My lecture will be an introductory lecture in which I introduce already the topics to be dealt with later on. Please feel free to ask questions anytime you want. I'm a text expert and I think the knowledge we all have, as Alka said, will help us to learn from each other. I'm very much interested in state aid but that is about the material conference. So the latest developments with respect to McDonald's case, the Starbucks case, the Apple case are of course of huge interest for the development of the taxes in the future. Everything has to do, all has to do with the autonomy of individual countries with respect to their tax power. And as you all know, Europe is not perfect. There are a lot of disparities. There is no harmonization. Well, there is some harmonization but not complete harmonization. And state law instruments is really an example of very, very hard law. Because as you all know, state law, if you conclude this is unlawful state law, then you have to notify it to the European Commission and there has to be a recovery. And if the Commission and the European Court of Justice decide that it is not compatible with the internal markets, well, then you know for sure that you have to pay back all the money received, including interest. And well, in taxation that is not completely new of course, but yeah, until now the Commission was quite hesitant to apply this instrument with respect to taxation. And now if you look at these ruling cases, it seems to be a change in the policy. And that's also for me a very interesting point. And then of course also the formal aspects of these regulations come into force. Well, my job is most of all to have a look at the modernization program, the modernization of state aid control. And that has everything to do with the economic and financial crisis that started around 2007, 2008, as you all know. After that moment, the state aid increased enormously. Until that time there was state aid, but that was only around one percent of EU GDP. It was quite a number, but all right, it was doable. But as of 2007, 2008, this one percent increased to 13 percent. So many, many state aid cases had to be notified to the European Commission. And that caused a lot of work, a lot of work for the Commission and a lot of work for the member states, as you can imagine. And well, a comparable development, at least in my country, with respect to the assessment of companies, mainly big companies. In the past, the tax administration had the attitude more or less, I exaggerate a little bit, to consider taxpayers as enemies. Beware, there's a war going on between taxpayers and the tax administration. And but that doesn't work because most taxpayers are willing to pay their taxes. They don't love to pay it, but they want to be compliant because they see that it's the law and it's also in their benefit to pay taxes. It's better to concentrate on these taxpayers, on those taxpayers who are not willing to be compliant. It's better to use your energy as a tax administration on these bad taxpayers. So we introduced the concept of enhanced cooperation, horizontal supervision, in which you say, well, the taxpayer and the tax inspector are more or less farmers. And the taxpayer, the company should be willing to look very critically to its own tax position and to develop a tax control framework in which you are able to detect all kinds of risks concerning your taxable position. And you must be willing to report failures or risks to your tax inspector within this kind of covenant. There's a covenant between the taxpayer and the tax inspector to be honest about the risks and to work in present, in the present time, and not in the past. We used to come with audits looking to the last five years, long questionnaires, cost a lot of money, cost a lot of time. And now if you use this concept, you can work in the present. And that's very much better for the quality of your information, of course. In return, the tax administration should give clearance. You should say, well, if you have a problem, this is the way how we could solve it. If you have a question, let's answer this question as soon as possible. So it's in the benefit of both the tax administration that makes free capacity to look at cases which are really dangerous from the perspective of the budget. And well, for the taxpayer, you have the certainty that what you are doing is also accepted by the tax inspector. Well, that's how it is in theory. In practice, there are some problems. One of the problems is that you should be able to agree to this degree. You will all accept that I'm the statement that you also should be able to go to court. But that's not really always the attitude of the Dutch tax inspector. He says, well, if you have such a covenant, we should try to come to an agreement, all kind of problems. And if you go to court, that is not really something that fits in this covenant. And I never understood it. I think you should act like a businessman, businesswoman, by saying, well, okay, there can always be situations in which you disagree. And then, of course, you should be able to go to court. That is part of the rule of law system. But in reality, you see hardly any cases brought before courts anymore if it concerns corporate income tax, for instance. They're all dealt with in this more private sphere of this horizontal supervision. So that's one of the drawbacks. But coming back to the European Commission, the same happened with respect to state aid. Because of this crisis, and because of all these state aid cases notified before the commission, it was practically undoable. So they said, let's give more responsibility to the member states. They should be more responsible for the way they are dealing with these state aid cases. So we trust the member states to give them more freedom. We extend the possibility of giving state aid that falls within the block exemption. But on the other hand, we will increase the exposed supervision. So there will be less ex ante supervision, less notifications, but the exposed supervision will be stricter. And also, the member states are requested to do a lot of exposed supervision by themselves. It has two big advantages. Member states have less administrative costs in this notification process, because they can handle these cases by themselves. And the commission can make free capacity to take care of the real difficult cases, like the ruling cases. Well, it has been a success. They introduced this modernization in 2012 and July 2012. It was finalized in 2014, but there are still some developments going on. I think the last development of importance was the paper on the notion of state aid 2016, and that's more or less the completion of this state aid modernization. It is considered to be a success, but of course, academics always try to find some disadvantages, and I will show you some. First of all, what are the three objectives mentioned by the European Commission with the modernization? First of all, to foster sustainable, smart and inclusive growth in a competitive internal market, so increased competitiveness. And that has prerequisite that you need to have a clear and consistent legal framework. You should be able to predict whether the state aid you provide is allowed yes or no. And that is state aid as such is not necessarily bad. It can be very necessary because the market doesn't solve all issues, but then you need to have very clear rules. Second objective, as said already, is that the Commission, which is not too big, the department dealing with the state aid, would like to make free capacity to focus on the real big issues, and not all these smaller issues. So that's also, there should be prioritization in order to increase the relevance of the state aid control. And the third objective is to streamline the rules and provide for faster decisions, and that should lead to more efficiency of the state aid procedures. Well, on the 8th of May 2012, we had a communication on the state aid modernization. This was not the first step, and the process already started in 2005 with the state aid action plan. That was a roadmap for state aid reform. And also before the crisis, the Commission realized that something should change, that should be more efficient. But this is more or less the result of these first steps, the same state aid modernization. And this communication announced a comprehensive reform program of the existing state aid instruments. And well, there were five main points, and I will deal with these five points, but they will come back in later lectures. First, an amendment of the enabling regulation and the procedural regulation. I'll come back to that. In order to streamline more the rules and to extend the exemptions. Then a revision and streamlining of the