Okay, so this is the house health care committee. This is Friday, March 25th, a little bit or 45. And it's, it's our intention to welcome welcome our witnesses to help us understand have an overview of the blueprint for health. And I've asked representative Donahue if she would facilitate the work here this afternoon. And so I'm going to turn it over to representative Donahue. Sure, thank you, Mr. Chair. Welcome everyone. And as the chair referenced, we're really interested we've we've got some members who have been around for a while we have a lot of new members. But we haven't had, even for those of us who have an idea what the blueprint is, we have not had an update on, you know, what's happened over the last several years in some time and we have a lot of new members who really don't have any background on the blueprint. So that's what we're really looking forward to today, not even any, you know, new pending issues but really what it's all about. And so if you could introduce yourselves and then we'll go around and introduce ourselves since we've got some new guests speaking today. Thank you. I'll start off my name is in a back as I am the director of health care reform in the agency of human services and I will note that here in Waterbury today we're having some internet issues so if I cut out I will rejoin by phone. All right, thank you. Good afternoon, representative Donnie you I'm John Saroian executive director for blueprint for health I'll turn it over to Julie. Hi there good afternoon I am Julie Parker I'm one of the assistant directors on the blueprint for health team. Thank you for having us. Good afternoon, my name is Laura Roshnik and I am a data analytics information minister here with the different for health. Thank you for having us. Thank you. Or maybe represent Peterson and go around quickly. Yes, I'm a representative of Peterson, I represent well in district to South America. Hi, it's a pleasure to meet you all Leslie Goldman, I am from Wyndham three, which is the bells falls area so northern northeast Wyndham County. I'm Elizabeth boroughs. I am from West Windsor, and I represent Windsor one which is heartland, West Windsor and Windsor over in the upper valley. And on you from Northfield also represent Berlin. Bill Lipper. Representing town of Heinsburg. We have as extension. With my page. Newport. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Yes, and we have by zoom. Brian, do you want to introduce yourself? Representative Brian Tina and Burlington. Thank you. Thank you. So if, if you have a plan for how you want to handle you do wonderful. Okay. I'll begin. I'll just provide some a high level overview of the blueprint program and orient you to where the program sits within the agency of human services, and then turn it over to Dr. And then the team Julie and Laura will and have prepared for you a blueprint overview that is comprehensive and will both describe the program and and answer some questions about what's been happening with the program recently. The blueprint for health is a patient centered medical home program for the state of Vermont. It is a model of it is a model that supports primary care. And that is certainly intended to support high quality integrated primary care in the state of Vermont. The team will go into detail about the timeline for the program. It is well established with more than a decade of being operated in the state. It's a multi payer reform initiative where payers participate from Medicaid commercial payers participate and Medicare also contributes funding to the blueprint for health via the all payer ACO model agreement that we have in place today. And the program has recently joined in the secretary's office at the agency of human services with the office of health care reform because the program is multi payer in its foundation and is essential as we continue to move forward with health care reform that is focused on improving health and well being and that where we are looking to see delivery system transformation that is incentivized by payment reform. We it's essential that we have a high performing strong primary care foundation in order for the state to be successful moving away from feed for service models of reimbursement and really thinking differently about providing care care that again is integrated care that is appropriate to meet people's needs and doing so in a way that can prevent that can prevent outcomes that are that can prevent you know higher cost outcomes for instance in the future. So that's that's a brief overview of the program where it sits with the office of health care reform as well as the blueprint in the office of health care reform. We also have the health information exchange program and it and the blueprint are complimentary in the support of health care reform initiatives using both data as well as the as well as the model of care that blueprint has established with primary care. So I'll turn it over to Dr. Siroyan now. I'm very pleased that Dr. Siroyan has joined the blueprint for health as the executive director. I'll let you hear directly from him. But it's it's very fortunate that we have him joining our team at the State of Vermont and it's very exciting that he's recently that he's recently joined us at the agency of human services. Thank you. Good afternoon representative Donahue chair Lippert and members of the House Committee on health care. Can you all hear me. Thank you. I greatly appreciate your invitation to introduce myself. I will keep my remarks about myself brief in both the interest of time and because I submitted a more detailed overview of my background for your perusal. I'm a board certified pediatrician with subspecialty certification in hospice and palliative medicine. I'm also a certified hospice medical director. My interest in medicine began at the age of 15 following the death of a favorite teacher son. My professional and personal goals have been developed by the guiding principle of serving others following his death at a very young age, whether as a physician, a musician I play banjo music and sing and do a lot of stuff like that. Father, husband, neighbor, friend or colleague. I asked myself the following question repeatedly. How can I make today and future days better for others. My work in Vermont began in March of 2013, following an almost 10 year career at the College of Physicians and Surgeons at Columbia University in New York City, where I was jointly appointed in the departments of anesthesiology and pediatrics. Before my position with the state of Vermont I worked for Bay out of home health care. First is the full time medical director for hospice and after eight years the regional medical director for hospice services across the entire practice. It's an honor to serve as the director of blueprint for health at the Agency of Human Services. In three quick months I have become more and more aware of how big the shoes of the founding and preceding predecessors Dr. Craig Jones and Beth Tansman are. I'm greatly enjoying the work, putting my management and people skills to use. I rely heavily on my experience as a provider who visited hundreds of people in their homes, oversaw thousands of care plans friend of life, and had innumerable, innumerable, innumerable collaborative conversations with providers around the state. When I live in Norwich with my wife and two sons who are 13 and almost 11. I will now introduce my colleagues who will present an overview of the blueprint for health. Current programs. Julie Parker is a licensed clinical mental health counselor, and one of our two assistant directors. She has been with the blueprint for two years prior to the blueprint she worked in the designated mental health system in various capacities for over 20 years. Julie is passionate about the blueprints unique ability to support communities by integrating physical and mental health for whole person health and wellness. Laura Resnick has an MA in economics and is one of our two data analytics and information administrators. She has worked for the blueprint for nearly three years, managing payment operations for the women's health initiative and the spoke program. She is a member of the agency of human services institutional review board. She cares deeply about using data and analytics to inform decision making and health care. I will now turn the floor over to Julie to begin the presentation. I may just ask for a moment. In doing the presentation, different people prefer different ways. If folks have questions, should they ask along the way or would you prefer to wait to the end when some of those questions might have been answered along the way. I am open. I am happy, Laura, I think Laura and I would be happy to answer any question as it comes up and I think if it's going to be talked about more later we could just share we'll share a little bit more about that later will that will that work. That's terrific. Yes, we have a question already from representative quarters. Okay, great. I had no idea that the agency of human services had an IRB. So that's new to me at some point, you don't have to answer that now but the institutional review board. I'd love to hear more about that. I can do a chat to make sure that it's not harmful. Wonderful. You can. Yep, we can we see your screen perfectly so wonderful. Great, thank you. Just the way it's set up. I don't see if hands are being raised so if someone on my team could help me if there are hands raised or again feel free to just interrupt I'm completely fine with that so I'll handle that here I will let you know there's a question. Thank you very much. Good afternoon everyone thank you again for having us, we appreciate any opportunity we can to share the wonderful work that the blueprint is doing in our community so really appreciate the time and your interest. So, I will move forward here. Here we go. So I have a timeline at the end of the presentation but just for time sake I'm going to start here in 2010 and we can review the timeline further if we'd like to at the end. I wanted to start here in 2010 in terms of the statutory framework I just like to read this a little piece of the framework. Integrating a system of health care for patients improving the health of the overall population and improving control over health care costs by promoting health maintenance prevention care and care coordination and management. And then just another little snippet 2016 was when our ACO agreement was was signed and we can talk about that further as we progress. There we go. I think one thing that's really interesting about the blueprint and one thing that I really have loved. When I did my work in Franklin County I worked at the designated agency there for 15 years and working closely with the state from that lens is just how much they innovate how much we work with communities and really want to hear and understand what's happening age community. Each community has a little bit of differences for for various reasons. And we want to make sure that we're checking in with them we're talking about it we're looking at their needs. And we're saying what what kind of changes need to happen how can we impact that how can we support that. How can we look across what's going across our agency of human services what is Dale doing what is departmental health doing what is media age doing and how we can innovate together and really transform our health system