ready might take it away. Thank you Chairman Bunn. I want to make sure I know how to make this thing work here. Do you get an explain? Okay. And then the pointer is? The black clock. Got it. Okay. Very good. Thank you. Thank you. Well, good afternoon. Good afternoon. I understand that we are the last of the hospitals coming before you over the last couple of weeks, so. Last but not least. Yeah. Thank you very much. We have a little bit of a story to tell you. Obviously, you've had a chance to see the slides beforehand, but we'll embellish those a little bit. But first, I want to begin by thanking the Green Mountain Care Board for inviting us here and giving us the time to tell the story, and hopefully we can answer adequately any questions that you might have. I also want to take the opportunity to express my appreciation to the staff of the hospital who do a wonderful job day in and day out providing care to the Springfield community and the patients that come to us. And to the folks on the hospital staff that helped Tom and I put this budget together for 2020. As you can see, it's a pretty conservative budget, we believe. But it's a very realistic budget, we hope. And we'll talk a little bit about that as we go through it. A little bit of background about Springfield Hospital. It is a critical access hospital. It is one of two in the state that are associated with a federally qualified health clinic. As you know, the clinic actually is operated by the organization called Springfield Medical Care Systems, SMCS, and actually the hospital is a home-owned subsidiary of that parent SMCS that operates the FQHC. So that's the way we're structured. Our hospital has an average daily census of about 12 acute patients. Sometimes it'll spike up to 17 or 18. It did that the other day. As you can imagine, that is a real challenge for us to have enough nursing staff to be able to handle those patients when they do spike up. But we do and we do a great job. We have a number of folks that are willing to be what we call on pervium. We will come in and take those shifts and they're very qualified people and then not work when the census goes down. So we average about 12. We also had a distinct 10-bed psychiatric unit. It's not on the campus in Springfield. It's down in Bellowsville at the old Rockingham Hospital that was converted to a 10-bed psychiatric behavioral medicine program. It averages about seven patients a day. It can go up to 10. That's our total capacity of the 10-bed distinct unit. There are days of the year that we are at 10. And we were there just recently. But most of the time we average around seven to eight patients a day. Springfield Hospital, we'll talk a little bit more about this, and Springfield Medical Care, the parent of the hospital, has filed chapter 11 with the bankruptcy courts chapter 11 reorganization petition that occurred on June 26. We'll talk a little bit more about that in a little while. But even with the cost that you're going to, the cost cuts that you're going to see in this budget and the other changes that we've done with operations, because of the uncertainty of those activity levels and the challenges that puts on the staff, we don't believe that the organization, as it is structured today, is sustainable. And so we're, and again, you're going to hear a little bit more about this in a little while, the steps that we're trying to take to see how we can reorganize the system of organization to function a little differently. From a financial point of view, we have about 10 days cash on hand. So we're living pretty much on the edge. And Tom, we'll talk about that a little bit further. And as I said, we're looking at trying to find a partner in our healthcare way we deliver healthcare in the area and the way that we could then restructure the organization. That's still being worked on as we speak. We have had several discussions with the Dartmouth healthcare organization and other potential partners. And we are currently in a state of where we are with those other organizations, the other organizations being Mountain and Scutney Hospital and Valley Regional Hospital. Along with Dartmouth, we're looking at how we structure those three hospitals along and have Dartmouth as a tertiary that would help support those three rural hospitals, provide care in their respective communities in a collaborative way. We actually, the Dartmouth organization is funding some financial projections that are being done by that firm called BKD. And we hope within the next two to three months to have those financial projections of how those three hospitals might be able to restructure, provide care to their communities in a more cost-effective and efficient way. The chapter 11 process that I talked about a second ago, it's a very fluid process. If you've ever been associated with any organization that's been through that, everyone tells us it will take anywhere from 6 to 12 months. The purpose for having done this strategy is, I think when we were here back in May, we talked about the fact that we can make the organization operate financially going forward. But it's the debt that had been accumulated has to be dealt with. And that's where the chapter 11 strategy process helps us deal with that. But it's moving slowly. The organization is a very complex organization because it is not only a hospital but an FQAC. There's a lot of local organizations entered chapter 11. There's a lot for the bankruptcy courts and the parties involved in that to understand how all of our organization works. And so it will be a slow moving process. We'll try to move along as quickly as we can from our perspective. So the budget that you've seen before you, and we'll talk a little bit about in a few minutes here, is one that's very much in transition. It does try to move us in towards a restructured organization for the future, but it can anticipate all the changes that might occur as a result of those discussions that I've referred to. It also does not and could not at the time that we put this together anticipate the cost of a chapter 11 position. So none of those costs are included in this budget. So the budget is one that if we operated just as we did in the past, this, you know, we would have some ability to be able to say the probability of these numbers being close to accurate and actually incurred. The difficulty with us having to be able to do that now is because of the chapter 11 restructuring process. It makes it very difficult to make those projections. We did not ask for another rate increase. Several people have asked me, why not? Basically because we didn't do that because we are so heavily used by the governmental payers, Medicare and Medicaid, 65 to 70% of our payers are paid by either Medicare or Medicaid. And those payments are fixed payments. So a rate increase only drives up the contractuals for that reason. And the other reason is the board appropriately so granted our request for an increase in the middle of the year. Many of the rate increases that we put in the insurance companies didn't necessarily honor or said they would honor it when they do their normal rate increases, which is first of October. So the 5% increase, we're not going to see some of that until October comes anyway. So that's why we did not ask for another rate increase. So we'll get into the meat of the budget right now. Tom Marshall, who's the RMCFO is going to handle several, the next several slides for me and explain some of the numbers that you see on there. So this is a picture of our operating results in 2017, 2018, our 2019 projected and going into the budget for 2020. As you can see revenue is a fairly flat throughout the year from projected to the budget, where we are in progress is in the operating expense line, we've reduced from $57 million, $5 million down to $51.4 million in the budget year. The projected of $56.7 million, I believe you all asked questions about how we were going to go from $56 million to $51 million in one year's time. But we've already started that process back in 2019 and we'll have some other slides that show that progress that we've already made to the expense reductions. Adjusted emissions, as you can see, have affected revenues. We're in the 98, 97, 98, 100 down to 8,400 in 2020. Average daily census has gone from 14.8 to 12 this year and in the budget, that's what we're using for average patient days. The birthing center has been closed during 2019, so that's affected some of those numbers in the census data. The site census has averaged, like Mike said, around seven a day. We're budgeting 5.7 within the budget year. If I can just add one point, when you look at the volume numbers, which is the adjusted emission line, it looks like we kind of fall off the cliff between 19 and 18, when in fact, if you look at it on a quarterly basis, the decline in activity has really started happening around July of 18 because of our fiscal year. And so the fiscal year that ended in September of 18 only had one quarter of some declines that started occurring around July and then started that decline had continued on and legally that has bottomed out and that activity level will continue to run. That'll be the new norm for us. That's what we anticipated in this budget, rather than those volumes coming back. We don't know the reasons for the decline. Could be population health efforts. That's probably what it is. It could be some of the publicity that the hospital has been through over the last six months or eight months in terms of what the public's images of the hospital. But we've seen that volume start to come back now. Not at great numbers, but it's not continuing to decline. So we're talking about the revenue declines and of course the closure of labor and delivery. We had 152 deliveries in 2018. We were down to 66 in 2019 when in May we closed the labor and delivery department. And gross revenues for labor and delivery in 2018 were $437,000. Net was $200,000. In 2019 we had a gross of $234,000 and net of $107,000. So that affected our top line mostly. Inpatient census again is down from 16.2 and 18 down to really 11.9 to 12 in the budget. We also averaged about 12 in our projected 2019 figures. The psych census has gone from 7.4 into the budget of 5.7. We've been running in this year of around seven in the psych center. How patient volumes, as Mike said, have come down quite a bit from 449,000 tests and visits in 2018 to 408 in the budget. And as of July, year to date, we had 420,000 visits this year projected to come in at 478,000 for the year. But again, it's slowing down quite rapidly. A lot of our EDE visits are down and therefore a lot of procedures are down on the outpatient basis. We had operating gross revenues in 2018 were $3.6 million and we had expenses. I'm sorry. That's the site facility was at $3.6 million and gross revenues in the budget will be down to 3.1 million. So there are no departments left on an operating basis that are losing money on the operating level currently. And with the changes in the restructuring, we still need a partner to successfully emerge from the Chapter 11 process as we talked about our expense cuts. Let me talk a little bit about those. Since this forum has been involved in January, and for me as the interim CEO and Wayne Schultz and now Tom, the two interim COPs have been here, we have really focused our efforts over that period of time of trying to reduce our expenditures to match up better with our revenues and the cash that we're bringing into the organization. So what we're trying to do on this slide is take a look at where we were in 2018 because those are the actual audited numbers instead of any projections that we were doing. And what are we saying those expenses for the entire organization are going to be in 2020? And then we gave you a list of some of the major factors. There's about $10 million reduction, which is