Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons (Chair)]: We are now live. This is Senate Health and Welfare. It is still January 14, and we're looking at the World Health Transformation Grant update from AHS and I'll let you both introduce yourselves for the record and then we'll go ahead. I will say that there were having questions about the grant so it'll be important for us to hear what you have to say. Great, great. Go right ahead. All right.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Thanks very much. I'm Jill Meza Olson. I am the Medicaid and Health Systems Director

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: for the Agency of Human Services. And I'm Sarah Rosenblum. I'm the Interim Director of Healthcare Reform for the Agency of Human Services.

[Senator Virginia "Ginny" Lyons (Chair)]: I'm gonna go ahead and share my screen. Shine to the beginning. Okay.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Super. Thanks very much. Thank you for having us today. So, as we talked about a little bit in the first hour of testimony, right now we're here to talk about the Rural Health Transformation Grant. So this is the federal grant that people have been hearing about that was passed as part of HR1 or Reconciliation Bill or One Big Beautiful Bill Act. All of those were the same words for the same thing passed back in July.

[Senator Virginia "Ginny" Lyons (Chair)]: That's my strategy for defense. There

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: we go. Okay. The big picture, the Rural Health Transformation Grant is a $50,000,000,000 initiative from CMS, the Centers for Medicare and Medicaid Services, to help states modernize their rural healthcare systems. So, it has particular goals around access, quality, sustainability. I would say our focus is really on how we can have this grant help us make our state system more affordable, but also help us with our access, particularly in rural areas. There are a series of goals associated with the grant, and then there was a funding design. Senator, And you were asking about this earlier. We had the Notice of Funding Opportunity was released on September 15. So that is essentially the grant application. That's the Fed saying to us, this is what the criteria are for scoring and this is what

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: we're looking for in the grant.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I started part time with the agency just about then because of this timing. So I could be on the Ground Floor of and we submitted the application on November 5. This was a very fast turnaround. I so I'm, as most of you know, new to working in state government and doing this kind of work. For the people I've talked to who are highly experienced, to do something this big that fast was unprecedented. No one as we know, we know, we live in these unprecedented times. It's always unprecedented nowadays. So that was one of those things that, you know, nobody had ever seen before, that a process that fast. So, it definitely a challenge for the agency to be responsive, we Yes, pulled it we pulled it off. We received an award notification on the twenty ninth, And so I think people have read in

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: the news that we were awarded actually, on the next slide. We were awarded $195,000,000.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: So this was the first every state assumed a $100,000,000 award. The the plan was that first half of this $50,000,000,000 would go, to all the states. Everyone would get a 100,000,000. What was really more a question was what would happen between a 100,000,000 and 200,000,000. So the grant the notice of funding opportunity said everyone should apply for 200,000,000. That we should build our budgets around that. And there were,

[Senator John Morley III (Member)]: actually keep going,

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: there were, let's see here, there were essentially the scoring was based on three things. There were metrics of how rural the state was that we don't control. Those were defined in the application, including how many FQHCs do you have, how many rural hospitals do you have, how large is your state in square miles. So a whole series of factors. There were also various policy preferences, I would say, that the application favored, many of which were not in place in Vermont. So we had those were two things that were essentially immutable at the time of application. Certain policies and then certain metrics of how rural we were. And then the third element for that second $100,000,000 was the strength of the application itself. So Vermont received an award of a $195,000,000 per year. So it was Per year. For 2000 by six. Because

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Yeah. That's a fantastic.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yes. Yes. And but it is a it is a five year grant opportunity, but there will be changes over time. So that was a lot we were very excited by by that figure, and I think that given the how we knew we were going to score on some of those other metrics, we were we feel like it was the strength of the application that resulted in the award that we got. So we're in sort of the middle third of states for total award. We are the second highest award in New England, very high per capita. We did well, and I think we've

[Senator Virginia "Ginny" Lyons (Chair)]: been really good about it. We have questions and

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Okay, all right. I

[Senator Virginia "Ginny" Lyons (Chair)]: really want us to move through this, but We will. It's only about seven slides. Just have both senators here on this side to answer. We have three questions. So we're going from Senator Benson to Senator Gillick to Senator Morley.

[Senator John Benson (Member)]: My question is, when you said this is five years, do we have to reapply each year? Or how does that work?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: It's it's not exactly a reapplication, but there is going to be sort of a redetermination of our budget based on our performance. Exactly.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: So every year, every state will have to submit, okay. Last year, you awarded us a $195,000,000. This is how much of that we've spent. This is how well we've performed on all of these metrics that we've already included and committed to in our application. And then the federal government is gonna recalculate everybody's awards every year. So there's no guarantee for the following four years of the program that we get $195,000,000. Could get more or could get less than that depending on how well we perform and how well we spend the money we've already been awarded.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yes. Senator Benson asked a question that I was going to ask, so thank you. So it sounds like we can't really count on much beyond this year. We had one great day when we got the award and now we're back to work. Pretty much. We tried to enjoy it, and then, yes, back to work. Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: Sure. Senator Morley, the introduction. So

[Senator John Morley III (Member)]: are all hospitals in your mind going to receive some of these dollars?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Let me talk about how the grant works. It's a little bit hard to answer that question in that way. So let me talk about how the grant works and some of the metric, the methodologies, and then

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: I think we'll get to that.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: It's not meant to be, it's not like all types of organizations get our guaranteed dollars. We have to we have to apply for projects that we're going to achieve and then put out grants and then

[Senator John Morley III (Member)]: Who's gonna determine who gets the great dollars?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: AHS. Let me go through the slides. Yeah, let them

[Senator Virginia "Ginny" Lyons (Chair)]: go through the grant and then we can ask all these little nitty gritties.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. I

[Unidentified participant(s) (multiple speakers under this ID)]: got a basic

[Senator Virginia "Ginny" Lyons (Chair)]: question. I'm sorry,

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: was there one more? No, we got to

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: go over questions. We're good. Okay.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: So, first of all, the notice of funding opportunity outlined the areas of focus for the application. So it said the kinds of things that CMS was looking for in our grant. We happen to think of it as one time funding. As Sarah said, we don't even know how much we'll get every year. And so it's not something where we want to add to the base. And so it's best used for launching new initiatives, transitioning to new models, buying things, promoting collaboration. So it's not for paying for billable services. We can't use it for that. We can't use it to pay for clinician salaries in general. We can't use it to supplant the state budget. So if there's something the state is already paying for, we can't use it for that. So there's a lot of things that are on the list of things that we actually can't use these dollars for, which is why it's, I think, for providers is likely to feel more indirect than direct, given the kinds of things we can't add into rates. We can't do the kinds of things that you might do if you were just thinking about bringing support directly to providers. It's not allowed by the federal government to release the dollars to us. Unobligated and unexpended funds will be redistributed above states, but we have until 09/30/2027 to spend the first year. So the first year is 2026 ending in October, and we have a report due this August. But we do have another year to spend dollars. And we just got a welcome packet from CMS. That was a little confusing to us,

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: but it we did get just get some materials from CMS that clarified that

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: with a nice little table we could read.

