AHS. Our staff are really, really thoughtful about this. They engaged really meaningfully in this process. Similarly, the members of the public and the partners and stakeholders that we worked with also really engaged with us in a really thoughtful manner. So I'll just say personally, I had joined the agency right around the time this act was being passed coming from a sister agency in state government. So this was kind of my introduction to AHS, which was a really, really awesome thing to get to know the agency that I was coming to work for. Just to reiterate one thing that Jacqueline pointed out, input represented how different people interact with an experienced agency from clients and advocates. We interact with general service processes, but don't know or care about the agency structure. Different from the corporate HS secretaries who lived the structure and relationships of HS as an agency level to their database, which has a really broad net. And we came up with a structure from all of this feedback, big and small, comprehensive and specific, strategic and tactical to generate a set of recommendations to speak to the themes, challenges and opportunities we identified during our process. I'm gonna go over the tier structure you see in front of us and go a little bit over that now, and then

[Jennifer Carbee, Office of Legislative Counsel]: we'll kind of dive into it a little bit more detail on the report.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: So tier one opportunities include those that need the highest level of decision making authority and scope. So this includes this category is also where potential solutions could include legislative remedies. So this is kind of speaking to the broad charge of the act, if you will. But we learned a lot that was not specific necessarily to the need for legislative change. So we have two additional tiers. And tier two opportunities really speaks to agency wide change initiatives, options where AHS executive leadership can advance internal reforms, including, for example, strengthening workforce supports, leadership development or hiring pipelines, improving communication, transparency, and interdepartmental collaboration, modernizing technology and data infrastructure, strategically aligning program and budget planning processes. All of these are really big things for us to do and we need to work on them internally and prioritize and figure out how to take them forward. But they're not ones that have a massive action. With that, I'd like to we're going to pass out a we have a visual aid. Jacqueline mentioned the teams development we used, both to organize the feedback we received and also to do the prioritization and kind of the second phase of our outreach. So we're going to pass this out to you all. I think we have enough copies. You're welcome to dive in. This is also available on our website. It's like Brenda is going to help us. Thanks, Brenda. We're going to go over the winners in terms of the most popular items that we heard about in our prioritization process when we go over tier two recommendations. And this will guide the agency's internal process to the next steps in terms of what we want to tackle for the tier two going forward.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Can we stop and just ask if there are any questions before you kind of jump in just about process? Because you're pretty clearly defined the process that you use, now you're kind of getting to results. So yes, go ahead, representative Gina.

[Rep. Brian Cina, Member, House Health Care Committee]: Yes. Is there a place I noticed that

[Ted Fisher, Principal Assistant and Communications Director, AHS]: as part of the process, talked about

[Rep. Brian Cina, Member, House Health Care Committee]: It was mentioned that about the history, like what led to agency of human services, what led to the current configuration. I tried looking and I couldn't find anywhere publicly where the origin of the agency of human services before 1970 is clearly articulated, I don't want to do that now. Is there a place we can go that you're aware of where that knowledge is stored, where you understand the roots of the agency?

[Ted Fisher, Principal Assistant and Communications Director, AHS]: Thank you, representative. That's a really great question. And we asked that question fairly early on in our process. The short answer is that there isn't.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: The legislation that currently exists, I think, does one of the best jobs in summarizing the goals. And you all did a fabulous job in writing and developing that. Catherine, it's true. So

[Ted Fisher, Principal Assistant and Communications Director, AHS]: as secretary said, the purpose statement of Act 119 has a really good high level concise but also very rich overview of that history. We dove a little bit deeper to try to understand some of that, but it took some work to do so. So there isn't, unfortunately, a really good summary beyond what is already in your act. And I would say that's pretty comprehensive.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Just for members, we had some difficulty unloading the actual report. It is on the Human Services webpage now. I'm not sure it's probably getting on the healthcare website. So what was previously there was the February 2025 update. So the November 1 report is is now there if you wanna take a look at it. Other questions from members? Go ahead, representative McGill.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah. I was just wondering. Could we would it be possible to share, like, a blank copy

[Unidentified committee member(s) or presenter (diarization overlaps)]: of the survey you sent out? Sure. That would be great.

[Rep. Jubilee McGill, Member, House Human Services Committee]: And the survey was that I think one of the things that Jacqueline did a good job that I want to reiterate is that it was an iterative process. The first thing we did was gather broad themes, and we did that each time and made sure that we had a way to get from the public, so there was a very logistical way. People could make comments from our website, new webpage. We also gathered information through surveys and interviews. Once we had the themes, we then clarified the niche and asked folks, Are these themes the right things?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Did we miss anything? And then after that, we said, Okay, and what should we do about it? And that's where we did both the research externally and internally. So what should we do about it? And then we went back and said, Did we get this right again? And so that's what she means by iterative. It was broad things. Did we get it right? Okay, what should we do about it? They would get that right. I appreciate that. Thank you.

[Rep. Theresa Wood, Chair, House Human Services Committee]: You. There are members who have

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: a question? Chats? Okay. Go ahead.

[Rep. Eric Maguire, Member, House Human Services Committee]: Thank you so much. I just got two quick questions. Did AHS formally evaluate whether DOC should remain within AHS as part of the restructuring review?

