I just want to mention a few things. One, Christina has not been able to get everything posted yet. Our internet has been down, as is everybody in state government since earlier this morning. So there's a few technical glitches, and it almost feels like the old days if there was a fire that burnt all the paper. But we'll get through. So with that, I'll turn it over to Susan Barrett for the executive director's report. Yes, thank you, Mr. Chair. That was the first thing I was going to announce was there was no internet. So that's done. The second thing I want to announce is next Wednesday. We will not be having a board meeting. We are going to start our hospital budget process starting August 20th. So we are going to take a much needed week to prepare what our budget hearing schedule is posted on our website. But I will tell you, the first day is here in the Pavilion Auditorium. So we're looking forward to seeing you all then. I think that's all I have to announce. Thank you. Thank you, Susan. The next item on the agenda are the minutes of Wednesday, August 1st. Is there a motion? Move to pass them. I'll second. It's been moved to approve the minutes of Wednesday, August 1st without any additions, deletions, or corrections. All those in favor signify by saying aye. Aye. Any opposed? OK. So at this time, I'm going to turn it over to the team from one care. If you want to come up to the head table there. I'm just going to give it one last time. Should I go ahead and start? Or do you want me to wait for technology? Let's wait 30 seconds. OK. We have any luck here? I have a moment of mindfulness. Yes, it is, isn't it? Big screen. I feel like I'm going to watch a movie. OK. Whenever you're ready, take it away. OK, great. I think we're just going to start with some introductions. So I'm Vicki Loner, Vice President and Chief Operating Officer for One Care Vermont. Good afternoon. I'm Sarah Barry. I'm the Director of Clinical and Quality Improvement for One Care. Great. And I'm Marissa Parisi. I'm the new Executive Director for Statewide Rise Vermont. That's really, that needs some oil to it. So we're really super excited to be here today. We have a pretty long presentation for you, but we're hoping to move rather swiftly through it because we know we're on limited time. So we're going to start it off talking about our population health model. And the way that we're going to move through this is Marissa is going to cover our primary prevention strategy. So she's going to be up first. And then Sarah Barry is going to move through and talk about our population health model from quadrants two through four, which I think you're all familiar with. And then I am going to end it with a discussion about how we did in Vermont Medicaid Next Generation Program for 2017. So with that, I am going to try to prove it. Can I not do that from here? Ooh. Oh, at the laptop. How do I get out of this? She's going to do it there. That's right. So I think we're going to just use paper. OK. So we're going to use paper. Great. So I guess we're going to start. It's very ironic because we had a discussion at our staff meeting this morning about efficiency measures and how we need to stop the paper. So I think we'll move right to slide four for everybody following on paper. And Marissa is going to kick us off. Great. Oh, this is great. We're going to move this way. So thank you so much for having me. I know that my colleagues from Franklin and Grand Isle were here last week and gave a pretty extensive presentation on the measurement study that they conducted on childhood BMI in Franklin and Grand Isle counties. And because you had such an extensive overview from our colleagues, I'm going to really stick to expansion and what we're doing to bring the RISE Vermont model to new health service areas across Vermont. And I do have a little bit more data to share with you. And I'm not going to get too deep into what RISE Vermont is because I think you know well. But I did want to just highlight a couple of things. So if you go to slide five, this talks a little bit about the RISE Vermont model. And it is very similar to the Vermont prevention model. And our colleagues from 3450 are going to present after this presentation. So what I thought I would share is just a little bit about how we work together and how our model is just slightly different and complementary to the work of the Vermont Department of Health. So RISE Vermont uses an evidence-based obesity reduction model that has been replicated in 29 countries. And we, as far as we know, we are the first place in the United States to use the model. And one of the key components of that is really linking health care and prevention. And so the exciting thing for RISE Vermont going statewide is that we are bringing campaigns like the first campaign that started through Northwestern Medical Center in Franklin and Grand El counties now to other parts of the state in helping RISE Vermont be based at the hospitals and also draw the hospital out into the community to really work even more directly on the social determinants of health through a community-based health and prevention model. And another way we're both a little different and similar to the 3450 effort in the Vermont Department of Health work is that we are really working in private and public partnership. Now that is often defined as working with businesses to improve health and wellness offerings to their employees so that when you are at your office or your work, you have the opportunity to improve your health through sponsored programs in your business. One thing we do a little bit differently through RISE Vermont is actually also ask the business to go one step further and change a primary business practice that wouldn't only benefit the employees but would benefit the community as a whole. So our biggest private public partnership in statewide expansion is really our hospitals. We are through the RISE Vermont statewide office that is based at OneCare reaching out to all of our hospitals statewide to ask them to bring RISE Vermont campaigns on board. But then we're also gonna ask them to think about what practices are going on for their employees and for their patients and perhaps change a core business practice that could help improve the quality of life for everyone. And I would love to at some point come back and tell you about how that's shaping up. Right now we have some ideas on policies around sugar sweetened beverages in our hospitals. Social marketing is another key component of RISE Vermont and a lot of people read that and think social media. It's actually defined a little bit differently for us where social marketing does include social media but it's really using traditional marketing methods with programming on the ground to have kind of a sandwich approach on making behavior change in our communities. And the last two pieces are monitoring and evaluation which is we are really hand in hand with the Vermont Department of Health on that. But political commitment is a little different and this is where we're really helpful to the Vermont Department of Health. And that is the RISE Vermont model includes changes to policy both within municipal level and perhaps at the state or even federal level to have policy determinants of health that really can help change people's behavior because the policy is better. So let me give you an example of what I mean. There are a few towns right now in Vermont who are working to pass their town plan and they've done wonderful work with the Vermont Department of Health to do things like have more access to the town forest and investments in labeling trails so that folks can get to those trails. Well, in a couple of towns, the town plan while it's included all this wonderful public health work has not passed because people didn't know that a vote was coming up or what the stakes were for their town. At RISE Vermont we're able to do the mobilization to go out and say, hey, this is what your town plan is about and you should really go vote for it. And that's something where we can be really helpful to our state partners at the Vermont Department of Health. So that's just a little bit more about the RISE Vermont model and how it's unique and very complementary to our state partners. So let's move to slide six. This is the only data slide because I think you got a lot of data last week but it's a little bit more about where obesity is going for the adult population in Vermont. So right now the adult obesity rate in Vermont is projected to reach 48% by 2030 and childhood rates are tracking about the same. The current rate of adult obesity is 27.1. So you heard from my colleagues last week that the measurement study that was conducted in Northwestern Vermont showed that actually those childhood rates could potentially actually be growing faster than is reported on the national average. In 2011, 48% of emergency department visits mentioned obesity and the projected growth rate of diabetes is 53% by 2030 from the 2010 rate. So that means the 2016 rate was 8.4%. So by 2030, as many as one in 10 Vermonters could have or be at risk for the disease. And the projected growth rate of heart disease is 400% by 2030 from the 2010 rate which means that one in five Vermonters could have or be at risk for the disease. So I share this just to share the overarching goal of RISE Vermont is to really change the environment around our people so that we can slow some of these rates. Because this means hugely rising healthcare costs and sicker communities and what we wanna do is intervene and help people embrace healthy lifestyles in the easiest way possible to slow these growth rates. So let's go to slide seven. And this is not a slide data-wise you need to absorb unless perhaps you're from Windsor County and it's of particular interest. I share only as an example of some of the data we're bringing to communities to really start the conversation about the health of their community. These are getting redesigned and some new data's coming out so they'll look a little different in the next few months. But in new communities where RISE Vermont is starting up we are sitting down with local stakeholders and bringing this type of data set to then start the conversation about the health of the community. Everything from smoking rates to BMI to physical activity, to consumption of fruits and vegetables, to listen to the community hear what the barriers are to improved health. So I just wanted to share that as an example. And then move on to our approach. So I'm on slide eight, right? Yeah, slide eight where you see the roadmap. So let me tell you a little bit about what my team and I have done since we arrived at OneCare in January to start the process of statewide RISE Vermont expansion. Since you've met our colleagues and founders at RISE Vermont in Northwestern Vermont, they have done such amazing work to get their local campaigns up and running around really improving the health and wellness of the community in every sector. And they were really in startup mode for the last few years. They have been on the ground working hard using this model and we were really brought in was to say, now can we package it? Because they had gone through all of the developmental stages to get to this incredible model. And now they wanted other hospitals to be able to just skip that and move right to where the most effective strategies could be employed. So we have done that and I'll tell you a little bit more about that. But what we have done is design a model where hospitals can get matching grants now from our statewide program to add a program manager for RISE Vermont at the hospital with the hospital as a backbone and use our toolkit to get started. And the very first thing when those program managers are hired that we ask them to do is to meet and listen to communities. So the very first thing before anybody starts making a plan about what we're gonna do, we talk to the people in the health service area. And that looks a little different in every community. In some cases it's the accountable communities for health group and others. There's a already preexisting group that's been worried about the health of their community for a long time and they've been happy that RISE Vermont has come along. But really what we do is sit down, that program manager gathers the people, sits down, asks the question, where should we be? Brings the data, like the local data sheet for each town in the health service area. And we've really figured out that one program manager for a population of about 10,000 is the right ratio. So right now with our new program managers, we're asking what towns meet us most and want us most. We don't want to be in a place where the community isn't ready for us. So they go through that process of meeting and listening to the communities and then they identify towns they are going to work in. And I'll tell you a little bit more as I go further through their presentation where those towns are. But once we meet with the community, we listen to them, we find out where we should be and what we should work on. We do an assessment of what already is going well. And in many cases, those are Vermont Department of Health programs. They are nonprofit programs. They are programs run by the town or rec department. And in some cases, it's just wonderful individuals who have always wanted to do something with their own expertise for the community. And once we do that assessment, we look at where we can actually provide additional funding or support to amplify those resources even more. So let me give you an example of what that might look like. In Richmond, which is one of our new towns, there is a local volunteer who is a naturalist and wanted to host butterfly walks and offered to host the regular walks. Well, because they didn't know how to get the word out about the regular walks, we can now get the word out, possibly pay for that person's time, offer butterfly nets and some notebooks for the participants. It's that type of local work. We are really working hard to amplify to improve the health of the community and offer more resources. So that's step two. Once we've done a full assessment of what's great in the communities we're gonna be part of, we start looking at where the gaps are. And in some cases, it might be regular physical activity or it might be access to nutrition. And that's where the program managers we have hired actually provide programming and try to fill those gaps. Always with the advisement of the local stakeholder group. So then step four, I've already mentioned this, but this is an area where we can really mobilize the community once we have become part of it and help people get excited about health and wellness opportunities. We can help do that advocacy and get our communities to say, hey, actually we do want more sidewalks. We do want more access to fresh local food. And that's where we have the opportunity to really educate whether it's the municipality or just educate the people to do their own advocacy to make change in their communities. And the last piece is monitoring and evaluation and replicating success. And the only thing I want to say about this, because I think it's pretty self-explanatory, is that we care a lot about what doesn't work. And I've worked in the nonprofit community for a long time in Vermont and I've seen a lot of programs just get tried and tried again in the same model, just hoping at some point someone will like it. I think it's probably sooner in the process that we need to say, you know what, we tried this a couple of times and it doesn't work, the community wants something different. So that's what's really core to the evaluation is making sure we're doing what's right for the people and giving them what they want to make change in their lives. Okay, so let's go to the next slide. And whether you know it or not, you know these folks, most of them were here last week, I feel like. This is the group from Franklin and Grand Isle Counties. This is the ground force of Rise Vermont. And the reason I put a photo of them in here is because the goal really for statewide expansion is creating teams like theirs across Vermont. And the reason I say that is because all of the folks who do the work in Franklin and Grand Isle Counties for the most part live in the communities they're working in. They're Vermonters, they already have great connections, they're already trusted members of their community. And what they've done is taken a step back, not ever told anybody what to do, but instead looked at their community through the lens of health.  