[Senator Virginia "Ginny" Lyons (Chair)]: Do you have those posted somewhere?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I don't think we've posted, I'm not sure if all of them have it as particularly useful as a general document, but I think the timelines are something we

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: can add to our website. Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: I yeah.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I don't think we have a timeline on our website yet. We've talked about it.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Right. Okay.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. Okay.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Think

[Senator Virginia "Ginny" Lyons (Chair)]: Wait, lot of people sorry. Sorry, Jay.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I just want to make sure I get that bottom. So sorry. All the funds need to be expended and or obligated by September, not this September the following. So we have a little extra time. So we have about twenty months instead of about eight months, but it's still a very fast turnaround. There are states that aren't prepared. I just can't anyway, because that's

[Senator Virginia "Ginny" Lyons (Chair)]: the state of mind. Yeah.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Okay, I think this is a question many people in the room are hoping we will answer. So in the notice of funding opportunity, we did count all of our FQHCs, all of our, they call them community mental health centers, we would call them designated agencies, as part of the rural metrics scoring no matter where they were. So whether they were in Chittenden County or not, didn't That was how the application was built. So you would count, and that was how the statute worked. You count all of the FQHUs regardless of location, so

[Senator Virginia "Ginny" Lyons (Chair)]: you need to be enrolled.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Our understanding is that all providers are eligible for these funds no matter where they're located. But what we're still working on with CMS is the methodology, the process, and specific criteria for the funding. None of these dollars have been released to us yet. We have quite a bit more work to do, I think, to explain to CMS exactly how we're gonna spend these dollars underneath the larger, the broad project plans that we've outlined. And I think this is where the question is going to come in, in terms of CMS has indicated that it needs to be spent to effectuate care in rural communities. CMS has not fully defined what they mean by that, but they have used the HRSA definition so far to reference rural and that leaves out Chittenden County. So that's essentially as much as we know today about how this will all work.

[Senator Virginia "Ginny" Lyons (Chair)]: Talk about a paradox. Yeah.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: But what we know we have to do is follow their rules. There's no question we have We to follow their have more work to do to understand exactly what that means and what it means by project, because we have different projects that do different things. So,

[Senator Virginia "Ginny" Lyons (Chair)]: a question for you that, obviously, I mean, question is in the room, And I'm of our friends are here, very concerned about what we're talking about. And New Hampshire, whole state, everybody, every large city and concentrated population area is included. Yeah. If you read what Hampshire is

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: saying, they're they are still saying they have to follow the rules that CMS lays out for methodology process and criteria. They will be the same rules will apply to them as applied to us. I think they have made clear that I think they they've sort of emphasized that there's no provider who isn't eligible to apply, but there's a lot of criteria that isn't yet sorted out. And I think when you read their materials, they acknowledge that as well. We're all waiting for conditional criteria from CMS on exactly how we can spend these dollars.

[Senator Virginia "Ginny" Lyons (Chair)]: I guess the other question that, you know, we're gonna hear from you folks in a little bit about How closely are you working with our FQHCs and our PAs and our others in Chittenden County. I'm just swearing off Chittenden County because that's where I'm hearing the questions and I represent Chittenden County and I'm concerned about it. And I'm concerned about it for a lot of different reasons, not simply because it's my district, but also because it's fundamental to care in the state and we'll hear that. Are you working closely with folks?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I would say we are not yet working closely with providers anywhere. And we are really in the in the process of figuring out how to set up the apparatus to to make this grant happen. We're in apparatus space, so we are building the team. Yeah. We are we haven't even yet had a meeting with CMS about how they expect this is going to work. We have a budget due, a revised budget due on January 30, and they may ask us a whole series of questions between then and the following month. We have submitted project plans that have broad budget goals but don't have all of the elements underneath developed that we're going to need in order for them to release the dollar. So there's a lot of work for us to do to have the kinds of specifics that I think everybody is looking for us to have. I there's a fear that people are gonna be left behind, and I can say we're not we're we're not leaving anyone behind. We are we are working now internally to be ready to have to to provide the information that everybody needs in the form of requests for proposals that we can submit. So what we're doing now is really a lot of what we're focused on is communication. So we're building a listserv essentially that people can subscribe to. So anybody who's interested in hearing from us when something important happens, like we announce a a funding opportunity, that they can sign up to get an email that says, hey. Funding opportunity. So they don't have to just track our website and hope that they don't miss it. Right? I think people are just afraid of missing important opportunities. So we have had an inbox where people can submit ideas and information to us. It's been our general health care reform inbox. We're working on creating something that's dedicated to rural health transformation. We're gonna build a team that is focused entirely on rural health transformation. Right now, it's been essentially me, Sarah, Will Dempsey, if you, you know, just a big team. The agency, small team. We just had to make it happen. We made it happen. But we need in order to really do the mechanics of writing grants and getting dollars out the door, we're gonna need people who are doing essentially nothing else. So that's the stage that we're in now.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Got it.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: As are all states. I mean, we have we are working closely. We're not gonna get out of step with other states. We have a little New England consortium that we've developed, so we're talking regularly, meeting regularly with our partners across New England, asking ourselves all the same questions. And then there are also we have national associations that we belong to that are creating essentially national national groups so that we can all learn from each other. And I would say where we are is we're Yeah.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Think like everybody else. Every state is grappling with the realities of, to your point, trying to release this amount of money on this time frame while following state procurement laws and meeting the Fed's expectations and guidelines.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: But just to be clear, Chittenden County will be included in this? There was a lot there were a lot of words. The providers are absolutely eligible to apply for for awards. The guidance we have so far from CMS is that the dollars need to be used for rural communities. Based on HRSA and And they have they haven't said quite that, but the the definition they've been using so far Okay. For scoring has been the HRSA. So that's as much as we know.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. So the information for scoring will be important for folks who are applying to

