Vermont Legislature SmartTranscripts:

[Representative Theresa Wood (Chair)]: Okay, good afternoon, folks. We are back, Health and Human Services. Thursday, we are now going to switch back to our conversation, picking up conversation on the emergency extraordinary financial relief for nursing homes. We have Helen Laban here, the executive director of the Vermont Healthcare Association, and the floor is yours. You for

[Helen Laban (Executive Director, Vermont Health Care Association)]: being here. You. So I am going to share a presentation here.

[Representative Theresa Wood (Chair)]: Hi, committee members. This is on our webpage.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Do you want to follow along? So hopefully this is showing it correctly. I was seeing this live streamed. Right. Okay, here we go. So as noted, I am the executive director of the Vermont Healthcare Association. We represent nursing homes, assisted living residences and residential care homes. I believe the last time you heard from me was on that assisted living residential care portion for budget. And today, we will be focusing on nursing homes. So just to recenter ourselves in extraordinary financial relief, here's a regulatory reference that you can look at if you want to know the details of where it lives in reimbursement regulations. And I should say this has been in regulations for quite a while. It gained more use during COVID-nineteen and the pandemic as the vehicle for helping nursing facilities who had destabilizing effects at that time. This is the overall purpose of it is protecting Medicaid recipients from the closing of a nursing facility in which they reside. And it sets a process for doing that. I just wanted to note that this is not the only place where the reimbursement structure or the regulatory structure talks about closures. This is only in the instances when there are external factors that are temporary and it's Medicaid beds that the state wants to preserve as available. So it's not the same as, say, a rate for if you were closing. It's not the same as receivership if there was individual fault, and it is only for facilities providing Medicaid access. So I know you heard from- Already. Already. Only one slide in. One sentence here.

[Representative Braxton Paquette (Guest)]: That facility does not have to exclusively be providing Medicaid services to Medicaid recipients, right? Just it's part of their

[Helen Laban (Executive Director, Vermont Health Care Association)]: It has to

[Representative Braxton Paquette (Guest)]: part of their mix.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Right. So there's two components to it. One is that you are providing Medicaid as part of your mix. And the other is that the state has determined that those are necessary Medicaid beds. So that's the two part test to that. So this slide is largely to tell you that Jamie Mooney, who you had in yesterday, is the person to give you all the detailed information on these reports. May have undersold just how much work she does, so I will do it on her behalf now. So these are the elements broadly that her division of rates saying we'll be looking at when they look at these requests. So first they have the audited financial statements. They're submitted by all facilities every year. They do a desk review. That review includes for Medicaid eligibility. So the way cost based reimbursement here works is not like when I turn in my receipts at the end of a quarter to VHCA for reimbursement. You have allowed costs that you are allowed to put on your report. They do additional calculations. There's caps, there's guardrails, there's different cost centers. It's a very complicated process. And so they're going to be reviewing all of that information and making those determinations. And that takes about eighteen months. When a facility wants to apply for extraordinary financial relief, they have an application that has to address 13 different elements of eligibility. No, I have not memorized them, but they are in the regulatory reference that I put at the first slide. And then as they extended back and forth with the Division of Rate Setting, once they have that initial framework from all of these details, they'll go back and forth with the facilities, asking for additional documentation and conversations. And occasionally, they'll meet with the folks who are doing the finances there. So it's a very extensive process. Will be on my skill set, useful to me as the executive director of Vermont Care Association, because at the end of the day, what I then have through this very involved process is independently verified external financial stressors that are gonna be impacting Medicaid access. That's what this whole review process is trying to get to. And that is the information we glean at the end of it. And it will help highlight systemic issues that could be undermining sector stability, which is more my concern than individual rewards. I'm not gonna go through all the many things on this slide, but these are the, within the recent calls for EFR, these are systemic issues that are within the rate structure itself. So if you look at that first report that Jamie will have given you from, I believe it was December, and they talk about in their different strategies to address reliance on extraordinary financial relief. This list here is primarily what she's talking about in that report. I put it in slightly less technical language. And the reason for that is that these are the factors that are directly within their control as the folks who set the reimbursement structure. Do wanna highlight just a couple of the ones on here that speak to a larger point as regards who is receiving this relief. So this first one, when you look at the report that Diva has provided to you and also at current rate levels, it's gonna become quickly evident that the lion's share of large awards are going to hospital owned nursing homes, and they also have the highest per diem rates as their base rate as well. And I just wanna note here that this is not particular to Vermont hospitalists. It's not like UVM necessarily was doing anything wrong to have those higher costs and with them higher rates. This is true nationally. It simply costs more to run a nursing home as a hospital. Operational folks, let me tell you, are happy to speak for hours about why this is true. But for our purposes, what I'm looking for is, is this different in Vermont than what we might see elsewhere? It's not, it just costs more. And then the other element, and this is sort of a traditional use of extraordinary financial relief is for very small facilities. So you see on this list two examples of reasons why small facilities will be using this. One is an element in the rate setting that the way they calculate and distribute costs, if you have below about 40 beds, you're carrying a disproportionate share of indirect and administrative costs, and that creates a problem for them. It has corrected for this disconnect in the past. And then the other one is if there's any administrative payment delays, like something goes wrong in the bureaucracy of CMS and you're not gonna get your Medicare payments for six months, a larger facility or a multi site provider will have reserves to buffer until they true up, but a small facility may not. And so they'll get money through extraordinary financial relief as later recoup. But they're using that to manage those cash flow interruptions that they may have.