so I think that's a real key part of the blueprint that I feel like it's important to talk about and something that I really value and I know our system values as well. So, as I mentioned the foundation of our blueprint is our patient centered medical homes. And so, and I'll talk about patients in my home a little bit a little bit further and what that means but generally speaking, it is to make sure that we are seamlessly supporting patients care and helping them with their care as they choose and would like to be involved in so we want to look at the health of the population so we're ensuring that screenings are done for what's called social determinants of health. Food insecurity housing insecurity interpersonal violence, mental health depression. So we want to make sure that those conversations are being had and being supported. We want to ensure that we're helping and supporting patients manage their chronic health conditions preventing chronic health conditions, if possible, those being exacerbated in some way, such as hypertension diabetes asthma. We don't want to increase a patient's experience of care and understand that more are they able to connect with their primary care provider or that office are they're getting their needs met. Our questions being asked to them for their whole health so that is their reproductive health their physical health their emotional health their mental health health and wellness overall so we want to ensure that those questions are being asked. And in the end, our hope is that it does reduce the cost of care and increase our Vermonters wellness overall and physical mental health being, you know, to the place that they desire it to be. So, one of the ways that we get information from our communities is the blueprint executive committee so they are really stakeholders and really share with us what they're seeing in our communities and that is a mix of folks. We just had our first one this this week with john at the helm, and it is a mixture of insurance providers, clinicians primary care providers are commissioners or designate so we try and it is in statute and we try to really have a great list of information from all different parties in our state, the best that we can to inform us of decisions we're making, or if we want to work on something new what would that look like would people be, you know, wanting to do that so the full list of the statute of folks that are invited to come as voting members is in our blueprint manual and a whole link to that at the end. The statewide network of what we call hospital or health service areas people use them sometimes interchangeably. And so when the blueprint started stakeholders came together and they said who do we want to be our administrative entity who is going to take this funding and disperse it to the community. With our all pair model and blueprint programming so there's one administrative entity within within each house health service hospital service area they must be centers for Medicare and Medicare Medicaid and Medicare services and it's broken up into 13 health service areas and under those are community health team leaders as well which I'll talk about, and our community improvement facilitators for each health service area. So for each health service area we have a program manager and the state provides a grant to that administrative entity, each year to provide for their salary and and the quality improvement soldiers salary we have some contracts that are separate but some that go through the administrative entity. And they have primary oversight of all the blueprint tasks that need to be done whether that's putting data, hiring, etc, they administer the funds. Now, it's really important to note that most of our administrative entities are the hospitals, but that position in and of itself the program manager is supporting both the hospital practices and any independent practices that are medical homes and and they're also responsible for what we call a community collaborative or an accountable communities for health where they bring partners together and talk about their goals and and things they want to work on in their communities. So a little bit about the blueprint programs we're going to talk about is the patient center medical homes, community health teams are having spoke, which is the system of opioid use disorder treatment, and our women's health initiative pregnancy intention initiative. So how do you become a patient center medical home. You have to meet NC QA guidelines, which stands for National Committee on quality assurance. And so you, you enter your practice, you go into a system it's called Q pass and you have to meet the national standards so there's basically six tiers of areas that you have to meet certain credentials or certain criteria under, you know, but just as a, as a few individuals, you know that you might, someone might be saying you know you need to be doing X amount of colorectal screenings you need to be doing depression screenings you need to be doing flu vaccinations you need to be patient experience one of the things for the NC QA is you have to do a survey of your patients and and see how they're how they're feeling about their patient experiences so there's some things that are set that they have to absolutely follow every year. And then there's some flexibility on things that are quality improvement facilitators can help them choose, or it might be certain things that we're asking at the state that they work on. So that's how you you start off being a patient center medical home and then also ongoing work so as you're getting information about gosh we are really low on our colorectal screening so we want to, you know, look at that and say how do we reach out to folks to get that how do we reach out to folks to get their flu vaccines what can we do how do we continue our, our quality improvement to meet those measures. So each hospital health service area has a quality improvement. Yeah, we have a question here if we could just represent Peter. Just have a question would you not getting what you mean by medical home. What do you mean by that. Yeah, so that is where someone would be getting most of their medical care, we call it their medical home. Most of their care is done their primary care is done at the medical home. So, oh my God, the medical care. Yeah. Okay. So, if you were a doctor that your medical. Yep. Yes. Sure. No problem. Thank you for for helping me clarify that term too. Can I ask if this is bill liberate I just I think to help clarify as well as like, let me just ask a question I think I know the answer to but I think others may wonder about is, is every primary care practice a part of the blueprint for health in Vermont. No. No. So what you're describing is how a primary care practice becomes part of the blueprint through this follow up on medical home. Correct. I mean, someone may still say, you know they feel like their primary care doctor is their medical home they get most of their medical care there. So in order to be part of the blueprint, you must meet the, the NC QA requirements to be a, you know, patients, what we call a patient centered medical home and receive blueprint funds, etc. You know we, I don't have the number of hand and I'm happy to share that with you I mean, I like to say, and there might be some practices I'm not aware of but I mean we're we're we're in the 90s 90% of folks you know I can think of a couple practices. And Dr. Corrigan, for example, was a doc in St. Albans and I think he's retiring. You know, one of the things is you have to have your electronic medical record to a certain part. He knew his retirement was coming up. It's just not something that he was wanting to do. And so, unfortunately, then, you know, we don't take off that box for to be a patient centered medical home. So that may be one example why someone says, you know, at that time I'm just not interested in that but there are some key things that have to be in place to to move towards that patient centered medical home, or you can make a plan to move towards that but you know some folks are just not not interested in doing that. Yeah. I'm just going to restate the large majority of track of primary care practices in the state of Vermont, both practices that are owned by hospitals independent practices and federally qualified health center primary care practices participate in and are deemed as patients with medical homes in the blueprint program. So Julie said it's, it's somewhere above 80% of practices so it is the large majority. Absolutely. Thank you for clarifying you know. So I just have a follow up question to that. What is the benefit to a practice to be in a medical home. That will definitely talk about that as we proceed. Okay, sure. Yeah. Great. So, So part of the NC QA is is that we provide a quality improvements facilitator to help those primary cares from the very beginning when we when we went to this model to help and support them to meet those criteria and also ongoing yearly, you have to reattest so to speak. Show your quality improvement show what you're working on and those kinds of things so that's one thing. A main focus of our quality improvement facilitators. Also, you know, for example, there was just a wait time work that the state had done and our quality improvement facilitators, you know shifted what they were doing help practices, figure out how to extract that data from their electronic health records to the state as as they were asked to so they can shift pretty quickly if there are state priorities that we need from primary care, the primary cares that are involved in in again the patient center medical homes. And they're just constantly looking at ways to improve care within within the patient center medical homes. I'm just going to turn this over for a second who I forgot we actually have this slide so just one moment we have a question here. Sure. It's not really questions just a comment, I think that you did a really nice job, putting a link in your presentation for a description of a primary care medical home. It's an article, and it will take you to once interested in going further to learn about that so just so people in the committee know that that's available. Thank you. It's on slide. Probably in the 30s. No, I'm looking at slide 10. Oh, okay. For some reason my my, I can't go back on my screen right now so I'm sorry about that. But thank you for sharing that appreciate it. I'm going to turn it over to Laura for a few, a few slides. So this slide shows the growth in the patient centered medical home program since July 2008 when it began to just a few months ago. And one thing that's notable is that there was steady growth for several years after it began, but that growth has leveled off in recent years and as discussed that's partly just because we've reached many of the primary care practices in the state and so many are participating that there are fewer that we can really bring into the program. So December 2001 to December 2021. We had 135 patient centered medical homes and at the, at those patient centered medical homes we had 147 CHD staff so community health team staff. And we have a little bit over 300,000 patients that were attributing to those patient centered medical homes and approximately a third of those are Vermont Medicaid patients. Next slide. We have a question. Yeah, I just want to understand your data I'm sorry. So, are you saying that you have 135 practices. 