So as we've been hiring throughout the state of Vermont for Rise Vermont campaigns to replicate, we keep this team in mind of what does it look like in Franklin, what was the real secret to their success and oftentimes it was the individuals that we hired that already had those community connections to do true collective impact where Rise Vermont is the backbone and it's really just bringing all of the other opportunities together for people to more easily access them. So let's move to the, well we can probably move ahead two slides because now I'll tell you much more specifically what we're doing on statewide expansion. But if you land on slide 11, I can just draw your attention to that very quickly. And this is the list of our statewide board of directors. So this board was formed before I started but it really is an incredible group of leaders in the healthcare field but also in the business field, in the community, in the physician community that are dedicated to Rise Vermont. And it's been very helpful to have this type of leadership to really open doors, to have very quick expansions so far of the Rise Vermont model. So I just wanted you to know it's myself, my colleague Emmy Wallenberg who's a master's of public health, who's our program manager who works at OneCare with me, Alida Duncan who's our social marketing strategist, Dr. Fontaine who part time as our medical director and then this board of directors who are really leading the charge. Okay, so onto slide 12. This is just a little bit about our toolkit that I mentioned. We really have worked very hard to curate all the good work that has happened in Franklin Grinnell counties to make this replicable toolkit. And the most important thing I wanna draw your attention to about the toolkit is we're working with our program managers to offer very community specific programs, but also make sure that we can offer things within a model that we can provide some statewide data at the end to really show that we're not just having an impact in Franklin and Grand Isle counties and maybe we're having a unique impact in Bennington County, but to be able to see if we're making some change at the statewide level. So having the toolkit and a framework for folks to work within, we're hoping we're gonna be able to really see some statewide shifts as Rise Vermont grows. So that's the only thing I wanted to mention about the toolkit. Okay, so this slide would have been animated to hopefully make it a little more clear, but it's not, so I will do my best to make it more clear. This is where we're headed. So the orange in the top left-hand corner, oh, maybe we're gonna get to see animation. What do we think, Connor? Oh, it's PDF, that's okay. That's okay. That's okay. Do you want to click? Sure, I'll click now. But I still need to make this slide more simple than it is. So at the very top of the state, Northwestern Medical Center has been implementing Rise Vermont in five communities since 2015. They're well-established, they're collecting data, they're seeing good results. UVMMC hired a Rise Vermont program manager in February. That program manager has met with a stakeholder group across Chittenden County representing all towns and has chosen Richmond, Huntington, and Bolton as the first communities to start in and she has launched programming there. Copley Hospital hired their program manager also in February. They have a employee health and wellness nurse named Cole Pearson who is working on both Rise Vermont and an employee health and wellness. And he has worked with the stakeholder group there and has identified Johnson and Morrisville to start work. Now I'm gonna jump down to Southwestern Vermont. Southwestern Medical Center was very inspired by Rise Vermont a few years ago so by the time we had come on board, they had already gathered a stakeholder group with the help of the Vermont Department of Health who was really passionate in that area about Rise Vermont and they had already chosen Bennington and North Bennington to start in. They have been advertising and interviewing for their program manager position. But because they didn't wanna wait since they had done so much legwork already, they have a fantastic masters of public health intern who has been providing Rise Vermont programming all summer and soon they will have their permanent position filled. Okay, so then if you jump up to Manuskatnee Hospital, they also have hired their program manager. They're going to be in four communities there. They're taking a team approach to Rise Vermont through their community health improvement team. Alice Stewart is the program manager. She has incredible amount of history and expertise working in public health there and it has a particular interest in food security in that community. And they also did the pre-legwork with their accountable communities for health to choose their communities so that went very quickly. Now the last two in the purple are Brattleboro Memorial Hospital and Porter Medical Center. Porter has identified an employee internally to be the Rise Vermont program manager and she hasn't started yet but she's coming to our first staff retreat of our new staff members in two weeks and she will get started in September and her first active duty will be to pull together their stakeholder group to choose communities. And then the last for this year is Brattleboro Memorial Hospital. Same thing, they have their position approved. They're gonna start advertising for it sometime this month and anticipate having a new program manager for Rise Vermont this fall. So in total, right now currently, we have Rise Vermont in 11 new communities across the state of Vermont that does not include Northwestern. If you include Northwestern, we're at 16 and we anticipate probably three to five new communities being added between Brattleboro and Porter. So that will be, we hope, by the end of the year, 21. Now, it's actually a little easier to see on your handout that it is up there. So now if you look at the yellow, the three hospital areas, service areas in yellow, North Country, CVMC and Springfield, we've had preliminary conversations with and have slated them to get started with Rise Vermont in the first quarter, first or second quarter of next year. Springfield is very ready to go and I think we'll be pretty close to ready by January one with North Country and CVMC. And the folks in green, we've just started having a conversation. They didn't, when we came on board initially, express interest straight away, but we've started to have more interest come in as Rise Vermont campaigns have started up across Vermont and seeing the good work that's already happening. There's more interest. So by the end of 2019, we do hope that there is a Rise Vermont campaign in every county of Vermont. Okay, so I've talked a lot about our stakeholders, but so I guess we don't have to spend a lot of time on the slide, but as of right now, we do have over 100 new local stakeholders. This is not, this does not include Northwestern who are participating in Rise Vermont steering committees and advising the work of the new campaigns. So I just note this again to really ensure everyone that we are not dictating what communities do. We are in the communities asking what they need, listening and believing them. I think that is the most important part is believing them, that they know best what their community needs and we are here to help make that happen. And we're very excited to have our 11 new towns. Okay, so the next slide on evaluating engagement and awareness, there's really three things we're looking to do with our evaluation. The first is to do very specific programmatic data collection. So we have pretty standardized methods of collecting data on who's coming to programs locally. So the program managers, whenever they're at a program they're looking at who's there, maybe what the general age is, are there kids, are there parents, are there more men, are there more women, that type of thing to really see how the programs are going. For the larger statewide data, we're using the Youth Risk Behavior Survey, the Pave Your Risk Factor Surveillance System and Medicaid data to track statewide trends. And we do hope that we are in this unique position and sitting at one care that we may be able to use some of their data in the future to see if there's any shift in areas where we are. That's something we're still looking into. And the last piece you heard a lot about last week is that we have a scientific advisory board who can take on special studies and investigations to look at a more micro level how our work is going. So we'll be working with that board to determine that in the future of what we might want to further investigate. Okay, so the next few slides are a little bit more of a show and tell about what having a Rise Vermont statewide office can do really for the whole state because I've told you a lot about how we're getting very, very local and in new communities.  So part of that for us is amplifying really good work that's happening in Vermont already. So this is an example of that. This summer we worked with the Vermont Department of Education and Hunger Free Vermont to place ads and do radio ads on promoting the summer meal program because many of our kids who receive free meals during the school year lose them during the summer. There are summer meal programs across Vermont that are very well run. They provide great nutrition for kids and actually Rise Vermont and a few different communities have stepped in to also provide physical activity at these sites. So this is an example of something that we can do to really amplify efforts and get even further in helping to work with all of our great Vermont programs to curate things for health. Oh yeah, could you do that? Thank you. I forgot about the clicker. That's all right, I'm under control. Okay. So here's another one and this example I'm particularly excited about because it's an area where we can use our lens of looking at things for health where other groups may not have looked at it for health. So we reached out a few months ago to Vermont Fish and Wildlife because one thing we were seeing from the programmatic data of who was attending programs in Franklin and Grand All County, we saw that it was primarily moms or women and they were bringing their kids, which is great, but there was not a lot of men. So we started to think, well, what could attract men to have great programs? And we were like Fish and Wildlife might know. So we reached out to them and they said, oh, well we've created this amazing program to get people out fishing. And the program is called Real Fun. I get it, Real Fun. Because I don't fish, somebody had to literally explain the real fun. But the real fun program is at 19 state parks. Vermont Fish and Wildlife provides equipment and bait at these 19 state parks for loan, for free for folks to get out and fish. Now the Fish and Wildlife started this program because they really want people out enjoying our natural environment. But it has such great health implications if people all of a sudden decide they love to fish and they're out in our natural environment, they're learning a new skill, hopefully they're with their families, maybe it's building community and certainly there's a physical activity component to it. So we did the same thing for Real Fun. This is our website right now. We have a radio ad running for Real Fun. We've placed print advertisement for Real Fun and we also, it might again be hard to see but you can see it on your handouts that we're having a contest for Real Fun. So if folks use the equipment, take a picture and post it on the Rise of Vermont website, they're entered into a raffle to win a $25 gift card to or vis to perhaps purchase your own fishing equipment in the future. So that type of amplification work, we think is gonna hopefully make a real difference. And Fish and Wildlife have been really grateful to us because they said, we love this program, we're really excited about it. They've had just enough marketing money to do a little bit of flyering at the state parks but not able to do a full media campaign about it. So we were really excited to be able to promote the program with the lens of health. The next slide is again, a little bit about us trying to curate all of the opportunities for Vermonters and their communities around health. This is an example of the Facebook page for Rise of Vermont in Bennington County. Every new community who signs on with Rise of Vermont gets their own Facebook page and their own section of the website so we can keep things as local as possible. So for example, if you wanted to go to Bennington County's website, it's bennington.risevt.org. And our social marketing strategist is helping with all of the maintenance of this and working with the local program managers to get as much information available to our communities on our social media handles and on our website. So the next slide is what you'll find when you land on our website. And I realized when I looked at this slide, this is from July that a lot of the opportunities that came up right away were from Johnson and Morrisville. That was just that happened that day. But if you look at it, when you arrive on the statewide page, you can see every opportunity happening in every Rise of Vermont community on that page. So say you are me and I spent the morning in Chittenden County but now I'm in Washington County. Our hope is that there aren't any statewide boundaries. So you might say, oh, I'm Washington County, great. I can go find out if there's a Rise of Vermont activity in Washington County because I'll be there today. So that's our goal with the statewide page but there are localized pages so that folks can get their local information. Okay, so the next slide, here's just a little bit about what's been going on since our program manager started. This photo here is of Cole Pearson. He is our program manager at Copley Hospital and he has been very engaged in getting his Rise of Vermont stakeholder group together. That's how Morrisville and Johnson were chosen as the communities that he would focus in. He has been doing quite a bit. He's been at Oxbow Park on Wednesday every week for Wednesday Night Live and in this photo he's actually sizing and giving out helmets to children and he has had a different health topic every week to engage the community at this community-based event. Coming in the fall, he's going to be doing the run for the heart, which is a 5K run and what we've seen great success with is if you've never run a 5K, it's really helpful to have a coach and a group to give it a try with. So he's actually using a Rise of Vermont mini grant to pay for a local coach to have a running