[Unidentified participant(s) (multiple speakers under this ID)]: have that scan. Yes.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: We will have to provide greater guidance when we have it for what we are looking for in those grants, which will reflect what CMS is saying they expect us to do. Right. At least

[Senator Virginia "Ginny" Lyons (Chair)]: gonna help other places too.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. All this work, I mean, everybody will be doing these questions are getting asked everywhere.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. Yeah. I'm glad it's you and not me.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. Okay. Keep going. Okay. So there's maybe 40 projects in this. I am not a subject matter expert, I would say, on any of them. But I do probably have, at this point, the list in my head more than anybody else. So there's that. For the list people, there's always list people. I'm the list person. On our website, we do have a version of our projects that is literally by project. So you can sort of see the name of the project and a short definition or description of what the project is. We also have the entire application narrative. It's there. People some people were really interested in reading all 70 pages. So I'm not going to attempt to go through every single project in great detail here. I've testified a number of times on this. It is just very hard to do. But there are, I think, some interesting examples that help people think about what we might do with these dollars. And again, limited by essentially one time funding, and there are things that we can't pay for that we care about, but can't use the dollars for. So

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: some

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: examples, let's see, new mobile health and dental units. So if we had organizations that were willing to staff and develop mobile health care, we could probably help them actually purchase the units and help get on your way. Capital expenditure. That's a capital expenditure. But what we can't do is we can't actually work too much on buildings. So we can't do a lot of facility upgrades. There is language in the grant about that, but as we've gotten more clarification, it's more like we can buy partitions, but we can't make buildings of higher value than they were when we started, so we can't do major renovations. So that became clear in the back and forth we've

[Senator Virginia "Ginny" Lyons (Chair)]: had. In one of the oldest building states.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: We well, and you may some of you may remember when I've I've testified about this over the summer with HRocque about what we were trying to do when we oh, you know what? Housing is still on the slide. At least it could come up. We gotta fix that. I know. Housing shouldn't be on that slide anymore. For that reason. For this reason. We had a housing

[Senator Virginia "Ginny" Lyons (Chair)]: You can't have workforce housing unless you're renovating a space.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: You can't have workforce housing, period. Period. Yeah. Unless you're just unless it just needs partitions and vent covers. Yeah. Got it. So we had a very creative idea to to essentially build on other housing programs in Vermont that would have created housing for healthcare workforce. And CMS in their question and answers, that's before we got the award said that's an unallowable expense. Can't do ourselves. We can't do capital expenditures of that nature. So they clarified in that process. What we were hoping was that they wouldn't apply the rules for capital improvements to health care facilities, that they wouldn't apply those rules to our

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: housing proposal, but they did. So that one we got to take that off that slide. Apologize. Yeah,

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: it's too bad. Apparently, it's not unusual. CMS is sort of historically not very in favor of ample improvements. Recovery housing, though, was something that is on the operational side we may be able to support so we can add to our recovery housing, adding to our mental health and substance abuse urgent care network. So again, starting up these programs. We can't pay for them over the long haul. We can't save for the billable services over the long haul, but often starting up a a new enterprise like that comes with start up costs that we we hope to be able to support. There are various technology proposals, AI transcription. There are some hospitals that are interested in a shared electronic health record. We're looking at that. Remote patient monitoring is a really great tool in rural communities where it's essentially monitoring of critical indicators of your status of your chronic disease that your provider, either home health agency or primary care, can see and understand how you're doing and maybe intervene before things go south. Lots of funding for workforce. So clinical training programs at clinical sites across the continuum. We tried not to leave anybody out and we tried to have end the rest language just in case we did leave somebody out by accident. So we did, I thought, a pretty good job of trying to be broad explicitly broad, but also leave room to have forgotten something we should have remembered. One thing I've said about given how fast we had to move, we are gonna be unpacking things we wish we had done differently. I have no doubt as we we do this, it could be

[Senator Virginia "Ginny" Lyons (Chair)]: had to move

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: fast. And then there's also various financial incentives for education. And again, this is across the continuum. It's not just nurses. It's not just hospitals. It's across the continuum. I think the workforce dollars are gonna be the ones that we're probably able to make to to sort of make happen and spend most quickly, just because there's a lot of mechanisms in place to do that and and initiatives that we can build on that exist today. I actually just wanna back up. I didn't say something that I usually say when I talk about rural health transformation, which is that and I did say it in our my you said in my earlier testimony, Rumman is a state that really works hard on health care. We are always trying and experimenting, and we always have a lot of ideas. Our secretary is someone who really, you know, has she spent a lot of her career at the agency. So her knowledge base about the kinds of programs that we've implemented and that have worked is astonishing, think is a fair word for how much she knows. And so we were able to build the application based on a lot of work that we that's either already being piloted someplace else or something that we wanna scale up, the blueprint for health, and trying to modernize the blueprint and expand the work that the Blueprint is doing. There's all kinds of things that we can build on instead of having to start from square one. And so that was our goal. Still a lot of work left to do to work out. There's many, many details details in front of us. I think I did talk about EMS. Our health department is going be leading the charge on this, but there's lots of interesting innovative ways to do what's called mobile integrated health. There's some other changes also that can happen in the EMS system. I am not an expert, but think about this. This is how I always talk about it. EMS is a clinical workforce that isn't always busy. They're not always taking care of the next patient. Sometimes they're so busy. And we saw the incredible role they played during the pandemic, right? Their ability to do some really important pieces of our testing and our, it was incredible, vaccinations, just amazing work. And so the idea is, and it's being piloted in the Brownboro area, but to help with some of the lab work that might need to happen pre surgery, some of the work that might need to happen, you know, clinical check ins post. We have home health. Used to work for home health not two months, three months ago, worked for home health. They have an important, you know, defined Medicare role in how work that in the home. There's lots of individuals who are not eligible for home health benefits who would benefit from care in the home, especially in rural areas. Going to the doctor is really hard for a lot of people. I always say this, if you are talking about, say, elderly relatives or disabled relatives, it's a family project. Right? It's it's a family project. And so to the extent that we can use either technology or in this case, actually a workforce to deliver care where people are from an access perspective, that is really, really, really impactful for those people. Totally. I can't believe I said that word, my husband, the writer. Impactful. Oh, yeah. It's not actually a. She's reacting right now. I can hear him up in

[Senator Virginia "Ginny" Lyons (Chair)]: his office even though he's, impacted as a dental term. Yeah. Yeah. Yeah.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: But it it it's it's really it's significant for families and to have that care delivered close to home. And to the extent that people can have eyes on and think about how folks are doing before they need a more expensive intervention. This is where we talk about right care, right time, right setting. We want to understand how people are doing before they have an event that's exacerbating. There's some things we can't prevent. There's a lot we can prevent if we know what's happening.