135 recognized primary care medical homes which represent 305,000 patients that sounds like a lot. I mean I'm not understanding that the relationship. Sorry, I'm going to bring that slide back up I'm so sorry there's some my, however this is right now. I don't know lately they go forward so one just get let me pause. Every minute. My apologies I were not I'm not used to zoom and I don't know about my why my computer. So just just if I can repeat the question or representative. Okay. If you're asking me to question I'm just trying to understand this is you're saying that they're 135 primary care medical homes in the state. Is that the blue line that's right. Yes. Okay, and that 135 practices represent 305,000 people. Yes. Yeah, so that that. So they, what we have done is we attribute patients and I can provide more detail on this and written testimony is we attribute patients on based on a two year look back. And number that 305,854 that represents how many patients we have attributed to those 135 practices across two years across all of the parents who have participated in our program. Yeah, I'm just not really understanding. So could you tell me how many per practice.  Yeah, I apologize representative I don't I don't have an average number of patients for practice. We do have like a. Thank you frozen. No, I can hear sorry I can't see anyone so I don't want to talk over anyone.  I think that partly that number. It makes more sense when you just think of how many primary care practices in the state are part of our program. As we discussed on the last slide, the majority of primary care practices and the state really are participating in the blueprint. So, maybe that helps make sense of why that number so substantial. So if I could follow up its representative Donahue. So, not all if a, if a practice is a blueprint practice that doesn't necessarily mean all of their patients are attributed patients is that correct, or all or are all of their patients attributed. So it's, we have some, we have some different algorithms that we use to determine how we attribute patients and like I said I can I can provide more information written testimony it's not not an area that I can recall every detail of right now I apologize but if we're looking for where a patient has the majority of their care. So, if you're receiving the majority of your primary care at a practice then that is where you'd be attributed to. And if that was a patient center medical home then that patient center medical home would would have you attributed as a patient. I think I'm sorry I think the questions coming up because if we have 80 to 90% of the practices are blueprint practices, but we only have 50% of the population of Vermont as an attributed patients so that was the disconnect I think people were trying to sort out. I apologize. So partly that's, you know, there could be people who are in non participating that are members of non participating payers that are then not attributed as patient centered medical home patients in this model. We're looking at patients who are members of the participating payers so that could be part of the But I think it's really important to note that the program is payer agnostic the services that are provided by a patient center medical home that's recognized in the blueprint program are provided blind to the payer type of any individual that is being served by that practice. So there's full. It doesn't matter if you know there are payers that are covering verminters that do not participate in contributing funds for the blueprint programs and services. However, the program and services are fully available to all verminters regardless of insurance type or insurance status so if you're uninsured in your, and you're receiving services from a practice for instance. You are equally served by the programs and services that are available. I apologize for misunderstanding the question. That's fine. No, I think we're all set now. I think the question was likely very unclear. It's always tricky when you you're learning a new presentation media. I can, I can see people now I figured out that button. Are there any additional questions about this slide. I think we're good for now. Great. Thank you. So earlier there was a question about essentially what the incentive is for practice to participate in the patient centered medical home program and this slide speaks to that so in addition to the funding that we provide to practices for community health team staffing. We also have payments that we send directly to practices, and these are the result of getting that NC QA recognition. And so every practice that gets that NC QA recognition gets a base payment of $3 ppm pm so per patient per month for commercial patients for $4 and 65 cents for Medicaid patients and then $2 and 5 cents for Medicare patients. In addition to that base payment practices are also eligible for two performance payments. And so one of the performance payments is based on health care utilization and this is measured at the practice level. And they can receive an additional up to 25 cents per member per month for both commercial and Medicaid based on their outcomes and the service utilization measure. And then they're also eligible for a performance payment for a quality measure and this one is measured at the community or health service area level. And once again this is up to an additional 25 cents per member per month. And for this measure we look at different outcomes such as the percent of adolescents with an annual well care visit, the percentage of children up to three years of age who have had to develop on the screening. The practices who are part of our program can receive these monthly payments in exchange for meeting these different quality and resource utilization metrics in addition to the NC QA certification. Okay, before you move all that out so we don't have to go back with, we have a question from representative page. I'm curious. What is the total amount that these practices receive per month. So, so that depends on the number of attributed patients. So, how much is it per patient then. So, if a practice is not receiving any of the performance payments, then they would receive that one that bullet point one they would receive that base payment for each type of patient. If it was a Medicare patient they would receive $2 and five cents for each of those Medicare members per month that were attributed to them. Then, you know, if they have a performance payment, let's say that they've reached up to the $25 the 25 cents for that reads that health care utilization performance payment, then they would receive that on top of that for that Medicare payment. So, for example, they would now receive $2 and 30 cents for that same Medicare patient, if they now have that health care utilization performance payment, and then you would add another 25 cents for that performance payment for the quality measure. If they qualify for that as well. So it's. Are there any additional funds that a practice would receive. So, these are the payments that go directly to the practices. We also give out community so participate participating pairs also provide community health team funds, and these are paid out quarterly. They're also based on the attributed patients but these go to the administrative entity in each blueprint health service area. So those don't go directly to the practices, although the practices can benefit from the community health team staff they're hired as a result of those funds. And we'll talk about that a little bit further about the community health team. Go ahead, excuse me. I just wanted, because I'm not. I'm not totally clear about the question. The, these are supplemental to the fact that the insurer, whether it's Medicare, Medicaid or commercial is paying the full regular visit fee. These are, these are on top of regardless of the person even saw the doctor that month it's not based on visits it's just that they are part of the practice. It's just that right. No, I was just saying, all of us have this up so she may want to look at us. Just have a dialogue. You're boasting what I'm sorry. So, the way that these are paid out, they're paid out by the insurers based on the insurers own attribution algorithms. The blueprint doesn't come up with the amount that should be paid to each practice, for example, gain wells that claims administrative administrator for Medicaid has their patient algorithm. Blue Cross Blue Shield Vermont has their own patient out attribution algorithm and that's how they determine which patients they're paying on behalf of. Do you have a follow up representative page. Well it just seems like such a minimum minimal amount. I don't understand why any practice would want to join up on on this community program or whatever it's called blueprint program. And we'll, we'll talk a little bit about community health teams and a few slides and that may share just a little more information about about additional benefits. I look forward to it. Thank you. Yes, thank you. Should I move forward. Yes, please. Okay, thank you. So, So this slide gives a an accounting of those numbers that we previously previously showed the payers claim based attributions. So, this is showing what it was in at the end of 2021 quarter three. So, one of the key points to see from this graph is that we have a number of pairs participating in the program. The payers who have the largest number of attributive patients are Blue Cross Blue Shield Vermont Medicaid and Medicare, but we still have significant participation from MVP and we also have members who are participating in the program from signal or attributed to the program. Okay. Thank you. So I want to touch a few minutes on community health teams and the funding slide will be further here so the role of the community health teams is just to support our primary care providers and identifying root causes of problems. Supporting with mental health screening for the social determinants of health as we talked about connecting them with effective interventions to support and manage chronic conditions if that's part of their care plan and their desire. And, you know, just overall offering connections with care teams so if we have folks that maybe have, you know, their medical home to get most of their care from their primary care but yet, maybe they're seeing an endocrinologist and they also have some other specialty services and it's someone that's helping coordinating care and providing providing that care coordination and support to the patient. And in the end, you know, the hope is it's also supporting the primary care providers and nurses that really we know their time is very limited with patients and so when we have folks that are coming in with many social determinants of health they're able to do a warm handoff to someone on the community health team that has that expertise that can do referrals, short term treatment, close the loop on services, coordinate care. So, funding for so we again as Laura mentioned so funding will go to an administrative entity to provide community health team to the community so there's there the typical funded positions are nurses mental health clinicians case managers care coordinators panel managers, dietitians and our community health workers. But what we do know right is that helping a community as a whole isn't