group and then those folks who are brand new to a 5K using a Rise of Vermont mini grant to pay the registration for the race for those new runners. The next slide. This is Stephanie Hartzfield from the University of Vermont Medical Center. She is the counterpart of Robin Catrick who is our program manager based at UBMMC and they launched their Rise of Vermont campaign at the 4th of July parade in Richmond with a healthy scavenger hunt for kids and they are at the Richmond farmers market every week with a booth doing education on nutrition and physical activity and right now they're doing quite a bit of work in Huntington and Bolton on promoting the use of the town forest. So my last slide is about Southwestern in Bennington. This is Rory Price who is our master's in public health intern this summer and that is the new smoothie bike that is owned by Rise of Vermont in Bennington. The smoothie bike has been moving all around Bennington throughout the summer. There's I think two events a week right now and they've been doing a lot of partnering with the fire department and also the local library to get the smoothie bike out and do nutrition education but also some work around physical activity. They've worked with the Vermont Department of Health to provide free bikes that are for alone not smoothie bikes just bikes that are for alone at the Vermont Department of Health which is located right downtown in Bennington and they also are planning their first 5K that's gonna be structured similarly to the one that Copley is doing at the 14th annual Bennington Battle Day event. So I'm very proud and excited to see the growth of Rise of Vermont already. I think we, I certainly feel like I owe our Northwestern colleagues a great deal of gratitude for the incredible work that they did to not only start Rise of Vermont but start talking about it for the last few years around Vermont because really what my colleagues at the state level have experienced since we started in January was just a lot of energy to get going. So once we've provided the toolkit and the resources and the structure it's really been a pleasure to see our hospitals so fully embrace Rise of Vermont and get going with the model and I know what their hope is is to be able to budget for it going forward and continue to add capacity so at a point in the future they won't just have one program manager but they would be able to provide that as many program managers as they need for their population in their health service area. And I'm happy to take any questions. Would you like us to keep going and then hold questions to the end or do you wanna take questions now? I guess Jess has a question. As I'm listening I'm curious about how, so I understand that you're not dictating what communities do and it's sort of a, from the ground up trying to decide what the communities need and helping them with that. I can see the advantages to that and the sense that communities know what they need to some degree they know what the health issues are in their own community and so helping them through figuring out what they need and getting to what they need but the flip side of that is I can imagine you lose scalability, right? You've got lots of little programs happening throughout the state. You've got a lot of resources diverted in lots of different ways and on the one hand that can be a petri dish for deciding what actually works. Some sort of rate in this county maybe we could transfer it to this county. But two things, one is the way to really test that is to do some sort of real evaluation of whether or not paying for butterfly walks or giving out free fishing equipment, how many more people that wouldn't have gone on a walk went on a walk or how many more people that wouldn't have fished or how do you actually, I mean, I saw your evaluation slide and it sounded like you were looking at who signs up and who shows up but how do you actually really test the impact of those programs so that you can then scale it up and expand it to other communities and what are you losing by having lots of little petri dish experiments throughout the state? Yeah, I think that's a good question so and there actually a multitude of questions packaged maybe one so maybe it could unpack a little bit. Go for it. Okay, great. So first, in Vermont, we really need to make sure our communities have local control and for anything to be successful at all. So that's why we are so committed to those local stakeholder groups choosing what types of activities they wanna do. And part of that is really a critical piece of the buy-in of new communities, right? And what we do with our toolkit is give our program managers parameters around what sectors you're doing those activities in. So in some cases it'll be school-based activities, business-based activities, municipal-based activities and then we try to look at that as a package of are we seeing any kind of movement programmatically in those different sectors? Do we have more uptake in the schools using our services? Do we have more businesses? So we're looking at that. Now the E-PODE model, when you're starting to say the bigger impact, especially on health, right? That's why we're here is we wanna reduce healthcare costs. The E-PODE model that's been used in other countries, it's taken about three to five years to see change in what they've been looking at are the BMI rates of kids. That's why our Northwestern colleagues are so passionate about their measurement study. So it's possible that we would replicate the measurement study in other places. But what we need to do with those micro-activities is build the trust of the community to allow us to do that, to measure that. Now, I think a second part of what you said is really important. And that is we can't have all popcorn, right? We can't have all unique activities. So for one, some activities I think just by getting started up in other areas are going to be real gold. And we're gonna be able to, you went through our statewide team, replicate those and follow all of those in terms of success. But what we're trying to do at the state level is actually package a couple of campaigns that are absolutely consistent. Like you will do these activities, we will have only this media so that we could offer those to the communities and it's only gonna work if we say you have the option to do this. We can't say you have to. But we're gonna offer them the option to do it and hope that we have uptake of that so that we can follow that more consistent campaign and see the results of that. The big picture answer about reducing obesity is that in every model that Epodes been used and this evidence-based took some, took time, took years. Haunted house with that noise. I know I'm gonna wake up when they embarrass tonight. All right, so I'm gonna talk about how the work that we're doing complements Rise Vermont and the primary prevention focus that Marissa was just describing and addresses the entire population that is attributed to One Care Vermont. So my focus today is on our population health model. You go forward, maybe two slides for me. Yep, I'll start with Quadra two and then address three and four together. So hopefully this visuals getting pretty familiar at this point. We are very purposeful in grounding people in this model and approach. Before I get there, if you just go back one, I do wanna address one of the questions that often comes up around our clinical priority areas. And so you'll see here that we have six themes that our clinical committees have chosen to bring forward and highlight as priorities across our entire network this year. And many of them should look familiar from conversations we had last year. There was very deliberate conversation about the intensity and prolonged focus that is needed in order to drive the significant amount of change that we wanna see. And so really the new difference from when we last spoke about this is in the sixth area in social determinants of health. And it was really determined because of the community-based interest that was growing through the accountable communities for health because of the growing body of literature about the intersection between lifestyle, your physical, mental and social and economic well-being and how those all interrelate that we needed to take some steps forward. And so in this area, the first things that we're focused on right now are really around food and security. And we're doing some work to understand at a baseline where our assessments happening through primary care practices and also in hospital settings. So there's some pilot projects going on, a lot of work to build out EMRs, use appropriate standardized questions. And at the same time, we're also interested in, are there other opportunities to leverage existing information about individuals so that we're not increasing the burden of the ask for additional screening tools or the burden for patients who are having to complete this information, perhaps multiple times. And so in doing that, we're really building some partnerships across leadership of the Agency of Human Services and looking for opportunities to share existing data and bring some human services staff that are community-based into our care coordination program. And we're also looking at how we can use other existing data sets to think differently about determination and risk factors associated with social determinants of health. And so we're looking at things like subscales around neighborhood stress, how far you might have to travel to get to your primary care provider. For an elderly population, we're looking more at social isolation and we're really trying to just uncover right now which factors are important in Vermont and where do the data exist? How might we use that information moving forward? So if we jump forward, I'm gonna talk for just a couple of minutes about quadrant two and to ground us all, these are roughly about four out of 10 Vermonters who have one or more chronic conditions. They tend to be pretty well managed. So these are individuals who are really benefiting from interventions that focus on regular connection to primary and specialty care services around those conditions and increased focus on self-management support. So education and information, tools and resources to help manage that condition. And some of the things I wanna focus on here are around our diabetes prevention and management learning collaborative. And one of the unique things that really started for us in 2017 is that we recognize the opportunity to grow a partnership across lots of organizations, to align all of these well-intentioned and sometimes disparate activities that are going on, driven by different priorities. And to say, can we look at the data together and identify where there are some common priorities, some gaps in care and then come together and work in a focused approach. And so last year we began that with a partnership with the health department, the blueprint, SASH, the Medicare, Quinn Quo and other organizations focused on controlling hypertension. And this year looking at the data, we really saw across our populations that there were opportunities to focus on diabetes management, but also to move a little bit more upstream and think about pre-diabetes and how do you prevent folks from actually officially being diagnosed with diabetes. And so we've brought both of those into a learner collaborative. We recruited statewide after we built really the content and identified the subject matter experts. And we have 15 practices that voluntarily have chosen to participate in this learning collaborative. They've now moved through two of the four in-person meetings. And the feedback we're receiving is extraordinarily positive. We actually are surveying folks after each meeting and the latest round of surveys after the second session in June, which was focused on motivational interviewing techniques, indicated that 90% of the participants had specific plans in place that they were going to bring back to their office and implement in the short term. And when we asked them more about what some of those plans were, a lot of it had to do with workflow development with recognizing that some of the resources and supports exist, but they weren't actively promoting them with patients. So when you look at self-management support programs, the Healthier Living Workshops, Diabetes Prevention Program, there was a lot of variation, even variation within practice on who was recommending those services, who knew when they happened or how frequently they were offered. And so we're seeing a lot of progress in that area. And we're just now maybe at the half point of this learning collaborative. The other thing that has happened in this area is that we've recognized that there are more opportunities to think about the existing self-management support programs that the Blueprint and the Health Department and other stakeholders have been offering. And to really take a step back and together as a group assess how are those working? Are there gaps or barriers that we might together be able to address? And so some of the things that we're working on together right now in the area of self-management support include restructuring the way that some of the Healthier Living Workshops are offered in business settings. So they're often a two and a half hour session once a week, and we're actually moving to providing some opportunities where people can go for a shorter period of time, an hour after work, twice a week for that six week duration. We're partnering with several organizations around tobacco cessation and bringing some new tobacco cessation education information to adolescents and really looking at some of the risks around chew and e-cigarettes and how we can address those critical issues. And then with the Diabetes Prevention Program, really looking at are there other modalities that we can use to offer those services? We've heard some critical feedback from some of our more rural parts of the state that all it takes is bad roads and bad weather for somebody to not be able to make it to that next class and then all of a sudden the habits lost and they're not making it to the one after that. And so how can we think about emerging technology, different ways to consider regional approaches to that? And so we're hoping to roll some of those things out in the next few months. And again, I just wanna be clear. This is not work that OneCare is doing in isolation. Really, this is a very much a collaboration and building on all of the work that's been going on through the health department, through the blueprint and others. And so really it's a new lens or a slightly different perspective of hearing feedback and thinking about opportunities to refresh and reinvigorate some of the great work that's already happening. Just wanna highlight in this area two of the network success stories. So we've talked in the past about one of the strategies that OneCare uses to disseminate information that is happening at a local level are these quick one page stories that highlight an area where there's perhaps a gap in care. We talk about what the key drivers are and what the changes are that could be made to improve that quality of care and associated outcomes. And the purpose is really to highlight what are those actions that are taken, the results obtained, and then what are the key lessons that are learned that if we wanted to bring this to another practice, to another health service area or even roll out statewide, what are some key things we need to think about? And that really I think echoes some of the strategies that Marisa was speaking about earlier in terms