[Senator Virginia "Ginny" Lyons (Chair)]: So, the question that we asked you earlier about the Medicare acts, Medicare use of tele medicine. That's going to be an important answer relative to this

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I can tell you that it's clear from this application that the policymakers at CMS right now are really interested in technology and use of technology as a strategy for delivering care. They are clearly in favor of it. There's a lot of emphasis on that at

[Senator Virginia "Ginny" Lyons (Chair)]: the end of the application.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: I think

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I actually talked about some of this. So, we have an RHT dedicated page that we're continuing to update. This is where eventually things will live, like our grant opportunities, information about how to subscribe to the listservs that we're working on. We are also working on some listening sessions so that we just have an opportunity to tell provider groups, and not just the association,

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: but also individual providers, what do we

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: know so far? And to start to hear from our provider partners in particular what kinds of questions they have based on what they've seen that we've proposed so far, so that as we're developing those grant applications in particular, we have more to work from and more feedback from the community. So, lots more work to, I think, have a more iterative process with our provider community as this goes forward. Let's see. I

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: think we talked about all

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: of this. I don't know why that's so late in this. And it's so funny. Every time I do this, I think I should move this around, and

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: then I wonder why I did it.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. Tell me if I could redo that. So, yeah, I think that's the end

[Senator Virginia "Ginny" Lyons (Chair)]: of the formal slides. Just sharing. Question. So within all all this money that's here, and obviously, you're sending out a request for proposals. And will, There's quite a bit of We to will. You'll have designated amounts of money for each of those proposals and then you're going to get a response from the community. Are there do we have the ability to do line item transfers within your RFPs? I mean, so could you take if you're seeing that you're getting many more mobile health crisis units, gee, this is gonna be great or transportation.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Oh, I see.

[Senator Virginia "Ginny" Lyons (Chair)]: So can you take the money over? You can't do that. We, not without federal approval. So we need to be judicious in our community engagement to ensure that what we're setting up is responsive.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Yes. So we are allowed to change the budget mid mid year, but it is not

[Senator John Morley III (Member)]: a

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: small process. Mhmm. And and needs to

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: be reapproved by the feds before it's perpetuated.

[Senator John Benson (Member)]: Yep. Question on that same kinda line. So you said if we don't use it, they take it back. But if we have other projects, say, one hospital estimates they need 100,000 it only comes in at $95,000 but we know there's another need, Are we allowed to not send that money back, but actually use it for another need?

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: We could redistribute it within the approved line item. But to senator Lyons' point, if you wanted to move it to a different line item, you'd have to submit back to the Feds.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. Yeah. And I I will say I do anticipate we're gonna have to make an adjustment because we have a lot we did a lot of estimating to come up with the initial budget, and I I think our strategy is to wait to try to do realignment so we have more information. So we're not trying to do all of that work between now and January 30 because we just don't have enough information, I think we will have to do some work within the larger budget to recalibrate as we start to have

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: a better sense for each of the projects.

[Senator Virginia "Ginny" Lyons (Chair)]: So I have a public service announcement to make. Okay. That stuff you're

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: dealing with. I'm the enforcer. We do have 16 person max limit in this room since COVID. So just henceforth, we should just be aware of that number as we're coming in and out of the room.

[Senator John Morley III (Member)]: I'm leaving that number.

[Senator Virginia "Ginny" Lyons (Chair)]: No. Don't leave. Have our staff should leave.

[Senator John Morley III (Member)]: I to go somewhere else. I just had think

[Senator Virginia "Ginny" Lyons (Chair)]: we're well over. We are very over. If you're an intern, you probably should leave at this point. And folks who are testifying should stay. Oh, wait.

[Unidentified participant(s) (multiple speakers under this ID)]: Could we just reverse that?

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: I'll get more coffee. This

[Senator Virginia "Ginny" Lyons (Chair)]: is where you want to be.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: No. It is where I want to be here. Absolutely.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Definitely

[Senator Virginia "Ginny" Lyons (Chair)]: And we're just gonna do it with with that account that's going on. We're I think this How are we

[Senator John Morley III (Member)]: gonna have to be sometimes?

[Senator Virginia "Ginny" Lyons (Chair)]: Total. No. I know. Okay, see you later. All right, this is helpful. Questions committee, other questions. So now this is our first crack at looking at this. We'll probably be back.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Question? Yeah, go ahead. Just want to leave with a little bit of peace of mind, which I may not, that may not be possible. But Vermont is the most rural state in the country. Yeah. Chittenden County's rural. I'm just, I want to make sure that Chittenden County is going to be a part of this. So I'm going say it again. All providers are eligible. All providers eligible. But CMS has said these dollars have to be used essentially for rural communities. The definition that we've seen so far has been HRSA based, which does eliminate Chittenden County, but they have not given us full guidance on what exactly how exactly all this works. There's a lot more work to do with CMS about how this will roll out. We don't have full information yet. Do have a sense of when we might have the information? Maybe in the next eight months? Yeah.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: Mean, I think when they step one would be to get the money, and then I think they'll start talking to us about how to spend the money. Yep. But to Jill's point, we haven't even had an initial conversation with them yet. Although it's scheduled.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: It's on account. I just you know, the slides were great, and I can't imagine the work happening while also excluding Chittenden County. I just don't see how that would help, number one, and I just don't see how it would be possible. But anyway, thank you.

[Senator Virginia "Ginny" Lyons (Chair)]: I have to think what I'm curious. CBMC is in Chittenden County, so we can apply or any other group.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: No one is just looking for applying. Right.