[Representative Daniel Noyes (Clerk)]: You said something about 40 beds. Is that national? Is there anything to that number? Is that like

[Helen Laban (Executive Director, Vermont Health Care Association)]: Because I believe that is what they put in the report. So that's best number that I was saying. They do look at national benchmarks and nationally they tend to use 80 as the cutoff for disproportionate impact of small facilities. In Vermont, we're on average smaller. I think that my guess is that Diva adjusted adjusted down for that. But you would have to ask Jamie about that.

[Representative Theresa Wood (Chair)]: Go ahead, Braxton.

[Representative Braxton Paquette (Guest)]: We were just talking about how the EFR process is fairly involved, 13 different elements, maybe additional information, and it could take months. If there is a cash shortfall due to waiting on CMS or otherwise, it doesn't seem like you have that amount of time to go through that process. There an expedited process when it's kind of just a float, if you will, until CMS catches up?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah, so you can do an expedited process. What they'll do is they will advance you, guesstimate how much you're gonna get. They'll advance you that if it was too much or too little, they'll true up later. But there's an expedited process if you're Because again, the requirement is that closure is imminent. So, if you had years to wait around, you wouldn't have closures imminent. So they have workarounds. That has created administrative problems right now in terms of just how much work it has created for the division of rate setting with so many applications. But there is a way to address that. I think those are the two key points. So the hospital and nursing homes and then the small facilities are called out in these. Why is this not fancy? Now I've gone too far. All right. So that prelude brings us to You already discussed this a lot yesterday. Workforce is what this brings us to. And we are seeing that the cost of workforce is a major driver in extraordinary financial relief. And in this context, we tend to be talking about nursing workforce. That's the largest of the staffing costs. So here we're talking about broad financial There are other major workforce shortages. Medical directors is one that the DHA is often talking about. But in this particular context, we're largely talking about others. And then to jog the memory of the legislature, you did provide funding, thank you very much, in 2025 and 2026 to understand Vermont's options for increasing workforce in nursing homes and also for pilot projects to recruit and retain workforce at individual facilities. So we've known that this is a problem and money has been put in to help solve it. I'm going to go through what we're seeing in terms of that workforce impact, but there are a lot of materials that we have posted on this that was funded by the legislature and the work that was done, and I've provided a website there for those who want lots of reports. So the first thing to know looking at this is just fundamentally math is not on our side in terms of workforce at nursing homes. So this graph is showing changes between 2010 and 2022 in different age ranges. We generally look at the 75 age group for demand for nursing homes. Age is the largest determining factor, and it tends to be over the age of 75. And when you look at the long term care versus short term rehab, in particularly the 80 age group. You can see that's gone up quite a bit. Similarly, the age group that would be most likely to enter nursing roles is declining. We've got an increased demand and decreased workforce. This is saying something similar through just a different graphic way of doing it. This is from the Joint Fiscal Office in their health care legislative briefing. So the first one was from the Department of Labor. This is from the Joint Fiscal Office. Similarly, the workforce that is available from other states is declining. So folks who might move here from other states to be that nurturing workforce is also less available. So these are national statistics looking at population projections, which again, we're using roughly to people demand for nursing services in this context. And these are the national increases that are being shown. So Vermont went up faster and sooner than other states, but the other states are also on that upward trajectory. Anne, can I ask you a question?