of identifying those ripe opportunities, the innovations that are happening and our job is just to shine a light on those. So here are two examples. This one is around the controlling hypertension area that was a focus last year and this is a practice in St. Albans. And you can see that they had set a goal if you look at the graph in the bottom right of achieving 80% of their patients in control of their blood pressure. And there's a lot of nuance clinically to what that means that we don't need to go into today. But if you look at the blue line, you'll see that increase that really over a matter of five or six months, they've made a pretty dramatic improvement in that cohort or in that patient population. And a lot of the work that they were doing was really around better identification of patients that might be either in this case have high blood pressure or not be well connected to their primary care and needing to come back in. They looked at community resources and supports and how they could make those connections happen. The next slide just coincidentally happens to be from the same health service area. I didn't realize I had grabbed that but this is a federally qualified health center, The Notch. And they were really focused on depression screening which is one of our quality measures and an important area for us to consider. And you can see that they were really implementing processes to standardize screening and to look at tiered processes to do some quick initial screens and then to move people into a more comprehensive screen as needed. And again, if you're just looking at the trajectory of that graph over the course of about a year, they've made pretty dramatic improvements from about 50% screen to 93, 94%. I'm gonna talk now a little bit about our latest activities in terms of our complex care coordination program. And so just again as a reminder, these are individuals who have multiple chronic conditions. They might have other comorbidities. They might have mental health issues. They might have social, behavioral, economic, legal needs, a whole multitude of things that really can exacerbate their health conditions that they're dealing with. It also includes however, folks who have had some acute or catastrophic event happen. So a major cancer diagnosis, an amputation, a car accident. And so it's really for our community-based care team members, they have to have such a breadth of expertise and they really do need to rely on a team-based approach to bring all of the skill sets together to support individuals at a vulnerable time or a time of more intense need. So in terms of the central components of our model, again, we have a standardized approach to the model. We've been rolling that out now in our 10 health service areas. Too great success. I mean, as I go talk in new communities, as we're thinking about engaging additional communities in the next year, these five kind of core building blocks resonate. People say they make sense. And so it really focuses on person-centered care, making sure that we use data-driven approaches to identify those folks that would fall into those high and very high-risk categories, focused on that multidisciplinary care team. And so really making sure that that care team extends well into the community and is not solely focused on, say, a primary care setting or a transition of care, but is really inclusive of a much broader array of services. And as we move forward in the next couple of years, I hope to be talking more with you about our human services partners and how we're bringing them more closely into the care team as well. The payment model continues much in the same format and so I don't think I need to cover that today. But the tools and training I do wanna cover in the next couple of slides because we've made tremendous progress and really again are relying on some centralized approaches to bring people together to share information, to identify best practice and disseminate that. And so one of the things we piloted in 2017 with our first four communities was something we called a core team. And what we did is we worked together in the communities to identify between five and seven individuals in each health service area that represented a wide array of leaders and community partners that had direct information and influence around care delivery, care process redesign. And we asked them to come together with their colleagues on a monthly basis and we alternated between in-person meetings and web-based meetings. And frankly, at the time we thought this will last six months and people will tell us that a meeting is enough. And instead, I think there's a lot of pride and a lot of opportunity for people to really be able to highlight what they've been doing. There's also some accountability that their turn is next to be reporting on the progress that they're making. And so as we moved into 2018, we took this concept and we expanded it across the 10 communities and in order to manage the size and scope, we actually now have defined a north and a south region. A lot of the work that they're doing is really about complex workflows that cross organizations. So sometimes they permeate deep within one organization and they get to the core of the issue about who does what, what are the handoffs, how do we make sure this has happened. But oftentimes it kind of explodes out from there and it's saying, okay, well I made the referral but how do I know that referral was actually received and is there follow-up happening and how do I know that that's happening. And so really starting to map just as we gave you a little snapshot here of some work going on at Central Vermont Medical Center, what does this look like? How do we capture the complexity? Where can we simplify? Where do we standardize? How do we learn from one another? A second key aspect of our implementation of the model has been around care coordination training. So in making the very conscious decision that we wanted a community-based model that really cemented and supported the work of the blueprint and of our accountable communities for health, we also recognized that we were going to really need to lean in and build on the earlier SIM-funded work around care coordination training. And so we have developed, you'll see in the second half of the slide here, a whole variety of workshops. They're offered in various locations around the state and they really target different audiences and different skill sets. So everything from I'm a brand new care coordinator, I've just been hired in with some of this funding and I need to understand what the core tools are. I need to understand what a care plan looks like, how to have an effective conversation with the patient to engage them in care coordination all the way through the other end of the spectrum, which for us right now is about how do we engage senior leadership in organizations to talk about more complex issues around resource allocation and sharing it, thinking about that differently, burnout, workforce development. And we really didn't know how that was gonna be received. It has in fact been received extraordinarily positively and people are looking for those opportunities to be creative and to think differently. Some of the conversations I think to come in this arena have to do with community health worker models and how we can incorporate and maybe build that workforce by having a trained lay workforce to support our licensed professionals, whether they be nurses or social workers, mental health counselors, et cetera. We also have spent some time talking about our care coordination communication platform called Care Navigator and I just wanna briefly highlight some of the successes we've had there as we've rolled this out even further into our communities. So as we are both engaging people and expanding training in the software itself, we're constantly working with our vendor to make enhancements and improvements. And so some of the things that we've done this year are to actually launch a patient resource library. So if you have diabetes, we have a compendium of resources and materials at different reading levels. Some of them might be video based, others are text based where we can send that information out to you. Now right now it's a little bit more cumbersome how we do that. But as we move forward into 2019, we'll actually have a web based mobile application that will allow for that sharing of information, both active and passive sharing. A second and huge accomplishment for us in the area of care coordination has been in partnering with our designated agencies around addressing data sharing concerns under 42 CFR part two. And so this has been a tough issue for all of us, but I'm really proud of the partnership among all of the designated agencies as well as across our network. And what we've been able to do successfully is overcome some historical barriers. And so we now have a common consent form that's being used in any cases where we have care team members from a designated agency, for example, that want to become part of the care team and where there might be information that could potentially be subject to 42 CFR part two. We now have a process and a workflow in place, not only to get that consent, but to prompt for a re-consent process 12 months later, it puts banners in place that highlight the fact that this does contain information that should not be re-disclosed. So some tremendous successes, I think there in the last six to nine months. At the end of June, we launched a pediatric shared care plan. And we also have gone live with event notification. And so we now have direct data feeds from vital on a daily basis and from patient paying for activities. So admissions, discharges and transfers that might happen outside of our network. So are outside the state. So we get information on that. And care team members are alerted automatically when any of those events take place. This is one of the biggest successes that we've seen. People really are enjoying this. It's causing a lot of more immediate action to take place for people to reach out to patients and see how they can wrap around those, you know, difficult or challenging events that are happening. And I've mentioned we're working actively right now on a mobile app and a new interface that will be more streamlined and effective. In terms of some data, we talked about training and just in the first six months of 2018, we had over 550 participants in those care coordination trainings, a huge undertaking for us because we never train more than about 30 people at a time. And that represents over 300 unique individuals trained statewide. We are not exclusive to our one care network. If this is anybody in any community in the state that is interested and part of our strategy there, is that we're hoping you'll want to join one care in the future, so let's get you trained now and really have everybody have the same base of knowledge and tools and resources. We have just about 300 in that six months, new individuals trained in Care Navigator. And we learned through the process last year that there were a bunch of people that got trained in Care Navigator that maybe weren't the right people. And so as that kind of dust has settled and sorted out, we've got about 400 people that are actively in Care Navigator and using it. Most of them are not providers. And so that's one of the things that we're still working to educate around and some confusion that we still hear in our network. The primary intention of this platform, again, is not to replicate an EMR. It's really a communication tool and device. And so the most meaningful members right now are care team members like a nurse in a primary care office or in a home health setting, a mental health counselor, somebody from a community-based organization. And so what our job is now is to make sure that information is getting back to our providers in an effective and efficient manner. You can see represented our community health teams are actually quite big users of the system itself. The next slide just gives you some very early information on the progress that we're making. So when we look across all of our payer programs, we have about 16,000 individuals that we consider to be at high or very high risk for one or more reasons. And just in the first six months, as we're both training and scaling up, so a lot of foundational work happening, we still have been able to outreach and identify lead care coordinators for over 2,000 patients during that time. Over 1,000 or 1,100 have two or more care team members communicating around that patient. We currently have about just under 300 shared care plans created. And while that's a modest number, you have to recognize that it takes at least three or four months of really active engagement and dialogue to get to the point that you meet our criteria for having a completed shared care plan. That really there's enough information there, there's enough engagement to be driving that process forward. And then we also track community programs because there's so many great things that are already happening and it's beneficial to our care team members to understand where they're connected. And so you can see about 1,000 of them, we already have documentation information around how they're connecting to one or more community programs. I put this slide in here just to call attention to a case study that was conducted last year in our first year of our pilot program with Medicaid around the rollout of our care coordination program. And I think it has some really important insights in it about how care team members are feeling about this program, about how it does meet the needs of the patients that they're serving, the local community, some early data that we were seeing. And so our hope is that we will be working on similar case studies that we can be sharing over the course of the next months and years. I'm gonna shift focus now and talk just about some of the innovations that we're working on. And one of the topics we've discussed a little bit in the past is around patient benefit enhancement waivers. And just to remind us all, because OneCare is a next generation ACO right now, we had the ability to apply to CMS for waivers to allow for these enhanced benefits. And we chose to apply to be able to provide all three, but we have taken a staggered approach to implementation. Frankly recognizing that capacity with tremendous amounts of change happening locally meant that we really needed to focus and make sure that we were doing this right. And so on the left, you'll see reference to the three day skilled nursing facility waiver. So this is waiving the requirement for three overnight stay before a patient who has Medicare benefits can go to a skilled nursing facility. We spent a lot of time kind of researching and developing a user manual, developing a curriculum in education. And we rolled this waiver out in Middlebury in the beginning of May. And we have had, I believe it's a dozen patients just in the last couple months that have taken advantage of this waiver. Because remember, this is an option for all patients. So there's an education process that happens. And what we're hearing is that it's going extraordinarily well. Patients are quite satisfied. The transition points and communication that need to happen between the inpatient and the skilled nursing facility that those are happening pretty smoothly. And so that built some confidence. And what we are in the process of doing now is going live down in Brattleboro. They actually challenged us back and said, we wanna go live with three skilled nursing facilities at the same time. And