guidelines and frameworks in accordance with what are called common principles for the assessment of compatibility with the internal market. As you know, it's the exclusive privilege of the Commission to determine whether a state aid measure is compatible with the internal market with article 107. But if you want member states to have more responsibility, with respect to these state aid measures, if you extend the exemptions, then of course these member states must know better what are the guiding principles to know what is compatible with the internal market. And also for national courts, this is very important. Then the third, a new de minimis regulation, small state aid, as you know, below 200,000 euro. It does not have to be notified. And the extension of the block exemption regulation. Then a new important interpretive notice on the notion of aid, which is meant also to be guidance. Of course, this cannot create new law, but can only give a summary of what has been decided already by the European Court of Justice. But it's very helpful for practice. And then what is for you very important is that this state aid modernization can only work if national courts are more involved in the application of this modernization. And there I think we will have some issues for debate. Because sometimes if you look at these rules, you get the impression that the national courts are only assistants of the European Commission. It's more or less helpful for the commission. But of course, courts are independent. They have their own responsibility. And how does this relate to the rules that we have to face? Well, we come back to all these points. Let's start with the first, the amendment of regulations. Well, first the enabling regulation. You will find it all on Blackboard, these regulations. There you find the extension of the list of categories of categories for eligible exemption measures. So here you find all the extra possibilities for exemptions, which are very helpful for the member states. Then there is a change in the procedural regulation, 22nd of July, 2013. There you see that the European Commission gets more tools to get information out of the market. And that is one of the complaints I heard, that sometimes that is considered to be a little bit burdensome.  The commission is able to ask a lot of information to certain sectors of the economy, and also with respect to certain instruments, certain eight instruments. The ruling cases we have seen as such an example, that the commission can say, well, let's focus now on the ruling practice within the European Union, how this ruling practice relates to the state aid regulations. And they are allowed to ask many, many questions in order to get market information. And, well, you cannot simply say, well, I have no time to answer it. You are obliged to answer all these questions. So that could be an extra administrative burden. Well, then there are rules for who is capable of complaining. Because before the modernization, it was not very clear who was entitled to complain before a court, and who had enough interest in complaining. And these rules have been made more clear now. So it has reduced the number of complaints. That was also one of the goals. Then as already said, there is now the possibility of settle inquiries to look how state aid relates to all kind of sectors in the industry, the economy. And then another point is the possibility to ask assistance of the European Commission. So courts can also consider the European Commission as an assistant. You can ask questions to the European Commission. You can ask more information about the case. You can ask also an opinion of the European Commission on that case. And there is always a debate, what is the influence, the value of this opinion of the European Commission. As court, you are free to do whatever you want to do with that opinion, but of course you can't do it without any reasoning. And mostly, the commission is the expert, and the courts don't have much experience with that. So sometimes you see that courts might be a little bit reluctant to ask an opinion from the European Commission, because they are afraid that they don't have any real freedom anymore to change that opinion. In any case, something to be discussed. If the commission comes with an opinion, then the commission does it as friends of the court. So the commission does not want to be favoring one of the parties. The commission wants to be neutral. It gives information and also the opinion are always in the common interest, in the interest of the union, and not sympathizing with one of the parties. But it also means that the commission is not going to hear the parties. So the commission comes with an opinion independent from what the parties say. In the Netherlands, I know that it is possible for the parties to react on the information given by the European Commission, and also to give a reaction on the statement of the other party. But you have no right to be heard by the commission. The only thing is that as courts, you must assess whether state aid is involved. You must assess whether all the requirements of Article 107, Section 1, are there. But it's the privilege of the commission to decide whether it is compatible with the internal markets. So even if you decide, well, I don't see any problem, but if the commission decides, well, I do see there is a problem. But of course, it has to be certified by the European Court of Justice. So in the end, there is always a court designing it. But then the position of the national court is weak. And there is a tension because you are used to be an independent court. And the commission is an administrative body, political responsibility. And especially the administrative courts are used to look whether the government, the administrative bodies are doing their job. And here, yeah, you have to respect the judgment of the European Commission. The revision and streamlining of guidelines and frameworks, and that is called the common assessment principles. Which are the principles to assess whether a state aid measure is in line with the internal markets. Before these guidelines, before these principles, there was the balancing test saying that the advantages of a state aid measure should be higher than the disadvantage. It should be a balancing, well, very broad approach. Now we have some more concrete rules. Still, they are rather general. First of all, there is a definition, a state aid measure must aim at an objective of common interest in accordance with Article 107, Section 3. So mind you, now we are talking about good state aid, allowed state aid. And not unlawful or illegal state aid. Then you find all kinds of categories in order to say, well, it is state aid, but it is compatible because we think it's a good goal, like research and development. There should be a need. The state aid measure must be targeted towards a situation where aid can bring about a material improvement that the market cannot deliver itself by remedying a market failure. So you see a very liberal approach. We believe in the market in the European Union, but sometimes the market cannot solve everything. And then state aid can be of help. Appropriateness, state aid measure must be an appropriate policy instrument to address the objective of common interest. And it also should be proportional, of course. And it should give an incentive. It should influence the behavior of the recipients. If you give state aid, and sometimes I have doubts, if you look at research and development incentives, I think every entrepreneur should do a lot of work on research and development. And sometimes you have the impression that all these R&D incentives are not real incentives for changing the behavior. They are just ways to be more competitive towards other countries. No. Also avoidance of undue negative effects, and there should be transparency. And this last is very important. Because there is no more responsibility on the level of member states, there should be transparency on what they are doing in this exemption possible. So they must make from time to time reports. They must mention what they have done, what they have brought under this exemption rule, and they should communicate this towards the European Commission. This is very important. And also very important is that if you make use of the general block exemption regulation, you must mention that. So you cannot say, well, it's obvious that this instrument falls under the block exemption regulation. No, you shouldn't mention it. Otherwise, it's not accepted, and then you should notify it. It's also decided by the General Court. Coming back to this block exemption regulation, which was extended in 2013. Well, some general aspects. We have a general limit