[Senator Virginia "Ginny" Lyons (Chair)]: It's for their service app has to somehow benefit rural community outside of the county.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Exactly. Helps. Don't helps. It So, have a clear definition of rural. We just have the indicator of what they've used so far.

[Senator Virginia "Ginny" Lyons (Chair)]: It might also help if I put in better equipment, will help this. Yes, exactly. That So, I'm also equipment might also benefit the person. The correct. Sounds right. Correct. Can you send us the nursing definition? Oh, would be great. Sure. Or link to it. Yeah.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: It's the Office of Rural Health. Yeah.

[Senator John Morley III (Member)]: Is I think you told me what time. This is a 50,000 foot level, the 10,000 foot level, and the one foot level. Mhmm. I wanna go back to the 50,000 foot level. I think you're we're receiving these funds from the federal government, CMS, to become more transformational, make things more efficient, effective. Mhmm. It's really But I'm I'm also concerned that the federal government's gonna start reducing Medicare's Medicaid. So I think we're gonna make it better with these dollars. And we're of course, you want adults, right, so you can do this stuff. But on the federal side, I'm envisioning, and I may be all wet on this, reductions to the states for Medicare, Medicaid.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: So what I always say about this is this opportunity doesn't solve every problem. This opportunity does what it does, and we are trying to maximize this opportunity for the things that it does. And I agree, there are other pressures and other concerns in our health care system that this does not address, but we our goal is to use this to the greatest good we can in Vermont.

[Senator Virginia "Ginny" Lyons (Chair)]: So Again, it was attached to the bill that did reduce Medicaid payments that required the state to pay the costs. So it was the carrot along with this That's what

[Senator John Morley III (Member)]: I thought, but I wasn't sure. So thank you for that.

[Senator Virginia "Ginny" Lyons (Chair)]: So we will have nice new technology, but if your hospital depends on Medicaid reimbursement, they're going to get money. The problem. That is a problem. Especially in my opinion in

[Senator John Morley III (Member)]: those rural areas. Yeah. They're saying that the rural areas are gonna get more money to this, but if you're if if if you're if you need Medicare Medicaid dollars to fund your institutions because of the the individuals you have in your rural areas, and they're cutting it, then

[Senator Virginia "Ginny" Lyons (Chair)]: Yep. Yep. It's already a problem. It's going to get worse. There we are. There it is.

[Senator John Benson (Member)]: That's why you're here.

[Senator John Morley III (Member)]: Yeah. Oh, yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: So, when we finish, we'll get you transferred to finance and you can get your health insurance. We'll come back to this. I do have one last question and I'm not sure you can answer it right away, but I understand that there could be guidelines and criteria and value based criteria based on what we can do. So as they come through or not, that would be all at all. Because we have a fairly liberal progressive state in certain areas, and it would be nice to know whether we're being punished for that in any way, because I'm not sure the legislature would like that. I don't think any of us would like it. It's a challenge, and money is still coming.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: These dollars really focus on things that I think it was broadly put on. Workforce, technology, various innovations. Think that they're broadly

[Senator Virginia "Ginny" Lyons (Chair)]: Constructed.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah, and clearly CMS liked our proposal, given the award that we received. I think that we were very thankful.

[Senator Virginia "Ginny" Lyons (Chair)]: I was gonna say, good work. I mean, we've all worked together to bring us to this point.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Exactly. It's good combination of lots of work. Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: Yep. We're absolutely. So If we have a tech center that might need an x-ray, she needs to train x-ray technicians. Helping you could buy that on ace.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Possibly, yes. I'm just thinking about whether we have a project that that fits under explicitly. I'm not sure about mean, I'm

[Senator Virginia "Ginny" Lyons (Chair)]: not sure that that is a major

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Stuff is good purchases with one time funding. Okay. Think we all think about this as one time funding. We all put that in our minds as we plan, that will

[Senator John Morley III (Member)]: help us.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah. So we are somewhat accustomed.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: And I know you have other witnesses, so I've

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, I thought you to get, but this is the first conversation about this, and then there are others that we'll be having, and some of those may happen down the hall and appropriations because there's an appropriations piece to this that we haven't discussed. But thank you and thank you for your work. I know it's a big job And obviously, I think for us and here, we hear from our constituents, and a key piece is to talk with those constituents who have an interest. And we're gonna hear from some of them right now from Chittenden County because they've been reaching out to us.

[Unidentified participant(s) (multiple speakers under this ID)]: Thank you. You're walk me a county senator. That's true.

[Senator Virginia "Ginny" Lyons (Chair)]: I'm happy to have any county come in and talk, and we do that regularly. It's rare that I identify a single geographic part of the state. This one's important. Thank you for the opportunity, Jessica. Yeah, you. You. And Sandy McGuire is here. She'll be checking the box with our center. Are you speaking for everyone?

[Unidentified participant(s) (multiple speakers under this ID)]: Wondering. That's efficient. I'm trying to be efficient. I

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: don't know about for everybody.

[Senator Virginia "Ginny" Lyons (Chair)]: We'll limit it. Thank you. You. And I know that there's an interest from the FQHCs. I've heard from our FQHD in Burlington, Jeff McKee. So you're representing folks. You're representing who? Could you introduce yourselves for the record? Good.

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: I'm Simone Rischermeyer, Executive of Mont Care Partners, representing the 16 of the designated specialized service agencies. And

[Sandy McGuire, CEO, Howard Center]: I'm Sandy McGuire, Howard Center CEO. Terrific. Designated agency in Chittenden.

[Senator Virginia "Ginny" Lyons (Chair)]: I can start.

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: That's okay. Thank you for being

[Senator Virginia "Ginny" Lyons (Chair)]: Did you want Jeff to introduce himself at this point or is he separate?

[Unidentified participant(s) (multiple speakers under this ID)]: I think But equal.