awfully significant, but it's the only way that we can try to stabilize the organization from a financial perspective. We've done these reductions very deliberately, very consciously, with a lot of discussion, trying to minimize the impact on the care that we provided, trying to find ways that our items of expense that are more of an administrative point of view. But obviously, we have had to touch some areas that are patient related. The first one as Tom had indicated is back in May, we stopped delivering baby. That saved the organization from an expense point of view, about $860,000 from what we spent in 2018 to zero in 2020. All of the changes that we did in the acute medical surgical side of things, staffing changes, restructuring the way we staffed, our expenses we were predicting for the acute medical surgical side is incorporating some of the reductions in violence. We'll be about $350,000. We've really done an annual basis less than it was in 2018. There's employee benefits of about $1.4 million that we're rejecting less expense in 2020 than we had in 2018. Mainly focused around our insurance program, our health insurance program. We're doing what a lot of other organizations have done previously, and that is we're raising deductibles, asking the employees to pay a little bit more for their premiums, along with some changes in the pension program that we're booking that making as well as obviously the FICA with fewer salary dollars. We have less FICA expense. The emergency department, I think we talked about that when we're here back in May, we've changed emergency room providers, and we've changed the way in which we paid for that service. We accomplished, I think, the fact that we now have 24 hour a day, seven day a week, 365 days a year, MD coverage in our emergency department. Prior to that, we had some shifts that were covered by physician's assistance. Not that the care is any different, but it's proven that a physician can do a couple of things. One, you can see more patients per hour physician assistance can do, so our throughput is faster. As well as as Tom referred to earlier, what we're seeing and experiencing is that there are fewer ancillary tests ordered by those doctors that work for the new firm. For example, the imaging test that they ordered, more of those are coming back positive, so there's less of a test being ordered to rule things out. The emergency room doctors who are all trained emergency room doctors with this firm just treat patients in a different way. We've seen our throughput times go down, turnaround times go down, and so it's been heavily beneficial for the patients as well as taking $3.3 million of expense out. It did reduce revenues because the firm bills for that professional component, so our revenues went down as well, but it did still took $3.3 million of gross expenses out. The hospitalist program, we changed the staffing there to a different kind of a staffing model and that we believe will save us almost a million dollars a year. No difference in the way we cover the hours, just the difference in the way we the number of providers that we have on at any given time, it's just more effective and efficient. We're proposing to change our anesthesia service. We are moving from a hospital employed provider staff to a outside firm that will recruit nurse anesthetists and place those nurse anesthetists at our location on a permanent basis. Those folks will be there. That we believe will save us almost one over a million dollars of staffing and locum cost. And then the final item, the key item there is we're trying to do our staffing without the heavy use of locums, the use of travelers. Locums in the ED alone, in addition to the $3.3 million savings, locums in the year 2018 cost the organization almost a half a million dollars. And we don't see the need to have to do that. For locums anymore because this outside firm recruits the doctors and the physician assistants that are staffed in the ED. And so that the need to have to use locums is almost no. So all of those items make up the majority of the $10 million in expense savings. Tom is now going to show you what some of that has done over the last couple of quarters. This is a 2019 fiscal year that we're coming rapidly to close on. For the first six months of the year, we had the gross revenues of $60 million. Then the next quarter, $24 million. And then for a year to date, June of $84 million were projected July through September of $25 million and finishing up with a projection of $110 million, $500,000 for the year. Now the real importance of this slide is to look at our operating expenses. We've gone from an annualized rate of $62 million in the first six months. We started making our cost reductions in March and April of that year. That quarter was coming as an annualized $53 million. And then so we're projecting the last quarter of the year July through September of the year. An annualized run rate of $49 million as opposed to our budget, which is $51 million next year. Now part of the reductions are all those items Mike had gone over, but we purposely are monitoring our expenses very closely. When we filed for bankruptcy on June 26th and prior to that, we were doing weekly cash flow projections, because as you saw, our cash was very tight. We were down to like two or three days at one point. So we're really managing our expenses based on our cash inflow. And under the bankruptcy rules, we have to maintain the payment schedule that we submit. We submit a 13-week schedule every 13 weeks. It's updated and we have to live by those expense categories. So that helps us control our expenses. We've had to redo how we order items. And that's been a learning process with the department heads. At one point, a lot of the department heads could do their own ordering and order supplies and services. And now we've centralized all of that. We're building up our materials management department and putting the tighter controls, because we've got to know each week what we actually need to spend. Now in bankruptcy, of course, we get relief from all our creditors that were in place prior to the filing, but post filing, we have to pay all our bills under the court orders. So we can incur anything more than we can actually pay. So we have to have real tight controls on that. And it's been a learning process for our department heads and staff of where we're accomplishing the goals as set forward. And that's reflected in the budget for next year. That's why we are able to feel very confident that we could achieve those expense goals within the budget for next year. This is kind of, again, a summary of what I just spoke about by quarter and how we're coming down with the expenses under this new control system. You've heard Tom and I now talk a lot about just the actual revenues and expenses of the organization. But we wanted to take a look at and use some information that we have received from One Care of Vermont back for the period of January to March in terms of what the total cost of care was in comparison to other hospitals to see if there was opportunities to look at it. And you can see on this graph that we tried to do is just reflect where Springfield Hospital ranked in terms of other hospitals in the state relative to some of those major categories of lines of care. And the area that popped out was obviously our emergency room. Both being two or more standard deviations above the meeting. And so we've done a few things in this next slide. We wanted to share with you a little bit about what we've done that we believe is going to have a major impact on that total cost of care measurement. This slide just lists off the bullet points that do that. The one I really want to take you down to is the second from the bottom. The biggest change we believe that will have an impact on the total cost of care was what I referred to earlier, the change in the providers in AED. The new model that we have an MD 24 by 7, they're less likely to admit to have longer observation periods. They have a greater capacity to determine the level of care on a very quick basis. And they appear to have a different, we'll call it a more appropriate use of imaging. And what I referred to earlier was that the fact that on average a physician is not just our location, it's across the country. On average, you can see one and a half patients an hour where the average for a physician assistant is more like a half patient an hour. They just move through the care for the patient much quicker. So that was probably the major impact that we think is going to have on that total cost of care. If you go back up to the top of that slide, the second biggest one is back in July of 19, just a month ago, we brought on to the staff and a care coordinator in the AED for follow up with mental health and substance abuse issues in placement. So some of the things that that person does are the next several bullet points. They're planning outreach by care user to develop more efficient and effective plan of care. They're providing onsite assessment for the intensive outpatient program that we have, which is basically a group therapy program in collaboration with the designated agency that's there in Springfield. The planning implementation of rapid access to the medication assistant therapy program. So all of those things that that care coordinator in the AED now can do that we didn't have before, we believe will have a major impact on the total cost of care. And then the last bullet that we've just recently instituted was increase in the capacity of same-day visits in our primary care practices at hours in Springfield, in London Dairy, Lundlow, Charlestown and Bellows are now seven days a week. Six days a week is London Dairy, five days a week is in Springfield. So we believe that added capacity for those walk-in type primary care services will have a major impact on that total cost of care also. One of the last things that we wanted to then address is the issue of the payment reform and the One Care for Life organization. We end the FGOAC as participated fully with all the payers in the years 2018 and 2019, we're in that right now. However, we believe that the challenges that we faced in 19 in getting some of the information on a timely basis puts us in a position that we believe at least for the Medicare payer that the board felt it was not fiduciary and responsible on their part to take on the potential added risk of participating in the One Care program for Medicare and that being the hospital being paid the traditional way was more predictable for us. The downside risk was less for the organization and so for the year 2020 and it'll be re-looked at in a year from now but in the year 2020 the organization will want to participate in Medicaid and Blue Cross for the ACO in 2020. So in case you have any questions concerning that. Then just to summarize if I can basically I think we've talked about this before when we were here in May in late 2018 and early 2019 we were an organization that was pretty close to classic on a financial point of view. It was very very minute by minute. Today we're an organization that's in a state of transition. We believe we've been able to get our arms around the cost of the organization without materially decreasing the quality of care that we provide. We had the CMS organization through the Department of Health visit us on July I think it was 8th and 9th shortly after we filed our petition in the bankruptcy courts. They spent two very intense days at our organization. What I've told people is they pretty much picked us up, shook us around and looked at everything that we did that actually gounded and went into the OR and at the end of that visit they said they were very impressed with the dedication that the staff had towards the patients. The energy level that they had, the enthusiasm that they had and that they did not see in any area where we were deficient in making sure that our care to our patients and the safety for our patients was being jeopardized.  