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So, let's sit where we will get to that

[Jennifer Carbee, Office of Legislative Counsel]: a minute.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: What you will see in the next few slides is a set of recommendations. Again, remember we gathered things to directly answer Representative Maguire your question. It didn't actually come. We thought maybe that would come up. The first thing came up really strongly, and then I'll give a little spoiler alert, was what should we do as an agency? And everyone, there was broad consensus that we shouldn't break up the agency. And remember at the beginning, I said there were areas where we had consensus and when we didn't, I'm going highlight that. There was broad consensus, and we'll go through the reasons why. The second thing that came up immediately was the conversation about substitutes and mental health and the lack of integration. That was an area where we didn't have everyone identified it as a problem, and they identified it early and often throughout the process. I think because we were still kind of coming out of legislative session, that was a question from last year, it brought it to the forefront. And there was some consensus there. What we saw though, was the majority of the people that we talked to talked about integration and integration of those two systems. The Department of Health and some of the providers that they work with were a little bit more skeptical. And so I wanna be honest, that one came up early, it came up often, and there was not always consensus. So that gave us really the insight that we needed to dig in deeper in terms of the how, not necessarily the what, everyone agreed on the what, but the how. After that, the conversation about DCF came up. It wasn't until we got towards the very end that we started hearing anything about DOC, and it wasn't often, it wasn't early, and that was another area where there wasn't always consensus. The majority of the people that So, when we heard it, we amplified it. We made sure we visited every single one of the DOC facilities. We talked to probation and parole. And for a small subset, particularly of the more seasoned staff, we heard, does DOC's mission align with the agency? And some of the folks are like, we're not for, is it public safety? Is it human services? When we amplified the question and asked it more clearly, we heard from a broad set of stakeholders that they felt like DOC really delivered human services and needed to stay connected with the agency, and that we weren't fully leveraging that. And that was a key theme that came out. And we heard from many staff information and parole that it was really essential for their work to keep the two things together. And we heard from many of the newer staff who are really working through the culture of really making sure that what we're doing in DOC is really restorative. We heard from them that they felt like there was value, but that they needed more growth than development. So, we'll go through that, but I want to make sure that as we go through these areas, because I want to highlight early and often, agents should stay together, question about substance use and mental health, question about DCF, they came up. The DOC one was, even though we amplified it, was a much was a much less substantive area of recommendation for change than the other three. So, not all the recommendations were created equally. Does that make sense?

[Rep. Eric Maguire, Member, House Human Services Committee]: Yeah, totally agree. And I understand fully the perspective of it is more practical and rational and applicable to keep DOC under the umbrella of AHS if we want to use that. It's very much ingrained. My hope with all of that is that does keeping DOC, is it going to advance the goals of Act 117 in regards to being more efficient, accountable, and coordinated of services as you outlined. That's what All

[Ted Fisher, Principal Assistant and Communications Director, AHS]: right, I'll leave it at that.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Yeah, I think that that's exactly I want to give a concrete example because we could stay up here at the ethereal, right? But I happened for Capital for a Day, we were visiting BMS, and this question came up with one of the emergency medical service providers in that area, and they recounted at least five examples of why it was really important to them for this to come together. And so, they're not someone who's doing in our culture. They're not someone who's doing great in the status quo. And those are the types of folks we wanted to get radical new ideas. So, those were the folks that when we had the opportunity, we really had conversations with it, so that we didn't have a status quo bias. And again, apparently, when we amplified that question and add a broad set of stakeholders, that I was surprised actually, that they really talked about the value that they saw. Another provider highlighted us working to try to get substance use and the full continuum of substance use treatment in DOC. And they're like, we don't see that in other states. We really like that really, that was a law enforcement partner. We really see that here. And we think that that's a value thing in HHS. So I'm hoping that answered your question. I took a little bit of extra time.

[Rep. Eric Maguire, Member, House Human Services Committee]: Yeah, yeah, yeah. No, but to your point, it's unified system. It's the only one in the country that's under an agency in human services. It can become difficult to coordinate it within the system, but there are many correctional systems throughout the country that their facilities are specifically designated if they're operating off a penitentiary type model or a more county type model, those systems of care are ingrained specifically of the scope of what's being housed. And, you know, like I said, as long as the efficiency and the accountability and the coordinated of services can really be pushed through, because we do recognize that as desperately needed, as you mentioned,

[Ted Fisher, Principal Assistant and Communications Director, AHS]: it is completely practical to keep everything ingrained

[Rep. Eric Maguire, Member, House Human Services Committee]: within AHS right

[Jennifer Carbee, Office of Legislative Counsel]: now.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: And that's where the tier two and three, I want to reframe. The tier two are

[Unidentified committee member(s) or presenter (diarization overlaps)]: things that we want to work with you

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: all too, but there are things that are much more operational. We did highlight some of those, and that's the value of this. We wanted to make sure that as we gathered information and data, we didn't just answer the structural question, but we also captured as people talk to us about things that we can improve, the operational pieces and the programmatic pieces that we captured those. And we do think we're an agency continuously interested in improving from a transparency standpoint. There are things that this report pointed out that are opportunities that we are committed to continue to drive forward at the programmatic level and at the organization level. Let's why don't we dive into those because that's where we were going.