[Senator Virginia "Ginny" Lyons (Chair)]: Separate. It's fine. Separate. But equal. To go after you guys. Terrific. Alright. Okay. Good. I just want

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: to begin by acknowledging the magnitude of the work that went into this proposal and to appreciate AHS. It's enormous. Just want to congratulate you on the outcome of the application. As part of a broader provider coalition, we did provide numerous recommendations in a short period of time, and we're pleased to see that some of those were in the application itself. It's essential that mental health, substance use, and developmental disability providers, and people who rely on them, are intricately engaged in and meaningfully supported by this transformation program. I learned a lot just this morning and appreciate how you're moving forward with the implementation of it. This is true broadly. It's especially true if we are going to move costly care out of hospitals in a community based settings, and so the investment is essential not only for primary care, but for men with all substance use and developmental disabilities. As you all know, the landscape we're functioning in is constantly changing. Just last night, we had one of our grants taken back by the federal government. And given how my telephone is blowing up this morning, I can tell you a lot of grants have been taken back a number Did of we remember that?

[Senator Virginia "Ginny" Lyons (Chair)]: Was that out in the news somewhere? I

[Jeff McKee, CEO, Community Health Centers (Chittenden & Southern Grand Isle Counties)]: saw it

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: at 11:00 last night when my students Oh, were breaking

[Senator Virginia "Ginny" Lyons (Chair)]: wow. Which grant do want ask?

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: Ours is a SAMHSA grant for teen youth and mental health first aid, and we've had a long

[Senator Virginia "Ginny" Lyons (Chair)]: stay Oh right, I knew that one was coming. That's terrible.

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: Yes, we've been doing it through BCP, our provider agencies and community partners since 2015, and it's been extremely valuable for youth and families and our schools. So I bring that up just because it is changing and I think we have to all be cautious about the federal investments as we are excited at the same time. As Jill mentioned, we've been talking about transformation and moving towards healthcare reform for decades and taking incremental steps, I think this can be an incredible opportunity, but also want to be cautious with it. I believe we have the potential for unique opportunity here for real change in shaping the lives of Vermonters who rely on our broad health delivery system. As a network, we are aligned with the state's transformation goals and are focused on increased access, strengthening our workforce, so it's great to hear how much priority there will be on that. Enhance data collection and analysis, and backroom efficiencies that streamline access and lower costs. Really centering the people, I keep saying this, but we want to center the people that we serve and Vermonters as we move towards transformation. In Chittenden County, Jill made it very clear about what they know at AHS about Chittenden County, and stuff important. In Chittenden County, which is often described as non rural, we have one designated agency and two specialized service agencies. And all of them are core components of Vermont's delivery system, providing essential mental health, substance use, and developmental disability services. The challenges are just the same, if not in some places, more intricate than they are in rural areas. And so it is, I would say that as Vermont prepares to achieve its transformation goals, BCP strongly encourages the state to fully leverage the flexibility and the intent of the federal language, which we see as we've known it, and I know you've heard more, it's clear that FQHCs and community mental health centers are explicitly defined as rural health facilities for the purpose of both state allotment and provider eligibility. So I'll just end with we're cautiously optimistic. We look forward to engaging in rail transformation statewide as we continue to uplift families and individuals living with mental health conditions, substance use challenges, and developmental disabilities. Cheryl will be back and talking about it, but we look forward to it, and it's big undertaking,

[Senator Virginia "Ginny" Lyons (Chair)]: so

[Simone Rueschemeyer, Executive Director, Vermont Care Partners]: I think we'll all keep our eyes on it.

[Sandy McGuire, CEO, Howard Center]: Thanks, Simone. As a Chittenden County resident, I am hopeful that as AHS, it's great and reassuring, pairing the intentions of the application and the hope and the vision for the state. I'm hopeful as a resident that all providers will be able to be allocated funds in our community, and I'm maybe heartened, it's hard in this environment these days, with the specific language that we believe exists that does, regardless of where Chittenden County lands in this application, does allow FQHCs and community mental health centers to be defined as rural, federally, be able to be allocated funds. So here to speak today about why the access to these funds is really critical for providers like Howard Center and how that need aligns with Vermont's goals for these dollars. I think many of you know designated agencies in Howard Center deliver a broad range of essential community mental health and substance use services, including crisis response and outpatient care. For many of these services, we're required to respond when people present for care, regardless of insurance status, geography, their address, timing, or acuity. That obligation is foundational to Vermont's system of care, it requires a stable workforce, appropriate facilities, and a reliable infrastructure to sustain. From the financial perspective, the challenge is structural rather than episodic. As a community based mental health center, substance use and developmental disability provider, we operate with very limited cash reserves and consistently thin margins. And while some of our reimbursement streams help cover our operational costs, reimbursement is not designed to support the really exciting type of work that was described today, the sustained upstream investment or temporary investment in workforce development, training capacity, supervision, sometimes physical environments, so I hear the restrictions on that, sadly, where care is delivered. This is compounded in Chittenden County, in particular at Howard Center, with our reimbursement rates, some of them having historically been among the lowest in the state, while our service area reflects some of the highest geographic costs for our staffing and facilities. Over time, as you all can imagine, that creates real pressure that shows up as staff burnout, deferred maintenance, not enough training, not enough investment in our workforce, and reduced flexibility, all of which undermine access. Vermont's own social vulnerability index places Chittenden County among the highest vulnerability counties in the state, reflecting concentrated socioeconomic housing, transportation, and demographic factors that are closely associated with higher health and behavioral health needs. That reality is exactly why the Rural Health Transformation Dollars matter. These funds are intended to stabilize and strengthen community based providers serving Vermonters with their greatest needs. These funds will directly support what Vermont has identified as priorities: Workforce Recruitment and Retention, expanded community based access, and care delivered in lower cost settings. Chittenden County, like the rest of the state, faces a tightening labor market and constrained pipeline of working age professionals relative to demand for our services. We compete for that same limited workforce with hospitals, schools and other sectors without the same resources. The transformation dollars provide an incredibly exciting, though we're all a bit cautious, opportunity to invest upstream in that training, supervision, retention, supports and modernized care settings so community providers can remain viable and effective. This is not about expansion or access, it's about maintaining capacity and preventing erosion in all parts of the system Vermont depends on to keep people out of emergency departments and inpatient beds. Ultimately, the funding is about Vermonters served, people seeking help before crisis escalates, families navigating mental health and substance use challenges, communities that rely on the services being available when they're needed, regardless of who they are or where they live. Ensuring that community mental health providers can remain stable and effective is essential to achieving the promise of the Rural Health Transformation Program. As I think about what we heard this morning, and I think the big picture, how this aligns so much, this opportunity, with the work that all of us at Vermonters are trying to do and the goals and the visions that we see. Every community is important, and there's so much excitement for, I think, our system in particular when we think about what we want to do. When we think about an EMR that potentially we could be able to look at what's happening in the hospital, they can look at what's happening with us when we can look at other providers, because they don't just stay in Milton or Charlotte or Burlington, they actually go across the lines into Washington County, and people are moving all across the state, and the ability of technology to do that. And when we think about with our workforce challenges all across, as we think about monitoring folks with their health needs and what that looks like, This is gonna be a statewide really exciting opportunity to really take advantage of a lot of the advancements that are out there that we have not in our system. We don't typically have the resources to be able to invest and get that one time step up that will pay off for years to come.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you all for your time. Thank you. And thank you for the work, John. This is very helpful. And I guess my word of encouragement that I shared earlier is to stay engaged and to stay communicating and I know that's gonna happen. That's the next step. I'm looking at Sarah behind you and Jill. The next steps are so critical to this, knowing that we have the hub and spoke, which is all all over the state and in Chittenden County, and we can't leave any of these facilities behind. Thank you. It feels good. And we also go ahead.