of 200,000 euros per three years, but has not been increased. There has been a temporary increase during the crisis years to 500,000, but now it's still the 200,000 limit. The rules have been clarified and simplified. But the drawback is that there are a lot of words now, and that can give rise to litigation, of course. Yeah, the general block exemption regulation is a kind of self-assessment. I started my story with the comparison with the horizontal supervision, self-assessment, and now at the level of the member states. There are still notification thresholds. They have been increased. So, for all kind of individual measures, there is a notification threshold, and you always have to look very carefully what is applicable in that case. The commission's goals were that around 70 to 90 percent of eight should fall under this general block exemption regulation. And it seems that this has been realized that about 90 percent of all the cases are now within this block exemption regulation. But that also means that the commission is not aware anymore of all these cases. Well, they have to be reported, of course, in this general summary. But the visibility is less than it used to be. On the other hand, you can imagine that it's no more practical. It works better like this. And again, you must refer to the GBER. And that's, of course, also for your judge. Your judge is very important. If there is a state aid and there is no explicit referring to the block exemption regulation, then you don't fall under the exemption. You have to notify. Yeah, I mentioned all kind of categories and types of aid measures. Regional aid as a means are very popular also to finance them. Environmental protection rules, research and development, training facilities. Well, you can look at them. Broadband infrastructure also. Aid for sport, heritage conservation, all these kind of things. Important, of course, also does not fall under this regulation. In general, all schemes that exceed 150 million euros. But mind you, there are, again, exceptions to this rule. And for regional aid, it can be higher than its 150 million euro. In any case, all eight exceeding 150 million will be evaluated exposed by the commission. And that's a process going on now. Also, export related activities are not under the GBR. If it only considers the use of domestic products, it's not considered agriculture productions, fisheries. That means you can give state aid, but you have to notify. Closure of coal mines. Undertakings with an outstanding recovery order. Of course, if you have to pay back, then you cannot fall under the GBR, except in the case of natural disasters. And I think that's applicable for Italy, the earthquakes. And also important, undertakings in difficulty. So then you're not allowed to use the GBR. And also, if there is a violation of EU law, if you, for instance, require the use of domestic products, then you know for sure this is against the EC Treaty, against freedoms, and then you cannot allow, use the exemption regulation. Well, interesting is what are unexpected consequences of the increased use of GBR? First of all, this is success because 90% of the cases falls now under this regulation. But it's not clear how member states understand and implement this GBR. So there's a possibility for mistakes due to misinterpretations. And we will have to wait for the final evaluation whether some aspects have to be changed. When member states have doubts, they can always ask the European Commission. And mostly they do so if they have doubts. And then it's possible that the European Commission sends a comfort letter saying, well, if you're doing it in this way, we don't see many problems or we don't see any problems. But yeah, what is the status of these comfort letters? Are they giving a legitimate expectation? Because they are never very concrete. They are always rather general. Problems from the Texas spectrum, you can rely on it. But here it is said, no, no, this is just general information. You cannot rely on that. But of course, only tax professionals, they could be interested in how does a rule work. But if a private person, an individual, phones the tax phone, he has a concrete problem. And he wants to know for sure what is the solution in my problem. At least that is the way he sees it or she sees it. So there's always a tension. And also in this situation, a comfort letter, of course, you would like to know this measure is in line with Article 107. But of course, it always depends on the details, whether after evaluation it still falls on that exemption. And then an important issue, and we'll come back to that also, if you receive the AIDS, and the Member States says, it's all under the general block exemption, you could say, yeah, okay, but I want to be sure that notification is not necessary. Because if afterwards, look at Starbucks, it seems that I have to pay back all of this, including interest. Well, I don't want this. So I want certainty already. Is that possible, yes or no? Then national courts, I think they have to judge whether state aid regulation falls in this general block exemption regulation. And then it's of course possible that you have different applications of this block exemption. And then the last part in the comfort letters, what is the legal value of these comfort letters? Well, fourth element, the notice on the notion of state aid, which is very helpful. But of course, it's only a summary of the state of the art of the case law with respect to state aid. So it has no constitutive effects. It's a way to help those who apply state aid measures. Then finally, the role of the courts. Well, you already said a lot about it. The main role of the national courts is to protect the interests of those who apply the state aid moves, especially the competitors who feel not at ease because a competitor, another competitor, gets the state aid. And Article 107 and 108 are very clear. If there is aid in principle, you have to notify it. And if the commission says, well, it is not compatible with the EU regulations, then a recovery must be made. So this is a very important thing to keep in mind. But as I said, national courts have no competence to assess the compatibility of the aid. That is the task of the commission. And the ECJ has said many times that if there is a decision made by the commission, that has to be followed by all authorities and bodies, including the judiciary, because that is something that is to be respected. But you must identify whether all the regulations of Article 107, Section 1, are there, especially the selectivity test. It's very important in this respect. So that's something national courts have to do. Also, you should implement negative decisions ordering recovery. And if the recovery is there, then the court can be used to realize that. Did I get you right that the decision by the commission is binding even the ECJ? No, no, not even ECJ has to confirm it, of course. But before the ECJ has confirmed it, not sure. But for you, you have to, so the recovery must be there. So Starbucks has to pay back received tax benefits, although we are still waiting for a decision of you being called just. So it's not something, well, let's wait and see. And then we pay back. No, you have to pay it back now. And even if the commission says there is no problem, U.S. National Court must order that the interest is paid back, because normally you have to wait for the decision when you've been commissioned, that it is compatible years or no. And you're not allowed to give to pay already the state aid. If you've done so, then you have given away an interest advantage. And that must be paid back. But we'll come back to that later on. Well, as I said, cooperation with the European Commission interpreting the block exemption regulation, and you, of course, can ask preliminary questions to the Court of Justice. Well, these are some of the main remedies. I will be very brief on that, because we'll come back to it. You can prevent the payments of unlawful aid. And unlawful aid is not notified aid or aid put into effect without respecting the standstill obligation, because you know if there is new aid, you must wait before the commission says it's all right before you can implement it. Then the recovery of unlawful aid is part of the remedies before national courts. The recovery of interest, of illegality interest. And it is also possible that a competitor demands damages to be paid. And then, of course, as always the issue, can you prove really the amount of the damage should be a concrete story. And also you can decide for interim measures. Interim recovery, for instance. Well, I would like to conclude with some questions without already giving the answers, because that's what we are aiming at today. First