[Representative Theresa Wood (Chair)]: You have data on we learned yesterday that the distance for a traveling contracted worker is 50 miles, and that's set by the industry. And that's the industry standard, but it ranges from like 25 I think it went as far I don't know what the blow was, but it went as high as 200 miles from the location of the work. Do we have data on how far people are traveling to their work location?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yes and no. So we have data on permanent staff, not traveling staff. Vermont's numbers, let me caveat this all by saying, I don't know the source of the data that you're describing. And I can definitely, if you have the reference, look it up. In general, one thing that we note that's different between the agency staff in Vermont nursing homes versus, say, Massachusetts, who I often talk to about this, is that in Met, it is common in other states to be using agency staff to pick up shifts. So they may be working at another nursing home, but they're picking up extra shifts. They're coming in when there's a call out. It's a temporary number of hours.

[Representative Theresa Wood (Chair)]: So that's the contract.

[Helen Laban (Executive Director, Vermont Health Care Association)]: That's a contracted nurse. Whereas in Vermont, and we know this by looking at the payroll, they're coming in to cover true workforce gaps in terms of the underlying staffing. And so the anticipation would be they would be coming from further away to do that full time role, because if they were available locally to work full time, they could be working as permanent staff full time. So I can look to see if we have the specific data, but my guess is that that won't hold necessarily in Vermont just because of the different nature of the work. That's my guess based on what other statistics are showing.

[Representative Theresa Wood (Chair)]: The other question that came up yesterday is whether or not you have data on what level of nursing we have the biggest need for? So is it RN, is it LPN, is it Do you have that? I think you'd go ahead and do a presentation. I do have that.

[Helen Laban (Executive Director, Vermont Health Care Association)]: And maybe I'll say that I do reference it later. So if I don't say specifically later on, remind me, but it does come in later. Yeah. Sounds great. Thank you. And here's another national data. This is showing ratio of folks available to be caregivers to those most likely to need the care, both for ones who might be professional and those who might be family caregivers. Again, ratio is going down. I should also note, although I don't have the data in here showing this is also out there, no surprise, the availability of labor entering the job market from other countries is significantly reduced rate. And then another national statistic, which is mirrored in Vermont, is that nursing homes took longer to recover nationally following COVID in terms of workforce. And so this is comparing 2020 to 2025. Other sectors came back with more workforce than prior to the pandemic, not so nursing homes. And a side note that sort of ties into what we were just saying about the nature of whether you're using agency or contract staff to pick up occasional shifts, which is, by the way, a very good We want agency and contract staff available to do that. Versus if you're using them to to cover an absolute shortage where you don't have full time folks, is that the longer you had that prolonged situation, sort of the harder it is to get out of it driven partially by the non competition clauses in agency staffing contracts. So no surprise if an agency is sending nurses out to work a nursing home, there's often a clause in there that the nursing home can't then just pick them up at the end of their contract as permanent employees. So that creates a barrier to folks who may want to leave the agency staffing role and then join the nursing home. And if the question is, do you have a bill to address that? Yes, you're about to, but yes, sir.

[Representative Braxton Paquette (Guest)]: Is there a buyout option?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah.

[Representative Braxton Paquette (Guest)]: The nursing home can hire if they pay the service at $20,000 or something?

[Helen Laban (Executive Director, Vermont Health Care Association)]: I think $20,000 would occasionally be a bargain. Per day. And there is currently work being done to prohibit those clauses for well, it's across the healthcare sector. But in this case, the reason why the HCA really wants this is for this situation.

[Representative Braxton Paquette (Guest)]: With the bill we had on this issue larger than died with that bill of health care? Is there something you're talking about something more specific? We had a bill about noncomputes.