just about the folks that we fund. Although you know we certainly can only provide so much but the larger community as our designated agencies or chronic care folks our peers our recovery coaches our food shelves so we know it takes an entire community to support each other. And that's what we do here in Vermont so I just wanted to point that out. Yeah, I have a question right now because it's always been a confusion for me. One of the things that the blueprint is clearly about is addressing coordinating for supporting for chronic care. Yeah, and yet we have this totally separate entity under the, I don't know if it's under the Department of Health or where it is but Vermont's chronic care initiative. What is the difference. Yeah, is the Vermont chronic care initiative under or part of the blueprint or is it separate and why would it be separate they're both addressing chronic care. Well, I will try to address that and then I, you know, if you want to or john chime in. So the front chronic care initiative I like to think of it as a continuum with our work. And so I do. While we are working in our community communities to support, obviously chronic health conditions that's not all the community health team does one repair agnostic and we work along the spectrum of any conditions that are happening so. Well, obviously, we want to support our folks that have chronic health conditions and be, you know, providing care coordination and all those things. There's also a large patient load of practices that we're supporting as well. So there are times that we refer to the Vermont chronic care initiative program from the community health team so they can take on a higher level of collaboration and coordination. There's a few other tasks that that they do. They support folks that are brand new to Medicaid. And they have a few other tasks that that I'm not 100% aware of just to be honest but I know that they have certain certain charges they do, and they also sort of I see them as a continuum with the community health team. Go ahead. Yeah, I can I can just building on what Julie explained. And the Vermont chronic care initiative is a short term intervention to assist Medicaid enrollees in particular with necessary care coordination and services, typically to stabilize those individuals. And a part of that stabilization is often that the chronic care team is working to establish a relationship between the enrollee and the patient centered medical home so you can imagine a scenario where someone has become disengaged for whatever reason with patient centered medical home, or perhaps has never been engaged, and there may be outreach to that individual for a number of reasons by the chronic care initiative to work with that individual, get that person stabilized and then connected with a long term relationship with a medical home so an example could be that a person who is who is currently without a home, maybe identified in the community through what the community networks, and through those networks which are connected to the chronic care initiative that individual could be referred to the chronic care initiative for instance, and again to work with the person to become stable with their condition, or conditions, and to be connected for a longer term on going with a patient centered medical home at which time the chronic care team would disengage from their work with that individual. And like Julie said, there are times where that intensive service from the chronic care team for a Medicaid enrollee might be something that is is is called from the patient centered medical home to help stabilize that individual. And I think it's a really, really great question and something that we do clarify from time to time in our community so appreciate that. So, as Laura mentioned, you know, there's the funding that she talked about. So additional funding is is to fund our community health team payment structure so health service areas receive funding to hire community health teams. So that's an additional money of $2 and 77 cents per patient per month for commercial payers and Medicaid and $2 and 51 cents for Medicare. So that is on top of the other funding that we talked about. So the terms of community health team. Go ahead. Was there a question I'm sorry. No. Okay, sorry. And so the way, again, the, so this is a little bit different where the funding comes to the administrative entity. So, the, the, the funding comes to let's just say Northwestern Medical Center in St. And, for instance, what they chose to do is they hire the nurses that go to the primary care docs. They pass through some money to independent practices. And they also work with their designated agency to hire the mental health clinicians that are in the practices. So they have a unique way they use their money. And that's talked about with the blueprint that's planned. That's, you know, something we work together on to say what is the best way to provide services within this community to the medical practices to the independent practices, etc. Do you want to contract with your DA, etc. So there's different ways that each house health service area managers their community health team money. Like we talked about earlier there's some flexibility in terms of, are there dieticians needed are their nutritionists are there. You know, social workers are their community health workers so there is some flexibility in terms of how they use that community health team money and they should be talking about it as a community as well. So there's there's three different ways also they get payment in that this is for our core community health team staff, and then we're going to talk about additional funding for medication assisted treatment staff and our pregnancy intention program so I'll talk further about that but just in terms of this specific payment structure for the community health team is there any questions on that before I move on. We have one. Okay. I have a question. This is a bill over it. So, one of the things I've always heard is that some that the patient doesn't necessarily need to know, or want to know. Yes, whether their medical home, whether their primary care physician is a participant in the blueprint for health. What they know is that there, if they are there, there might be some of this additional funding may be allowing that primary care office to hire a mental health clinician who's working in the same setting to offer what people talk sometimes referred to as a soft handoff or a warm handoff. It's soft and warm and it's yes, absolutely. So this is where I'm sorry, go ahead. I was saying that I think I think what we're spending a lot of time on it and it's good that we do need to understand how the funding works and all that, but the practical impact is that in fact, primary care practices that participate in the medical home model and primary care for health do get both resources for that particular practice, the payments per model member per month, but then they also benefit from the work of these community health teams. And it, and it but it's not necessarily labeled blueprint for health to the, to the community or to the patient. Because these are enhanced. I'm saying it but I'm asking as well as a hundred percent enhanced support. Yes, for these patients who are working with those primary care practices is that am I getting understanding that. Absolutely and you know what sometimes even the staff doesn't know where their funding comes from to be paid and we're okay with that. And as Ina mentioned, it's para agnostic. So if practice, you know, one of the tricky parts is, you know, there's only so much funding right only so many positions that can be hired so somebody may not be there every single day at a certain practice depending on their attribution, but essentially yes the primary care docs are so thankful that they can do that warm handoff to someone and have that patient gain support and so I feel like what we hear is certainly this is one of the most beneficial services that they can can have embedded within their practice. So what I've heard over time is that it's better. It's a whole lot better than just saying, well, let me give you a phone number to call to make a referral. The rate of actual referral is much lower than if you can actually introduce somebody. Yep, 100%. Yeah, I used to I was a crisis worker and a case manager and, you know, and working in St. Albans and a primary doc would call crisis and say like we need somebody this is pre blueprint, and I'd be like, our crisis team will be right at work right or we'll meet him in the parking lot so we can even do warm handoff for services. But yes, we know that if someone is having a challenging time having that warm handoff and having that person to talk to you and follow up on in the moment. Someone's more likely to engage and stay engaged right it's just, I mean it's human nature. Yeah. Representative Goldman has a question. Yeah, I just want to make sure I understand this. From what I understand to do the work to become a primary care medical home, you go through. I would think of some of rigorous process that then becomes an honor. You know that it allows you to take your practice and what you provide to your patients to the next level. It allows you to create an infrastructure around them. So when different things are needed, those services are in place. So the process itself has merit, because it does create a network. I think around patients to support them through different parts of their needs. Does that sound right. I mean, absolutely. It's a rigorous process to be able to do this. Yeah, absolutely. And that's why I mean I get the money is important. I'm not a primary care provider but I will say, and John you can correct me but I think it also holds people accountable in different ways like not in a negative way but certainly like we can go about our work and and forget to look at things again not in a negative way. But when we're sort of at that level of being a patient center medical home we do have to stop and say wait a minute. Yeah, we why didn't we do depression screenings this year that what happened to our workflow that we forgot to do that or we just stopped doing that we want to be doing that we want to be looking at colorectal screenings we so it also is like this accountability that I do feel like some practices have shared with us that that being a part of that process is making sure that they're providing the best care and making sure they're looking at all these different areas of how where and how they can improve. And so they're they're not inadvertently missing things again not in a negative way but just in a how do we hold ourselves accountable to the goals that we want to have in the work that we're doing and I think that's the positive feedback we get and the value of people feel in being and TQ a credited and a patient center medical home. If that makes sense. Representative Cordes has a question. How does the quality data get managed to manages it is that where the IRB gets involved. How. So when you're looking who manages the data about screenings and medical information about whether you're, you're meeting the specific goals how does that happen. Yeah, sure that's that's a combination between. Well, certainly if it's a hospital, you know, lots of hospitals have data management departments that might work with our quality improvement facilitators are