while the initial thought was, wow, that's a lot. In reality, it's exactly what needed to happen because what that facilitates is patient choice and where they want to go. And we had three SNFs that were qualified and met the criteria. And so we're rolling that forward right now. They went live quite recently. And coming up very quickly behind our Central Vermont Medical Center, UVM Medical Center. And then we'll be continuing to expand there. In terms of the post-acute home discharge waiver, I have to say that one's been a lot more complex for us. We are still working on getting to implementation there. We've run into some legal challenges that we're sorting through. And I think that we are onto some solutions now, but frankly, the challenges we've worked with colleagues and other ACOs around the country is that we've chosen a very unique approach for how we want to implement this waiver. And again, it reflects our community-based and partnership-driven approach here in Vermont, which says that this isn't about the hospital hiring a new person to go out into the home. This is really about how do we partner with our existing home health agencies and those resources. And so the technical details of money flow and legal exchange of information have just taken us a little bit longer than we expected. But our hope is that we will be ready to implement in the first pilot community at the end of September. And the telehealth waiver has been a fun one for us. It's turned out that the timing was just perfect, that CMS changed some rules on us late this spring and actually removed some barriers that were causing us a little bit of consternation when it came to adoption, and having to do with some additional data that we're gonna have to be collected solely for the purpose of recording and had some big system implications for how that would be done. They've relaxed those rules, changed those requirements, and so we're now out and starting to educate around this waiver and the opportunities there. In terms of future waiver opportunities, we are actively working with staff for the Green Mountain Care Board and through others to elicit information right now about the highest priority item, which is for us around home IB infusion therapy. And so we're working right now with some subject matter experts in our network to put together the first draft of a white paper that we'll be bringing back to the staff at the Green Mountain Care Board later this fall and then working through together about what the scope of that proposal might be that we then work together to submit on to CMMI later in the fall. All of this with the hope that it would be received positively and be something that we would be able to implement in 2020. Sometimes we spend a lot of time talking about quality improvement initiatives and some of the things that are more front and center that have the pretty graphs that go with them, but I wanna highlight some of the pull up your sleeves, nitty gritty work that needs to happen to support our network. And so a lot of work on our team this year has gone into partnering with Vital to improve some of the quality of the clinical data feeds and we're really pleased to be expanding the partnership with Capital Health Partners and the blueprint around that. And again, this is all about alignment and prioritization, looking for opportunities and some quick wins. And so some of the things we've identified together is that there are some hospital-based EMRs that are not feeding information through the HIE directly. They're transmitting flat files and when that happens, we're not receiving that information and we've identified that and are in the process of correcting that, which will improve the quality of the information that we have available. We've also been working with our payers in particular with Medicaid and with Blue Cross Blue Shield around being able to get some additional information about beneficiaries or patients with substance use disorder information and where we've been able to come to agreement is around being able to receive some aggregate de-identified information, but more at the health service area level and even the organizational level so that we can start to understand what we can track and how we can provide data and information to support the quality improvement and have some idea of what's going on with our quality measures. So there's still more work to be done, but I'm really encouraged by the partnership and the progress there in the last months. We spoke already about the network success stories and some of the partnerships. We've been working very actively with our Medicaid partners around initiation and engagement of substance use treatment, working on education of our network and with our blueprint partners around the whole cadre of quality measures. And then on the next slide you'll see, we've spoken a little bit about a pilot program that one carries funding. This is a partnership with SASH and what it does is embeds a mental health clinician from Howard Center into congregate housing sites that are part of SASH. And we've been very excited to watch the progress of that. And so here, this is actually already outdated information. I can see it's from May and there's been a lot of change really quickly. But that embedded mental health clinician has had ready access to members living in those sites who have really welcomed her in and she's had an approach and a style that has really facilitated engagement. She's done a lot of proactive education and outreach, a lot of screening and has the ability to then refer on for more complex services. So that, again, for us has been a wonderful partnership and learning opportunity and we continue to study how that's going to better understand what the impact will be overall on our populations. As we've worked really hard together on quality measures and looking at how we can reduce the administrative burden, I have to say since I started two and a half years ago, we have maybe one quarter, one fifth as many quality measures as we had in our shared savings programs. That's a tremendous savings in terms of really having a focused approach, reducing the variation and frankly the fractured attention that was being paid in different directions and has allowed us to really get focused and provide some new tools and resources to our network. And so one of the initiatives that we've been working hard on is providing concise and very clear information to our network about the specifications for all of the quality measures and being able to point out how well aligned they are now that when we're talking about Medicaid or Blue Cross Blue Shield, we're talking about a same definition or at most we might have a slightly different benchmark that we're comparing to. And I know we've talked about this and it was just approved by the board very recently but the collaborative work with the Office of the Healthcare Advocate with the board staff, one care in our network around aligning the Medicare quality measures under the all-payer model has just been a tremendous success from our standpoint in terms of not only the process but again, bringing everything into an alignment in a way that allows us to drive focused improvement and so we're really hopeful that we'll see quite a bit in terms of results in the next 12 to 18 months in that arena. Would you like questions now or at the end? Any questions? Guess we'll go to the end. Okay. Will you click for me? All right, so I'm gonna bring us a little bit way back in the time machine to the 2017 VMNG Vermont Medicaid Next Generation Program and I thought what might be helpful is to just level set a little bit on the basic core components of the VMNG program and so I'm gonna start with that. Great, so right there. So remember, one of the main differences with the VMNG program versus our traditional shared savings program was that attribution was prospectively set at the beginning of the year and that's a big deal because that means that all the patients or all the people in the program are known at the beginning of the year so that you can do those outreach programs, you can have the care coordination programs and also from a financial stability standpoint, it's important to understand who your population is that you're serving for that entire year so that was a big component of the program and that's moved on through all the program offerings that we've had at OneCare for both our Medicare and our commercial for 2018. This was our first risk-based program that we offered at OneCare Vermont and so we started with a 3% upside-downside risk corridor and that has to continued into 2018 mainly because OneCare moved from having one risk-based program to three risk-based programs in the matter of a year so that is a tremendous leap especially when you're thinking about the total cost of care calculations when it comes to Medicare, that's a very large dollar amount. So one of the biggest charges for us was hospitals were now on a fixed perspective payment so hospitals were put on a budget essentially for the year for the population that they managed underneath the Medicaid program. There was no financial risk, this was really important and I think key to people kind of coming into the model, there was no financial risk involved for independent practitioners for FQHCs for the continuum of care providers so all the risk was borne by the hospitals for the VMNG program. And then to add to that there were some additional investments that we made because we've heard very core to again getting people involved in this model and core to the model is investments in primary care so we made a lot of investments in primary care in the first year of the program. So we had the 325 which was the population health management payments that really covered those quadrants one to two in the model and then come July of that year we started really investing in the care coordination model and that was that $15 PM PM for the very high and high risk individuals. And then as Sarah had talked about a big piece of this and working with our partners at Medicaid was making sure that the quality measures were aligned with the all payer model because remember when we started the Vermont Medicaid program that was year zero, I guess we'll call it under all payer model. So really this is the program that kind of launched us into year one so it was very important to start off with a program that really paralleled what we wanted to do going forward. We also created a value based incentive fund and this was new in that providers would be rewarded regardless of shared savings, right? Regardless of whether or not there were savings in total cost of care because what we're trying to do is provide investments in primary care to increase quality. So that was a very valuable tool to have as part of that program offering. And then we're always getting asked this question the benefits really continued to be the same under the program so the ACO didn't have the authority to change the benefit contract under the ACO. So the benefits all stayed the same as they were for all Medicaid beneficiaries. And then one of the really exciting things that Medicaid took a leap of faith with us on was waiving of the prior authorization and that was critical really to providers acceptance of this model to see that there would be some movement towards taking away some of those administrative burdens from the provider practices as they're willing to take risk underneath this model. So I thought about like doing a Letterman's top 10 but I only got to eight and it was also a matter of time. The one thing you'll notice that I haven't highlighted in here and I just wanna make sure that I'm clear to talk about it is the financial targets and that's because currently right now we're still working with the Department of Vermont Health Access and doing the reconciliation for the financial targets. And I think one of the big lessons that we've learned out of this is don't do your financial reconciliation at the same time as the end of the state fiscal year. Like those two collisions are not a good thing. So we are very close to doing that and we're very close to getting there at this point in time. And I would say though that we're fairly comfortable in that we feel that we're still in that like 1% margin within the total cost of care. And to us that feels like a huge success for the program that we are that close because we were really building this program right at the same time. We were trying to operationalize it and so that to us felt like a big win. So I'm not gonna read all these because I am trying something really new and radical for one care. I do not have words on a slide. And we're just gonna talk through what we view as some of the really key successes in the program this year. So as I had talked about earlier, really this was year zero under all payer model. And we really feel like we couldn't have picked a better partner than in diva for this first year going into this. We worked really hard to stand this program up. I think you all probably remember the number that there were 333 readiness requirements that we as an ACO needed to work through with the Department of Vermont Health Access in order to even launch this program. So there was a lot of rolling up your sleeves to get this program up and running and off the ground. Not to mention the provider education and seminars that we had to go through for these four communities. I would say that one of the biggest wins too as part of this program was we developed a core team that continues to meet much like the core team are the care coordinators. That really looks at how is the program running? What are the operational challenges? Where can we do better? And so I think every year that we go into this program we make more and more enhancements because that core team is in place and they're constantly monitoring the program and trying to understand how can we really make this better? So that is very important. So I think we talked about this with the hospitals. One of the biggest movements in this was really moving the payment model that supports the care model. So really supports that innovation. So the hospitals as part of this year one program agreed to live under this fixed perspective payment model. And what that meant was that we could enable them to invest in things like the care coordination program. They could invest in things like primary prevention. They could invest in the quality improvement incentive program. So this was a big movement away. Still hospitals have a foot in both canoes right now. They're not totally out of the fee for service world. They're still in half fixed payments, half fee for service. But this provided the momentum to start trusting the process that really this payment that we set course for is really working for them and providing some of those abilities to invest upstream. So I think we outlined a lot of this but really providing that investment to primary care was really core as part of this model. So providing for that population health payment, that 325 payment to do things like make sure that they have access to the primary care, make sure they're coming in for their wellness visits, making sure people are getting called back for preventative care visits and things that they need to really solidify in order to stay healthy and well in their communities. And I have to say that we've seen some really good preliminary outcomes with just in of itself access to primary care in the first year of our program. We saw that about 96% I think was the final number of people that were attributed, saw their primary care or had a