[Representative Theresa Wood (Chair)]: Yeah,

[Helen Laban (Executive Director, Vermont Health Care Association)]: so I'm not the person in charge of adding that language into another bill, but I believe it's being added into five eighty three in the Senate so that the health care sector language will continue. Thank you. So getting around to looking for solutions, knowing that we're in a bad situation, I'm gonna tell you, if you think there's gonna be a silver bullet in this next set of slides, there's not. But we do have a lot of information. Again, we had that funding to look at this. We hired the Bronx Business Roundtable Research and Education Foundation, as well as working with a couple of other consulting groups And helped by the fact that this is being studied nationally, because there's national concern about nursing shortages. So, I'm just gonna go over some of this. So we looked at what I call sort of the usual suspects reasons for why you might be experiencing this and how you might solve it, looking at how it's playing out in general across Vermont. So the first is the question of how our wages compare. I'm the representative for the nursing home sector. I am going to tell you that you should give us plenty of money to pay our staff more. So starting from a fundamental position that our caregivers should have additional wages. That being said, we are not out of the norm regionally. We're above the New England average and The US average. Oh, and I realized I forgot what I had promised about talking about the different licensure levels. Pause here. So we are looking at this at the LNAs. So we look at the LNAs, the LPNs, and the RNs. The LNAs are by far the largest number of hours spent in doing direct care work is LNAs. Also tend to be the beginning of that nursing pipeline. And they also are the level where it used to be unheard of to be using contract staff, agency staff at the LNA level. That was more of an RN thing. In Vermont, we saw that change and we were at 30% as measured in hours per resident day, LNAs being agency or contract. So this was really alarming because that's a big chunk of the workforce, just in sheer numbers. They're the ones who are most interacting with residents where you have the highest disruption from that turnover. And it also indicated that we had a problem in our pipeline for future nurses and RNs. LPNs, which are a smaller part, but a crucial part of that staffing, that they're at 40%. So things are not looking better as you go further down the licensure. Our RNs, however, certainly we want support for RNs, also a range of RNs, for example, the educators who train those LNAs and the LPNs. So it's not like that workforce is full of opportunities, but we're not as far off from the national averages for that one. We're more like 7% compared to a national average of 5% for agency staff for registered nurses. So it's really the LNAs and the LPNs that we are going to be focused on. And we're using the LNAs here as an indicator of workforce constraint.

[Unidentified Committee Member]: How do we compare with other states in regards to the license share for an LNA? Are our regulations to get licensed much stricter than other states? Or are they comparable across the line? Is an LNA that's operating in one state? Is that license automatically transferable

[Helen Laban (Executive Director, Vermont Health Care Association)]: in Vermont? Yeah. And there have been some bottlenecks in that, primarily around just the logistics of the training and testing that the state changed up their contract and resolved. The particular requirements are not significantly more onerous. There isn't a compact like there is for RN for various technical reasons, but you can transfer. There's a process where you can bring someone in from another state and bring their LNA license in. And additionally, are avenues, for example, if you're a current LPN or RN student, and you've had enough, experience there, you can test it as an LNA without doing the clinical and didactic portion of the training. So if you go to that website that I had linked, we actually have an overview of different pathways into LNA that we mapped out and looked for bottlenecks. Like I said, there was one, which was the problems with the entity that was doing the testing that have since been resolved. So we did resolve one of those. The board of nursing resolved it.

[Representative Daniel Noyes (Clerk)]: Kind of along the same lines, yesterday we had community nurses at the older Vermonters Caucus, and they were talking about many people left the workforce during COVID, especially in nursing fields across all ranges, I guess. And now for them to come back into the workforce, there's a licensure issue because What certain amount of do you think about that? I mean, is there anything that we could do?

[Helen Laban (Executive Director, Vermont Health Care Association)]: So there was, we heard about that with LNAs and there was a bill either last year or the year before that let you after, I think it was a You'll have to But I think it was like a five year break. You could still come back in.

[Representative Braxton Paquette (Guest)]: So

[Helen Laban (Executive Director, Vermont Health Care Association)]: again, we had heard a problem. Was addressed. What I'm hearing from our members is that when someone is retiring, it's because they were five years after when they originally wanted to retire, and they were sticking it out to solve. So I don't know if that's gonna be a big source in this particular sector at the higher licensure levels.

[Unidentified Committee Member]: Gotcha.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah. Thank you. Another element is where we segued into this sort of with that last conversation. So where you're getting that training and certification. It tends to be based on interviews and just logic that LNAs do like to get that training and certification from their employer. They can work while they are getting it. They can continue to earn. And then, of course, the nursing home's like that because you don't have your eye captured by being an emergency room nurse or whatever. You're going to be working in that long term care sector. So we knew that there was going be a shift towards employer based training opportunities and the data bore that out. There was a significant shift from the 1970s where apparently, I don't know what was going on in the 1970s. Apparently none of these systems existed in the 1970s and you were on your own, to the 2020s when it's primarily employer based. And when we say employer based, about two thirds of Vermont nursing homes have an in house LNA program. Some of that might be hybrid, like bringing in remote people for the classroom portion and then doing hands on, but about two thirds. And then others are going to be partnering with neighboring facilities, hospitals, or schools to support that training.