We have begun the restructure of our cost of providing care and continue to do that every day. We're always looking for ways that we can do things better and cost us less. We thank the state for helping us with our cash crunch in the early part of 2019. We thank the board here for listening to us back in May and bringing us a price increase. And so we continue to work on that. We have tried to address the past debt by doing a very well thought out by the board decision to file a chapter of a reorganization petition. That's challenging for the organizations. It's challenging for the staff. It's challenging for the community to understand. But we are open. We are anxious to take care of patients who come to us. And we're trying to collaborate with hospitals like Brattle who are sending some of their staff up, their obstetric staff, so that if it's convenient for a woman who is pregnant to see their provider prenatal type services, they can do that right there in Springfield on our campus and have access to all of the ultrasounds and so forth that they might need. So we're trying to do those kinds of things while we do this debt restructuring. And then finally, we're spending a lot of time with folks from the Dartmouth organization, from Montescutney, from Valley Region, trying to see how we can restructure the way we provide care for those communities in a more cost-effective way of doing that. So that's kind of where we're at. This is only going to work if our community supports us during this period of time. Our staff has been phenomenal. They have supported us all along. There have been some staff that have left because of the uncertainty of the organization's future. And I don't criticize them for that. I understand that. But the staff that are there are very dedicated to Springfield Hospital, to the Springfield Medical Care clinics, and to the community and the patients who come see us. So with that, I just want to, I guess, our recommendation would be that the board with C-50 be able to approve our 2020 budget as we've submitted it. We're ready to answer any questions that you might have. Thank you. Thank you, Mike and Tom. I'm going to start with Jess. You don't want to forget me this time? That's right. Okay. Well, thank you for the presentation. I guess my first question is, given your financial situation that you came into, you have to say no choice but to do a deep dive into your expenses in it. Judging by what you've done, saving $10 million in one year, it's huge deep cuts and lots of thought that went into it. Finding opportunities for cost-eating. We've just had budgetary and a bunch of hospitals, many of whom are not in the same situation, but are facing many of the margins and looking for opportunities for cost-eating. I'm wondering if there are any lessons that you would share places where other hospitals might look. Things that surprised you when you walked into Springfield Hospital and saw this is the way they were doing it. Wow. Here's a little hanging fruit. What lessons could you give in part? I'll try to address that because I've got more tenure than Tom. I was there from the very technical term, the giddy up. It's difficult to answer your questions. It's a great question, but it's difficult to answer it because every organization is different. Tom referred to earlier, and I'm going to try not to be critical of the previous management of that administrator and so forth, but the organization was, as Tom referred to a little while ago, kind of loose in the way in which they ordered supplies and so forth. Everybody could order a supply, and if they found out that it might take two days, they were ordering it on Amazon. So we had to tighten that up. We had to try to get to a centralized purchasing arrangement. So those are the kinds of things we did. One of the big pieces in the puzzle of the cost was looking at that service of Chaubert. That was a very difficult one, not one that every community can do. But for us, it was a must. We didn't have a choice because we just couldn't find other areas that we could reduce cost and continue to run that program. It's only because we made that decision that we could change some of the staffing for our hospitals and change some of the staffing in our anesthesia services, because now we do not have to have someone waiting in the wings all the time for any woman who would come in for the ED and have to have a surgery C-section. So those kinds of things, I think it's just, boy, to try to generalize it, it's just not that other hospitals aren't doing it, and that's why I'm trying not to be critical, because it's hard to... I know I put you on the spot. Yeah, it's hard to answer that because you don't know what other hospitals are doing, but for us, it was just tightening up a lot of practices and policies that we had, things that we had to get our arms around and not stock our shelves so much, try to get people to see that it may take... Yeah, no hoarding, it may take an extra four or five hours to get, so you don't need to stock up 12 of them. It's just some of the basic stuff that we had to do, and then some of it was, as you knew before, we had to ask people to give up some of their pay for some period of time. You know, and some people have criticized us for having done that, but it gave us the opportunity for a short period of time to be able to have our expenses lower than what our revenue that we're bringing in, so we can buy ourselves the time to do some of these other things. So I know I'm not answering your question, but I'll... Let's talk a little bit about this, and the other, I guess my second question related to that, you've also had to think about appropriateness of care, right? Balancing access to what was needed by your community with can you cost effectively deliver, and you have enough volume to be able to produce the quality outcomes that you would want, and so I can imagine some of the, you know, you did some service line evaluation, right, to some degree, and the fact that you're encouraged to hear from Mount of Stutney that the four hospitals, Dartmouth, Hitchcock, Valley Regional, Springfield, Mount of Stutney, are getting together to think about some sort of regional planning in terms of service lines, and I'm wondering if there's anything you can speak to with respect to that, what criteria will you use to try and figure out who does what to ensure that access to care is not compromised, but it's delivered in a cost-effective, high-quality way? Yeah, I don't think there's not going, there's be a little bit of science in it. I've been involved in these kinds of situations before we're hospitals, I've tried to get together, there's a lot of just gut feeling, and when I say that what I mean is there'll be hospitals that will do a particular line of business better, and when you take a look at some of the measurements or some of the capabilities of doing it, for example, if I get specific, we've got two very highly qualified urologists, for a hospital or science that have two urologists, you know, it's marvelous, and so, you know, but when I sit down with the other three CEOs in Dartmouth, I'll be pushing that if we're going to start looking at centers of excellence between those three hospitals, that urology could be on the table for Springfield to maintain or find a way to do that, because what we don't want to do is do something that will scare those two urologists away, and that uncertainty, because they're being recruited, like every other physician especially is being recruited on a daily basis, on an hourly basis, and so we've got to be careful about, you know, how we move forward. So there'll be a little bit of that kind of discussion that, you know, where those patients come from, which organization would be best to have it at, but the whole idea would be let's not try to triplicate what we're doing, because that's not very cost effective, and it begins to challenge the quality, because you can't assure yourself that if you need two specialists to do that particular service, you're going to be able to get six of them to come to this area, you can get two, but you may not be able to get six. I think we're all looking forward to the results of all those conversations. Can you turn to the total cost of care slide? I think it was 10. Yeah, that one? Yeah, that one, that'd be great. So first of all, I want to say I appreciate the efforts that you're making to lower total cost of care, to think about these initiatives, you know, you've got several initiatives to address the total cost of care in your community, particularly in light of the financial situation that you've been under, that you're still finding time to think about ways to address this. A couple things. The slide, I think, I don't know if you could redo it for us, because unless I'm misunderstanding this, the orange is reflects being one to two standard deviations either above or below. There's a big difference. You have almost two standard deviations above and almost two standard deviations below. There's a big difference in there, but they're all colored the same way on here. So I'm wondering if you could resubmit this with another way of looking at it. So we can tell where are you above the average and where are you below the average. And you can have darker colors if you're way above the average and a slightly lighter shade if you're slightly above the average. But you see what I'm saying? Yes, definitely. We use this, the initial time we used this, this was more directional, and that's why we did it this way. The direction we wanted to really hone in on what we thought to be the greatest opportunity for success and not get scattered in too many different places. And I just bring that up because in the data that we submitted in our guidance, the total cost of care for the Springfield HSA, actually not risk adjusted, but Springfield is the second highest on that chart in our budget guidance. In the blueprint profiles, it's also second highest in the state, and that is risk adjusted. And it was the third highest in resource use. So when you look through some of the blueprint profile individual data, advanced imaging goes really high, as you mentioned, and I'm really glad that you've got a methodology to try and address some of that. But screening rates, chronic disease management were low, inpatient use was high, admissions for conditions that could have been prevented by early intervention, primary care were high. So to me, it almost suggested that there wasn't enough primary care in the community for some of the conditions that we're seeing not being addressed, not being managed, not being screened for. So I'm also really happy to see that you're increasing capacity for primary care in the community. But I'm still, that data is a little out of date in the census 2017, and that's what the blueprint profiles have now. So it would be helpful for us to see this is one care data, much more recent, but color-coded in a more specific way. That'd be helpful. A question about your bed. So we always hear in all of our hospital budget process, the number of borders for psych patients and ERs, the lack of capacity for psych beds. You have 10 psych beds. And my question to you is, it's been at our documentary has been about seven. I would have thought it would be closer to 10, given what we have in the state of need for psych beds. But I'm even more surprised that in the budget for 2020, it's dropping to 5.7. So can you just tell me, just to me, there's a disconnect between the obvious need in the state for psych beds and the dropping in projected capacity or utilization there. I think the only connection that we can really draw is we are limited to being voluntary admissions to that psych unit. And so we can't. And those are all stepped out, right? That I don't know, Kim. I don't want to say yes, I believe it is, but. Well, we're definitely not inpatient at cube psych beds. Right. No. But there, but some of the, some of the, I thought some of the pipeline issue was there were that step down or people having trouble placing people when they're ready to leave hospitals, there aren't enough places in place, particularly for geriatric. I guess I'm just trying to understand. The other thing is, the second reason is, is that, that we're trying to approach this on a very conservative basis. We're trying to underestimate and overperform.  