[Rep. Eric Maguire, Member, House Human Services Committee]: Thank you so much.

[Rep. Theresa Wood, Chair, House Human Services Committee]: So is there one more question and then we should continue on.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: One last question on the process piece. Thank you so much. And I appreciate that outreach for this included and extended beyond AHS. It was partner agencies and groups because we are all web interwoven to try to serve Vermonters in whichever capacity we do. Although I am very curious in just sheer percentage, What was the response rate from strictly AHS employees? I'll have to jump back to find the exact number, we can get that for you. Lastly, was every single AHS employee reached out to in this? Yeah. That's helpful.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: And multiple times, and we tried to put the methodology. We tried to pass as broad a broad brush as possible, writing that. So multiple secretary sends a monthly all staff email. So we would get a date every month. We sent out a specific email about that. We asked recognizing some folks, depending on their schedule or whatever, maybe that's not their first priority to read. We asked departments to send their own versions. We asked supervisors to reach out. We sent out the surveys. We publicized the open comment form. We visited all of the correctional facilities as well as our Vermont Psychiatric Care Hospital and our other DMH operated facility. We also tabled in our Waterbury office complex and visited our district offices, literally just engaged people kind of in the hallway, went to staff meetings. There was a lot of different ways for folks to provide us that kind of feedback. Some of those were casual and informal conversations that were, for me, some of the richest conversations were sitting in the lobby of our office and hearing from different folks having a conversation, people from different departments talking about one specific challenge, something like that. Jack or I might have been curious to take notes to more formal or more structured engagement. So that's true for both staff and for our public engagement process.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Thank you. We have a lot to get through.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So actually,

[Ted Fisher, Principal Assistant and Communications Director, AHS]: on the last slide there, I just want to draw out explicitly to kind of pause in between the tiers. The tier three are our actionable, smaller discrete projects. Those are either department or program level or making more discrete things by the level agency that we can just start working on. So they're not at the higher level of needing to consider and prioritize developing a large amount of resources to continuous improvement. There's a lot of really awesome things in there that may be easier fixes or might be just things for departments to kind of integrate into their continuous improvement work there. So we will go over and give some examples of those as well.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Thank you. Okay.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: So firstly, because we have dwelled and did dwell a lot at the challenges of this, it's important to just recognize our strengths. These themes on the slide here summarize the areas where we heard that Ah is successful at fulfilling its mission and meeting the needs of our clients. We heard a lot about that or a lot of, hey, we do this really well. What about this other thing? We heard a lot of really awesome benefits of the agency as it is currently structured, those are also things for us to think about as we move forward and change. Input again, based on the input from all of our sources and some of these key themes of strength, these are resources and practices and systems that we will lean on as we go forward and move our recommendations through implementation and ongoing improvements. We want to make sure that as we do change and as we do improve, we sustain and amplify ourselves in that case. So I'm going briefly present those to Okay, so for slide eight, this is the order we'll be reviewing the findings and the recommendations for the rest of the presentation. You'll see for tier two here, the themes for revisiting AHS, that's the document we passed out to you. These are kind of like the top ones from our feedback process here in terms of the prioritizing. And these thematic areas that we passed out to you represent most of the feedback we've received in some form through our analysis. Do you want to just note that by and large, the feedback we received didn't speak to broad organizational or systems change. It was focused on, here's the problems I see in front of me, or here's the opportunities, or what if we did this? So there's a lot of, like a really wealth of things for us to mine, specifically department and program level work there. And they really do reflect the experiences and day to day impacts for the people who interact with our agency, including our own staff,

[Jennifer Carbee, Office of Legislative Counsel]: as well as our partners and clients.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: On the next few slides, we'll go over our tier one recommendations. Before we do that, I just wanna know upfront that as the secretary mentioned a little bit earlier in responding to your question representative, there are some commonalities among them in terms of each of the tier one recommendations, but they're all unique in their own way. And we came to each of them differently based on, again, the overall evidence feedback we've received. So we looked at everything we heard about just that, hey, we think you should move this program here, we think you should reorganize this. We took a broad approach looking at everything both in how we identify the challenges that underlie the tier one recommendations, as well as are where we landed ultimately in terms of what we're recommending in the report. The scope and scale of the challenges identified and the impact or urgency of each is different, And I'll try to note kind of that context as we go through. And Secretary noted that a little bit already for DOC, I mean,