[Representative Theresa Wood (Chair)]: So is that happening? So the employer based training and helping with getting them on the pass for licensure for whatever level. Is that happening at all nursing homes right now? Or I know the two thirds, you said, have their own. Yeah. So they won't necessarily all

[Helen Laban (Executive Director, Vermont Health Care Association)]: be doing it for a variety of reasons. Some put pauses on their programs. There's a technical federal requirements for who's delivering the training. So there's some who are not offering it and they need to find a new option to do it. So like if you see the Rural Health Transformation Fund, LNA development, that's kind of targeting that situation. Some might choose not to have their own training. I don't know specifically what Woodbridge does, but if CVMC has an LNA training program, then it seems logical that Woodbridge is gonna be using CVMC. And some just have very good relationships with either sister facilities, if there are some with the same owner. Like the Northeast Kingdom has three with the same owner, so they may have one at one facility. So they they're all gonna have a strategy for this. They may they may not have chosen to have it be in in on their own particular facility. The shipping and route pieces.

[Representative Braxton Paquette (Guest)]: The you said for these in house programs to train LNAs, the staff, before they become an LNA, are I don't know what the rest of the staffing structure looks like. Are they aids? What what's that position called? Or how are they?

[Helen Laban (Executive Director, Vermont Health Care Association)]: There are many options. Can I interest you in a career in nursing care? Because there are endless options.

[Representative Braxton Paquette (Guest)]: Treat community and

[Helen Laban (Executive Director, Vermont Health Care Association)]: agency nurse. So there are a lot of different roles they can take. They can shadow current LNAs and provide assistance to them. They can work with activity staff. They can work with dining and assistance with dining. You do need to have a certain amount of training before you interact directly with residents. So it will depend on what the interest is or what they're worth. I have a friend who just finished LNA training. And while she was training, she was rebuilding the computer inventory system for the kitchen. So there's a range of different roles that folks may pursue. Also notable, and these slides don't get into this, but I feel I need to note this. We also find that folks who enter long term care through being an LNA don't necessarily go on to be an LPN or an RN. Some might become administrators, some might become activities programs, some might become a registered dietitian. So it's a very common entry point to a range of different careers in the nursing home sector, not necessarily continuing on that nursing track.

[Representative Braxton Paquette (Guest)]: Second thing to Representative Noyes' point earlier about whether some people can come back into the field if they've stepped away from COVID or otherwise. In another lifetime, I practiced law and I did a fair bit of workers' compensation of the profession we're talking about here in the nursing home setting. LNAs, it was higher than others. I had a number of LNA clients because it is physically demanding work. Is there sort of expected aging out, if you will, of actively being an LNA, LPN, RN, and how do those differ?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yes. Again, in other aspects of this study that we did not include in this particular slide show, we heard a fair amount of that from current LNAs who were older, that the physical demands, I mean, a very physical job. The physical demands were more than they wanted. So we actually saw a drop off in satisfaction in those older age categories for that particular reason. Now, at that same time, you're gonna have a lot of experience. So under our programs, some of the providers use their LNA grant money to help have leadership development programming, mentor programming, onboarding programming, additional payments for senior LNAs fulfilling those roles to help there be within that LNA function for those with more experience, a job that valued that experience and helped bring in a new generation of LNAs.

[Representative Braxton Paquette (Guest)]: I just think this further challenges the graphs you were showing us earlier about the aging population and the declining workforce age, that these are folks who are not working later. This is further challenging that.

[Helen Laban (Executive Director, Vermont Health Care Association)]: It is, we had a national presentation about this at our annual meeting where they said, well, the cutoff for really being young enough to be an LNA is 45. Of course, I'm not young enough to be in LNA anymore. Okay. There we go. So certainly people do do it past that age, but that's when they really begin to see folks leaving the more physical aspects of the role.

[Representative Theresa Wood (Chair)]: Another question, are you aware of any impact by health care workers, especially nurses, being recruited by other neighboring countries? Because we had a member here that was recruited, and I've heard of other people that were getting heavily recruited by the Canadian provinces, and being offered for their And I don't think we have anything similar We have, I think, physicians and higher level of health care fields, but not the preferred. So

[Helen Laban (Executive Director, Vermont Health Care Association)]: not so much in Vermont for nursing home direct care workers. That being said, if I were another country looking to recruit, I wouldn't choose the state with the deepest workforce shortage and the highest wages for the region. So that doesn't mean that it isn't happening, but Vermont's probably not the ideal place to be recruiting out of. Go ahead.