of all, the question, especially also to Alki, we have many, many courts. Of course, many courts around the European Union, but also within one country. It could make a difference whether you go to the civil court or whether you go to an administrative court. The administrative court is more used to judge cases against the government. Civil courts might have a different attitude. But also, of course, there are possibilities that there are differences in cultures between the countries. Well, national judges do not always have sufficient knowledge about state aid. You do have sufficient knowledge now, but not all judges are here. Then the role of national courts with respect to GBR procedures, to talk about it, and also the visibility, are really memories states that's transparent with respect to this GBR. The status of opinions, comfort levels provided by the European Commission, and how does it really works in practice? How do you make a decision between preliminary questions to the European Court of Justice that take a long time or asking opinions, information from the Commission? What if a recipient wants certainty on compatibility? Can you claim that, although it falls within the GBR, according to the member states? And then, of course, the role of national courts towards the Commission. You, as court, have to identify state aid measures. But, yeah, is it really a test which can be disconnected to the test of Article 107, Section 2 and 3? Or is it more or less also interconnected? And then the last point is more a political point. This whole procedure was done to make more capacity free at the level of the Commission. But if you see the extra tasks the Commission has taken, these opinions, but also the management information tools, has the Commission sufficient capacity? If you look at enormous work to be done with respect to the ruling cases, well, that's also an interesting question. Do we need another modernisation? Okay, thank you very much. Do you have questions at this time, urgent questions?


So we're going to get started, so for those of you who I didn't formally introduce myself, my name is Anthony Knox and I'm the Community Relations Manager for the Visiting Nurse and Hospice for Vermont, New Hampshire. And within, I mean I have a variety of different things that I do within my role, but one of my favorite parts of the job is to be able to do some training and education about the services that we provide within the VNH as we refer to ourself. One question that was asked prior to the start of the presentation here was kind of the affiliation between Dartmouth Health and Visiting Nurse and Hospice for Vermont, New Hampshire. And what Dartmouth Health is the overarching umbrella of organizations that, you know, it's kind of like a governing body to be able to get consistency across the board for all of the different affiliates that are a part of the Dartmouth Health System, which includes Dartmouth-Hitchcock Medical Center, Alice Peck Day Memorial Hospital, Mount Skutney Hospital and Health Center, Cheshire Medical Center, New London Hospital, and the Visiting Nurse and Hospice for Vermont, New Hampshire. And just recently we have started the partnership with Southwestern Vermont down in Bennington. So, and then there are, you know, if you've been catching up on the news, there are some articles about Valley Regional Hospital in Claremont, New Hampshire is also in the process of becoming part of the Dartmouth Health System. So, but for all of the different organizations, we are all independent to one another. We have our own CEO, we have our own board of directors, and, you know, we all have different, you know, goals and objectives that we're trying to provide to the community members. But under the umbrella of Dartmouth Health, we're all just trying to have that same consistency and expectation of services that are being provided to anybody who needs those services. So, and of course, mine is Visiting Nurse and Hospice. So, today's presentation is going to just be able to go through talking about all the different services that are available to you right from within the comfort of your own home. You know, it's something that is different than obviously a traditional hospital setting because that we don't have, you know, we don't have a brick and mortar location that you're coming to. We're coming to you to be able to provide the supports to you. And so, you know, we're dedicated to providing outstanding care to you within your own home. You know, and it could not, it could be someone you love, someone you care for, you know, in your home, outside of your home. But again, we're coming to you. And the other piece of it too is that people don't understand is that it doesn't necessarily just have to be your actual home.  You know, we'll go and provide those supports to individuals wherever they need that support because at the end of the day, we just need to take care of people. We need to try to get them into a better position. We cover over 140 towns throughout Vermont and New Hampshire. And the next slide will show you a map of all those areas. And again, it's a variety of services, skilled nursing, rehabilitation, hospice, personal care services, and that's from birth to end of life. You know, we don't, you know, we're not just an adult service agency. We also provide supports to children and we'll go more in depth throughout the presentation. And again, we're a nonprofit, so our only goal is to help you. And we don't disqualify somebody from being able to receive services based on propensity to pay, having insurance, anything like that. If you need the supports, we're going to go provide those supports to you. So that's just a little bit of background for us. As you can see here with our service area map, you know, we are primarily in Vermont, specifically Windsor and Wyndham counties. But then we head on over to Orange County as well to be able to provide support. And then we have a little bit of New Hampshire that we cover throughout our catchment area. And, you know, one of the things with the fact that we provide services in Vermont and New Hampshire, we're the only Vermont agency that does that. So, and again, it's a smaller territory within New Hampshire. But again, we try to provide as much care as humanly possible in our areas. So we have technically five different departments of visiting nursing hospice for Vermont and New Hampshire. We provide home health care, which includes skilled nursing, physical therapy, occupational therapy, and speech therapy. Within that as well, individuals can also get home health aids to be able to help with personal care needs specifically around, you know, bathing and things like that. And then we also have social work services available, you know, to, you know, essentially, you know, a little bit of case management supports to try to help direct people to additional supports that they can utilize that, you know, potentially when we're done providing that support to them, that home health support. But they still need some additional supports. We can connect them with local councils on aging or just other social service agencies that can provide that support to individuals.  But understanding that it's just the support that's being provided at the end of life for somebody who, you know, is done with any sort of curative treatments that's just ready to, you know, live the life, their best life possible with whatever time that they have left. We have a long-term case management program, which is, you know, for, you know, from some other social service agencies, it's that case management support to help keep somebody living in their home as long as possible. It's to be able to get them connected to other social service agencies on a more long-term basis. So, you know, essentially, if you qualify for long-term case management, it's not going to go anywhere unless you are ready for it to, you know, stop providing that service or you reach a higher level of care that's needed where you're going to have those supports around you at all times. So, you know, it helps provide the ability for people to stay in their homes longer than maybe they would have been able to otherwise. We also have a help at home program, which is kind of within long-term case management, but it's still separate. The biggest difference with that is that it's a pay for, it's a fee for service. So, you know, it's not, there are some insurances that cover it, but if you can tell me what insurances actually cover it, that would be lovely. But for the most part, it's a fee for service that people can pay to have somebody come in and provide a variety of services that will go more in depth with later in the presentation. And then we have a maternal child healthcare program. And so, literally, this is a program that is when the child hasn't been born yet up until the age of 21. And again, we'll go way more in depth as far as all the different services that are provided to that individual and as well as their families as we get later in there. So, before I start diving into anything, if there are any questions that anybody has, all right, we'll keep going. All right, so home healthcare skilled nursing. So, commonly, the supports that are being provided to somebody with the home healthcare skilled nursing side of things is after an injury, illness, surgery, or it could also be complications related to chronic illnesses that they have. So, essentially, for all of these supports, a primary care doctor, the surgeon, the ER doc, wherever that individual may be would determine, hey, you can actually use some supports inside your home. We, you know, and that there are services available to you to be able to come in and help with those services. We come in and assess what's happening with the individual based on the medical history that's been provided to us. You know, again, if it's a surgery, it's a little more clear cut.   