[Jennifer Carbee, Office of Legislative Counsel]: we could revisit that or summarize it as well.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: And as we noted previously, we didn't go into conversations asking folks whether we should make structural changes. We asked what the biggest challenge is. And one last important thing about tier one, while broadly speaking, our tier one recommendations include possible legislative solutions. For many of our tier one recommendations, we don't actually contemplate legislative solutions being the best approach to move forward. In many cases, our recommendations is that the agency takes specific steps or work to strengthen existing structures and systems. There are a few reasons for this. First, we consider the high cost of change. Jacqueline alluded this a little bit at the bottom in the methodology. This is both in terms of financial or other resource costs, as well as the potential impacts to programs we take that really, really seriously. We wanna make sure that whatever we do do, we're maintaining the standard that we're at. There's a natural high bar to end that any challenge needs to overcome. And so in many of these cases, we want to be transparent about what we will be looked into, but we propose other remedies. And in cases where we do contemplate legislative changes, it's important that they be made thoughtful against them. Okay, so our first tier one is the agency of human services. I just noted that a lot of our feedback wasn't structural in nature, but it's probably not surprising that we did hear about a fair amount of feedback that directly addresses this question. And that's because the context of us approaching say our staff for a meeting, they saw, oh, this is an act about, you know, re envisioning the agency of human services. And so that was what the clear focus of the act was for our participants. And there was a lot of really well reasoned and valuable comments both for keeping the agency as one and for dividing the organization with a variety of different models considered. We heard a lot about challenges and opportunities that while they didn't reference organizational questions directly, they have a bearing on the overall question of the agency's organization. So we're listing some

[Jennifer Carbee, Office of Legislative Counsel]: of the challenges we identified here on

[Ted Fisher, Principal Assistant and Communications Director, AHS]: the slide. However, far more often we heard that the agency is stronger and better able to meet the needs of providers as a single unified agency. And we heard less specifically whether to change the structure and more about the need to improve the coordination and integration of the current system and the opportunities for us to do that. And you'll see reflected to address what you see reflected on the slide and which splitting up the organization won't necessarily solve. So we're happy to dive deeper into any of these if you would like, but we have some recommendations on our next slide. So much of what we do and how we do is dependent on alignment of services across the course of life, the life course of Vermonters and how to meet their varied experiences and needs for the communities that we all belong to. From behind the scenes work on fraudulent policy to on the ground direct

[Jennifer Carbee, Office of Legislative Counsel]: interactions with

[Ted Fisher, Principal Assistant and Communications Director, AHS]: clients, their experience is better when we have fewer barriers to overcome in how we support the bond. And we heard from participants among all types of groups who engaged with us, general staff conference to field staff discussion groups, to meetings with advocates and clients, interviews with current and former leaders within HHS and other state agencies and departments. So let's really break down barriers, widen ways to streamline working together better. And then finally, we really just looked at the question of, would a different org chart solve the problem, and would that be worth the cost? And the cost of splitting AHS would be too high, both in actual financials and in the disruption in organizational impact on staff, and most importantly, in the impact of the outcomes for clients. So what our recommendation is that we strengthen, keep AHS together and strengthen as a unified agency. Strengthening AHS's internal structures and systems positions the agency to pivot quickly in emergent situations without encountering unnecessary structural barriers, excuse me. We also just experienced really broad support even in the context of diving deep into critical challenges, that we consistently heard that addressing the coordination internally would be

[Jennifer Carbee, Office of Legislative Counsel]: more beneficial rather than starting that.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: So the next item that we discussed or looked into in terms of our tier one recommendations is the Department for Children and Families. We didn't hear as much structural feedback directly from participants as we did with the Agency of Human Services. We heard a lot about the broad scope of work with DCF and about how that scope impacts the experience of staff and clients. Much of the work of DCF, ESD and Economic Services Division and Family Services Division is highly invisible. It involves direct interaction with a large population of children and families across Vermont. And it's not surprising, therefore, that we heard frequently about DCF in nearly all groups and methods during our information gathering. It was a very common topic, even if we were speaking about like more of those operational focus questions. Many divisions and programs from DCF are represented in the field and coordination of service is essential. However, there are some clear differences in the type of work that's done by various divisions in the silos and operations. We've also heard largely from DCF and other AHS staff, but employees of the field services division and yes, the economic services division, sometimes identify much more closely with their divisions than as DCF as a whole. This is unique to DCF as compared to other parts of the agency, for example, Dale employees, need to have a Dale employee. And oftentimes, if you ask DCF, they'll identify them as belonging to their division. We observed that the, quote unquote, walls between these divisions, which are also the largest divisions in AHS, are high, which impacts the various experience of those who work with or interact with DCF. So there was a sort of natural impetus for us to look at whether a different organization structure might be worthwhile. There's also some question of kind of the brand, right? We're unique in Vermont in that we have both economic services offered as part of the Department for Children and Families and Family Services. Some, many other states split that up and have either two agency or department level organizations they can sell, and then we have