And again, don't know why, why that doesn't jive better with what appears to be a demand in the state, other than the fact that we are solely voluntary admission status with the state. But we try to be conservative and project that census. We need that census. And there's not a lot of additional staff we need to have to have nine or 10 patients versus seven or eight. So it's a big plus to us if we have another one or two patients a day. And that was one of the operations that was actually breaking even or actually contributing to a margin, right? It was. Yeah. And my final question I've been asking all the hospitals to get a census relative pricing. So service that's reimbursed by Medicare, $100. That's frankly, what would the same service be reimbursed on average by your commercial payers? I'm sorry, I fully understand the question. So a service that's being provided a Medicare patient comes in, it's reimbursed at $100. That very same service, a commercial payer comes in. What would that reimbursement be on average, given that's a commercial payment? Same service, different payer. You can get back to me if you need to. Yeah. I think what you're asking is we were looking at this before we came over here today and what the difference for Medicare charge versus what we're getting paid on average. And I believe that was someone in the neighborhood of 42%. So we get 42 cents for every dollar that we charge a Medicare patient, we get 42 cents in reimbursement. So I think what you're saying is it would almost have to be $1.42 to the commercial payer in order to cover the shortfall that we're not getting from Medicare. If our charges were equals our cost. But that's not going to be the case either. So we'll have to get back to you. That'd be fine. Let's see if we can answer that. Thank you. Okay, Marie. Thank you for the presentation. A few questions are somewhat rude to the bankruptcy. But I know as you've gone through this process, you need to pay everybody now going forward. However, have you had any issues with suppliers or continuity of supply for people maybe weren't getting paid for some of the stuff that was in the past that now you expect to partner with in the future? Are you having any other concerns with any vendors or suppliers? Many. It's initially almost day one. It's been a constant negotiation with a lot of our key vendors to assure them that even though what we owe them in the past is now put into the bankruptcy protection that we have to pay them going forward and will pay them going forward. So it's been, I've been on a lot of conversations with CEOs of the companies that represent the vendors and we could pull, we could force vendors to supply to us through the courts, but that's a very expensive and time-consuming process. It's better if we can negotiate. Even if, a lot of times we wind up negotiating, we prepay for services and now we're starting to get to the point where we can maybe get a net 10 days to pay and eventually we hope we can get back to a reasonable net 15 or net 30 payment plan with our key vendors. Okay, so some of it's prepay and are you seeing any vendors or because you have to change suppliers costs going up? No, no, we haven't had to change suppliers yet. One is linen. Oh well, linen, the linen provider went bankrupt on their own and we went from a laundry service to immediately we're now going into a linen rental program and it's going to cost us twice as much to do that program but we were at a position in the area that there was no alternative. Clean, laundry went out of business with servicing a lot of hospitals. And going back to your financial results, your trending page you have, a couple questions on that. One, in 19 where your operating income is the negative 6.5, you know in your most recent financials you have a little over eight million dollars in other operating revenue, although of course it's not revenue, it's a loss, getting to 15 million, you know how it's a loss. Do anything move in 19 from what would have been an expense category to those areas and in 20 what's your projection because you have zero there for other operating. So it's not on this slide. It's your non-operating revenue. Are they transfers? Yeah, so can you talk a little bit? Those are costs that are part of SMCS and that the hospital we have cross expenditures. For example our health benefit program is all paid by the hospital and on a cash basis and the cost of that is transferred over on the books to SMCS. We have staff that's on SMCS books that's transferred over to the hospitals. We have a lot of cross pollination going on and that line over the years it was detrimental to the hospital the positive to SMCS when we had those kind of services. I guess there's a follow-up so in 19 it's a negative 8.6 million right and in 20 we have it as zero and just want to... Yeah we're moving towards where SMCS has to stand on its own as well as the hospital will be standing on its that's going to be forced to us through the bankruptcy process so we're planning on that going forward. So that was another question. So as far as the FQHC you're not subsidizing the FQHC in the 2020 budget? Correct. You started off talking a little bit about there was some conservatism in the forecast that always worries me a little bit especially with the history with Springfield but when you look at the 11 million if you look at the projected July through September of your net patient revenue it's 11 million in the last quarter and your projected 19 is 49 million and your projected 20 is 49 million but most of that trend had occurred in the first six months of the year so just want to talk about how comfortable you are that that's going to increase each quarter to get you to a run rate of 48 million for 2020 because obviously you cut some services things have changed and that's part of the reason why you're coming down so I see you know you had 9 million in the in your third quarter you're projecting 11 for the fourth but you know the first two quarters were running more like 14 million each. We've had a number of adjusting entries that we've had to record in contractual adjustments that are catch up entries even from back in 2018 that the current books we brought in some of our quorum experts on reimbursement and issues and you know the PIP program with one care etc we've had to make a lot of adjustments to our contractuals the net revenue numbers historically right now are now being trued up we expect in 2020 we'll have that all in enough shape that we we feel confident in our net revenue numbers going forward but we've had a lot of catch up entries about some of that contractual change actually was a favorable change we had a two million dollar and where did that book through in the month of May so that would have been 11 for that quarter and then it's 11 now I'm just saying get to 49 million you have to get back that trend going up right each quarter and but that stabilize what we feel is our going forward contractual that we've baked into the budget going forward and it's not a true run rate to just to take that one quarter okay it's just you know in the past the expense load you kind of have that as a base that's harder to change and if you ended up only coming in at 44 million that would be a challenge and I know you'll be watching it every day if you need to and then you talked a little bit about why you didn't do a commercial rate increase and I would just question you know whether or not you know if if in fact when you're saying it didn't really go through potentially when you did the secondary one this year because then if it did if some of the did go through in May you wouldn't be seeing a new increase until you know a year plus later so not saying the board would approve it but obviously you're in a lot of financial difficulty and if there were a commercial rate that was trying to put forward you know what were your thoughts on that yeah again it was it was more the fact that the the amount of dollars that ends up falling to the net revenue line from a rate increase for us it's just not you know it's not significant enough to be continuing to raise our prices I'm concerned that we're going to get to a point for the folks who are price shopping that the prices are just going to get you know to a point where they're going to choose to go elsewhere because our prices are so high they don't understand the concept that we've got it was more of a price market sensitivity issue right and you're about 45 is what your revenue comes in commercial so you're you're not on the lowest but you're on the lower side but you know because of some of the other hospitals don't know about that but I understand what you're saying the commercial gets fairly high that's all I have things just a couple of questions sticking with the payor mix here for a second so I'm looking at your history um from 2016 to 2018 uh that the Medicaid was uh between 13.6 percent or 14.4 percent of your NPR commercial 53.3 percent 56.2 percent and Medicare 29.8 percent 33 percent and now the most recent is for 2019 projected and uh Medicaid is up to 18 percent commercial is just noted is around 45 percent and Medicare is um at 35 percent so I'm kind of looking at that and then thinking about this morning's conversation about the capacity that exists within 20 miles of Mount Scottney and Springfield and and the hospitals in New Hampshire and I'm just wondering as you hope that things are bottoming out here and making a turn uh and meeting with people that might be potential partners what are the two or three positives reactions that you get from those folks that uh inspire you to that that there is the light at the end of this tunnel not sure if I know that there's a light at the end of the tunnel or not um I think you know the kernel that I'm getting is the willingness for for us to talk pretty frankly around the table um and to talk about the fact that uh we've got to look at trying not to duplicate and triplicate what each of us are doing that's not going to be the success in the future but we also recognize that uh we today each have our own boards that are in our own balance sheets that we have to worry about um and and so I think there's only one single kernel if I understand your question I think there's only one single kernel that keeps me optimistic is that that uh Dr. Paris uh Dina Howard um Steve LeBlanc and myself are willing to have these kinds of conversations and pretty frankly in an open conversation we're not trying to hide the why I can't I can't even think about talking about that because that's kind of like a sacred count we've got to have that in this community we're not approaching any of that that fashion we're approaching any you know how do we best do this amongst the three hospitals with Dartmouth supporters with those conversations start going sideways on me I'm going to lose that optimism and uh my other question was just looking at the uh trying to get totally acclimated to the math here associated with healthcare provider tax and so I'm looking at from 2018 to 2020 the total operating expenses um at 83 percent of what they were in 2018 but the provider tax is at four and a half percent at at a hundred and four and a half percent so provider