You know, but again, for illnesses, I mean, it could have been a stroke. It could have been, you know, a variety of different medical conditions that happened that now require some additional support within that home.  And some of the things, you know, again, that we do within that is, you know, we assess your current physical condition. We provide whatever the appropriate treatment is. So upon the assessment, we determine, okay, we need to do x, y, and z. And, you know, in good, bad, or indifferent, there is going to be some homework that's going to be done, expectations of doing some of these exercises or whatever the case may be in between visits. And then we can also help with modifying or reorganizing your home.  It could, you know, cause the injury to get worse, not heal as quickly. So we try to assist with, you know, swapping some things around and kind of helping out. We can also, you know, as part of the social work case management supports, we can also try to help connect you with organizations that may be able to help, maybe with some home modifications, because, you know, maybe your walking isn't going to be exactly the way that it was prior to your injury, and now you're going to need a ramp to get into the house, or, you know, maybe you need railings attached or something like that to your house. We can also try to help facilitate getting people into, to help with that. We, ourselves, are not personally going to fix, you know, things within the house, but we may be able to help adjust some things as we're going. Yep, so our nurses have the ability to do, to take labs where needed, you know, do different tests, things like that, and then we work with, you know, whatever the local hospital is, to be able to go and drop off that, you know, that lab work and things like that. So, and again, it's all based on providers' orders. So we can't do anything unless a doctor has essentially prescribed it for us. So, yes, yes.   And again, physical therapy, occupational therapy, and speech therapy will all come directly to your home. And what we also find specifically with, you know, P-T-O-T and speech therapy is that if you're doing these exercises in your home and you, you know, understand how to do them within your home, you're far more likely to get better than you go to an outpatient physical therapy office because you're learning how to do stuff in that setting and things like that. And sometimes it translates to home, but a lot of times it doesn't. And so, like, you have a really good understanding. You can get in that, that routine right at your home, understanding it.  But we help, we help get you back to baseline of where you were or back to a point where it's going to be easy for you to actually get to these appointments. And we'll talk a little bit, too, about how to qualify for, for these home health services, which is, we're going to talk about it right now. So the, the primary thing around home health services in particular is that you're tech, you're quote, unquote, homebound. Now, homebound just means that it's a taxing effort for you to get out of your home.  It's not like you have to stay home, you know, during the, you know, however long of a process we're going to be in your home. But you have, it has to be very difficult for you to get out. And, and again, most pre-op patients are also considered homebound because you're going to be on pain medications, especially at the beginning.  So you're probably going to, you're probably going to qualify for home health services based on that as well. But absences from your home are, are infrequent.  You're always on the road. You're doing all these fun things. You're going to concerts and baseball games, whatever the case may be. Right now, you're probably not going to, but there are still reasons why you're going to leave your home.    And all of these reasons are beneficial, specifically, probably for your mental health beyond anything else. So, but again, it's not, it's not like from sun up to sun down, you're going to be gone all day because then, well, then you're probably moving around okay, you're, you probably don't actually need some in-home services at that point, but, you know, and then individuals who, you know, maybe have some vision impairment in particular, you know, would be considered homebound because, you know, you need that support potentially to get out of the house.  Cardiac disease is another big thing. So, you know, we know a lot of people with cardiac disease and heart troubles and things like that, you know, have a lot of fatigue and even getting out of the house is very difficult for them. Those are people that for sure qualify for our services to be able to come in and provide that support within the home. And then, you know, again, you have the ability to drive around, but you, you know, it's still very difficult for you to drive around based on what your current medical condition is. Those, these are, you know, these are just some of the reasons as to why you would qualify for in-home support to get better. Hospice care.   It's a lot of people think that it's just that little bit of support right at the very end of life. But one of the things that I want people to really understand about hospice care is that it's a service that is available long before the end, quote, unquote. And we'll talk a little bit more about that in a moment, but in order, in order to qualify for hospice care, two providers would have to agree that there is a life expectancy of less than six months. So our medical director, Dr. Christy Maloney and the primary care provider, the ER doc, whomever is essentially assessing this patient would make the determination that this individual has less than six months to live based on their current medical prognosis as well as just understanding that if there was no treatment being provided and we just let the disease run its natural course, that this individual would pass away within six months. The care that's provided is palliative, which just means managing the symptoms of that individual. It's not curative. So for example, somebody who's been on chemo for cancer wouldn't be able to be on chemo for cancer because that's curative versus managing the symptoms that that individual has. And the full team that provides support to the individual nurses, doctors, chaplains, and our social workers all have a part in providing supports to individuals and not only just the individual who is the patient, but also the care team around that individual. So specifically in the hospice situation, not only taking care of the patient, but also taking care of that patient's care team is as important during hospice. So some of the qualifications for hospice is just kind of the general guidelines. So again, a life limiting condition. So six months or less that that individual has remaining. The progression of the disease. So again, going back to cancer, stage one cancer, maybe not qualifying for hospice based on that stage four cancer, we're probably talking, hospice supports would be a valuable resource for individuals. Frequent hospitalizations, office or ER visits, as this individual is going to the hospital more and more often for a variety of different reasons, there may be some underlying causes that some additional lab work or testing needs to be done to kind of determine perhaps this individual is actively dying and may need the hospice supports that are available. Weight loss is greater than 10% over the past six months. And then the patient or family wants to focus on symptom relief and management and they're not looking to cure.  