[Jennifer Carbee, Office of Legislative Counsel]: the model of one department.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: We fully investigated this in terms of what the potential other models would look like and all of that. But again, we need to look from the measure of DCF serves some of our most vulnerable promoters. They do really, really critical work. There's a lot of, there's that again, cost financial in terms of resources and potential impacts. So our recommendation is that we really need to invest some time and effort into strengthening DCF. The feedback again was really about how can we improve things. So it really makes sense for us to work on trying to break down some of those barriers, trying to work on making sure that the coordination is very tight between the different parts of GCF that works together, investing and strengthening from the department and some of its leadership operations in terms of providing the capacity to manage what is a very, very large department within our agency. So at this point, while we didn't investigate whether a structural change would be warranted as part of the charge of this report, we are not recommending changing how to be structured. Okay, our third tier three or tier one excuse me recommendation is about mental health integrations. We currently have a lot of services for substance use and mental health offered by both the Department of Mental Health and also the Health Department. The systems, and as the secretary mentioned earlier in responding to your question, alluded to in this one to your question, members, about DOC. We did hear quite frequently that we need to improve the way we coordinate services in substance use and mental health, and that there are some challenges there and duplication of services, siloed systems, a lot of coordination work needed to be done there. This input showed up in conversations with organizations and groups, as well as people working directly in the field, as well as comments in the DBH and DMH staff. And I just want to reflect with the Secretary of Energy earlier. There was not unanimous there was not unanimity about what the best option is here. There are strong perspectives depending on who you ask about how this should work. But there's clear agreement across those perspectives that we need to make progress in solving the problem if you think from a perspective of the client. For example, there are two different provider systems and two different billing systems, which means that some of you think folks who struggle with mental health and substance abuse are some of our

[Jennifer Carbee, Office of Legislative Counsel]: most vulnerable providers.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: And they also struggle with lack of housing. Many cases, parts of the agency touch some of our most vulnerable monitors. And so providing a system that is streamlined and seamless as possible for them is really, really difficult. You talk about people trying to navigate a tough situation in their life. And so from our perspective, we really need to solve the underlying challenge. And here is where we do make a structural recommendation, which is that we should integrate clinical and substance use functions into DMH. Again, here the focus is on coherence, thinking about the perspective of the client and making sure that we are improving the standard of care experienced in the field care and reducing the vagaries. So we mentioned, we talked a little bit about this already. Our last tier one recommendation is related to DOC. And as the secretary mentioned, we heard some perspective that's really very, I'm just going to mirror the way you asked the question representative in terms of should DOC be somewhere else. We did hear some perspective about that. We spoke to a broad, broad group of DOC employees. We went to all of our correctional facilities and basically sat back on the right, sat with as many corrections officers as we possibly could in those visits and asked a lot of questions. We also spoke to probation and federal units, DOC, excuse me, central office folks. We did not hear universally, and we were prepared for this question because in doing our pre work research, we looked into the previous conversations about structural change. So we knew that there had been thoughts or questions or suggestions about working DOC or making DOC its own agency, and we did hear some of that. But what we did really hear really specifically was a lot of, we have a lot of challenges at DOC. I know that these committees have heard a lot about DOC and the various challenges that they face. So we heard a lot of very tactical operational feedback from line folks, concerns about scheduling, concerns about staffing. I think we've all heard those from DOC and I'm sure DOC is sure we'd be happy to talk more about that with you. We have a lot of what we kind of think of as tier three recommendations that were things for DOC to work on. And I gotta say from working with getting to know DOC as part of this process, that's something they already think a lot about. So we did hear some questions about whether or not DOC is the largest department, I think, in state government would make sense somewhere else. Because we heard that, we went into scoping and admitting to it. The secretary, kind of can go to the next slide. The Secretary did go into some of what we came down on already and did it more eloquently, frankly, than I'm going to be able to do it here, but we see a huge amount of benefits from having DOC be part of the agency achievement services. Again, thinking about cost of change, impact to services of a population of vulnerable Vermonters, impact to staff and staffing levels, which we know are some that's a key consideration of any kind of change, as well as the ability for integration with the other departments within the agency of human services. We are not, for those reasons, recommending when it's time to I'll give you some really, really just very granular examples of why. We heard we had a focus group with the managers, and I'm going to forget which of our field service offices it was. We had a focus group with the managers or the division, with the directors for this field services region from each of our departments. That's the health department, the family services division at DCF, the economic services at DCF, DOCs, probation and parole. And I think we had like high availability there in the health department. So we had a good group of folks. And the DOC, the director from the DOC unit of

[Jennifer Carbee, Office of Legislative Counsel]: the probation and parole unit in that

[Ted Fisher, Principal Assistant and Communications Director, AHS]: field service just talked about how important and critical the relationships with their colleagues in the room, with family services, with economic services were to doing their job and how much they worked together. And that's not to say that they were part of another agency, they couldn't necessarily build those, but the entire focus of that conversation is how can we strengthen? How can we make it better? How can we work better together? And so from our perspective, the remedy to the challenge we're seeing is to strengthen the existing structure and streamline rather than making a structural change, if that makes sense.

[Rep. Eric Maguire, Member, House Human Services Committee]: Yeah, of course it makes sense because when you dug deeper and probably look at what the fiscal number would have been to remove it out of that parliament, I find it hard to believe coming into legislation saying, Hey, by the way, we wanna remove DOC when you get $100,000,000 That's pretty-

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I think this is the end of the tier one recommendation. Yes. I want to give you the opportunity to

[Unidentified committee member(s) or presenter (diarization overlaps)]: talk a lot to see if you want us to keep going into greater than three or what the reason of pause.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Not seeing any emergent questions right this moment. So

[Ted Fisher, Principal Assistant and Communications Director, AHS]: And we wanted to give you a good because of the challenge of the report, wanted to do a good accounting of all of our tier ones specifically. But we're going to give a more high level our tier two and tier three, and we'd be happy to talk more as we go to the

[Jennifer Carbee, Office of Legislative Counsel]: process. Please go ahead.

