Vermont Legislature SmartTranscripts:

[Theresa Wood (Chair)]: Okay. Welcome back, folks. Let's just debrief a little bit about what we heard this morning. Dan, I'm gonna refer to you because you were the expert in this area. I

[Daniel Noyes (Clerk)]: don't know if I'm the expert, but I definitely am interested in some of our first parts of our discussion where we're talking about people moving from skilled nursing facilities to home and community based providers, whether it's res care or maybe back home. I would just be interested in, are there barriers for people and how do we make it easier for them to go from rehab in a nursing home to maybe being in the nursing home for a while, but is there a way that people can then go to res care, assuming it's available and meets their needs, or even go home with supports at home, because if we can move down the continuum of care in terms of cost and keeping with their So that was kind of early in our conversation and I'd be interested in hearing more about that, but then also workforce. I mean, I think a lot of the drivers are, as we can clearly see, workforce. And I just am wondering about some of the programs that we've been implementing around engaging people in nursing as a, and I've talked about this, we've been talking about this for years, like how do you get people into this line of work? And is there even enough to deal with like, what are the actual needs? We saw ratios and percentages, but it'd be interesting what the actual numbers are. And is there any way that these are obtainable and what's the plan to get there?

[Theresa Wood (Chair)]: Yeah, think the One of the things that was just kind of striking to me was, I appreciate that there's this kind of intensity of focus on assuring that our skilled nursing facilities remain intact and remain viable businesses. It's a support that we need for Vermonters. What I sort of continue to be concerned about is that we don't have that same sense of intensity around home and community based visits, around the lower level options. We have the same discussion when it comes to DCF. We were just talking about

[Daniel Noyes (Clerk)]: it just downstairs. High end systems of care.

[Theresa Wood (Chair)]: High end and I think we've proven over the last thirty years that the lower cost services of people generally wanna stay in their home communities and in their own homes as long as possible. And yet we don't have that same kind of attention. And I can tell you right now that they're in fact finding between the departmentagency of human services and the workers who do the direct care who are paid through ARRIS. And they're not even offering $20 an hour. And they don't get any health insurance And they make it as hard as possible. Me. They have paid time off. It's this combined time off. You can use it for sick time or vacation or whatever. And they make it so difficult for people to use that. So if a client dies, they lose whatever time has been accumulated for that person, if that person was their employer. And I'm just like, yeah, not right. And it sounds like they're making a few strides, but that sort of direct care. Know I've helped a friend do it for many years now. It can be backbreaking. It can be very intensive. You can be dealing with things that other people just really have no concept about, and they won't even pay $20 an hour for that direct care. That I just am- work for the list donors. Makes And when you

[Unidentified Committee Member]: no look at that and the amount of money that we've been investing in the extraordinary financial relief for nursing homes for the last several years, I mean, is just startling, right? Like that on the lower end, people are barely making $20 an hour.

[Theresa Wood (Chair)]: They're not, they're not even close to $20 an hour.

[Unidentified Committee Member]: And on the highest end, we're spending millions and millions on for profit companies that it's fixed growth. And another thing that was really interesting to me, and we had discussions about this earlier, is just the makeup of the workforce. How many of these professionals are living in Vermont just driving over the 50 miles. That to me is a huge kind of a red flag. 30 miles. Yeah, but it's

[Daniel Noyes (Clerk)]: so much more money.

[Unidentified Committee Member]: Three times Well,

[Theresa Wood (Chair)]: you have to be careful because the people doing the work don't get three times more. It costs the organization three times more and it's costing us taxpayers But three times it's the organization that employs those people that's getting the big I mean, they make more than they do.

[Unidentified Committee Member]: Yeah. And I'm not claiming the workforce. Mean, businesses go where the best financial decision for themselves, if they can make it happen. I mean, anybody would do that. But it's like we are giving the wrong incentives to the organization. We're incentivizing them to hire more

[Theresa Wood (Chair)]: That's the way it shakes out. Because then when it's rebased, it's based upon those expenses.

[Unidentified Committee Member]: Yeah, I

[Jubilee McGill (Member)]: do want to ask them, because I and I didn't think of this now is in that tab five, the nursing staff employee to contracted travel ratio, wondering if we could break that out even more so we can get a better picture of what type of worker is the actual shortage, because it looks like they have LTN, nurses, ADHD, and RNs. Because I think part of how we Okay, if we have a shortage of RNs or LPNs or LNAs, how can we target through, is it educational support so we can create more? I think having that kind of breakdown will help us be able to, If it's LNAs, that's a six week course. Could be paying that. Would be an easy thing. RNs, obviously LPNs is a little harder, but I think getting that kind of information, if there's those shortages will help us figure out, be able to find solutions.

[Theresa Wood (Chair)]: I know at Central Vermont Hospital, just because I go there, is that they actually have an in house curriculum for advancement into RN. It doesn't pay for. They're growing their own app right from within. So I'm like you know? And they they were talking about this at I it must have been a Washington County presentation of some sort. I don't remember. But I I like you know, that's, you know, that's cool. I mean, and, like, to what it's spent are, some of these larger nursing homes, are they investing in that kind of development that they could, like you said, grow their own RNs? Some cases, I think it's a high percentage of the nurses' aids, the LPN or the LNA that was being contracted out for at this point in time. Yeah, it would be helpful to sort of have that breakdown.