independent practices work with our quality improvement facilitators there there has to be someone in the practice that you know understands what it means and they're they're working on that our quality improvement facilitators you know they're not there all the time but they're helping support and and and we you know again we pay them as a blueprint you know contract to staff to thread admin entities to do that work to support practices but again part of that earlier funding that Laura talked about that is some funding to help offset the cost of the time it takes for someone to do that work and then again we have our quality improvement facilitators that can come in and help you that as well and you know we know that hospitals and bigger organizations and small organizations have to report lots of other measures so there's usually someone in the practice that is designated to be looking at this measure other health effective status that's there's other measures that they're looking at anyway for you know Blue Cross Blue Shield outside of this kind of a thing. Thank you. Sure. Yeah. Well one more question here representative. That's fine. I'm just curious about our your ratings I mean how how are we doing or how are you doing throughout the state with your quality with through your measurements and everything. So, trying to think of the best way to answer that. I guess I could say pre pandemic, you know pandemic and now at this point you're probably recovering to a certain degree. Mm hmm. So, we do a patient center medical home every year those results survey are our cap surveys but it's called consumer. I'm going to forget the for I'm going to forget the acronym at this time so we are doing we do a survey in terms of how how people feel about their providers but Laura is there other data. Yeah, yeah, thank you. Yeah, so we've previously reported and in some previous annual reports they're available on our website different you know resource utilization and quality metrics on different health service areas. We also produced data profiles at the HSA level for 2018 data that's available on our website that describes certain measures how different health service areas are performing on those. We also have an analytics contractor who works with the all pair claims database and with clinical data that we receive from vital to really look at some of the measures that we discussed on the previous slide about you know the, you know, well, well visits on different different metrics that we use to try to understand the quality of the healthcare provided in different health service areas. And so that's, that's one way that we try to track how practices are doing for the most recent year it's it's difficult because of the pandemic utilization was so low that we're still trying to figure out how to kind of look at these recent years. So we can provide more information on quality metrics and additional testimony. Thank you. I think we're all set. Okay, great. So that's our program managers have is to facilitate and accountable communities for health meeting within their community. And that's again where various community partners come together to really talk about what's happening in their community, where how do we work together how do we coordinate care how do we collaborate are there things we want to work on together as a community so some folks meet monthly some folks meet bi weekly, some folks have different break off groups from these that might work on transitions of care or suicide prevention or things like that so it's one of the areas that our program managers do do work on bringing community all community partners together. We're going to talk a little bit about our hub and spoke programming and our pregnancy intention programming next. Our hub and spoke medication assisted treatment is Vermont system of medication assisted treatment supporting people in recovery from opioid use disorder. And we know that this is considered a very effective treatment. Our medications designate two settings where medication assisted treatment can take place opioid treatment programs and office based opioid treatment settings which a lot of times people refer to the obots so you may hear somebody say that. Sorry, my slides. Our hub and spoke programs starting in started in 2013 so our hubs which are called OTPs opioid treatment programs with eight program sites we'll show you a map in a second. They've been dispensed buprenorphine and Vivitrol in addition to methadone. They provide care care managers counselors nurses psychiatry. And there's a monthly bundled rate for methadone and home health services, where we focus in the blueprint is is the spokes that's our charge to work on and so that's the office based opioid treatment. We have 75 practice setting with spoke community health team staffing. We'll talk about this is an additional level of support to these practices, where they receive based on their patient counts out full time nurse and a full time addiction or mental health counselor counselor based on 100 patients. So if they have they serve 75 it will be prorated but again that funding goes to the administrative entity and the staff is then provided. And it's considered part of our community health team. You know, the thing we really focus on is the collaboration between the hubs and the spokes and it's really important that we're, we're working closely together as community partners and providers to make sure that when we're seeing folks we're getting them to the level of care they need whether it's an intensity of a hub, or moving to a spoke or vice versa, depending on you know what what the person struggling with and going through and needing for services so we really depend on each other in terms of providing that best care. A program that ADAP works on is what's called rapid access to medication but I thought it was important to talk about is what we what we really try to do is if someone comes to an emergency department, and they're saying okay I'm ready I need I need to stop using opioids. If there's a prescriber in the ED they they can start whatever makes sense to them. And then the goal is that they get them into whatever again service level they need within three days so they have we have these community agreements with each other. And they're unable, you know there's no providers that that that are waiver to do that type of prescription. They still have that commitment to get them into the level services they need within three days so again, it's very important that we're working closely together as communities to address this. And there are also more two departments across the state that have recovery coaches that then they're called and made a connection with the patient to help support them to engage in whatever treatment they're desiring or just encourage encourage them so it's a very important program. Then Peterson has a question. Sure. Yeah, so I'm looking at slide 19 I know we're back free from where you are. You can. You know look at the. Yep, I truly apologize. I don't know why my. If you kept that view. Yeah, sure, sure. 19 is that we said. Yeah, sure. Community for health will address the medical and non medical needs of effective measurement results and outcomes, including social economic and behavioral factors. What does that mean. So, for example, you know, a group might come together and they may say, you know, we want to, you know, work on housing, we want we're finding in our community that this is the there's. There's a situation with housing and we want to dig into that and see if we can do something about that we housing obviously is a challenging issue. We know that we have X amount of unemployment rate and that is an economic impact for our community. So how are we working together with low rehab, are we finding that, you know, folks are able to get jobs because maybe they have some type of, you know, record in the system that's impacting their work and so is there something we can do can we work with Hanna Fords can we work with other community partners or employers in this in this area to make some kind of, you know, work agreement or is there so really it's really looking at in that particular community, what is making it challenging for people to feel successful to get jobs to get housing to maintain their mental health is they're not access to resources is there not a homeless shelter. Is there not a warming station is there not a food shelf right so it's coming together and looking at all those components to say, maybe what are we lacking and what do we need in our community to kind of make all these needs be supportive and come together do we not have a peer network for folks that we really want to work on helping people be connected with other folks who have similar situations do we have a high pregnancy rate and we really want to support our folks on that do we not have daycare. So, does that help. Yeah, yes. But this is for folks that need it correct I mean you're doing it on an individual basis for someone who has those needs it's not. It's not something you're working on is a general part of what you do you're working on it. For an individual who has some of those needs. On an individual basis, yes, but if we're if the community is seeing patterns on certain things. Then they might come together and say, you know they're coming together monthly to say wow we have this issue that's is just this thread through the community that we need to have more accessible x y and z. But yeah so it's we're seeing it on an individual level and we're working on it and then we're seeing it so larger need for the community as a whole. So how do we as community partners address that. Okay, so someone comes in with a health problem and they don't have a job. Yeah, you each have a place to try to get the person a job is that. Sure, absolutely. Yeah, you know communities are really great and I feel like our community health team, they really know each other in the community like. So who should I call the food shelf somebody has a food. Here's my main contact book rehab that always helps, you know, you know so they have all those kind of tools and relationships across the community. So they're absolutely able to work together and support those whatever the needs, the needs are I mean we know, you know, there's a shortage of housing we know some other things but if they're coming in then we're the community health team is taking that addressing it supporting that maybe there's a referral that needs to be made or another warm handoff to someone in the community to then work on that special need or whatever it is but absolutely. Okay, you asking patients questions that lead you to some of these things that is that what you do. Okay, so again practices do it can do it a little bit differently so they screen for what again we call social determinants of health so that's housing and food insecurity and interpersonal violence and depression and all those things so we'd love to have more consistency as a state certainly that everybody's doing it on the same in the same way or using the same screening tools but we also know it's important just to be screened and to be asking those questions so you know also our folks need to be honest what might be going on for them, and then if they're, let's say they came in to get their, you know, thyroid check because it's just that time to renew their medications and then