relationship set with their primary care. So those payments are working and they're really important to the model. The quality improvement and measurement, so the Value Basin Center Fund was also very good to this. So in the past I think we've really taken a stick approach to quality improvement and saying, you know, if you don't do well on quality, if you earned any short savings, we're gonna take that away from you. So this was a way to say, no, we really want to invest in quality. We're gonna put the money up front. It won't be paid out until we know how we do on our quality results but it will be there because we're really invested in the quality improvement aspect of things. And then of course there was a care coordination funding that started in July, so it started midway through the year because we really had to get buy-in from both the primary care community and the continuum of care because they helped us to build that program. We didn't build that in isolation so I think that was really important to buy-in of the overall program. So we've talked about this a lot, right? This is all about the partnerships. This is all about building off from current reform efforts. This isn't about building something brand new and I think that the Medicaid program really helped us in solidifying our partnerships, especially with the continuum of care providers and that they helped to build our care coordination model and they're a very valuable asset in the care coordination model and we're so grateful for their support and their guidance along the way. And so this was really key to having them help us build the model as well as to provide them as well some financial supports to be part of the model. So this is always a burning question. Does this just like make more works? Like is being in an ACO really cause more work? And really what we're trying to do is to save time and reduce some of that administrative burden on the providers. And we think we've got a good start. Like we haven't solved it completely but we've got a good start. And the Medicaid program really, again, kind of started the movement in that. Reducing and eliminating the prior authorization requirements for those things that were within our control and under our total cost of care was huge. It was really a gift to our providers and they understand that, well, this is kind of hard because it's not all of my patients right now, it's only part of my patients, but it's progress and it's better than having to do the prior authorizations for all of their patients right now. As Sarah talked about, really aligning our quality measures so we don't have 50 some odd quality measures that were like really pay attention to this one when they've got a sea of quality measures ahead of them. And the other thing that we really have been working hard to do is to try to capitalize on the claims measures as much as possible because that the ACO can do for the providers and there's no sort of data abstraction that they have to do or to support or help in their office. We do provide that level of support to the practices to be able to abstract the measures. And when we can, we try to do it remotely, but if we have to physically go in their office, we know that can be a distraction for them. So we really wanna try to leverage as much as possible those claims data measures as well as to work with our partners at vital to be able to extract as much clinical data as we possibly can and make sure that it's reliable. And then I would say the other thing is really just leveraging our relationship with the blueprint for health and making sure that our clinical initiatives are aligned that our care coordination programs are aligned if we're having events that we're offering that we're trying to co-host and do them together. And Sarah and her team have been working really hard with the staff at blueprint to say, you know, what do your practice facilitators do? What do your project managers do? What are our clinical consultants do? And make sure that that's clear and known to the practices so that they have as much support as they need to be. You're already there. In terms of, you know, Sarah Mercer really talked a lot about a population health model, but I will say with the Medicaid program is improving that access was really important. So making sure that people are linked to primary care provider was one of our big goals in the program. And we really, we feel that we met that with not that 96% number, providing some changes in the way that we pay for services allowed for some of those investments up front through like the quality measures and the care coordination. So again, that felt like a really big win. You know, providing support to people with chronic illnesses or people with really complex needs to those programs is also really instrumental in how we're all gonna be successful because I think why we're in this at the end of the day is to have, you know, healthier people that live in Vermont because we wanna be healthy as well. And then we've talked a lot about the patient centered approach and this is really evident. I think comes out strongly in our care coordination model and that we are really focusing on what the patients want and what the patients need and we're no longer focusing on, you know, what can we do to treat a specific illness or problem? And we're doing that in many ways. We're partnering differently with each other, right? We're coming together through these team-based approaches through care coordination and having a common shared care plan. And we're partnering different with patients. We're asking them what's important to them. We're making sure that their goals are front and center and we're making sure that they get to decide who their lead care coordinator is and not us. So those are all fundamental shifts in the way that we're delivering care and looking at things differently. I hate to steal Sarah's glory on this one but we're happy to announce that for the Medicaid program, we did receive 17 out of the 20 points that were available to us for the quality measurement and improvement which means that 85% of our value-based incentive fund will go back out to our network and we're currently, because we're currently working through the reconciliation process that funds haven't been released yet but once that's reconciled, we'll make sure to get that out to our network. And you know, this is, I have to say this is amazing because a lot of these measures were new and so these are our baseline measures and so kudos to really the good workout and the communities and to Sarah and her team because this was from my vantage point a huge success for year one of our program. And the last thing I'll say is the providers obviously think it's a success too because we moved from having four communities that were really interested in being part of a risk-based program when we started the Medicaid program to 10 provider communities that signed up for 2018 and six of them said, hey, I don't wanna just do this for Medicaid. I wanna do this for commercial and I wanna do this for my Medicare population as well. So we think that this was really the proof of concept that was needed to get provided excited and motivated and moving in this direction. And so we're tremendously thankful to our partnership that we had with the Department of Vermont Health Access on this and really helping to make this an incredibly successful program for 2017. Any questions from the board? Tom, I have a question. So one of the, in terms of the partnerships I kind of think locally here. I think of Studio Zenith, a number of yoga studios, a cycling studio, first in fitness. And I'm just wondering in terms of do those kinds of private sector providers of things that may help you lose weight, which they have helped me, although I'm not all the way there yet. But do they have any statewide organizations that can kind of work with you folks to become part of that fabric of providers that a primary care physician might say, here's a pharmaceutical solution to your issue, but here's a non-pharmaceutical solution to your issue. And so that just becomes part of a routine option that a primary care physician can offer one of their patients is. So I just don't know, it's a kind of a basic question. Do those kinds of activities have a statewide organization that you can work with? And you're asking primarily for Rise Vermont. Actually I don't need a microphone. So not to my knowledge, but what we've asked our program managers to do is to reach out to those businesses. And it's really based on the track record of what Northwestern Vermont has done. They did a really nice job reaching out to gyms, to yoga studios, that kind of thing. And also asking them, would they be willing to donate their services for, they call them show up events. So offering local free events in the community where you could just show up and try yoga, show up and try Duke's fitness. What might CrossFit feel like so that I don't have to commit my own dollars to it before I know if I'll like it or not. So and in many cases, what the gyms have done in Northwestern have said, and of course we're always looking for new business. So why don't we offer them a free week? So that work mostly happens on the ground. I have not, I don't know of an organization that gets all the businesses together in the physical fitness field. We have worked with the governor's council on physical fitness though, on the corporate cup and encouraging other businesses to be part of that. But a lot of what you were talking about is happening at the local level. And again, we're trying to curate that so that if it's the day you want to change your life, you can come to Ryse-Romant and we can help you to conduit to those businesses. Great, Jess. So, great, thank you. Lots of successes here, I think honestly, to be proud of and I understand the analogy of trying to build a plane while you're also trying to fly it. And I think that's a lot of what happened this year. Particularly successes with respect to the Medicaid program and building the infrastructure for care coordination, reducing administrative burden for providers of the prior office waiver. I think those are all fantastic things. Two questions come to mind. One is you mentioned this great number, 96% of Medicaid patients attributed had access to a primary care visit this year. Do you have any idea either what is the percentage of non-attributed Medicaid patients and or those patients prior to being a part of the one care network? I'm trying to figure out impact about how has that changed? I know that you made absolute diva can answer that better than you, but I'm wondering if you've tried to assess that. I can't give you the exact numbers, but I can tell you that through the legislative process, they put out a reporting requirement on a quarterly basis to do some analysis of those people that are attributed to the ACO versus those individuals that are potentially attributed to the ACO, but not either because their community is not in or because they didn't have a visit with their primary care provider. And what we've consistently seen through those reporting mechanisms is that those individuals in the ACOs do have more visits with their primary care providers. And I think that they also had more visits with mental health counselors as well. So you are seeing a slight difference in the movement between those individuals in an ACO and those that are potentially attributed and not outside the ACO. But it would be really interesting to like do an analysis of that specifically to say why and what are some of the things that are being done differently. One of the concerns I have from the care navigator, so I just want to touch on that a little bit. You mentioned, Sarah, that most of, there's 400 active users of this, so the care navigator is your care coordination tool, right? And with 400 active users, most of whom are not providers kind of struck me as worrisome. First of all, are you worried about it? And second of all, what do you think is the percentage of the providers in your network that are using it? Those are great questions. I'm not worried about it at this phase in our evolution because I think we've been doing a tremendous amount of learning just about the amount of training, the baseline knowledge that we to establish, and also recognizing that we're trying to work on transforming the healthcare delivery system, but that needs to take a stepwise approach and so we can't go from A to Z all at once. So in order to make that happen from a context of care coordination, it's really about organizing the resources and those community supports. The people who frankly have a little bit more time in their day to have those ongoing relationships and at the same time can identify some of the flags and point people back in the direction of those primary care providers or specialty care providers. We have recognized in the last few months that there is more specific and focused outreach that we need to do with primary care practices specifically and so that's something that we're in the process of kind of reorganizing a few of my team members to get them focused on moving forward. And some of that's direct feedback and some of that is we didn't really speak about it today but one of the changes that we're in the process of moving forward for 2019 related to the payment programs that Vicki described is that we have established and passed through our board a set of clinical criteria for primary care. So a set of standards that you need to meet in order to maintain those 325 PMPMs and the care coordination dollars. Now for anyone who's actively engaged in the work that we do, there should not be anything radical there. These are concepts that we're asking for individual practice sites to positively attest that they're doing these things. So we're not asking for huge audits or lots of other administrative work there but it's really an affirmation from more of an education standpoint to say, let's make sure that we permeate more broadly our network with an understanding of what those core concepts are and how they relate back to the bigger picture. So it's things like making sure that there is a workflow and process in place in each primary care setting that actively looks to outreach and identify individuals that haven't been in for their primary care visit or once we've identified somebody who's high risk to try and effectively engage them in care coordination. There are requirements though that say that as individuals are engaged in care coordination that we wanna direct them towards care navigator as a tool to document that care plan and be able to share that across those settings. And we also added some language that said, if that really doesn't work in your community and you have another community based solution that allows for the kind of community wide team and information sharing, then come talk to us about it and let's figure out how we can do that. And we are in active conversations about that in at least one setting. That's fantastic. You've probably heard this feedback before, but some of the conversations that we've had over the last year about administrative burden with providers, I will tell you that Care Navigator comes up as another layer of administrative burden with respect to having to open up another interface and input data. As you're building this out and trying to do the outreach to the provider community, I just would encourage you to continue doing that because I think that I can imagine that the vehicle will work eventually, but getting feedback from providers to make it more user friendly will encourage their