[Rep. Theresa Wood, Chair, House Human Services Committee]: No, no, it's fine. One of the things that I particularly appreciated in the approach is that the agency took the opportunity to be thinking about this very holistically, not just the charge that was put in Act 119, but what are we going to do with what we learned? We're making this big effort. So we should use it as an opportunity to learn about the experiences of our staff, of the people who we interact with, our community providers, and people receive services. And so I appreciate that and appreciate some of the themes that have arisen, I think probably for most of us probably aren't surprising. And we'll be looking to see how do we move from there? What's the engagement that we have back, the feedback process back? It's always good to have collected, analyzed, assessed, developed themes. Then how do we respond back to all of those people who took the time and the effort to participate in the process to let them know what are we doing with the information that you shared with us and the time you took to do that?

[Rep. Lori Houghton, Chair, House Health Care Committee]: I was just concerned. I'm very pleased with your recommendations regarding substance use being integrated with DMH. Is there any legislative Do you need anything legislatively to

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: So, I don't want to get out over my skis here.

[Rep. Theresa Wood, Chair, House Human Services Committee]: I was just going say. It also wasn't I think it's important that you said outright, it wasn't consensus necessarily about that.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: For this one, big thing is going to matter the how we do it. I've been around for a long time. I can't believe how much gray hair I have at this point. We did this once before where we put mental health into Department of Health, There were some real lessons learned related to that, putting it into a larger department. A lot of the folks felt like we lost the mental health focus. And that's why we actually feel like why this made more sense, because it would actually amplify substance use rather than make it so that it was less of a focus. We also learned that time that how you make these types of organizational changes really matters. We put folks together, but we didn't really achieve integration. If we do that again, it's not worth it. The whole point here is to change the way that we provide services. Integrated payment models, integrated measurement, make sure that individuals can go, if they choose, that their mental health, the provider that they see for mental health is in mental health, has some cost of their subsidies balance. So, they don't have to go to two separate folks. And so, for this one, I think it really does matter. But your question was, I don't want to get over my skis whether we need legislation. I know it's something that's been contemplated or it's being contemplated this year. When we looked into it, the last time, there are a few ways this could be done. I don't have the authority to do it myself as the Secretary of the Agency of Human Services. I can't speak legally, but what we investigated, a couple of options would be at the beginning of a biennium, the governor could do it, or it needs to be done by the legislature. It would require us to do more investigation to find out all of the options, but that's what we found the last time that we looked at. So, two things there, a couple of options to kind of do it. We want to do it soon. It likely would take legislation. Second, the how really matters so that we do it well and have to do it right this time.

[Rep. Theresa Wood, Chair, House Human Services Committee]: I'll get to you in just a second, Daisy. I think it's really important when you said the how and using our sort of past experiences. I, too, was around for the mental health change and the Dale change. I think that some would argue that the Dale change hasn't always and may not also be successful on the developmental services side when DMH and DDS were separated into two separate departments. And mostly around, they utilized the same provider system. And so that has made it cumbersome in terms of oversight and accountability for those agencies, as well as implementation of things that go across that service provider system. So, Representative Beckel. I just wanted to add that I did introduce a short form bill to integrate DSU with DMH. So if you should need any legislation, there is a placeholder for you.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: One of the things that we can talk about is, when we dug into the data, and we have departments come back and share it, as many as 80% of the individuals in both of these systems have co occurring. That's why this makes sense. They're being asked, some of the folks with the most complex lives are being asked to navigate two systems that are separate. We are one of five states that keeps them separate. So remember, did, we looked into what other states do. We are one of five states. So we are the minority of states that keeps these systems a separate system.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Representative Chino.

[Jennifer Carbee, Office of Legislative Counsel]: I heard you say you don't wanna get over your skis. I don't skied. I assume that means like, you don't wanna fall because we're asking you to jump ahead of yourself, but just to this topic of combining, acknowledging occurring something that I'm wondering if it would be useful for the legislature to consider moving forward is the way we silo things between the health and human services committee. Like, does it make sense for substance use disorder to continue to be in a separate committee from the rest of healthcare? Maybe this session we don't change it, but like in the future, should future legislators consider that at

[Ted Fisher, Principal Assistant and Communications Director, AHS]: the very least so that there's

[Rep. Brian Cina, Member, House Health Care Committee]: more coordinated policy from the legislative.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: I'll leave that to the legislature. But I will say that some of our biggest successes in our substance use are now in acknowledging substance use as a healthcare issue. I was around and helped kick off hub and spoke, and it's fundamentally changed the healthcare stuff. Can't you stop there, I want to be really clear. Fundamentally changed the way that we deliver services for individuals who are experiencing opioid use disorder. It acknowledged it's a chronic healthcare condition. It destigmatized it, made it so they could get care, female primary care practices in the healthcare system. It really acknowledged that substance use is not human failing, but instead is a health condition that we can serve and that we can treat ethically, and that we can treat with dignity and compassion. And so I think it's a good question. I'll leave it for you all to contemplate. It is challenging for us to sometimes navigate the fact that mental health and substance use who we see as health things are in two separate places, which does contribute to different payment systems, different evaluation approaches, different ways that we deliver services. So, it's a good question. I'll leave