they come in and say, you know, I'm struggling, I don't have food, you know I can't make ends meet and then hopefully that provider is then saying great. I've got Julie Parker here I'd love for you to meet her she really helps people with all those things, she's right down the hall let me go get her. And then ideally then I would come in and be like, you know happy to meet let's talk let me see what I can do shift out of that room go to a different room. Talk about those needs, ask additional questions, you know if I'm meeting with that person and we have very skilled people, and I'm thinking there might be something else let me let me pull out a screen tool let me ask a few more questions about what might be happening. And then again so that's the screening brief or longer term interventions and helping that person navigate to the services that they need so. Yeah, yeah, absolutely. I think I will leave it like this so I can go back. Okay, so Laura ticket 23 please. We often have people asking where are the hubs located across the state. And so this is a map of the current hub so the green lines just showed that the territory, so to speak for each hub where the hubs themselves are those orange dots and so you can see that we have hubs, pretty evenly spread throughout the state. Okay, so this graph shows the growth in our program from January 2013 to September 2021. So you can see that there's been a substantial growth in the number of spoken making prescribers the number of spoke Medicaid patients. We have another metric that we use often which shows the spoke medication assisted medication assisted treatment prescribers who have more than 10 patients on their panel because we feel like that's a greater level of engagement with the spoke program perhaps then one or two patients. And it also showed that we have a substantial number of spoke medication assisted treatment FTS hired so these are community health team staff that assist in the spokes. And I just want to emphasize that this the spoke program is a is a Medicaid program so this is, these are only Medicaid patients and we define a spoke Medicaid patient as a patient who had a for whom Medicaid paid a buprenorphine or vivid trial pharmacy plan. So we have a question here from representative bearers. Hi, thank you. Is the increase attributable to increased in capacity or increased patients. So that's, that's a tough question to answer. We're always trying to determine, you know what the whether there is sufficient access but it's, it's, it's a tricky question. We do believe that we have increased access, for sure, over the earlier years of the program but there is also likely increased demand. It's a little bit easier to measure at some of the spokes because they used to report you know the number of individuals were waiting lists. But, but we, yeah, we don't have an easy answer for that I apologize. The spoke services are pretty prescriptive in a way you know we with community health team as we talked about it can be nurses or dieticians or mental health. And we're very prescriptive in the spoke programming where again with the hundred patients it needs to be a nurse, and it needs to be a counselor or mental health clinician licensed drug and alcohol counselor. And this is just kind of prescribes, you know what the tasks we're hoping that they're doing which is very similar to the community health team generally. But there's an added level of the medical piece of things so ensuring that you know safety in terms of use, just continuing use etc so just a little snapshot of that. And then specifically what the funding is for those for those two positions that are then again going to the administrative entity to hire to move forward or passing through to an entity to hire. Okay, our next program is our pregnancy intention program so our 45% of all pregnancies are unintended and so that's where the prams data from the Department of Health in 2018. And healthy for mantra school is to reduce that rate to 35%. So, when this when this came forward in 2017. There was a conversation about, you know, are we talking about it enough with folks and so, and is there access do people have access to contraception to family planning to discussion to discussing their. Their hopes and so we are supporting our patient center medical homes and also our specialty practices which is something a little bit different and so we ask that folks are asking one key question which is, what is your pregnancy intention and so if someone says you know I'm intending to get pregnant this year, great and so I did a screening with you and it looks like you're using a lot of substances so how do we help support you having the healthiest pregnancy that you can. If someone says you know I'm not interested in getting pregnant this this you know year. Here are all your options that I just want to talk to you about as a provider and so that you're knowledgeable and you can make a choice that you feel like is right for you if someone says that they are interested in contraception then we want to encourage as clinically indicated by our medical partners that the modern and most effective contraception, which is long acting reversible contraception and so we asked providers to be able to to provide that same day again of all the clinical indicators are there. And we asked for additional screenings for those folks again around substance use, depression, homelessness, housing, food all those other things. And we also encourage care coordination agreements from specialty care, Planned Parenthood, primary care so that again we can get folks to where they need to be and that we're always continuing to build community partner relationships so if a practice says you know I want to be involved in this programming. That is another payment that they can receive and at this point it is just a Medicaid program. And so we have 46 practices, 24 specialty practices and 12 Planned Parenthood practices and we provide them with per member per month payments of $1.25 for ages 15 to 44. If they are interested in and again being part of this program. This is the first time we're really well besides the spoke I should say, in a different way we're digging into the specialty practices because we're at OBGYN practices if they'd like to engage. And so another benefit is that we provide them again the specialty practices with funding to hire a mental health clinician. So if it's a patient center medical home that wants to do the pregnancy intention programming. They already have staffing there that's funded but it's specialty practices OBGYN practices. They don't they've never had that access to mental health that was that was augmented maybe they chose to hire somebody but that was augmented or supported by us so we also provide a one time payment to practices based on their attribution or client clients from 15 to 44 with Medicaid to have on site. The Lark products so that if again if someone comes in they don't have to order from the pharmacy wait go pick it up from the pharmacy and have another appointment with their doc they can say you know go through that process and if they say yes I'm interested. All the clinical indicators make it safe, then they have it on the shelf they can take it off and and provide it to that person that's interested so. So that's just another benefit of work that people are most likely already doing and talking about what their, with their patients that were able to support. We have a couple of questions here represent first. Thank you. I wondered whether whether there are other services for women at the women's health initiative that aren't related to family planning. So this is really a pregnancy intention program. That's that was, you know, funded, certainly if if you know again if if someone's there for other reasons and we have a staff there we would offer support. And there are other programs. There's something there's a grant through like the Department of Health, called the stamp grant that helps pregnant moms and postnatal moms and. So there are some different funded programs that different specialty practices that we don't necessarily take the lead on but they're there are some terms of things like complications related to menopause. So I just want to interject one thing which is that those PM PM payments to the practices those practices, the, and our one time payment and the CHT payments. They are not based just on interactions that the payment that the patient has with the practice for contraceptive services they also include other services relating to women's health so it could be breast cancer screening it could be. It could be annual well women visits. We do only include patients as attributed if they are ages 15 to 44, but that doesn't mean that they don't also receive the services of the community health team staff that are in place. So for the purposes of payment, it is that that restricted age window although a broader set of procedure codes than just associated with contraception but the services are available to everyone at that practice. Thank you for the clarity.  Are we reducing that 45% level at all that we that we're seeing and how do we identify that. We are continuing to work on on managing that data to be honest and so it's a little bit challenging in terms of how it's measured through the prams through Vermont Department of Health. So, what else do you think you'd say about that Laura. So, I would say that pregnancy intention in Vermont is in most states is measured through prams the pregnancy risk assessment monitoring survey. As Julie mentioned and so that isn't something that that we ourselves monitor but we work closely with our colleagues at the Department of Health to understand what patterns they're seeing. As we've tried we do try to understand trends that we see in contraception in annual well women visits, but we're still that's kind of still work in progress because this is a bit of a newer program. So we're still working to try and understand how best to to monitor some of these things for, because for example, you know with long acting reversible contraceptive. So why do we look at annual levels to understand what's going on because if a woman has a device inserted she could have that for a number of years and so you may not be looking. You have to kind of trying to model the life cycle, these devices, a little bit more so so work in progress. Thank you. I have a question. So, this is bill liquor. The women's health initiative is that it says it's it's is it's restricted to Medicaid patients and the attribution is is Medicaid on the exact correct. Yes, but it's pay or agnostic as well like we really we always go into these I mean we would never if there's a blue cross loop shield payment person if there's a signal. Our resources are going to be there for anybody but in terms of actual where the money is coming from. In terms of actually providing the service, your pay or agnostic whatever patient might benefit from it, but the payment, the practices of Medicaid payment and attribution is that correct. Yes, correct. So it's and it's and it's a page of practice would apply to be part of that particular initiative I see it's 46 practices is that right, which yeah. So not all practices choose to participate in the special initiative special practices not the primary care practice. There's some primary care practices that don't have providers that are comfortable