Like I don't want to do this anymore. And so they made the decision, family supported it and they had gone on hospice at that point. And then some of the common diseases to qualify for hospice. And again, I didn't include cancer on here. I kind of feel that that's a very, very common reason for somebody to go on hospice. But again, it's essentially end stage diseases. Once a doctor or provider has determined that they're at the end stage, then they're likely gonna qualify for hospice. But we also provide hospice care to individuals after having a stroke or coma, again, depending on what the prognosis is based on that. And then ALS is another thing. And some of the dementia, ALS, Alzheimer's, things like that can be very challenging to kind of diagnose. But the other thing to understand is that, an individual who has a prognosis of six months or less, that doesn't mean necessarily that they will pass away in that next six months. We have had people on hospice that have remained alive for two years. It's a very slow progression, but with the supports that they were receiving, they were able to live their life for the next two years and not just being stuck at home sick, like being able to go out and live their life, travel, do all these different things. And one of the things, and I don't remember if I put it in the presentation, but just because you're receiving home health or you're receiving hospice supports here in Rochester, Vermont, you can go to Rochester, New Hampshire, Rochester, New York. It was the only three Rochester's I know off the top of my head, but you could go to California, you can go overseas, things like that. And what the home health agency, VNH is able to do is we would contact the local home health and hospice agency in that area that you're gonna be and be able to continue those services right there with you. So say you've got family in California, out in Los Angeles, we're gonna connect with an agency in Los Angeles, transfer your care to them while you're there for however long. And then when you leave, they're gonna transfer it right back to us. So there's no laps in services, no laps in getting whatever treatment that you need.  That's really the only difference. And what does the hospice benefit cover? So one of the things too that I really want to stress related to hospice is that it's an entitled benefit, especially for anybody who's on Medicare.  And other insurances will as well, I will say, thankfully, most individuals who are on our hospice service have Medicare. There's not a lot that are on private insurance or Medicaid or all these different things. But again, we provide a variety of services that the individual can receive during this time. And not only the individual, but the family providing services. And I want to in particular talk about the social worker and chaplaincy services, which is kind of in the middle of this slide. Our social worker, social work team in particular really helps with advanced care paper, advanced care directives, advanced care paperwork to just have everything in line for that individual. And maybe it was very sudden that this individual is now has a prognosis of six months or less. And there's no funeral arrangements set up. There's no anything set up. Our social work team can provide those supports to help coordinate and get that stuff together. Because we know that especially at the end of life, all of that stuff really falls by the wayside and you really want to just spend time with that individual. And we're here to help with kind of the paperwork aspects of things to just really be able to help the loved ones of that individual. In addition to while the individual is still with us, after they've passed away, we, our chaplaincy program still provides support up to 12 months after the individual has passed away. Rather it's one-on-one sessions, phone calls, emails, text messages, whatever it is that you're looking for, we're able to just continue to provide that support. And I say 12 months, we have individuals who on the anniversary of their loved one passing away still reaches out to our chaplains 10 years after the fact. So our chaplains are never going to say, sorry, it's only 12 months. It'll go on for as long as they need that support and they're more than happy to do that. In addition, our social work team also helps with any end of life after the individual has passed away, paperwork and maybe they have a question about like probate corg or all these different things. Like our team is still there to be able to assist after the individual has passed away. And then in addition to, we also help coordinate respite care for individuals. Rather it's potentially somebody coming to the house, more likely than not, it's they have the ability to go to a local facility, a hospital, a nursing home, whatever the case may be. We have contracts throughout the state of Vermont to have people be able to stay in a facility maybe for a weekend. I think it's up to a week, something like that where the individual can go there, get the care that they need, and their caregivers can have a break. And we all know that that's also so important to be able to have those breaks and just get that little bit of extra support. So we help coordinate that as well. Any questions about the hospice benefits or anything like that? So, Jack Boehring Center is one of the places that we work with, but I mean, we would also potentially, I think at one point, and I don't quote me on this, but like Giffer Medical, I think has some respite beds, things like that, to be able to just keep, we try to keep them as local as possible while at the same time understanding that it may be a little bit of a drive. And again, even if it's a respite situation where you, the individual goes there to be able to stay overnight for a few nights so that you as the caregiver have the ability to sleep for a few nights. It's not to say that you're not gonna still go see them during the day and spend time and do those different things like that, but maybe it's just, you need to be able to get a few nights of sleep, kind of thing. So we try to get the individual as close as possible to where their home is. It's all just a matter of availability. And so one of the other big parts is volunteering for hospice. So my friend Nils here in the back is our bereavement and volunteer coordinator for our hospice program. And one of the things that we find is as important as anything the VNH is doing around nursing and chaplaincy and social work and things like that are volunteers to be able to go spend time with the individual. And a big part of this too is to provide a little bit of respite for the caregivers. So that way maybe they need to go, they have a hair appointment. They need to go run, grab groceries, whatever the case may be. We can have somebody come in and hang out with them for a little bit. And even for some individuals who maybe don't have a lot of family in the area, supports in the area, things like that.  So I mean again, this is the smallest list humanly possible of what you could do for being a hospice volunteer. But essentially it's just being there for the individual and providing some support. So again, we're always looking for people who want to volunteer. You can go to our website vnhcare.org to learn a lot more about it. Or after the presentation, just ask Nils. So our long-term case management services. So this is a service that primarily, Medicaid patients in particular are the ones that receive the service, but all insurances are accepted related to it. But so one of the things to understand with this is that so you would have a case manager who's essentially coordinating all the supports that you have. And they're traditionally one of our staff, but there are some situations where you may be able to hire your own case manager to kind of manage all of your supports. And we'll talk about that in a minute. But we help coordinate a variety of different services for you or a loved one to be able to stay in home longer than potentially you would have been able to otherwise. So we provide several things within the home. Again, we help with coordinating with emergency response systems, lifelines and all those kind of things where you compress a button and have somebody come to your home as well as assistive devices, home modifications. I mean we can help coordinate with potentially getting one of those seats that bring you up the stairs or help with building a ramp outside your house. So it's different things like that that may be needed for you to be able to stay in your home. Otherwise you might have to go live with a family member or go live in a nursing home or whatever the case may be. So we do a bunch of different stuff. Outside of the