[Rep. Brian Cina, Member, House Health Care Committee]: that to all of you at the time. Thank you.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Okay, thank

[Ted Fisher, Principal Assistant and Communications Director, AHS]: We can go in as much or as little as you'd like in the interest of time. I just want to orient folks using the slide slide in front of you. You also have the full list of tiers in front of you. And again,

[Jennifer Carbee, Office of Legislative Counsel]: also be found on our website as well.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: So the themes, there are 21 themes that we identified through the process of looking into basically our first phase, as Jack mentioned earlier, of the broad brush strokes of outreach and engagement. Those break down into six high level categories. Those are at the top of the slide with little arrows, strength and alignment, capacity, use research just widely, etcetera. And all of the 21 themes fit into one of those categories. To answer your question, representative, when we did the prioritization and did kind of like our second set of public outreach, we asked people to basically say, what are the most important? I think. We ask

[Jennifer Carbee, Office of Legislative Counsel]: for the top five or six to rank.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: We ask just to rank. Pick the most important ones to them. And we again can share that survey after the fact. And that generated the list below. So the prioritization on the second half of the slide there are the five priorities of those total 21 themes. They were the top 10. These five priorities were in the top 10 in both internal and external prioritization surveys. So we asked staff, we had a comment form for staff and then a prioritization survey for staff. We had an open comment form for the public and then a prioritization survey for the public. We wanted to see where there was difference between what A List staff on top of

[Jennifer Carbee, Office of Legislative Counsel]: the priorities and what the public about with the province.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: So I'm going to read them because I think they're important for us to just kind of be top of mind as we go forward. So the first one from our prioritization is to make sure groups we fund are effective, include staff and clients early in planning, make sure we work towards the same goals, make it easier to understand available services and better connect programs, services and technology. So some of these are things that, they're big things for us to work on. Some of them are things that we're already working on. Right around the time I joined the agency and we started this process. We made some changes to the way the leadership team of the agency functions and operates to be more collaborative. Samuelson mentioned the executive leadership team of the agency and kind of its formal process of making sure that all of the commissioners of the departments are together at the table when we make executive decisions on behalf of the agency in terms of direction and budget and things like that. And so really, those kinds of, that's just a good example of, among many others, of work that is already in progress. So thinking about next steps, and I've got thinking about a little bit of a next step slide. We have a lot of work to look at what we learned and map it against what we already have worked in terms of work in progress and figure out what are the things we're going to tackle first and what are we already put on and then figure out how we move forward in that. That's kind of the beginning of the process where we make sure we finished our project, got the legislative report done, and we now have a next phase

[Jennifer Carbee, Office of Legislative Counsel]: of Act 119 in terms of how we move this project forward.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: Can I further give you example? Because I think, Chair, for you, it goes to your question of, if we're going do this work, I didn't just want a report that we put on the show. Ted's example, I'm hoping that you'll see reflected in this legislative session. The executive leadership team, I've been on it at the agency previously, previously administrations, we've always met. But this year, we went through seeing these results and also knowing that it was a goal for better integration of our agency and collaboration. Created an executive leadership team, we created a charter, everybody does that. But we also said for the process this year when we were developing our budget, we went through a different process. Jennifer, we come in to talk about budget, we'll walk through that, but we'll get ahead of the budget, which will be released next week. But the way that we did it is we asked each of our leaders and said, You have two roles in our agency. You're an executive leadership team member who leads this agency, and you are a commissioner of your department. Those two things don't always go hand in hand, but you need to do that. So, we have one agency budget. Each department has money that funds their programs, but we have one agency budget. We're going to do a budget process this year that reflects that goal that we are one agency. And the first thing that we did was we went through all of Medicaid programs and we looked at which ones had evaluation data, how long have they been evaluated, what that data actually showed us, which programs were affected, which weren't. And we presented that back to the executive leadership team. We also set priorities and we said, what are our priorities as an agency? We know some of the housing, mental health, substance use, our healthcare, and making sure that we have a strong and healthy workforce within our agency. Then when we went to the budget process, instead of giving each department a target, the executive leadership team established the budget as an agency this year, now this department budgets. Fundamentally changed the way that our commissioners work at, look at programs. So, instead of being responsible, many of you have probably seen it before and telling it happened in the agency, when I've been in it, where one department said, I'm gonna shut off this program, but I know it's gonna impact the other part of the program, will leave it to the secretary's office to sort that out. We didn't do that this year. They made decisions as a commissioner's group about what things were affected, what things we wanted to invest in, what our priorities were. That is a fundamental change so that we can achieve some of the goals that are here on this budget. And I ask you to continuously ask us where we're doing that, but we are looking at every single one of our teams to make sure that they are working and that they understand that they are both department and that they are in leadership with our agency. It's changing the processes, I believe will change the way that those services are delivered on the ground. And so, it may sound ethereal, but it was very tangible the way that we did it this year and how it is impacting the way that our departments are thinking about themselves, not as individuals, but across each other. That's directly related to the work that we've done here. It's directly related to the feedback that we've heard from legislators and other people over the last five or ten years.