tax still going up and your operating expenses going down and um is is is is that what should be happening as I understand it the provider tax is a percentage of net revenue not so much your expenses so cool it is but uh I don't think they base it on the budget I think they they're basing it on historical numbers so it's going to take a little while for that to catch up for that calculation as I understand it Robin um most of my questions have been asked so I had just have a couple of clarifying questions um in your narrative um you indicated you weren't expecting any additional pay health reform payments and I'm assuming that's because the population health payments from the ACO go to the FQHC so those will be brought up separately is that that's correct that's that that gets reported on the SMCS records thank you um and you had said that you understandably had not included the cost of the bankruptcy proceeding in your budget can you just give us a sense of magnitude in terms of what that might look like we've we've been told to plan on somewhere in the magnitude of about a 1.2 to 1.5 million dollar yeah that's legal fees and professional services and the trustee cost the court cost that's if we can get out within six to twelve months it goes on longer than 12 months and that number is going to keep it larger and larger so Mike and Tom are you the two committed to staying through the restructure um Mr. Chairman I can say I am um Tom has had some personal things that that have come up in the last week or two that you will probably have to make a change at that CFO level we do have uh that's going to be hard on you because this will be number three um sorry Tom yeah I don't know if I'm chasing him away but um I hope I'm not uh yes but on the other hand um these are very very talented CFOs and it doesn't take them long it's probably more difficult on the accounting staff the training that they have to take time out to do the training when the person is coming on then and so much difficult on there but um they're very talented executives you know we're very fortunate um it's going to sound like a commercial but and so maybe it is uh you know I've been around for a long time we have a lot of very talented executives that want to work for form and so I'm very confident that I don't we already have somebody lined up very experienced knowledgeable knows what the situation is um and we're working on a transition timetable right now but I'm I'm committed you've got willing and as they got willing and the creek don't rise I'll be here perfect you talked about um expansion of the primary care practices and yet last year you lost money in the primary care practices is the expansion result of better knowledge of when people would actually access the care or how did you come to the conclusion to expand and something that was losing money are you referring to the walking clinics yep um primarily from the standpoint that that's what we believe the customer really wanted um and um we're going to try to see if that's what they wanted by making sure that they show up that they if it turns out after several months that we're not as busy as we thought we were going to be then we'll have to pull those that that you know staffing back but at this point um it's a contracted service it's not a hired service so we can get out of that relative equipment so help me understand because I know that technically we're focused on the hospital side here the hospitals was fully owned by the FQHC the bank allowed for separate filings of the two entities so what does it mean for the hospital if the FQHC continues to lose money um it will have almost an impossible task of coming out of Chapter 11 if it continues to lose money it's going to have to show an exoplanet that exoplanet is going to have to show that it can stand on its own financial could it possible result result of the bankruptcy court beat though a split up of the entity um it could be Mr. Chairman I think it's going to be more of this um the issue that's going to play into that more is going to be this regional planning that we're working on because because you know no one can own that FQHC I think I've given my general counsel coronary so I thought a lot of the question does the uh estimate that you gave us earlier in include the um creditors I'm sorry you gave us an estimate of the cost of the bankruptcy proceeding oh no that's not that's not the settlement of the creditors that's just the attorneys and professional fees for the court itself the court itself and so forth okay that's we we haven't gotten to the point and we're a little ways away from figuring out the settlement for the creditors and what that the amount of debt of the organization might have to continue to care as a result of that and I'm assuming much to my chagrin the attorneys get paid first oh yes that's what I thought but the court really is got high controls on that the court decides what the attorneys will be paid okay I guess that's all the questions I had at this time Robin from your questions around the primary care I would assume that if if part of what's going on as you expand ours people stay locally instead of perhaps going to primary care someplace else not only does that help to FQHC but it could also help some of your ancillary services and referrals back to the hospital is that a fair assumption that's what part of our logic yes okay thanks I just wanted to make sure my logic was matching thanks okay at this point we're going to turn it over to the healthcare advocate thank you thank you thanks for your presentation looking at your bad debt and free care members I recognize that you are small and so you know a percent of bad debt as compared to your medication revenue that looks high or seemingly high to us might be related to a few small a few cases I guess that's really my question here your numbers for 2018 you're showing 11 percent your bad debt is 100 percent of your net patient revenue your best that's significantly higher than the other hospitals you have the idea what's going on I think it's probably a combination of a couple of things one is and I don't know this for facts so I can argue against or correct it but since I've been there I've been told that the economy of our service area is one of the poorest in the state and so I think we have a number of people who either came qualified for any kind of the free care programs and then just choose not to pay the other thing that that we've been working on is trying to tighten up our whole collection our hospital collection efforts before it goes off to a collection agency because once it goes off to a collection agency it's basically written off as bad debt and if there's any recovery it's offset so if we can improve our services we can reduce the amount of money that we have to send it to that debt then the other comment sort of just generally when we look at your 2018 numbers your public payer versus private payer you don't low you actually look like you're in better shape than many in the hospitals and that's confusing to me that for 2018 some other people said some of these numbers said that we were showing 45 percent of your net patient revenues from the public payer and 54 percent from the commercial payers and you know I see you sort of shaking your head that again we're comparing you to the other hospitals it just sort of leads me to the question well actually it did lead to the question a moment ago you said you didn't ask for a rate increase because of how little impact it has yet all the other hospitals will come in and ask for a rate increase even the smaller percentage of the net patient revenue coming from commercial payers but but I'm wondering if those other hospitals had they gotten a bid year this past year would also ask for another if they didn't get one 12 months ago I mean we would be also asking for a rate increase but since we just got one that doesn't make a difference for everyone that's good okay thank you this is my question okay so at this time I'm going to open it up to the public for any comments about the Springfield budget. Dale. I didn't see anything in documentation and I realize this may not be totally relevant maybe to the type of presentation this was but considering during chapter 11 wouldn't there be a concern about surveying the community from a qualitative quantitative perspective to see how they are responding to what is happening with the hospital because they're the ones that are going to support this hospital in order for it to be successful so I'm just kind of wondering did I miss something where's that something that tells me how the community is responding to this well I think that in Mike may want to say some more on this but he's had a number of town hall type meetings with the community trying to explain the situation what what you're bringing up was my concern from the beginning that the community itself needs to get more involved that they truly want to save their hospital and that's been a concern of mine from the get go but Mike I don't know if you want to add anything sure I can I can add that we have had several rounds and Josh Dufresne who's in the audience and is very very involved in the community and involved at the hospital and with the clinic has been joining me on these town hall meetings where we're trying to get the feedback from the community as to how they're feeling initially those were very well attended the last round there wasn't as many people attending so we're not reaching out to as many people as we were hoping the other thing that we did is every three years we have to do a community needs assessment and we're just completing ours now and as a part of that there are focus groups as a part of that process and we're using that opportunity so that we're not over flooding people with town hall meetings or surveys or anything like that we use that process of meeting with the people during the community health needs assessment to get some kind of reaction as to how they're feeling about their community hospital just in general in addition to the community needs that we're doing. Okay is there another public comment? Jeff? Yeah I'm Jeff Keeman with the hospital association just a few quick thank yous as we conclude first thanks to the powers that be that these hearings are over and really importantly thanks to Mike Halstead and Josh Dufresne and the team at Springfield for really amazing efforts to begin to stabilize a really struggling hospital that's critical to care in Vermont and then last thanks to the board for a couple things thank you for the opportunity to address you at the beginning of these hearings with with sort of the perspective of the hospital association we really appreciate that opportunity and thank you as well for your thoughtful questions this is not an easy process and the outcome is really important and you took it seriously and always do and we thank you for that and then finally thank you for the good judgment you're about to use in reaching the right conclusions thanks. We'll see in two weeks if you still say that. Yeah but thank you. You have one over here. Oh yeah. Mr. Chairman do you ask the hospital if they do radical prostitutimies? So Mike? Nope. The question from Mr. Davis is do you do radical prostitutimies? I don't have a clue but I'm looking at my chief medical officer back there. We have the capability I don't know if they're done at Springfield we have your office at Dartmouth as well so it depends on the case and I'm not exactly sure what exactly is he doing at Springfield. Is there any other public comment? Seeing none I wish to thank the team from Springfield I know it's been some trying times a lot of hours put in trying to save the hospital and I know this board appreciates all the work that everyone to try to keep services available for people in the Springfield community so thank you.