home, we can also help with coordinating supports within different types of living situations. So I mean again, it may not be your home but maybe you're living in a like a next level down from a nursing home kind of thing. Like I'm thinking of the Woodlands in Lebanon, New Hampshire. It's a assisted living facility. Everybody's independent, is able to do different things but there's somebody there at all times to be able to assist with a variety of different things. Like you still don't meet the nursing home level that you may need and you can still live at home but maybe you need somebody to come check on you twice a day kind of thing. We can help coordinate stuff like that and still provide supports for that individual there. And then up to everything and eventually getting to a nursing home and where you would have those fully well-rounded supports we can help coordinate and help with long-term Medicaid to help pay for those kind of things and things like that. So we provide a lot of different things within the long-term case management service. And again, within our long-term case management, I mean we're there. We're there to help with whatever it is that you may need. Again, we may not be, as the VNH, we may not be the specific agency to help with everything, but we're gonna help get that well-rounded supports around you. Whether it's we help you get food stamps set up or we help you with rent assistance or fuel assistance or all these different things. We connect with Sevka to be able to help winterize your home and do different things. We're providing that case management supports and it can be a situation where we're there once a month. There's situations where we may need to be there every day. And it's all gonna be determined upon what that individual needs. So we provide, again, it's just to be able to help you stay in your home as long as possible. And within the long-term case management program, we have the ability of doing something that's called flexible choices. And basically what that means is that you would come to us, we'd get you all approved to be able to have this long-term case management, but maybe you know somebody who can be the quote-unquote case manager for you. Maybe it's a brother or a friend or whatever the case may be. And they may be then responsible for ensuring that a plan is developed for how the funding that you're receiving through this program is being used. Within that funding, you would also be able to hire what's called a personal care attendant to potentially take you to doctor's appointments or grocery shopping or running all of these different errands and things like that. But also just some companionship services for you. So essentially it's the same services, but you have more flexibility with who would actually be providing that service to you versus with us with the VNH, it would be one of our case managers, one of our personal care attendants, and maybe you don't gel as well with them and you know somebody that you would gel with better. They're still, those individuals would still be working with the VNH just like you are to ensure that money is being appropriately used to provide these services and whatnot. But again, you have more flexibility. And again, our PCA staffs, maybe they're not keen on taking you out at seven o'clock at night to go do something. But maybe your person that you know is very willing to take you out at seven o'clock at night to do some sort of activity. So, and that's something that can be discussed with our long-term case management team and get that all set up. And I've already explained to you what makes flexible choices different than traditional services. So I'm just going to skip this slide. And then our help at home program again, I had mentioned that at the beginning. Again, it's a fee for service program. As you can see, it's about right now, it's $35 an hour for the first 40 hours and then $45 thereafter. And then there's also mileage involved if you're asking the one of the individual to transport you to appointments and things like that. But, and it's non, it's non medical. Like that's the most important thing to remember as well is that, you know, they're not going to be able to specifically help you with any of the maybe medical things that you need outside of, they can help with setting up like pill planners and things like that, helping with the medications. But like they can't check your blood pressure. They can't check your blood sugar.  Like that's not what they're trained to be able to do. But they can help with personal care stuff like showering or toileting and things like that dependent upon if those are things that are needed. So, and again, this kind of falls under the long-term case management program but it is a separate entity altogether. Yes. So, so from what I understand with some insurances is that it, there are some insurances that have those supports in it but it's for a short period of time like maybe a year or two max. And so it's a matter of just kind of like talking with that insurance company and understanding that some. So for like, for example, like maybe you're on the tail end of being able to live independently but you have this, you know, this insurance that could potentially have somebody come in and help like with home making and things like that. You know, we would be able to, you know, and then, you know, provide that over the next two years and then maybe in that two year timeframe it's kind of transitioning into the next phase of your life as far as where you're gonna live and things like that. But ultimately what I would just say is talk to your insurance agent or that company or whatever and just make sure you have an understanding. I am to have, you know, understand that there are some insurances that it's a lifetime benefit to be able to do stuff like this on top of then, you know, if you need to go into a nursing home it's all set and ready to go. But that is few and far between that there's usually a timeframe in which you can utilize it. And what I understand is like maybe you use it for a year you don't need to use it again for another five and then you use the rest of it like within a year or something like that. So, no, no. So this is, this and long-term case management don't actually require referrals. It's just a matter of calling the VNH and asking us about these services and getting you set up. And in both the help at home not so much a like assessment and determination kind of thing. Cause again it's a fee for service but the long-term case management they would do an assessment to determine whether or not you meet the qualifications for it. And there's, you know, within the long-term case management there's, you know, there's income requirements and, you know, a variety of different things that you would go through with our intake person related to that. All right. And then, because a lot of people really don't understand that we also have a maternal child health program.  So, you know, and we provide services including skilled nursing, strong families which is a very specific education program that we'll talk about and a pediatric palliative care program. So different than our hospice program if there is unfortunately a child who needs to go through hospice care our pediatric palliative care program actually cares for that. So, and it's obviously it's a different skill set to be able to provide that end of life care for someone under the age of 21 versus someone who is in their nineties, you know. So, so skilled nursing. So skilled nursing within the program this has to have a referral from a doctor to receive those services.  