[Rep. Theresa Wood, Chair, House Human Services Committee]: I think having the yes. I think having the taking action that key individuals in leadership positions view themselves as part of each and every department and program and constituent group, and not just their own, I think is I think that's good progress.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: And they make decisions together, not decisions where each department presented a budget. They built that budget together. And I'm hopeful that as ask for concessions this year, like coming in to present our budgets to you, and we ask to do that as all of departments together, they will help us so that we can represent every single department, but it also represents that level of collaboration. You saw that last year when we did our substance use proposals. Those proposals last year, some of the work to get this done, but not for this session, but last session, even more for this session. They developed those proposals as a unit and housing proposals were developed that way rather than department like DCF being responsible for it. Every single one of those commissioners sat at the table or their staff sat at the table to develop those, the bullet, the budget and those programmatic proposals. It is a fundamental change

[Unidentified committee member(s) or presenter (diarization overlaps)]: in the way that we do our work. Representative Gearfeng, Madam Chair. Thank you for this information. This is really enlightening. Do you currently, are you building mechanisms to look across the agency to find out what is currently working well and then being able to duplicate that across the agency or departments, for example. I work in state government, full transparency, and there are certain divisions that do things really well. They do communication well, they do service coordination well. So are you building that out in the outset to kind of, rather than building it all new, hey, so and so has done this really well, can we just get that across the whole division, the agency, or at least the department? It's a work

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: in progress. But yes, that's what we do at Matrix Circumstance. I think Ted just said we were going give an example.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: I was just saying, we actually learned a lot of what is going well as part of this. So part of our process, next steps, is going to be like, hey, you should go look at the example of this department or this division or this program within one other, one of your colleague departments, because they have a good solution to this problem. We also have an ongoing process of continuous improvement and sharing of lessons. So want be transparent, that is a lot of the work that Jacqueline leads on behalf of the agency and every department has their own continuous improvement and performance improvement folks. And this will be useful. Lot of this will be useful to that, but there is, I think your question also gets us like, what will we need to do on top of it? And the answer is we don't quite know yet. We're still in the process of digging into the tier twos and tier threes and figuring it out. So there may be things, additional things that we do or undertake or a better response that's

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: But the process helped us identify those, those are the things that we see for our company's development.

[Unidentified committee member(s) or presenter (diarization overlaps)]: And if I could just follow-up, I think I love the tier twos and threes because those are things that internally the agency can continually work on, right? And I think for me personally, it would be really helpful if you all come back at some period of time and give maybe some timeframes around some of the tiers two and three. So there's some goals around, like, Okay, these are things we identified, are things that we can do internally without legislative approval, and it's within our purview to do them. How long will it take for us to do that? And then that way you'll have targets. I think it would really help with staff morale that we're working towards continuous improvement with real targets and benchmarks in place with an idea of what we're kind of moving towards.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: We'd be happy to come back and share progress updates with all of you. We also have to do some, we need to give some updates to our staff and also seek staff feedback on sort of where we landed and what we're thinking for next steps. So more to come.

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: We're almost out of time.

[Rep. Theresa Wood, Chair, House Human Services Committee]: Just was no,

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: no, that's all fine. Good, go ahead check-in.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: I just want to

[Rep. Theresa Wood, Chair, House Human Services Committee]: I'm just going to check-in with Chira if

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: she had any no questions.

[Ted Fisher, Principal Assistant and Communications Director, AHS]: I just want to say that the tier three, we've kind of, I think, already gone over that. But the tier three examples, some of the examples are on there. We have spreadsheets worth of them that we're going to be working on chunking out, and some are specific to departments. There's one that isn't on the slide that I just think is really awesome to change the call center to hold music. No, but seriously, we have people who are on

[Jennifer Carbee, Office of Legislative Counsel]: hold for hours,

[Ted Fisher, Principal Assistant and Communications Director, AHS]: hearing from more than one person. But this is an example of the level of granularity and specificity of things that can make a difference for people who may have to pick up a phone. Is

[Jenney Samuelson, Secretary, Vermont Agency of Human Services]: we talking about hours or the music?

[Ted Fisher, Principal Assistant and Communications Director, AHS]: One was specific to the music. Specific to the This

[Rep. Theresa Wood, Chair, House Human Services Committee]: thank you. We could go a lot of different places with that, Ted. So I think. So thank you. Thank all three of you and to those folks listening. Thank you out there to the over a thousand folks who participated in the process. And what you're hearing from the administration is that this is part of a continuous quality improvement process and the feedback loops need to be continual and often. And we look forward to seeing the sort of revised budget presentations that we'll start to see next week and look forward to the collaborative nature of your executive leadership team we take a look at those and dive deep into them. And as you know, we've you know, the chair of the House Appropriations Committee sent out some guidance back in October about how we are going to be changing our process a bit as well. And hopefully they don't collide, but they complement each other. So thank you all for being here. St. Beth, has anything else?