What's going on everyone Sam here with Leighton sports cards, and I am ripping one box of 2021 penini Don Russ optic Football for Jeffrey H. So good luck Jeffrey see what we got in here, man. Hopefully something huge Donny Smith on top Marcus Stevenson got Russell Wilson Aqua to 299 Nice Russ off a OA rookie got Josh Allen a little bit of a color match to 299 on the Aqua That is the Jags Josh Allen was in this so far Micah Parsons base rookie and Aqua again Clyde Edwards to layer this time to 299 Nice CEH. I thought that was another one for a second. I was like no shot for in a row Nice Trey Lance base rookie Niners and Peyton Turner silver circles to 125 Elijah Moore and Chuba Hubbard purple to 50. There you go. Nice Chuba 37 of 50 on the Chuba Hubbard solid one there For sure for sure for sure Mari Rogers got silver Jeremiah Usukura moa. Nice J. Okay. We pay Frank's got orange Deon Jones to 199 oh Nice pink velocity Greg Newsom the third rookie auto for the Browns 11 of 30 Nice one there 2021 first rounder starting corner there solid solid auto there Jeffrey Javante rookie Sunday Samuel Jr base rookie Skridge base rookie Jeffrey's now a part of the Skridge Club Simi Fajoco got Great Iron Kings rookie a Mamre St. Brown insert lion Z's O'Jallari got silver Eric Dickerson or hollow. I should say Gabriel Cox got red to 99 Justin Jefferson 64 of 99 on the Jay Jedis Nico Collins rookie Texans and no problem Mike. I just saw the thank you. Sorry about that. You got it, man Luke Farrell got global Jamie Gillan Browns punter love there Patrick Sir tan got off color maps lime green to 35 Dallas Goddard for the Eagles Who does love the Skridge picture? Oh, yeah, you know it Luca Josh Palmer nice legendary logos Trey Lance nice one there silver Yes, Invicta one of our YouTube members and customers made it for me sent it to me on discord Zach Wilson base rookie silver Frank Clark Yeah, Skridge picture was needed for sure fighting Darth Vader Joe Burrow penny Sewell and last pack here near Smith Marseille and elite series rookie Ramandre Stevenson That'll do it for your break there Jeffrey congrats on the hits man. We'll get those right out to you


Hello, welcome to OER at the Museum. This presentation provides a broad toolbox for involving a local cultural institution in an open educational project based on our experiences at Jefferson Patterson Park and Museum from April 2021 to the present. I'm Chris Given, the Digital Education Coordinator for JPPM presenting on behalf of myself and my colleague Noah Boone, the Digital Education Content Developer. For the last 18 months, we have been implementing an OER initiative at Jefferson Patterson Park and Museum, including surveying practitioners and users, developing content and training others. The process itself, as indicated, is very broad. It's designed to be filled in with your own content along the way. So the bulk of the presentation is about defining these steps and then providing some details about concerns that your museum partner might have based on this experience. We believe that museums and OER go together. Our experience as JPPM got started publishing OER, though, is that museums are underrepresented in the OER community. We know there is an interest in using resources from museums, often at the local level, but sometimes more widely as well. Educators often use visits to cultural institutions to highlight concepts, add engaging components, see real-world examples, or just rely on staff expertise. Since educators and related OER practitioners have the greater experience and more targeted resources at getting started publishing OER, we advocate the use of partnerships as a way to support museums within the OER community. Alternatively, if you are not knowledgeable about OER and are interested in partnering with a museum that is not knowledgeable either, our observations should still help. Jefferson Patterson Park and Museum, or JPPM, is a state-operated park, historic site, and museum in Southern Maryland. The park is open to the public, serves local schools from K through 12, hosts secondary students, and even provides professional education. And it attracts visitors with its green spaces, historic sites, and cultural activities. Our OER initiative began in the spring of 2021 thanks to funding received through a grant from the IMLS CARES Act grants for museums and libraries. For the bulk of our presentation, we'll be covering a relatively simple process that has worked well for us here at JPPM. However, the process is intentionally broad, so you can integrate it with your preferred tools for planning. Rather than giving a full-fledged tool kit, we're providing a tool box with drawers or areas for your preferred tools that you might already be using or for new ones for you to discover. Those areas or drawers are ideation, dialogue, brainstorming, revisiting your schedule, deciding responsibilities, creation, publication, and evaluation. The first step in our process is ideation. This is the time where you consider what resources might result from a partnership or what partners you should recruit to create a given resource. Think about information to give your museum partner. Multiple contacts helped us determine what the classroom setups were like, what technology and devices were being used, what sites were available and which were not. In our tool box, after ideation about the type of OER to result from the partnership and your potential partners, dialogue comes next. In this case, dialogue means the initial conversations with a potential museum partner, outlining the broad goals, probably providing a broad definition of OER and inviting further discussion. Dialogue can easily start with a cold contact or go through previous contacts. Some considerations you may want to include in your initial contact are the overall goal, the time you expect will be needed, and possible expenses or specialized resources. We've used a structure where we conducted the initial ideation, then launched dialogue through email before meeting in person to brainstorm the next step in our toolbox, followed by working periods. The key is to find a balance that works for you between having all the details and providing flexibility. You may have to start thinking about how to justify the value of OER throughout your partnership with a museum. One of the most important things that you will engage with is justifying open educational resources. Here, we've gathered some of the topics that will probably come up at some point. We've grouped them with dialogue even though they're probably a little too in-depth for you to cover all of them. But you do want to start thinking about how you will lay the groundwork to justify to your museum partner that open educational resources are worth engaging in. Some things to specifically cover that we have considered are concerns from the museum, that they already make content free and available online. So how is OER different? You may want to talk about how OER can provide natural avenues for an institution to collect feedback on its efforts. You may highlight that accessibility is not just extra work, including the accessibility facilitated by having proper digital licensing. That museums have a high level of social trust and OER can help maintain that. And finally, that open or free won't necessarily mean cost the museum money. So the first of these is answering the question, don't we already do this? Museums might assume that because they publish content for free online, it's the same thing as open educational resources. As part of our grant, we conducted an informal review of 123 institutions that we took to be similar. The main finding from all this was that an enormous number of institutions, 96 of the 123, published materials without any clear license. Copyrighted materials could also be found in some cases, which were clearly intended to be used, but there were no terms or conditions for their use. Additionally, file formats considered relatively closed were especially common, especially PDFs. To us, this made it clear that museums which are making their content available for free online, with the goal of widespread distribution isn't necessarily engaged in the process of making open resources. There is still a difference, right? Copyright or closed formats like PDFs make the five Rs of OER technically or legally difficult or even impossible. We observed that licensing ambiguity, such as cases where no license is indicated, or where materials are openly available but are indicated as having a copyright without corresponding conditions for use, can be a form of natural deterrent for lawful users, right? For the ones who are unaware of the finer details of licensing who wish to remain lawful or set a good example for students, it could just be less daunting to not use a resource rather than figure out if they can use it. So just because a museum is engaged in publishing content online for free doesn't mean that they're already engaged in creating OER. There are some important differences in the openness revolving around especially the licensing. As the following slides will illustrate, there's also positive reasons for a museum partner to create OER. So first, OER can provide some natural feedback. Your museum partner could specifically benefit from creating OER resources because OER has several natural ways to provide feedback. First, remixing is a form of feedback. While remixes may be done for reasons that are unique to each author, the ability to see how your material has been remixed as is found in some repositories offers the chance to review what instructors are looking for and generalize that for other resources. A clear benefit for a museum partner. Second, analytics of some kind are often available for content published in repositories. So your museum partner might find these analytics more appealing than trying to implement say the full suite of Google analytics to understand how their resources are being used currently. They could allow your partner to see at least how many people have viewed a resource, are saving it or downloading it, just depending on the repository. Plus, the ability to go to a group of existing repository users where there is already a setup and audience that is commenting and rating content is probably more productive for your partner than trying to implement the ability to collect comments on their own website. Just the process of engaging in a partnership with you provides passive feedback for the museum. It can be beneficial in that way. Working closely will allow them to see how full-time educators and formal settings plan content, design it, think about it in general, what it is they're interested in, and so on. While simultaneously creating a resource that the partner can continue to use afterward, while accessibility and licensing best practices can look overwhelming at first, it's important for your museum partner to know that they don't have to be an expert to get started. For your museum partner, these best practices may feel like an extra step or extra work, right? From our experience, the appearance of extra work is only true at first. After becoming familiar with these best practices, you shift from making inaccessible or unlicensable materials that need fixed in a separate step before publishing to creating materials that just naturally incorporate accessible and licensable materials. It's really a shift in thinking rather than some sort of extra step that will always have to be done. There are also good reasons, besides the fact that it's the right thing to do, for a museum partner to make inclusive resources. More inclusive resources help increase the diversity of people who can use and remix the materials, and these may be diverse voices the museum is lacking. In the right repository, any remixes of content are automatically visible and linked, so museums can observe where they can diversify, improvements to make, what folks are interested in, different interpretation of events, and so on. Next, OER can help maintain social trust. So this is a more theoretical benefit to a museum partner. The American Alliance of Museums surveys find that museums are considered almost as trustworthy as family members. They're considered more trustworthy than the local news, national news, and often even more than the government. Now, this trust is distributed along lines of race. Museums have more work to do in that regard, but as a generally trusted institution, museum partners are both out there setting examples for others and are being policed by their potential critics. Learning accessibility and licensing best practices within your partnership will help them continue to set positive examples of both. Alternatives like releasing materials