Infant has difficulty feeding or failure to thrive and the children has a new diagnosis requiring in-home education following hospitalization. So, one of the things, you know, especially within our skilled nursing program for children is moms and dads who maybe don't understand how to use some of the equipment that that child is gonna need to use temporarily for the rest of their life, whatever the case may be. So, we're able to provide that care in-home so that they understand better how to take care of their child. You know, again, the primary goals and objectives are to provide that support to the child and the mom in particular. You know, obviously dad is gonna get the same education as mom is in a lot of these situations. But there's a lot of situations where the mom needs to be the primary focus and in particular with the Strong Families program that is available to new moms from the time that the child hasn't been born yet up until about two years. This is a very specific educational program that has been developed. It was actually developed in Australia and Vermont is one of two states currently that utilize this program. We have been trying for it to also be in New Hampshire because we know it's such a valuable resource and New Hampshire has not wanted to do it yet. So, but essentially the Strong Families program helps provide an educational foundation for new moms in particular to be able to care for their child. Within the program, there are 25 specific lesson plans that a mom goes through to just better understand providing the supports. And we have had moms who are on their second or third child who are doing this program as opposed to right after their first one. And it's also something that can be done with every child because we all know every kid is different in that, especially in that first couple of years. So, and it's something that it goes up to two years of age for that child or if you get through all the educational stuff sooner than that, then you're able to quote unquote graduate and you're ready to go. That doesn't mean that we're done, we're all set kind of thing. We're still available to be able to provide education and support to new moms if they have any additional questions and things like that. So, similarly to chaplaincy services after somebody has passed away, we're gonna be in your life if you need us to still be there and provide that additional support. So, and then again, with the pediatric palliative care program for children, it's offered to anybody 21 years or younger with a medical condition, with a prognosis of death that is highly probable to be before the child reaches 21. So, unlike hospice, this support being provided can last 21 years essentially. You know, an individual can also still receive curative treatment during this. So, you know, it's possible that a child is not going to see their 21st birthday, but they can still receive all the treatments that they need to hopefully, you know, beat whatever diseases is happening in this situation. And again, it's very similar to our hospice services, you know, providing that support to the individual in whatever capacity it may be, you know, up to and including, understanding that they're probably not gonna be cured and, you know, they have to come to that realization that unfortunately this individual is going to pass away.  You know, we're able to provide the supports to that individual, help coordinate, and then of course, you know, providing any family grief counseling and bereavement supports to that individual's family. So, are there any questions that anybody has with anything that I've talked about over the last 45 minutes or so? Well, again, like I said, my name's Anthony Knox. I'm the Community Relations Manager. In the packets that you all have, you have all of my contact information, but there's also some business cards on the back table if there are any questions. Please don't hesitate to call me, email me to be able to answer. And I wanna thank you all for coming and hanging out with me this morning. So, it was great and I hope you all got something out of it. So, have a great day.


She ran outside on the balcony and closed the door and called the other we didn't know what she was doing Where she thought she was whatever and she came in there. She's like my boss wants to talk to you This is what I believe I'm sharing that with you for nothing. Just get out there and succeed Good morning Absolutely, man, I've got a I've got a three bedroom and Perdido sky. It's a nice unit for $4.99 I mean it needs paint and stuff. I mean, it's kind of weird colors, but the layout, I mean, it's a it's a big unit I mean, it's got a wide living room in it. It's you know, it's a good unique kind of unit That that pretty nice guy.   I'll see what I can do to kind of stir the pod up over there ship Why see if I can't come up with the three bedroom in the next week or so All right, and this time if he needs anything or whatever feel tell him feel free to call me if you have any questions Or anything I can do to help him All right, man You got somebody who wants to be an Asian Yeah, he's actually a client he bought a condo from me How are you bro? 48 All right, the same man. You don't look 48, bro. Yeah, I've been doing it since I'm in real face. Let's do that Okay, so you want to do the crash and all that because right? Yep, say that how do you do it? Did you have to get out of business on How do you do it? I afraid a lot Lord, how are we gonna pay the mortgage payment this month and then uh, and then somebody call and say hey I got a cash deal coming close next Tuesday That's work. Thank you. Thank you Lord Just watching you and seeing what you're teaching and we've been doing it long time. Yeah That's another thing with prayer is my business changed when I when I started having on the gross, right? All right, I just made a total transition Yeah, I just want to take check it out.  Yeah Maybe make it up early and work out Get here and go through my notes And then When you make time to make those uh, those new new phone calls I don't make a lot of you don't do a lot of as far as up You know I'm cooking you're you're making those. I'm making those basically just for the video Yeah, yeah, that's my problem I'm too busy. I don't have time to make the busy cell and then great Yeah, you know, that's the thing you make phone calls. You can make three show busy You can't make phone calls anymore. You know, right, but if the market slows down, I'm gonna get back at I'll stay busy if I start slow down. I'll just very busy making calls, you know Listen to create phone calls. So they're calling you You get How many what's the days of the market every longest listing There's some of the road price that are 1500 a.m. Right, right. So that's how we do it too. Right. We love to sit there till it's ill, right So that's that's how you can build in the door. You know, I do a lot of splits to take like a 40 acre jack Splits up into four times. Right, right. I have about two lids So or about 20 may have a different buyer building for 20 or 30 Yeah, four different price points. Yeah, I mean, we got we've got C-pines. We have another 40 units or so We're gonna build there Then we're working on this Eight more units on the water Shores and we've got a 22 house So, you know, I got a pretty heavy head it's building a lot of houses I Build We can play get kicked out of one of the condos couple weeks ago, you know Yeah There was a cleaner in there, you know, and what it was dirty So we were we just walked in She's like, oh, hey, you know, and I was like, hey, how you doing? She's like, oh, I was like, I'm just an agent She's like, okay. I was like, we're just gonna do a little filming. She's like, all right, you know And then so I got on the phone and had phone call Blake started kind of filming stuff next thing We know that lady ran outside and got on the phone What you do She ran outside on the balcony and closed the door and called the other way and what she was doing We're such use whatever she came in there. She's like, my boss will stop you. I was like, I said all this I was like, you need to talk to Chad and I said all this up. So You need to talk to him about it But it was funny because Blake got it all film. He got her reaction and everything when I was talking to the boss And I said something like we're not gonna work We would film if it was dirty or something like that and the lady She was like going like this I'm going to do all this stuff that was like dirty And I was like that and we got her all we got her on film So now instead of the video being called $3.5 million condo is gonna be called getting kicked out of a $3.5 million condo I can't wait to see that. It's gonna be good. What up? Look who I got with me and the number six real estate agent for remakes in the state of Florida out of Crestview Brett sir Wow, there's some heavy hitters in Florida and Blake just had an almost had a baby last night It happens it happens Just crush Burn yeah, all right anything I could do for you man. Let me know.  Okay, let me know Okay, I'll be glad to get on the zoom for 30 minutes Yeah, we do like our office meet me. Yeah, we do a 30 on Monday morning first Monday of the month Just email me. Okay, so that's it. Yeah, look at some dates and do the live What works little thing? Yeah, see me for office. Thank you. Thank you, sir. Yeah, man. Thank you, brother I mean enjoy some cake. Okay, sir. Yeah Look at that.    He's an agent Mississippi. He bought like a half a million dollar house Probably it was worth 750. I guess when he sold me or something And Yeah, he sold without me And I The thing is is if I were to have a better job Of talking, you know staying culture touch or getting more frequently, you know, I probably done that deal You know, but it's like I've got thousands of clients. How do you call it? See what I'm saying?