[Unidentified participant(s) (multiple speakers under this ID)]: We'll help get the COVID numbers back as we need.

[Sarah Rosenblum, Interim Director of Healthcare Reform, Vermont Agency of Human Services]: I think we're good.

[Senator Virginia "Ginny" Lyons (Chair)]: Are you gonna testify first? Yes. Come on up and state your name for the record. Oh, and by the way, you have some terrific testimony that you've submitted to us in writing. You said you sent it along to Melissa.

[Mary Kate Mohlman, Director of Vermont Public Policy, Bi-State Primary Care Association]: All right, good morning. Board of the committee, I'm chair. My name is Mary Kate Mollman. I am the director of Vermont Public Policy for our Bi State Primary Care Association. Bi State supports FQHC, federally qualified health centers in Vermont, as well as New Hampshire. Obviously, I'm gonna talk about Vermont FQHC's. We also support Planned Parenthood, Northern New England, and Vermont's free and referral clinics. Just a brief word about Bi State, a primary care association, we are tasked by HRSA to, and funded by HRSA, to support community health centers. We call them QHCs here, we refer to them now. There is a PCA, primary care association, every single state, so we work really closely with our PCAs across the country. We also work very closely with our national organization, and I say that because five state was one of the lead PCAs working with our national partners to work with members of Congress to get federally qualified health centers defined as rural health facilities, regardless of location, in HR one. We can't take credit for the community mental health centers to be included, but we are happy to be in the same boat. And actually, FQHCs are listed twice. They are listed specifically as FQHCs, and they are listed as three thirty grant recipients. So Congress based choice in FQHCs for rural health facilities. And I bring this up because it has been it was our work in that that our interpretation, that FQHC is sort of defined as rural health facilities, that if, that they are used to first, determine the amount of funding that the state should receive, and as such, should also be eligible to receive funding regardless of where they're located. And the idea is that they can use these funds to support their entire patient population, which is critical as a safety net provider.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Make sure I've covered everything.

[Mary Kate Mohlman, Director of Vermont Public Policy, Bi-State Primary Care Association]: This has been the interpretation that we have experienced in New Hampshire. They have, so FQHCs in, Nashua, Manchester, they are intending or anticipating to receive funding. And so, yeah, so that's our first point, that FQHCs are defined as rural health facilities, and as such, regardless of their location, are eligible to receive funding to support their entire patient population. That said, I also want to be really respectful of where the state is coming from. The federal government has been very clear that if the money is not spent according to how they want it spent, that is at risk for getting clawed back. And I I just I wanna be really clear that we respect that that is a very real concern. I mean, really respect the the state doing their due diligence to ensure that funding is being spent in a way that

[Senator Virginia "Ginny" Lyons (Chair)]: doesn't need to be clawed back.

[Mary Kate Mohlman, Director of Vermont Public Policy, Bi-State Primary Care Association]: Because there's there's anything worse than not getting funding. It's having to spend the money and then give it back.

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: Yeah. The baby is fighting for death. Don't know. But within the parameters, how the money can be spent, how do you use the Right. Used by FQH And again, if that's a general question, that's fine. Because I mean, it is fairly narrow in terms of how it

[Mary Kate Mohlman, Director of Vermont Public Policy, Bi-State Primary Care Association]: can be used. Yeah. So we were part of the group that submitted our recommendations to the agency on how the funding could be used in some of the projects, Workforce development and recruitment and retention are all key pieces that we support. The technology aspects, I think there's some real opportunities around upgrading EMRs, AI scribes, which can really do some work to reduce the administrative burden that our primary care providers experience, that telehealth remote monitoring. There's really some opportunities from some good innovative work to change how we care for people and how we coordinate with our partners across the state. So like at QHCs working with oncologists, working with EMS, with our hospitals. So those are the two key things I want to say, and then I want to turn it over to Chuck, who can really talk about his work for his organization, Community Health Centers in the Burlington and Grand Isle areas, about how, even though they are located in a so called urban or non rural location, they really do have a broader footprint that supports patients outside of Chittenden County and supports, and then not all the parts of Chittenden County are very, very urban. Represent

[Senator Virginia "Ginny" Lyons (Chair)]: the rural, right? I know what it's like here.

[Unidentified participant(s) (multiple speakers under this ID)]: And then, and also how that urban location is actually really beneficial and that people do move around a lot. So at that point, that's what I have to say. And if anyone has any questions, I defer to the chair,

[Senator Virginia "Ginny" Lyons (Chair)]: but I'd also We'll hear from Jeff and we'll come back with questions. One ask I have is please submit so that you can testify. So welcome and Jeff why don't you introduce yourself for the record and stay there if you'd Go right ahead. It's good to have you here.