into a public domain lack protections that your museum partner may wish for. On the other hand, copywriting materials is naturally restrictive and as we argue can discourage lawful users even when the copyrighted materials are freely available. The use of licensing schemes like Creative Commons with OER provide some guardrails, encouraging lawful users and providing some protection compared to the public domain and it models good digital citizenship for people watching the museum's activities. Lastly, a bit of personal experience. OER can also provide a friendly introduction to concerns about democratizing educational content. This is a growing area of dialogue for museums so it offers some tangential benefits to your partner in addition to OER's contribution to their social trust. The last specific concern that you may think about justifying to your partner is the worry that publishing materials for free such as OER really means that the materials are costing the museum money because of lost revenue. Obviously this mostly applies to materials that are usually provided to paying educators but we founded a concern even within our institution since OER's purpose isn't to generate revenue, it may have to be part of a larger stable of content to satisfy a museum partner that's worried about this but it could result in increased visits to the museum partner or it fits with a long-term strategy perhaps that could allay concerns about giving away content. Unfortunately these may be solutions that are outside the area of your partnership. Of practical benefit to your partner, content produced in the partnership naturally includes that insight that we mentioned, this allows them to gain more experience with what educators are looking for. OER produced in the course of the partnership might be valuable for that insight alone. Ultimately it's worth distilling the other justifications here as sort of a cumulative case to invest in OER even if there's not a clear immediate financial gain. First that freely publishing materials is often not enough to ensure that they are openly usable and that copywriting them is often too strict. Next that OER will include built-in opportunities for your partner to collect feedback, that accessibility and licensing are not just extra work. Finally that OER will help museums work within the social trust that they've earned. After initiating that dialogue remotely or in person we moved on to brainstorming. This is gonna be a more substantive process that might be where you actually cover some of those previous concerns. We did conduct brainstorming in person after the initial dialogue was conducted via email. Something to think about as you approach brainstorming especially with a partner is that most museums display only a small fraction of their total collection. Items that may not be good for public display may be perfect for open resources. One possibility to try and get a handle on what resources the museum has during brainstorming is to see their collection's space. This is where museums store their artifacts that aren't on display or to try and go through a tour of some space with the potential partner and get some of the trivia of items that are already on display, but stories that may not typically get told can come out, things that make staff personally appreciate an artifact or weird stories which have not been confirmed would all be excellent areas to explore for creating a resource if you don't already have an idea. Given the depth of collections at most museums, the depth of institutional knowledge about those collections, the possibility of discovering hidden curiosities, special access for students in the work resulting from the partnership or the hopefully contagious enthusiasm for museum staff, the museum in a partnership can serve as an educational force multiplier to make content even more engaging, exciting or real. Revisiting the schedule at this point will help you and your partner set a joint timeline and manage your expectations. The next step is related, deciding responsibilities. Our approach is intended to be co-creative. At some point it may become necessary to formally divide responsibilities and assign roles for practical reasons such as scheduling or just to help keep things moving forward without overwhelming one part of the partnership. There are also some natural roles in a partnership that are worth highlighting in particular. If one partner is already well-versed in licensing or accessibility or other areas of inclusion, great. They can help educate other partners by offering constructive feedback during the creation phase. If no partner is knowledgeable, then we suggest having someone take on the role of say licensing czar and this person doesn't need to be an expert or quickly become one, they just need to get a head start in learning about licensing, which they can then use to help guide the other members of this partnership. We especially like this method because any czar's at our museum staff embed that experience in the museum's institutional knowledge after the partnership ends. This is a possible benefit to the museum partner and can help address that concern about free content costing the museum money and lost opportunities. And of course, each partner can learn the details of licensing on their own if that's preferred. Our emphasis is always on organically reaching a working flow, so whatever it needs or whatever it takes to balance your partnership. Creating awareness of your partnership's resources and or advertising its existence are processes that might naturally rest with certain partners. From JPPM's experience in a partnership between an educator or similar OER practitioner and a museum, it's probably natural for the educator to spread word of mouth about the resource to their colleagues. On the flip side, the museum probably has well developed advertising channels such as social media. After deciding responsibilities and setting up roles, the process moves into the creation phase. Creation is the fun part, working together to create the resource. We have a very rough process or a very broad process that we use, but we encourage whatever works naturally. And this process started with identifying a need, something that might already occur as you engage in dialogue with your museum partner during your ideation phase or which may have already been decided during your brainstorming. After identifying a need, our research would look into similar resources further, collecting new information as needed and collecting existing park resources. Planning took various forms depending on the format intended for the final resource. Production was a fairly straightforward process. It's easy to see how this process can be abstracted to fit with our museum partnership toolbox as well. A lot of it might happen just naturally for example, the reviews that we did were necessary because we were converting other staff's work. But in a partnership, the review is probably going to be a natural impulse as things wrap up to compare each partner's contributions and make sure that they align with each other, that they work well, even that the formatting is the same. After creating the resource, you are going to move into publication and evaluation. While publishing can be a simple task, there are some considerations that are probably worth making in advance. So naturally you'll want to decide where you're going to publish this resource. However, you may want to think about who will be doing the publishing? Does one partner have an institutional account that you can use? Would it be strange if each partner published separately? How will you evaluate the resulting resource? Will those evaluations result in edits, in new versions? Or will they just be incorporated into future projects? If they result in edits or new versions and each partner published separately, will you try and reconcile the differences between each copy? Finally, will evaluations be shared between all partners? Because these questions and the decision where to publish are ones that are going to rely on the chosen repository, the sites that are available, for the institution to use, and so on. We really don't have a lot of detail that we can provide here. And we know that local conditions vary. So here we've provided a very basic toolbox to guide your partnership from this very first step of ideation into dialogue, then brainstorming, revisiting your schedule, creation, and finally publishing and evaluation. That you can fill in with the tools you prefer or which evolve naturally as needed. After 18 months of creating OER at our museum, we see that there's a real potential in these partnerships. This is beneficial for educators and practitioners to bring new members into the OER community. It helps gain useful resources and it engages with these local educational multipliers. Museums benefit themselves. They're going to get insight into what you are seeking and what local educators want. They're going to find an environment that's hopefully providing a gentle introduction to some important topics. I wanna thank you for joining me today. I know I have compressed a lot of information into a short period of time. So I am available to answer questions both in the chat on the side here or I am reachable until the end of my grant at least at the email address chris.given at Marilyn.gov. Once again, thank you.


Let us look at the case where if there is a change in the input prices, how it affects the least cost input combination. So, change in input price if you look at it affects the optimal combination of inputs at different magnitude depending on the nature of the input price change. So, if all input price change in the same proportion, so it bound to happen the optimal combination of inputs has to change, if there is a change in the input price either in the different magnitude or in the same magnitude depends on the nature of the input price change. So, if all input price changes in the same proportion the relative prices of input that is the slope of the budget constant or they may remain unaffected. So, if all input prices changes in the same proportion the relative prices of inputs also if you look at the moves in the same proportion and those are remain unaffected, but when the input prices changes at a different rate in the same direction or the opposite direction or the price of only one input changes while the price of other input remain constant the relative price of input will change. Input price when it change in the different rate in the same direction, different rate in the opposite direction, input price of one changes or the remaining constant the relative price of input will change. This change in the relative input out price change in both in the input combination and the level of output as a result of substitution effect of change in the relative prices of input. So, this change in the relative input prices changes both the input combination and the level of output. So, whenever there is a change in the input prices it affects the input combination and the level of output as a result of substitution effect of change in the relative price. So, a change in the relative price of inputs either in the same or the opposite would imply that some input have become cheaper in relation to the others. So, cost minimization firm attempts to substitute relatively cheaper inputs for more expenses one refers to the substitution effect of relative input price change. Because whenever the price of one input changes, it becomes cheaper with respect to the other inputs. And what the cost minimizing producer or cost minimization firms they do it over here, they generally try to replace the expensive input with respect to the cheaper inputs and this is generally known as the substitution effect of relative input price change. So, this numericals we will just look at later that how the quantity of labour and capital changes, before that we will look at the graphical representation that when there is a change in the input prices, how it affects the least cost input, how it affects the level of output or how it affects the level of input combination. So, initially this is the isocost, K L is the isocost, Q is the output, Q 1 is the isoquant and this is the level of output. Now, price of labour input decreases with the help of that now the quantity of the or if you look at the isocost will change from K L to K L dash. So, once it changes from K L to K L dash, then in this case now what is the new input combination? The new input combination is if you look at this becomes L 3 that is L 1 and this is K 2, this is K 1. So, with the change in the input price now the firm will use more of labour and less of capital that is the reason the combination now earlier it is K 1, L 1, now it is K 3, K 2 and L 3. Now, to get to keep it in the same level what the producer will do the may be at least at the same level of output still want to change the input combination.  