[Unidentified Committee Member]: I was wondering on this chart here, the notion of financial aid, it's pretty extensive and it's the thing that's shrinking on this. Can you speak to that? Is it a lack of availability or programs changed? People just not looking for financial aid and doesn't support it?

[Helen Laban (Executive Director, Vermont Health Care Association)]: No, I think it's because you see that employer section growing in the employer pays for it. So it's simply not needed in that.

[Unidentified Committee Member]: So who provides the financial aid in some of these prior times?

[Helen Laban (Executive Director, Vermont Health Care Association)]: That's a good question. I would have to look at the notes on the report. I find he was providing that.

[Unidentified Committee Member]: So

[Helen Laban (Executive Director, Vermont Health Care Association)]: this is sort of a complicated one. It's gonna highlight some of the tensions here. And you saw this in states that weren't Vermont as an area of concern, but one of the problems is going to be if you have a staffing shortage, especially a national shortage like we saw during the pandemic, but your demand hasn't gone down, it's only gone up. If you're trying to do more with less staff, then that's gonna be a problem for care quality, which is where we usually talk about this, but in terms of this context, also for working environment. And so you would expect to see high attrition when you're in that situation. We can track how that works through nursing homes, their daily payroll to CMS, and that's in a public database. And so we can track not only what's happening in Vermont, but how that compares to other states. There's also a standardized form for measuring the acuity of the residents within your facility. So you can also track, is this a population that probably needs more or less on average staffing than another? So looking at that data, Vermont, we do have minimum staffing requirements and state regulations, which not every state does. We are not staffing to the minimum. We have robust staffing that's beyond that minimum requirement, which we would expect. I mean, the minimum is the minimum, and you would only really be doing that if you had low acuity residents. So we are about an hour above. And that's our HPRD and ACNUM snuck in there, that's hours per resident day. And Helen, how does that compare with other states? So that is, depending on what status is, zero point seven five to forty five minutes more than the national average. And then about an hour more than stays with that lower tier staffing ratios. And with the case mix being about the same, which makes sense, it's full population based. We also saw that throughout workforce disruptions, maintained that staffing. And then we also, the state does very extensive census reports. You can see if a facility What you want to see when a facility is struggling with staffing for whatever reason is if they put up pause on admissions or a pause on complex care admissions while they stabilize the staffing. And so we do also see that roughly when we look at facility census reports. Which is all good. That's what we want to see. I mean, we don't want there to be a workforce shortage, but if you're going to have that, that's what you want to see. At the same time, so the line is the national census. It shows sort of what the trends were prior to, during, and then following COVID. The recovery that we had nationally, Vermont more than recovered. So now we're around at the last estimate, 87% census. And so we are walking that line between we're using agency staffing to retain access, and we've done that. It was expensive, but we kept that access. We're also about to hit another problem, which is that 90% is generally considered being at capacity for your nursing home beds. So just to have in the back of your minds, we've got a third problem that's about to enter, which is that, as you saw in those demographics, with the increasing demand, we're also getting our ceiling for capacity.

[Representative Braxton Paquette (Guest)]: So if I can just reinforce, we've had conversations in here with various witnesses and expressing some concern about where Vermont is with respect to our census, this would indicate we're actually doing well. I mean, we're starting to hit up against the problem you just identified, but we're not leaving beds vacant at a higher rate than the national average.

[Helen Laban (Executive Director, Vermont Health Care Association)]: No, not gratuitously at least. I mean, the beds that are vacant are vacant for a reason. And then, there's also the softer science of why people like to be in nursing homes. And so generally, what we hear that folks wanna be nurses in nursing homes is the daily direct interaction with the residents and building relationships with them, which distinguishes this kind of work from other nursing in other settings. We also hear that folks like the flexibility and the pace of the residential setting. And then also, we talked about this before, the opportunities for career growth. It's really being an L and A in a nursing home, if you wanna get into any aspect of healthcare, is a great entry point. And so we know that that's broadly true. We wanted to see if we are hearing the same thing from Vermont LNAs and lo and behold, we are. So we are not missing those elements. Similarly, the top challenges that were expressed were largely stemming from workforce shortages. Turnover in staffing, covering when someone has a call out. Like I said, we don't necessarily have the same flex that other states might. The workload pressure, frustrations with coworker reliability. I did not We really need agency staffing contracted staff. They play a very important role in general, not just in a time of workforce shortage. So I don't want to just paint a broad brush saying negative things about that. I will say that when you read the interviews that go behind the statistics, that primarily people are complaining about the impact of having to rely on agency and contract staffing. And so we hear their frustrations. I think everyone shares their frustrations. At the same time, we honor the work of the individuals who are here as agency nurses that are really what is keeping our nursing homes functioning right now. I think you pointed out that