providing anything but oral contraceptives so they they're not comfortable. Even though in this program we actually provide training we contract with Dr McAfee who is a fantastic doctor at the UVM health network so we provide training opportunities and education but we also provide primary care docs that aren't comfortable doing doing that type of work. And so, but as we'll see on the next slide, it has grown quite quite a bit since inception in 2017. Right. And just as I remember the data from the hub and spoke it, the graph showed it said it was Medicaid. And the hub and spoke is, is that is the payments for is that strictly attributed to medic based on Medicaid as well. Yes, so the spoke patients, the spoke payments are based only on the Medicaid patient panel providers, although once again the services are available to everyone. I was going to say I was interested the services are broadly available however was that. Yeah, I just wanted to confirm that it's payment agnostic as well. And the medication assisted treatment is payment agnostic as well. Is that correct. The health team staff. Yes. For the spoke services. Yeah. Because we're speaking over each other so I'll just be silent and maybe you can answer the question one of you can answer the question is it is the medication assisted treatment program payment payer agnostic as well. Maybe health team staff that we fund through the spoke program or payer agnostic, the claims for the medication, go through the, the individuals and sure. So we provide those wraparound services through the spoke maybe health team staff and every person, regardless of of their pair can access those so those services are, are payer agnostic, but not the medication assisted treatment itself. So if someone got a prescription that, and they had blue cross blue shield. They that would their prescription would go through their blue cross blue shield. But if they're at a site and they just need wraparound support on anything that is payer agnostic. So anybody can come in meet with a spoke nurse meet with a spoke counselor. Anybody can have that that level of services. Thank you. Absolutely. I'm sorry, I just thought of a question in that scenario or when you're working with patients throughout this whole process. What if someone comes, well, I may rephrase this if someone comes in who is uninsured. Is there any conversation about helping them either have you know get on Medicaid or work with an insurance company. Absolutely. Yep, that's a lot of work the community health team does, for sure folks definitely come in. They've just moved here they've lost their insurance they've lost their job they've gotten a new job there's a waiting period you know so absolutely. When I talk about the community health team like having all the tools and their tool belt like they have to have a little bit of knowledge about a lot of things to help for sure but that is definitely one thing they support quite a bit. Thank you. So I just, I would like to add something just for clarity so all of these payments that the group provides are on top of regular fee for service reimbursement that clinicians receive for the services so we are not replacing the fee for service that a clinician doesn't get for doing a work insertion, but we're helping to fund additional services around that work and help support and make that our concerns should more possible at the one time payment, essentially. This figure shows the development of the women's health initiative. So it is our newest program and so it doesn't have quite as much as, for example the PCMH is because we still have some room to grow. But at this point in time we have 22 patients that are medical homes were participating and this is as 20 as of 2021 quarter three and 24 women specialty practices. So we have a little bit over 13,000 patients that are attributed to those specialists and across all of our women's specialty health specialty practices we have 15.9 CHT staff as of 2021 quarter three. So those patients that are attributed to specialists are Medicaid patients. I have a question broadly the women's health initiative. What, what generated that to be part of the blueprint for health. What was the impetus or the initiative that make brought it to be part of the added to the blueprint for health was that where did that initiative come from. Does anybody speak to that. The history, I don't honestly fully know I wasn't been here about two plus years. I'm guessing, again, you know, please stop me if you know different. I think that it was the prams data and there was some conversations because I've looked back at some documents of the planning committees. There was some conversation it appears from maternal child health and Vermont Department of Health, and they came together to look at the pregnancy rate and my understanding is from those planning meetings and discussions that that this came to fruition. But I, and that's just kind of me going back and reading some some notes on that but if you know or Laura, if I'm missing the history. I'm missing some history obviously please, you know, fill that in. I'll go back further but that's my, that is my understanding. Yeah, I'm not sure exactly but I think that a lot of women get their primary care of their own GYN people. So that it made sense to integrate those two ideas of where they get their primary care, but I just was curious as to who, who or how it came to be that they said let's use the blueprint for health as a model. I don't think I'm going to go into that but what they were looking at the population of where primary care was obtained. It could be an either place. I think it was also a priority of the one of the previous HS secretaries. That's, that's what I'm understanding as well but I, yes, I do think the broader picture of where are people getting their health services, and where can we be to question what's your pregnancy intention. How can we support you. And we know a lot of folks may not go to special care or may not see a OBGYN every year for an annual visit but instead they go to their primary care for their annual visit so I think, I think was a few things that came together is my understanding. But just, I think broadening again that home health as we're talking about that whole care where do where to get my health services, and ensuring we're asking all pertinent questions about health. And as Julie mentioned, and spoke to early in the presentation, the blueprint program, and the staff that work in the central office at the Agency of Human Services have a lot of skills and expertise to drive innovation. And so when a problem may be identified or an issue is identified, the blueprint has in its toolbox data and information to inform a potential strategy to address the issue, as well as a staff that can can formulate a new payment model or a system redesign or an innovation to answer the issue so I think in that way, the I don't have all the history about how the issue came to arise but it was an issue that that was one that certainly the blueprint could use its strength and its engine for innovating in delivery in delivery system change and bring that to bear for addressing the issue. Yeah. Thank you. Yeah, I have a question that I'll save for the, it's more global so after you after you finish the current set of slides but representative page has a question right now. Are there any other types of care that you're looking to expand with your program besides women's health specialty programs, maybe childcare. I do see specialties do cover mental health care of some sort or referrals to specialists. They do include pediatric practices and our patient center medical home program. So there are existing pediatric practices within our existing programs. Yeah. And again, if you want to speak to this to I think we are always innovating and I think we've, you know, as everybody has been in a reactionary mode as needed for the past two, two years due to coven so I feel like our fingers are cross right that we're coming towards a different era here and I think that our innovation engines are starting to go in a way where we're talking about some different programming and some things that the community has now been able to start thinking about again and that's what we're hearing from our program managers is like, I feel like I could probably take a small breath here and now I want to, you know, readjust and think about some future goals of new innovations of work that we might want to do but I don't know that we have anything specifically right here on the that we have to share today that I know of the lots of ideas and lots of innovations we're talking about as a team for sure. Key priority priority areas as well such as focusing on access to primary care, focusing on furthering and strengthening the programs that drive towards integrating mental health and substance use disorder services. For example, our key, our key objectives that we are looking at in the coming year. Thank you, you know, yeah, I mean, we're a big part of the mental health integration Council around integration so there's lots of lots of things happening for sure. Okay. Okay. Could you address a little bit more about your interactions I guess with the mental health clinicians with your program. Do you mean outside the primary care or mental health clinicians that connect to like one. Pardon me. Both would be fine. Sure. Okay, yeah. Well, most practices I would say do have some hours or embedded mental health clinician. And I think that we're always working and strengthening our relationship with both private practitioners and communities and our designated agency. You know we're working together with Department of Mental Health around mental health integration we have a lot of subcommittees that we're working on in terms of how do we integrate that. I am a member of our suicide prevention committee and like for instance last year. We did what we called a primary care mini grant where departmental health shared some funds with us and we funneled those to the primary care offices to do some additional training on different suicide prevention clinical models, and also part of the funding was used to have primary care folks, clinicians and nurses actually working with designated agencies, crisis and clinicians to start talking about pathways to care, so that there's a mutual, you know, working towards higher level care again lower level care how do we, how do we support folks from community departments back to their primary care and or again to the designated agency system or independent clinicians so that's an example of something that we've been working on and talking about for the future, you know, could we can we do that again how do we continue that work so I think we're always looking at building relationships with community partners and I think, you know, some areas some somehow server series might say the relationship is great with X, Y and Z, and other people say we need to work on a relationship with that or the DA or, you know, what have you so that really is a part of that earlier accountable communities for health, where those groups come together and talk about again referral pathways working together effective treatment clinical care for folks in their community, general health and wellness so it's always a work in progress but something I feel like communities are really committed to because we can't do we can't