They will try to draw a parallel line which also tangent at a point which is at this level. So, suppose this is your point E, this is your point E 1, this is your point E 2. So, at this case if you look at still it uses a higher level of labour as compared to the previous level, but it is use a also a higher level of capital. So, the movement from this E 2, E 1 is the price effect that is in the form of L 1 to L 3. The movement from may be E 1 to E 2 is budget effect, because the producer is trying to keep the income level, the real income level of the producer at the same level that is the reason we got a compensated budget line which is may be K dash and L dash which compensate or which may be the reduce the real income of the producer in term of change in the input prices and that leads to a different combination that is E 2. So, E 1 to E 2, E 1 the movement from E 2, E 1 is the price effect which is in term of the labour input because use we can say L 1 and L 3 movement from E 1 to E 2 is that is L 2 to L 3 is because of the income effect, because the real income is changing and movement from may be E 2, E 2 is the substitution effect because of the change in the real income. So, if you look at the price effect is the combination of the substitution effect and the income effect. So, if you remember your price effect substitution effect and income effect in case of the consumer theory this is nothing but the counter part of the counter part of the counter part of that in the production theory which talks about the change in the input prices. If there is a change in the input prices generally the producer try to substitute that with a cheaper input as compared to expensive input that is the reason they go on using more of that input. So, in this case also the same thing has happened the producer is once the price of labour has gone down the producer has try to optimize it and use more of the labour as compared to the capital and that leads to the combination of the change in the input combination or also the change in the level of output. Now, next we will see the input combination or may be the input combination how it changes or how to find out numerically when the production function is given price of inputs is given like W and R and if the production function is given and to produce a specific level of output how to optimize the cost of production and what should be the minimum cost of production. For that we will just take a example of a we will take a numerical example like Q is equal to 100 K that is to the power 0.5 and L to the power 0.5 this production function is in the form of a Cub Douglas production function where W is 30 and R is 40. So, W is the price of labour that is 30 rupees R is the price of capital that is 40 rupees and what we need to do here we need to find the quantity of labour and capital that the firm should use in order to minimize the cost of producing of 144 units of output. So, if we look at this the minimization of case like the second case where the unit of output is given we need to minimize the cost and what is the minimum cost we need to find out that then how we will go for this we will use the we will take the help of the Lagrangian multiplier to solve this. So, Q is equal to 100 K 0.5 and L 0.5 and here if you look at then we have W is equal to 30 and R is equal to 40. So, first we will try to find out the composite function. Now, composite function is rupees 30 L plus rupees 40 K plus lambda dash that is Q 0 minus 100 L to the power 0.5 K to the power 0.5. Now, what we need to do we need to find out the first order condition the first order condition we need to find del z by del L that is 30 minus lambda dash 50 L minus 0.5 K to the power 0.5 K 0.5 has to be equal to 0 or 50 lambda dash L minus 0.5 K 0.5 has to be equal to 30. Suppose this is our equation 1. Now, we will need to look at the first order partial derivative or the first order derivative or the partial derivative with respect to the other input. In the first case we have checked it for L. Now, we will check it for K. So, here we need to find out del partial derivative with respect to K that gives us 40 minus lambda dash 50 L 0.5 K minus 0.5 which has to be equal to 0 or 50 lambda dash L 0 to the power 0.5 K to the power minus 0.5 which is equal to 40 let us call it equation 2. Now, to find out the partial derivative with respect to lambda that is Q 0 minus 100 L 0.5 K 0.5 which is equal to 0. So, you can call it 100 L to the power 0.5 K to the power 0.5 which is equal to Q 0 that is equation 3. Now, if you divide equation 1 by equation 2. Suppose equation 1 by equation 2 then this is 30 by 40 equal to lambda dash that is 50 L minus 0.5 K 0.5 then lambda dash 50 L 0.5 K minus 0.5 simplifying this again. So, if you simplify this then this is 3 by 4 equal to K 0.5 K 0.5 L 0.5 and L 0.5 that comes out to be 0.5. So, this is comes to 3 by 4 by K by L. So, K is equal to we can say 3 by 4 L or 0.75 L. So, in order to take the first order partial derivative once we get the partial derivative out of the first order derivative with respect to L then the first order derivative with respect to K and then the first order derivative with respect to lambda and then we solve for the value K in term of L. Now, what we have got from all this calculation that is K is equal to 3 by 4 L. Now, we will see how we can substitute the value of K into value of this into the equation and find out the value of K and L because ultimately what we need to find out we need to find out ultimately to produce 144 units of output what is the minimum cost because the minimum cost the firm has to incur or what should be the minimum cost or on which ISO cost they have to learn. So, if you substitute the value of K into the given production function for 144 units of output that is 144 that is 100 L 0.5 and 0.75 L because K is equal to 0.75 L. So, that comes to 100 L 0.75 which comes to 1, 4, 4, 100 L and 0.75 then it comes to 14486.6 that comes to 16.67. So, 16.67 is the value of L. Now, we to find out K is equal to 3 by 4 L. So, that comes to 12.5. So, 12.5 is the capital and 16.67 is the labour. So, capital and labour we need we got the value of capital and labour. Next we need to find out what is the cost when the capital is labour is 16.67 and capital is 12.5 because ultimately again let me remind it ultimately we need to find out what is the minimum cost of producing this given level of output. So, C is equal to W L plus R K. So, W is 30, L is 16.67 plus R is 40 and K is 12.5. So, that comes to rupees 100 point 1000.50. So, that comes to 100. So, in order to produce 1, 4, 4 output this is the minimum cost. So, this is the given level of output and this is the minimum cost. So, whether it is a minimization case or maximization case how generally we solve it numerically we solve it numerically with the help of this Lagrangian multiplier method where we take into the where we take the constant in the form of a Lagrangian multiplier. We formulate a composite function then we take the first order partial derivative with respect to 0. Simplifying this that gives us the value of capital and labour we put the value of capital and labour in the production function equation. We get the exact value of capital and labour use this in the cost function and that gives us the minimum cost of producing the given level of output. Now, let us see if you remember in the last class we talk about the short run production function that is in term of the law of diminishing return. Next we will see that numerically how we get the value of the three stages the different stages of production and how we find out the value of average product marginal product and at what level generally the diminishing marginal return set in and what level labour is the average product labour is the highest. So, the firm produces the output according to the production function that is Q is equal to 100 k L minus L Q. So, the production function is 100 k L minus L to the power Q capital is fixed at 10 because this is a short run production function. Now, what we need to do we need to find out the value of average product we need to find out the value of marginal product and then maybe we can find out what is the different stages or what is the different level of output or level of labour where the firm or where the producer is achieving the different level of output. So, first we will find out the marginal product of labour. Now, marginal product of labour is del Q by del L. So, that comes to 20 k L minus 3 L square. So, that comes to 200 L minus 3 L square. Now, so this is the marginal product of labour. Now, we will find out the average product of labour. Average product of labour is Q by L. So, that comes to 10 k L minus L square which is equal to since k is equal to 10. So, this is 100 L minus L square. So, average product for average product is 100 L minus L square. Marginal product for labour is 200 L minus 3 L square. Now, second one is we need to find out when MPL is maximum. MPL is maximum where the first order partial derivative with respect to L is equal to 0. So, that comes to 200 minus 6 L which is equal to 0. L is equal to 33.33. Now, what is the significance of this level of labour? The significance of this level of labour is that at this level since marginal product of labour is maximum beyond this generally the law of diminishing returns at in. If you remember your three stages of production function like how the total product curve. So, initially it is convex then it is convex and then it is decreasing. So, this corresponding to this or marginal product of labour is maximum because after this the total product of labour is increasing at a decreasing rate and beyond this MPL is maximum and beyond this if you look at then the total product is increasing at the decreasing rate and marginal product is decreasing. So, we can say corresponding to this point MPL is maximum and this is the point where the law of diminishing return set in. And the second point we look at is when MPL is equal to 0. MPL is equal to 0 when this 200 L minus 3 L square is equal to 0. So, in this case maybe L is equal to if you find out this comes to 66.66 and where this value of L comes the value of L comes at this point because corresponding to this MPL is 0 and TPL is maximum. So, if you remember from till this point this is your point beyond which there is the law of diminishing return set in. Then when a average product of labour is highest average productive labour is highest when DAPL with respect to DL is 0 that comes to L is equal to 50. So, this comes somehow here the average product of labour is maximum when it intersecting the marginal product of labour. So, corresponding to this L is equal to 50. So, now we can say that from 0 to 50 the first stage of production from 50 to 66 unit of labour second stage of production and beyond 66 unit of labour we have third stage of production. And how we have identified this first stage, second stage and third stage? First stage ends till the point the marginal product is equal to the average product and average product is maximum at that point where marginal product is equal to the average product. Where the second stage ends? Second stage ends when the total product level is maximum or the marginal product is 0. So, that achieve at the unit of labour unit at 66 beyond 66 we have the third stage of production. So, depends upon the labour unit we can find out at which level generally the stages of production are decided whether at the first stage, whether at the second stage and third stage. So, first stage is up to a point where the marginal product of labour is equal to the average product of labour. Second stage is the point where total product of labour is maximum marginal product of labour is 0 and third point is beyond this. So, once we find out the value of labour where marginal product of labour is equal to 0 that is the definition of the second stage. Once we find out the maximum value of APL that gives us the may be the beginning of the second stage and when we find the marginal product of labour is maximum that gives us the point beyond which the law of diminishing return setting. So, in the next session we will talk about the cost of production different types of cost, how the cost function is formulated and what is the logic of different shape of the cost function in the short term and in the long run. So, these are the session references generally these are the references that is being used for the preparation of this particular session.