uptake, their usage and help us achieve scale as we're trying to get more providers in the network. Absolutely and I would just add to that that one of the key strategies for us is really getting this mobile application out. I've just spent the last day and a half with our vendor looking at it and really helping redefine it and it takes what is frankly a moderately cumbersome process of learning a brand new tool that you do have to log into separately and makes it on a phone or a tablet a much more intuitive user friendly process. So you don't need specific training to go in and say, oh, click on this button. Here's your care plan and I can see exactly what I need to and here's how I input that information. So it'll be a couple months before we're really ready to move that forward, but I think that it will cause a kind of fundamental shift in that conversation because it reduces some of, even that training burden that exists, right? All time is precious. Okay, other questions or comments from the board? If not, we'll open it up to the public for questions or comments. Pam. Mr. Chairman, you asked if he had any experience he asked on payments that would have been made outside of the four hospitals that were involved in this program, that's to say, here, people traveling and so forth. And specifically, have you had to go back to Eva, the Eva money being paid outside of 3% of those payments? Let me try to answer what I think your question is and see if I get it right. So we're still reconciling here one of our programs. So we think we're within 1% of our targets. So that would mean we're still within that 3% corridor of our band right now. And so that's what we're looking to reconcile with Eva is to say, are we indeed, are we 1% over or are we 1% under? But we think that's where we're sitting right now for the 2017 VMNG arrangement. In terms of care that's outside of the participants, that is in our total cost of care calculation. So we're always looking at where is care being received, where are people going for services? Are they participating with the ACO? Are they not participating with the ACO? If they're receiving a whole bunch of care outside of Vermont, does the primary care provider actually have a handle on that and do they understand that? Do they need maybe to have care coordination services to be connected? Because that's an important aspect of this, having that data and knowledge and information to say, are people receiving their care a little bit everywhere, kind of like that popcorn approach, but for a care approach, or are they really receiving care that's being supported through the primary care provider? Was that your question or was it a somewhat different twist? Yeah. Go for it. The $93 million for the 31-down. Yes. Yes. About 65 to 70% of that money was, hospitals didn't get any more money if they went over. Correct. Correct. The other 30% of that, but a piece of that, is the obligation that you would have for the attributed patients of that. The care that was not delivered within the network, within the core place, could be anywhere. It could be Florida, it could be Bennington, it could be any, okay, and so my question was, have you noted that you could figure out, yeah, were you surprised at all by the spending pattern in that piece of the $93 million? Yeah, so I don't have exact numbers for you right now because we're still reconciling that, but what we did see overall is that the traditional fee for service did run hotter than, so ran higher than what we had anticipated versus those facilities that were on kind of the fixed perspective payment. So we did see that the fee for service ran higher than we had originally anticipated it to be. So it's all like looking at historical data, right, and saying we think this is how the fee for service that's not locked into that fixed perspective payment is going to look, but it did run more than what we thought it did. And my follow-up was simply, you get to the point where you have the yellow line. No, no. Thank you. Okay, other questions or comments from the public? Seeing none, thank you very much. Great, thank you. Now we'll invite our friends from the Montefarment of Health. If for anybody who's out there and I see some laptops open so you probably already know this, but the internet is back on. Him whenever you're ready. Great, thank you so much for having us. My name is Tracy Dolan, and I'm the Deputy Commissioner for the Department of Health. And with me today is our Director of Health Promotion and Disease Prevention, Julia Rao. We wanted to come today to talk to you a little bit about our primary prevention approach, 3-4-50. One of the goals of the all-pair model is to reduce chronic disease. And as you likely know, some of the goals that the higher level goals of the all-pair model came out of the state health improvement plan. And so one of the goals of the state health improvement plan is to reduce chronic disease. The Department of Health has a long history of working to prevent chronic disease. The exciting thing that you're gonna learn about today, which is our 3-4-50 approach, is really that it allows us a framework to pull together a variety of approaches and with that alignment and synergy to really work at the community level toward the primary prevention for chronic disease. So chronic disease can be addressed all along the health continuum. And the Department of Health really tries to focus on the prevention side. We would say not just in Vermont, but nationwide there is a lack of investment in primary prevention. It's very important. It saves us money when we can get in early and prevent some of the illnesses we see later in life. And so we're very committed. We're really excited about this approach. We regularly get calls from other states to learn about it. And Julie will talk to you a little bit about how we learned about it. And we're also excited about the opportunities that allows us to partner. So for example, partnership with Rise For Not. As you probably know, Rise Vermont came out of a partnership between the Department of Health and Northwest Medical Center in St. Alden several years ago and has really blossomed in that community. And since then, Rise Vermont is now beginning to spread into other communities. And so we're excited about that opportunity because we have staff working on 3450. And so as Rise Vermont enters a community, we're ready to partner. We have a long history in most of these communities, decades. And so we work in WIC, a variety of maternal child health programs. We have epidemiological capacity in each of these communities, emergency preparedness. So we have a lot of partnerships. And what 3450 allows us to do in a really nice succinct way is to utilize those partnerships and address some of the higher level work we need to do. And Julie will talk to you a little bit about how different kinds of interventions have different impacts. And so we really seek to look at systems change and policy change in order to move our communities forward and our state forward in order to prevent chronic disease. So thank you and I hope you enjoy our presentation and we hope to have some time for questions after. Thanks, Chacy. Thanks for allowing us to be here today to talk a little bit about this effort. We're gonna try and breeze through the slides fairly quickly to allow time for questions at the end. So it's gonna be a pretty high level overview of 3450. So part of the challenge that we've faced in chronic disease prevention for quite a while is that most of our funding from the Centers for Disease Control and Prevention is very siloed. It comes down in the form of funding for cardiovascular disease, tobacco control, asthma. And it hasn't really coalesced around chronic disease as a whole concept. When in fact, as most healthcare providers will tell you and others, is that the chronic diseases are very interrelated and in fact, many people have multiple chronic conditions. And they come down to shared behaviors. And so 3450 is a way to both highlight those shared behaviors and shared causes of chronic disease as well as provide concrete actions to help move multiple sectors forward. So the three are three behaviors of tobacco use, physical and activity, and poor diet that lead to the four chronic diseases of cardiovascular disease, thank you. Cardiovascular disease, cardiovascular disease, diabetes, cancer, and lung disease that together result more than 50% of deaths in Vermont. So the problem with chronic disease is that a lot of Vermonters see chronic disease as their fate. Their father had a heart attack at 50 or their sister was diagnosed with diabetes at 32 and they sort of just say, wow, that's my fate. And that's also the perspective of a lot of leaders and decision makers is that chronic disease is just something that happens to people because we all know so many people with heart disease, diabetes, lung disease. When in fact, there are things that we can do about it. And so three, four, 50 helps to create that epiphany. We're then able to direct people to those concrete actions. And I think it's really important to note that three, four, 50 is not a public facing campaign. It's not a public message to Joe Vermonter on the street. It's really targeted at leaders of sectors that can make a difference. So businesses, schools and childcare centers, municipalities, faith communities, those leaders that can change the context within which we live in order to make it easier for Vermonters to live healthy lives. So that doesn't tell, these are the health behaviors that contribute to the chronic disease and this is for both youth and adults here in Vermont. We're doing fairly well with tobacco use but physical activity and fruit and vegetable intake which are sort of proxies for obesity we're really not doing well at all. But this doesn't tell the whole story. We can go on to the next slide. That was all Vermonters. There are two or more Vermonts. There's the Vermont of the general public and then there's the Vermont of certain populations that face significantly greater disparities in healthcare outcomes. And these next few slides highlight those. So this one are the three behaviors but it's broken out by low SES, non-low SES with low SES being people at 250% of federal poverty level with a high school education or lower. And you can see in each one of these it's statistically significant the difference between the two populations. These are chronic disease diagnoses for Vermonters with disability, Vermonters without disability. In some cases it's four to five times greater the burden of disease for Vermonters with disability than for those without a disability. And then finally risk factors for chronic disease and this is adults without depression, adults with depression. Again, they're statistically significant the differences between the two. And I think it's important that this is not to highlight that these are personal failures but in fact it's the system that has failed people that there are barriers both historical and social barriers for people in Vermont to have equal access to the opportunity to be healthy. And what we are trying to do with 3450 is to target those populations that bear the greatest burden of these chronic diseases. This is just a quick slide to show that it is 56% of deaths in Vermont are due to just those four diseases alone that come from those three behaviors. And as I'm sure you know, the cost of chronic disease to the state and healthcare costs is significant. This is just an estimate by the Centers for Disease Control and Prevention for healthcare costs related just to those four diseases and where it's projected to go in the next, just two more years. We'll have to update their chart. So, this you've probably seen this pyramid before but it really highlights the different ways that we can go about addressing disease and preventing disease. These are the factors that impact health and affect health and where we can make those changes. Work is needed in all of these levels but the sweet spot for public health is changing the context and that is one of the areas that has the largest impact because it's not working at individual by individual. It's focusing on the environments and changing the context within which people live. So things like community water fluoridation. People don't have to make the choice to access fluoride in their water. The community is fluoridated and it helps everybody. Things like smoke-free laws, smoke-free indoor air, smoke-free public places, tobacco taxes, those are all proven strategies that improve health for large populations of people without them having to necessarily wake up in the morning and say, I'm gonna make a behavior change in my life. These strategies change the context to make it easier for them. So what 3-4-50 is trying to do is to engage all sectors. Tackling chronic disease is not something that the health department can do alone and it's not something that healthcare providers can do alone. We haven't gotten to where we are as a state and as a nation in terms of chronic disease overnight. It's happened because the context has changed around us. The context of larger serving sizes. Changes to the way food is developed, the way food is grown and the way food is served. Changes to our work style were far more sedentary. These have had slow effects over time that have changed the context around us that have created the situation that we're in. What 3-4-50 does is work to change that context across multiple sectors where people live, where their kids go to school, where they go to work, where they're communities, where they are in their communities to change those contexts. This is a sample, because there's so many, Vermont is fortunate. We have a lot of things happening in a lot of different arenas that are all driving towards the same outcomes. Things like Rise Vermont, which is doing such fabulous work, 3-4-50 across the state, the accountable communities for health that are in almost all communities across the state, that it can become kind of confusing. And so our local office staff and Barry created this graphic to highlight those three efforts in particular, Rise Vermont, their local accountable community for health and 3-4-50 to show that we aren't duplicating what we're doing, but we are in fact creating a synergy through our efforts to really change the environment and change how people are living in Vermont. So while 3-4-50 is focusing on, I call it grass tops engagement, because we're looking to leaders to make changes within their sphere of influence, there are others in the community that are focusing on mobilizing the community to take advantage of those changes, to really live a healthier life. There are others that are bringing partners to the table that haven't been there to talk about how they can become involved and engaged in this effort. So this is just a really nice example that highlights how we complement each other, but don't conflict. I'm gonna jump in and add one thing. While there are often a variety of initiatives going on in the community, one of our challenges is dose. We often have an initiative that you might hear about. What we often don't have is that enough of a dosage to make the maximum optimal impact we'd like to have. So 3-4-50 has two main objectives and it has been rolling out over the past two years. The first year that was to create that epiphany to make sure that folks are hearing it are becoming aware of those underlying commonalities of these four chronic diseases. And the fact that we can do something about it. The second year, which we're just emerging from now, has really been to then engage those