[Jeff McKee, CEO, Community Health Centers (Chittenden & Southern Grand Isle Counties)]: Well, you for having me. Jeff McKee, CEO of the Community Health Centers. We're the FQHC serving Chittenden and Southern Grand Isle Counties. We serve about more than 35,000 patients with integrated primary care, mental health, psychiatry and dental services across all those sites across nine sites in those Chittenden and Southern Grand All County. So first off, I'd like to just say congratulations and yay Jill and Sarah and their teams. This is an amazing, wonderful problem to have. Like, let's just acknowledge that. How do you spend $200,000,000 a year or thereabouts is an amazing problem that you know, that's a once in a once in a lifetime kind of a thing to have to solve. So we'll do the best with that. And I also want to just acknowledge that I think there's very little philosophical difference between probably anyone at AHS or in the in the room that you're in, or any of the FQHCs and what we'd like to see if it were all up to us. So we're trying to figure out the very best way to serve as many Vermonters as we can, under the rules that we've been given and to the best of our ability as we understand them. So it's a it's a challenge we're all in in together. But I'd like to talk a little bit about the some of the uniqueness of of Chittenden County and kind of what it means to be rural within Chittenden County. So if you live in Huntington or Richmond or Westford or Bolton, you know, those are amazingly rural towns with the same amount of challenges as any rural community anywhere else in Vermont. And so the the the federal kind of definition that we're following, and I get they need to start someplace with this applies great if you're working in a in a big city with lots of little suburban areas around it to call the entire county, you know, a single metropolitan statistical area. I don't think that same methodology applies in Vermont in any kind of logical way where you have one city Burlington, which barely meets the threshold for the MSA, and then categorize everything around it as also being part of that. So I'm hopeful that we can, you know, work with AHS to give the HRSA the, you know, the education they need about what it means to be, you know, kind of very uniquely among all of the states in the in the statistics, the metropolitan statistical areas. You know, our our definition is just different, and I hope we can convince them of that. We actually serve almost about 40% of our patients come from what would be considered, in my opinion, a rural area of Chittenden County. Right and to and so while it's great, we, Joe's very good about and I and I appreciate it parsing the language that I'm thrilled that the federally qualified health centers, including CHC can apply for the funds. But if we can't apply it to serve Chittenden County residents, I'm not sure what that does for us, right? And so we really got to push super hard on that where we can and to try to make that happen so we can serve all those other communities. The second thing I wanted to talk about is kind of what I would say is, is the draw of Chittenden County to serve rural patients from across the state. So we serve 6,000 patients outside of Chittenden County that literally come to CHC from every corner of the state. We have expertise, We have a reputation. We have services that they can't get other places, and so they come to us for that. We also know that every every kind of population center Chittenden, Chittenden County and Burlington being kind of the the largest magnitude of it, draw people to them. It's where the jobs are, it's where the services are, it's where the supports are, It's where the transportation is. People come from all over the state to live in Chittenden County, and while they may be resting their head today on a pillow that's in Chittenden County, it's hard to just say because that's where they're resting their head today, that that's not a still a rural kind of a community member in many ways. For example, you know, we don't have great statistics on where people came from, We just know where they where they are today. But in our homeless health care program at our, we call our safe harbor program, which is the state's only federally designated health care for the homeless program, my clinicians there absolutely swear to me that more than half the people they serve through HHP were recently living in another community. So what is rural and what is the role of all health care providers? I mean, that's my particular story working at community health centers, but I think every human service and health care organization in Chittenden County has the same issue, particularly the hospital. There is no bigger draw of rural patients, rural people seeking care to Chittenden County than our hospital at UVM Medical Center, and some of those patients don't go all the way home. They stay here for any number of reasons. So I think we got to just kind of figure out how we serve them. Putting those services in those communities, I don't think is going to keep is is going to make a market impact on the draw of people to Chittenden County to receive services because of all those other infrastructure factors that are here and that keep people here. The last point I wanted to make, and I know folks have already touched on this is sustainability, right? And so I think the advice to consider this one time money is terrific, but one time money that builds either builds programming in some manner, the programming needs to be sustained. So startup is great and we need the startup funds to get us going. But if we don't have ongoing sustainable funding, we're not doing anybody any good at the end of five years, and in fact, we're going to have a giant huge mess. And one of the things we, I think we've learned from the hospital experience is that we can't put every service in every community. Right? We need to find who's going to who, where the population centers are, where the areas of expertise are. How do you get a critical mass of both patients and qualified providers in the same place to sustain the program in an ongoing manner? And that absolutely means building on services and supports and health infrastructure in Chittenden County. I take for example, our program at Champlain Island sits in South Huron, Vermont Grand Isle County. Grand Isle is only a full time primary care, only dental services, only psychiatry and mental health services that are located there.

[Senator John Morley III (Member)]: And

[Jeff McKee, CEO, Community Health Centers (Chittenden & Southern Grand Isle Counties)]: the reason that no one else is there doing that is because it doesn't make sense financially, right? You don't have enough people on an ongoing basis to build new programming in all of these places, and so we get to do it and just and and cover the the little bit of loss that we have with it because we build it on the infrastructure of what we do in in the center of Chittenden County, right? There's no new administration. We pay for the building and the providers and we can do that, but you can't do that everywhere and you can't do it without a court to build upon. And so for all sorts of reasons, we need to be thinking about how do we really be careful not to build overbuild the system in places that can't sustain at the end of five years. And and I think it was brought up in a couple of times. I think the key to it is something that you all mentioned, which was. This shouldn't be either or conversations. It's either rural or urban, right? It needs to be both. How do you use the infrastructure in the urban settings to also support the rural areas of our state? It should never be either or like how do we do them both and to make sure that the application requirements or application opportunities rather through when when they finally come out, include that understanding. It's not one or the other. How are you going to exclusively serve rural communities? How do you also serve rural communities and build upon what you already have? So those are the three main points that I wanted to make, and I'm glad to answer any specific questions folks may have.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you, Jeff, and please do get us some written testimony so we have the three important points. I don't think we've heard anyone disagreeing with any one of those points. It's how do we accomplish that? Hopefully our administrative leaders will be working collaboratively with folks in the community to realize the potential of the grant fully. It's really important. Thank you all for your thoughts on this one. Questions committee. I think any Jill or Sarah did you want to respond to anything that you've heard at this point? No. I appreciate

[Jill Mazza Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services]: the opportunity but nothing for

[Senator Virginia "Ginny" Lyons (Chair)]: We're good. We're getting to a good place. I hope. It's good. Yeah, no, it's great. I will say that I hear from my constituents and so this one really came out of a megaphone with some of our leading providers in the county and it was important for us to have this conversation. We'll keep at it. This is good. We're going to take a short break of about seven minutes