[Jubilee McGill (Member)]: And that's also the lowest paid. That is true. That's probably the easiest. I mean, like I said earlier, I worked as an LNA, I was a young single mom. That's how I went through college is I worked nights on the memory care ward at Hill and Porter. And my friend stayed with my child and it allowed me to work and do my homework in between calls and things. But it's a really hard job. You're doing those basic activities of daily And that's one where I think if we just pay them more, we could probably incentivize. A lot of people are looking for work that can pay well, that can support their families. So if that's truly in my head, was thinking this is a problem of meeting a lot

[Theresa Wood (Chair)]: of RNs. But We don't really know how to But

[Jubilee McGill (Member)]: that little piece of the puzzle, I think, is the easiest fix. Yeah, also understand

[Unidentified Committee Member]: getting assessment of best practices, like something you cited in Central Vermont, if that's something that can be modeled across the state, and Dale Doctor. Madiva can kind of present it to when there's an application for an EFR, if they're being proactive, to your point, before getting to that emergency Here are some things you should be trying that we know will work, that other organizations have had success with. We are going

[Theresa Wood (Chair)]: meet Helen Laban, who we've had here before. She was listening and she wants to come in and they actually have surveyed their members and she has some information and data she would like to present as well. So we're we're inviting her in to do that.

[Daniel Noyes (Clerk)]: You you almost think, like, for the amount of money we're spending to the EFR, is there a possibility of putting some money into how to get out in front of that. And would it reduce it enough? You know, what would be the measurement? How do we know that would be a good investment? Like, because maybe that's something we should be talking about. Like, whether they're at Dale or whether it's, outside with a private contractor that's trying to bring all of these together so that we don't end up with

[Theresa Wood (Chair)]: I hear you. I think because of the way the rate setting system is set up right now, sort of perverse incentive is already being realized in increased rates. So that's the real reason why the number of EFRs are coming down because the rates have now been adjusted to reflect all of those contracted And

[Unidentified Committee Member]: so they're getting higher rates now. Plus it's 3%, right? What's 3%?

[Daniel Noyes (Clerk)]: The annual. Annual statutory increase is three, three and

[Theresa Wood (Chair)]: a half. No, no, it's based on a formula. It's a formula. Yeah, it's based on a formula.

[Unidentified Committee Member]: So they're getting an annual They're an annual

[Theresa Wood (Chair)]: They're doing rebasing and having Yeah, an it's the only place in state government that that has happened. Last year was 3%.

[Daniel Noyes (Clerk)]: It was that looked like over 10 Have we increased those rates on top of, is this making it so that Yeah, how can they afford 30% more workforce at those levels?

[Theresa Wood (Chair)]: Yeah, well, we don't actually know the vacancy rates, the staff vacancy rates. We knew what proportion of the, are contracted versus employees. But that didn't show their It doesn't show capacity. Yeah. What's the are there what's the vacant positions? What are the capacity issues? And one of the other things that a gentleman by the name of Bart Hill used to produce at Dale, he's since retired, but we could see the vacancy rate month to month at every facility. Yeah.

[Unidentified Committee Member]: We should

[Theresa Wood (Chair)]: ask I need to report that. Yes, the website is not easy to navigate, even for people who understand it and understand all the terminology and I still can't find it. So, because we talk about there, I mean, what we hear is that there isn't a lot of vacancies, but then you see on the EFR in 2025, at least two or three of them was because of low occupancy that they got EFR. You don't get any money if you don't have any people there. And so I'm like, low occupancy. It's like it doesn't compute, right? So we're not going to take any particular action on this this year, but this is right. I think one thing Ray and I were researching during the break was what's the requirement about my distance for travel? What makes it a traveler? Well, industry sets it. And the common industry standard is 50 miles, but it's as high as 200 in some places. So there's no federal statute. There's no IRS thing. It literally is set by the industry. That's something we could have an impact on here, what would be considered a traveler. Now you can imagine that that would bring quite a few people out of the woodwork. But is it a problem that solves itself? Or is this something that we need to take proactive measures about? Because we saw this reaction after COVID. We're six years out. But right, we're six years out now. And we are so far an outlier on this. And I just don't see sufficient progress being made. When you look at some of those ratios of contracted to-

[Jubilee McGill (Member)]: Only three of them are at or below the national average. Right. Which is so interesting. I

[Unidentified Committee Member]: I appreciate the departments at first, you know, they are taking this seriously, and they have been working. The numbers are coming, you know, trending the right direction. But when you're thinking about, you know, Commissioner Bowen said, these are extraordinary. Extraordinary is not supposed to be nine out of what it's 33. Extraordinary should be one or two. You know what I mean? So when you think about it in that way, when you have such a high number that are, it's still a big problem. So I'd be curious to see what the next set of numbers shows as far as how many locations during the I'm sure VA next year in January.

[Theresa Wood (Chair)]: Well, actually show in the report, not the spreadsheet, but in the report, they give us FY26 data to Oh, And it's smaller. It's going to be smaller because their rates are So not being that's, like I said, that's the perverse incentive that we have. Well, it's not perverse. Guess what I'm saying is that I recognize that we have to pay the cost of care. There's so many elements that go into that. And there's so many outside influencing factors, like how much are people paying in real estate costs? What are their operating costs? The management fees, we saw that hospitals are the ones that are owned by hospitals, the management fees have, we don't know if they disallowed them or what, but that was one of the reasons for meeting both at Helen Porter and at Woodridge. So there's a lot to dig into, but honestly, we have more data now than we ever saw.

[Unidentified Committee Member]: Yeah. Is so important.

[Theresa Wood (Chair)]: Yeah. Okay. So have a good lunch, everybody. Thank you, We'll be back at 01:00 having some oh, no. Not here. We'll be on the Don't floor at forget we have an amendment on June that representative Arsenault will be offering and Jubilee will report our committee's discussion on that. And representative Steady is presenting a bill as well to 10. So