partners to make concrete changes. We have, this is 75, when you include the work of our St. Alden's District Office to engage partners as well. We have over 82 businesses, schools, municipalities, child care centers, faith communities, and now we have some social clubs coming on board. The Moose Lodge in St. John'sbury approached our district office staff and said, hey, we're hearing about 3-4-50 and we're really intrigued by this. We wanna do something with this. So now we're trying to come up with a sign on form that social clubs can join on and they can help make a change in their community. So we are now taking what we call a bite snack meal approach to our work across sectors. The bite is really providing tip sheets to help them understand here are five relatively easy, low, and no cost steps that you can take within your work, within your town, within your school to make sustainable long-term changes. And it's critical that we've pulled out evidence-based interventions. These are steps that have been proven through research published in the Community Guide or other places as being evidence-based. The snack are the sign-on forms that we have, those 82 partners that have signed on and that is them identifying what concrete steps they're going to make in the next six to 12 months to change the context that they have control over. And then the meal approach are the toolkits that we have available and that our offices of local health work closely with these partners that once they kind of gotten a taste for it and said, you know, this isn't really all that hard and it's not costing me that much as a business, but I'm starting to see a return on investment. Now we want to take the deep dive and do this long in-depth analysis of our work site. What are additional policies we can put into place? What are additional environmental strategies that change the context and how can we continue to support our workers to be healthier? Because what we're finding is, as they're getting healthier, our insurance rates are going down. We have lower absentee rates. And that's how we're moving this forward. So these are some healthy steps for businesses. Schools and childcare settings, things like simply maturing, are you meeting the nutritional standards? Do you have a farm to school and might you have a garden that the kids can work in? That's an evidence-based intervention. Enhanced physical education and working with schools to integrate physical activity in their school day. On the school piece, an exciting thing that happened was a couple of years ago, the Department of Health worked with the Agency of Education to update their standards to require the movement, the 30 minutes a day. And now what we've got is our staff on the ground working with schools to really figure out how to implement that, particularly in grades where it's a little trickier and working with them on school wellness policies to ensure that those updated guidelines are now getting implemented. And then municipalities, the Health Department has long done work with municipalities on healthy community design. And this is a way to help break it down for communities to start to take concrete steps towards getting there. And our healthy community design resource is available online for them as well. So it would be really easy for us to just do these interventions wherever we can. And what may end up then happening is that those that are already skewing towards healthy just become healthier. But we continue to leave certain populations in the dust and that is what we do not wanna do. And so even though we may be limited by resources, by using the data that we have, we're working to really target interventions so that the employers that we're working with and that we're trying to reach out to are those employers that maybe employ lower SES workers. We want to work with organizations that maybe employ individuals who have disabilities in order to better reach those populations to focus on schools that have free and reduced lunch rate at 50% or greater. It's because those are the areas that we know where there are greater disparities. So our goal is not to try to improve health for the higher SES educated folks who are already experiencing better health, but improving Vermont's health outcomes by really focusing on those populations that bear that greater burden of disease. What's been really exciting has been the engagement that folks have had around this, in part because seeing them really get chronic disease suddenly in a way that they'd never really talked about it before, like, oh, I never really thought about it, but yeah, it does come down to these three behaviors and how can we do that? Partners like JPik that have been promoting it, a lot of what we're trying to do in these early stages with three, four, 50 is like what tech companies do with early adopters. So they have a new product out. They look for that 10, 15% of the population that are early adopters that are gonna get it and then they're gonna start talking about it and get other people excited. And then that pulls the rest of the population along. In part, that's what we're doing with three, four, 50, is working with partners and those that are poised to make these steps so that they can get excited like JPik, like the city of Barry, like Mounis-Gutney Hospital. And then they start to bring others along to say, hey, this wasn't that hard. You can do it too and the health department can help. Mayor, Mayor Herring from Barry actually met with our chronic disease specialist, so our staff in a variety of districts and he came to that meeting to talk to them so that they could learn a little bit more about how do I get a mayor in my community excited about that? So that partnership has been really wonderful.  I've talked with folks from a number of different states from the Centers for Disease Control and Prevention and even from a public health department in England that are interested in how they can use some of the learning that we've done and some of the work that we've done and begin to implement similar strategies. So it's not just primary prevention and it's not just with multiple sectors in the community that we do our work. You may be familiar with our change packets. And this really breaks out our work across sectors. So there's a clinical approach, the community clinical linkages and then the environmental strategies. 3, 450 falls squarely in those environmental strategies but a lot of the work that we do is also with healthcare partners and through the blueprint. And so it's a collaborative effort to not only address primary prevention but also secondary prevention. So again, we didn't get here overnight and we're not gonna get out of this situation overnight. What we're really looking at is hopefully within 10 years we begin to see a reduction of the disparities. So we're not looking at overall Vermont percentages because that's not really gonna necessarily tell us the story. But looking instead at how are we doing at those disparities? Are Vermonters with disabilities still four times more likely to have cardiovascular disease than Vermonters without disabilities? That's what we're really trying to get at. And if in 10 years we can start to see a reduction in those disparities, we'll know we're making a difference and we'll then lead Vermont to be one of the healthiest states in the country. The Department of Health is really big on performance management. We have scorecards. So the scorecards do address things like these more global indicators that Julie's speaking of. But we also have scorecards that speak to our own program progress. So we don't wait 10 years to determine our success in a day to day way. What we do is look at quarterly, annually. Are we achieving our targets? With the belief that because we're doing the evidence base we get to where Julie's talking about and reducing those gaps. And then just there's a whole section on our website about 3-4-50 that talks about who our partners are. We are adding to it on a weekly basis. It provides information about the evidence base, the sign on forms, the toolkits, et cetera. And I think it's really important to talk about the resources that we have going towards 3-4-50. So while we don't have a line item in the health department budget that says 3-4-50 and we don't have a federal grant specifically for that, we're finding ways to really leverage our federal funding to be able to provide some of this work and better integrate our work. We have offices of local health around the state with halftime chronic disease designees and others that are focusing on this work and finding these partners and doing this changing of the context. And we're also leveraging a federal block grant to provide some seed money to a couple of communities. Again, not spreading it across the whole state but looking at are there a couple of communities that are really well poised like St. John'sbury that has just been rocking 3-4-50 and really doing a good job of layering their interventions in a very intentional way. So that over time we can see are those communities where we're really being definite about layering those interventions, are we seeing a bigger result in those communities than other communities where we don't have the resources to layer it and so it is more of a scattershot approach. So in addition to the chronic disease designees, which is a staff person, part of a staff person's halftime in each district, we have, of course, district directors and so they take a lead and they often take the lead role with new partners. So for example, as Rhys Ramont brings in somebody through the local hospital, our district director would join up with that person and talk about what's our work plan? How do we wanna align our work? What levels do we wanna hit? We also have school health liaisons. So they are aware and understand a 3-4-50 framework and they're able to work through the schools. We have maternal child health and we have others who are able to work in their sectors. The nice thing about 3-4-50 is that it really feels synergistic and we're able to really bring it together and the leadership of institutions, of municipalities have really caught on to this idea of 3-4-50, it's memorable, but it also really makes you feel like I can actually do something about that and so it's that empowering of many of the leaders in the community that really helps move it forward. Great, I think we're done. Okay, questions and comments from the board? Yeah, I just had a question on how do you keep the, how are you gonna keep the businesses engaged? So you have 75 signed up now, so they're signed on forms. I mean, how are you gonna be able to keep them engaged year after year? Because certainly one of the slides that was in the last presentation, I was kind of shocked by, which was that in 2030, they were looking at 48% of adult Vermonters being obese and you kind of just look at that and say, there's all these programs that are trying to help stop that and how are we gonna keep this engaged year after year? Because it's kind of snappy, I have a 3-4-50, I did see it in some of the hospital write-ups, but it's sometimes hard to keep the momentum. It is absolutely hard to keep the momentum and that's precisely what we have to do because it is going to take so long to turn the ship or at least start to write it. And our chronic disease designes aren't just reaching out to get the initial sign on, but we have a system through the central office that I oversee where we're able to send sort of tickler reminders to the district offices. Okay, six months ago you signed up these entities within your community. One year ago you signed up these, it's time to reach out to them to find out, A, how's it going? Are you getting any positive feedback? Are you seeing a difference in things? You wanna share a success story. Two, are you ready to take the next step?  Maybe you should go for gold or maybe you're not ready for that, but you just need some technical assistance to get over a couple of hurdles that you've faced in those first six months. So the district offices are there to continually check in at points in time to find out where they are, how they're doing and how they can take that next step forward as well as capture successes to highlight in newsletters or in the local paper or via social media. So that's really the intent of our district office staff is to not just do one touch, but do multiple touches. I would add that municipalities, mayors, people at that level in the community, if they incorporate into their town plan that three, four, 50 is just part of the fabric, that also helps, because now we've got another higher level institution really pushing businesses. And ideally having some positive peer pressure and competing with each other. We've had towns that have been recognized nationally under Michelle Obama's, the former first ladies initiative. And so that really gives some real credence. And so we're hoping three, four, 50 can move in that same way and get people excited, but our staff are permanent and that's the great thing. They will continue to be there because that's just the core work of what we do.  And it's also critical to note that the interventions that we're talking about here with three, four, 50 are not events or activities that the entities do, but actually policies that they implement or environmental changes. So the intent being that these are long-term changes. Once that policy is in place, ideally that policy will stay in place. Once that work site has a break area with a microwave and a refrigerator, so people are bringing their lunch rather than eating out, that should be in place in perpetuity. So that factor remains constant and that allows for the success to continue. Can we ensure that Rise Vermont and three, four, 50 are not duplication of services and rather complement each other? I think Tracy talked a little bit about that in that a lot of how it works well is when it hits the ground together. So right now we have three, four, 50 working across the state and we really see three, four, 50 as laying the groundwork and helping to prep the environment. So we're out, we're changing the context. We're starting to create those opportunities that when Rise comes to the community, they can really help mobilize people to take advantage of it. And so that when they do come, they're working with our district offices in concert to say, how do we enhance each other's work? So if the health department is working with a town like Barry on incorporating health language, then how can Rise help to ensure that those efforts are utilized by the citizens of that community or that that town plan is passed by the people of that city? In addition, the guidance given to the Rise-Vermont coordinators as they come on board and the guidance given to our staff around three, four, 50, referencing each other and require that they actually come together and work together. So it's less that we leave it up to let's see what happens and much more that in both organizations we really direct them to work together to make sure that it would be rare that there would be duplication because there's actually a lot of work to be done but that ideally they are working in such a way that it's synergistic. Any other questions or comments from the board? If not, I'll open it up to the public for any questions or comments. Seeing none, thank you very much. Thank you. Is there any old business to come before the board? None, is there any new business to come? Seeing none, is there a motion to adjourn? Good moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Any opposed? Thank you, everyone.