do it without each other I mean that's really the key and what we talk about as community is we all need each other to support each other. Thank you. Yeah, you're welcome, of course. We're looking at probably wrapping up around 330 so okay perfect so I think we're on track, but I think those your history of the blueprint slides are have some important bullet points there when we get to that yeah sure. So, Laura do you want to briefly touch on these two and that. Yeah, so in the interest of kind of speeding through these, we engage in a variety of different sorts of research and evaluation initiatives. We have different profiles of our different programs available on our website. We've mentioned some of these before the annual reports, community profiles. Yeah, so those are some resources that are available to understand our programs in a little bit more detail. So we use a variety of data sources to produce those. I'll just kind of speed through this that we get data in our blueprint portal which is a web portal that we have that allows our field staff to enter information about community health team hires. And that helps us understand the community health team locations and scale and different parts of the state. We also have access to identified Medicaid claims we have access to the health care uniform reporting and evaluation all claims database. We also have clinical data extracts from from our information technology leaders and we also administer and receive data on this patient satisfaction. The consumer assessment of healthcare providers and systems the caps on patients at the medical service so there's a probably a few things I've missed on that slide but we have a variety of data that we use to try and understand our programs. So we, we've made this timeline just with some snippets and certainly if they're, you know, you want additional information. But you know we started in 2003 with Governor Douglas to who wanted to control the cost for. Yeah, if I could just inject a question because my question actually. The heading of my head actually ties into this and I'm wondering if you do the timeline. When you're referencing different components of the blueprint, the heading of this is the history of the blueprint. I'm interested in that interrelationship how you're connecting it as part of the history of the blueprint when the ACO or the all payer model and how those connect. When there's multiple places ensures do care management the ACO who's does care management the blueprint does care management. So really if I'm understanding sort of where this all comes together here and I'm just wondering if you want to speak to that when you were talking about that where the ACO sort of began here in 2012 and then which led to the agreement etc is that what I'm understanding. I think I think the question is the question is about the interaction between the blueprint for health as a multi payer program and the accountable care organization, all pair accountable care organization model agreement which is also a multi payer or we all all payer program is that is that the question. Yes, how they interconnect because this is labeled as all the history of the blueprint, and it injects, you know all these other pieces and I've always had a question or concern about. We have all these different models for care coordination and are we, you know overlapping or missing people because there's different organizations all doing care coordination. The blueprint does serve as this very important foundation of primary care for the state of Vermont and, of course, when we look to again transition from the primary excuse me transition to new payment models that really put an emphasis on health and well being. And that will allow providers to shift in how they're delivering care relative to a budget and the strength and the base or the baseline of the of the strong primary care network in the state of Vermont is very important so that's the first way that we think about the interaction with blueprint for health and the all payer accountable care organization model agreement. I really think that, you know, the blueprint being an established program in the state of Vermont for years proceeding the agreement, provided for some among our federal partners that Vermont was that Vermont was well positioned for further payment reform in the state because it could draw on that foundation of strong primary care with its particular assets being the community health teams as one of those assets for coordinating care for promoting the more further integration of services across the care continuum and all of the other activities that Julie is explained so well in the presentation this afternoon. The other way that the blueprint very much overlaps with or why it's important that there's a timeline that indicates the all payer ACO model alongside the blueprint is because the all payer ACO model is a model that at the heart of it the agreement that we have with the federal government really that it's core is about how Medicare can join with other payers in paying differently for health care in Vermont Medicare is is certainly a large portion of Medicare beneficiaries are a large portion of Vermont's insured population. And without Medicare's participation as we look to transform care, you know, we would see the incentives weekend for providers. So with Medicare's participation in the all payer model, that's how funding from Medicare as a payer continues, and that is carried through to the blueprint where Laura was showing the slide that demonstrates the dollars per person per month for Medicare beneficiary that those dollars are flowing because Vermont has a contract with our federal partners that allows Medicare to join in payment reform in the state. So I think those are the those are the key ways where we see the interaction on the timeline. And again the care coordination activities, and the risk stratification models for instance that the accountable care organization has utilized do build on the existing foundation and resources from the blueprint for health. Thank you that's very helpful. Any other questions as as wrap up kind of questions as we, oh look perfect slide yes questions thoughts. I want to just say that I have over the number of years, certainly been familiarized with different aspects of the blueprint for health but this is how this is helpful to me in refreshing my sense of some of the more recent of the blueprint and and how it builds on the foundation of the patient medical home patient centered medical home I guess that's the acronym we're using. And I appreciate what there are times it's still hard to kind of figure out how it all fits together, in terms of the per member per month and which initiative is funded by which payer. But I appreciate understanding more and continuing to appreciate what's the what the issues are I think I'm left with there's one one question which I'm not going to try to ask us to answer now but I'll just put it on the table which is, you can only have a patient centered medical home if you have a primary care provider. That's a given, but if someone doesn't have access to a primary care provider. I guess my question is I guess they are they are left by definition left out of access to primary care and health care, except through to free clinics and well that's that's a whole nother conversation but that the blueprint is built on the system of primary care and I guess, again, one of the, one of the foundational important backbones of health care in Vermont that we want to continue to strengthen and value. I think I'll leave it there. I just want to say real quick and I'm sorry, Jets are going over here if you're doing noise. I think we're also working really hard to ask folks about do they have access to primary care so I think it's mandated now in the Department of Mental Health like in their intake questionnaires and with Dale and sash and other community partners that really any door someone's coming in. I just want to ask, do you have a primary care doctor can I help you find one, you know, can I connect you to those resources so even if somebody at the food shelf called St. Almond's primary care and said I have someone here, and they really need primary care do you have openings that community health team worker could meet with that person and get them engaged get record whatever they need, or even just talk to them and go to that, maybe another primary care office, and that's okay. So that person can help them. So that is a goal to ensure that people have the care that they need so I sorry I just wanted to note that last. I actually appreciate that response so that part of the community health team response is that anyone who does not have primary care part one of their, one of their pieces of work would be to try to help connect them with a primary care practice. That's that's actually very helpful to hear. Absolutely. Thank you very much. We always feel appreciative when we're asked to talk about our program because again, we feel passionate about it I feel passionate about it I've worked in communities. This is my passion in life and so I'm just really always pleased to talk about it so thank you very much for for having us here and we're happy to answer further questions and the money piece can be challenging at times to you got to hear it a few times even myself and we're so thankful to have our data team as well that helps walk us through some of those things, because I'm not a complete data person, being a more clinical person so thank you. I think we have one last question. Thank you Julie actually for giving an example of St. Alvin's because I think it's easier to imagine when you're specific I know is a really wonderful set of work so sometimes when there's specific examples to help us. It's really helpful when we meet again which helps. Thank you. Thank you. Thank you all thank you, and others. Call it a wrap for today. We've had a busy long we chair liver. Yes. Before we go, can I just say thank you to you. I'm sorry, I was trying to figure out what voice this was I was looking for the. I have to just go please. I have just going over to you so you might hear like close we must be close together then. Yeah, I'm at home right now in Burlington in the old north end. I just want to thank you all for the work you're doing. And, and I'm wondering if I could forward an email to you that I had sent out to the general assembly and governor about the social determinants of health just to see your if you had any thoughts about that, and you'd want to talk with me more because I've been talking with different members of the administration and learning more about what's already happening and how to enhance it and I feel like we are. We just did a lot of that in our budget which was great, but I feel like we could always do more. So I just wanted to thank you and then ask if you'd be willing to take a look and maybe just check back in but I don't want to create extra work it'd be more if you like had any thoughts like oh, you might want to look at this or that. Anyone that knows me knows that I have thoughts about any everything. Okay, thank you. I'm a talker and I'm always any and help anybody would I'm sure be willing to as well but yeah, thank you. Absolutely. Yeah. Okay, well I'm going to bring this to a close officially for us today. Thank you represent down here for facilitating and let's.