[Representative Theresa Wood (Chair)]: the role of the agency and contracted staff, it was designed to fill a different gap that we're using it for in Vermont. So it makes sense why there is, I I talked about morale issues yesterday. I can imagine it is not a great feeling to have contract employees coming in and then, you know, and it's great that we have that resource, or else our nursing homes would be closing, but it's still, they're filling a gap that they were not designed to fill.

[Helen Laban (Executive Director, Vermont Health Care Association)]: No, and I think that frustration is felt all around on that. So you all may have noticed that there was no universal answer in that overview of problems we looked at. In the absence of one answer, we have funded a lot of different projects through the funding that was set aside. And I'm sure there are other projects from other funding sources. These are just the ones from that original allocation. We asked nursing homes to identify what projects they wanted to do. They have funding to do it. Here's a list. Again, there's a link if you wanna see materials built from that, looking at all sorts of different aspects of what they might do. And so we have these pilots available or in process right now.

[Unidentified Committee Member]: Just so I understand, on the list here, if there's nothing under subcategory, does that mean that it's not an issue?

[Helen Laban (Executive Director, Vermont Health Care Association)]: No, no, These are just all different projects. Working out. So it just wasn't working out. Yeah. Leadership training was just leadership training. Yep. Yep. These are all just different projects. I should say How are you spending the works? Do have any kind of data on what's working? Yeah, we do. I can send you the report that we sent to Dale. So the reports that we first did for Dale was done after the first cohort had just finished. Right? So there was a limit to how much we can glean, but we still can glean a fair amount. So I'm happy to send that report to Yeah. A lot of effort has been made. In terms of sustaining improvements moving forward, so a positive force to sustain these improvements, The Rural Health Transformation Fund, as referenced, does have LNAIN Workforce Development Track. And then Vermont is also going to be participating in the CMS nursing home staffing campaign, and that has more of an LPN and RN focus. Obviously, we're very interested in the LPN aspect of it, as well as general training and development opportunities. And these are two new programs available to us that were not there when the state funding became available. So we feel that having had those two years of work ahead of these, we're very well positioned to take advantage of new federal opportunities. A negative is rate volatility, and that remains one of the primary destabilizing factors. Getting back to that list at the very beginning of things within the rate setting structure that caused financial distress from VHDA's perspective, the volatility in the rates from one quarter to another. It makes it extraordinarily difficult for facilities to plan to stabilize their finances, to invest in things like growing their workforce. And so again, we don't need to go into the details here. I have some of them on this slide. What we're seeing in terms of volatility and the impacts on daily operations is quite high. So that is something that we hope to continue to discuss with rate setting and look for solutions on that one. And that, I believe, is it. There you go. That is the extraordinary financial relief needs and efforts by Vermont Nursing Homes.

[Representative Theresa Wood (Chair)]: Thank you, Helen. Thank you. Folks, have any other questions?

[Representative Braxton Paquette (Guest)]: I'm going put in a plug for our colleague Dan, who is a champion of older Vermonters and does a lot of work and with some help this year from his intern, Ren, with the older Vermonters caucus. He gets lots of great information and witnesses, including Ellen who has come and shared information. So thank you to you both for that.

[Representative Daniel Noyes (Clerk)]: I think it's something that we're gonna be continuing to talk about in this committee and in this building, whether it's financial aid for nursing homes, write down just access to care and workforce and housing and everything else that goes along with successful aging.

[Representative Braxton Paquette (Guest)]: That's part of not being 45 anymore. My

[Helen Laban (Executive Director, Vermont Health Care Association)]: back really hurts, to be honest.

[Representative Theresa Wood (Chair)]: Well, thank you. Thank you so much for this opportunity.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Great, let me close out of here.

[Representative Theresa Wood (Chair)]: Oh, we were just laughing because we were like, yeah, you're not 45? No. I'm

[Helen Laban (Executive Director, Vermont Health Care Association)]: not. Kidding. Seriously.