So Paul's informed me that you have a choreographed jump chart, and whenever you're ready to proceed, Paul, go take it away. Okay, yeah, so everything is kind of meant to be like a kid group. We do have seven presenters here. Again, I'm Paul Megson, I'm my right assistant at SportsMD. Brian Sexton and Lee, Selene Chawry, Laura Rooker, Bob Bursey, and Laura Robles. Each of us will take part in different parts of the presentation. So those are the people who will be presenting. And with respect to hospital issues, we'll turn right now to Brian Sexton, who's director of our ER services. But I'll tell you, one of the hospital issues this year is NVRH will have its first CEO in 32 years. So, for the record, this is the 32nd time of business. And it's always interesting. Brian, you're up. We will greet you in this hall. I appreciate the opportunity to speak with you today. In the interest of time, I will keep my comments brief until the point. First, I'd like to say I'm going to stress this. We have a bed problem in the state and region. It is far too often the case that critically ill patients requiring specialty care are refused by appropriate treatment facilities. This is because of lack of debt or staff capability. Just last month, as a brief example, our emergency department had to transfer a patient two states over to the main medical center in Portland, Maine, because our tertiary care facilities here were full. I find this unacceptable. The most common, regularly lacking inpatient specialized care in our state is psychiatry. And because of this lack of resource, there's often a significant delay in the transfer of emergency patients into psychiatric crisis to appropriate Vermont psychiatric treatment facilities. Specifically, these facilities cite lack of bed and staffing capabilities. As a result of this, patients are housed at NBRH, psychiatric patients with critical psychiatric illness, sometimes for days awaiting this transfer. Not a question of whether the transfer is appropriate, it's a question of capability in our state. These patients require intensive care and a significant amount of resources to protect both the patient, other patients, and our staff. This is a huge challenge for NBRH. Also of note, our volume of patients presenting with acute mental illness has increased on an average of 24 per month to 33 per month presenting to our emergency department over the past year. We've been cited by CMS who notes concerns specifically with patient observer level of training, restraint applications, and the physical space restrictions of our emergency department layout. NBRH is invested in this population. We have taken significant steps to enhance the psychiatric care that we can offer given those restraints. Specifically, we have augmented our staffing by training or in the process of training all of our emergency staff in CPI for critical prevention interventions and services. We have trained patient observers now. We're all medically trained. We've been working very closely with our care management and security teams to ensure safety. Cases are always reviewed as part of the QA and QI initiative. NBRH recognizes the importance of allocation services and they're fortunate to have Dr. Swartz now part of our team focusing on improving psychiatric treatment programs. At this point, again, in the interest of time, I'd like to transition to Sling Chalaburi, CNL, and Dr. Swartz to present some of the very specific innovative initiatives focused on treating mental health illness and reducing ED utilization in our community. Good afternoon, board. I just want to talk to you briefly about one of the initiatives that we're doing which Dr. Sexton has just talked about. We have met as a team with other agencies, North East Kingdom Human Services and Northern counties, with the intent of trying to reduce or change the way we do mental health in the North East Kingdom. One of the things we're doing is a two-faced approach. This coming year, what we'd like to do is have embedded mental health workers in the emergency department with the intent of trying to direct patients to the appropriate services as far as mental health is concerned and decrease mental utilization and decrease the use of a hospital thus reducing the impact of healthcare dollars and improving the care that we're giving for our patients. And then the second approach is a model that we've seen in California where they've actually done psychiatric and mental health urgent cares. And so that's what we're trying to do. And so there is a detailed explanation of that and I'm happy to share that with you, but at a safe time I'm going to end it over to Dr. Schwartz. Thank you very much. So I've been at NBRH since October 2017, not quite a year. I work 20 hours a week at the hospital Monday through Thursday and I'm available by phone 70s per week to the inpatient and outpatient providers who might have questions, urge you questions for me regarding the patients they're caring for in a moment. So I'm working with NBRH to develop a collaborative care model in which mental health care is embedded in the primary care practices. And this model is based on a well researched national collaborative care model which is both cost-effective and improves mental health care and access. The way we're beginning this sort of population-based approach in the outpatient setting to assessment and treatment of mental health in the primary care setting is to look at benzodiazepines prescribed within Kingdom Internal Medicine which is one of the NBRH practices. Benzodiazepines, as you know, are a potential drug of abuse and I'm talking with providers about the appropriate ways to prescribe it in the long-term adverse effects of benzodiazepine use in patients. And so we've done, through a practice-wide chart review of patients on long-term benzodiazepines, we hope to dig deeper into the patient's histories and determine the underlying problems that the benzos have been prescribed and to come up with different and safer treatment strategies for the underlying problem, thereby reducing the overall prescribing of medications. Now, in the statistics that I saw, we're not particularly, we're not necessarily higher in the state but we can always improve that. The use of benzodiazepines and thereby reduce risk for diversion and substance use. So that's an example of just a general work within an outpatient practice. So my outpatient face-to-face patient work is mostly a one-time consultation work. So I see a new patient every day or each of the four days I'm there. On Mondays I'm embedded in the pediatric clinic, seeing a child there and on the other days I see an adult that comes from one of the NBRH primary care practices and also from women's wellness which for some patients sort of functions as their main medical home. My outpatient consultations are designed to help the primary care provider deliver the mental health care. For example, I might be referred to an adult with depression for whom several medications have already been tried and there's not an improvement in symptoms. And so in my consultation I have an hour and a half to meet with a patient, dig into what the problems are and together with the patient formulate a better understanding of the nature of the problem and come up with new treatment strategies. That may include medications, activity, diet, supplements and particular psychotherapeutic interventions that will help with their particular problem. I do not myself do the ongoing psychiatric treatment but I do spend in that consultation considerable time with a patient doing psychoeducation and help them go forward with the treatment. I write a detailed consultation note to the primary care doctor or nurse practitioner with my diagnostic impression and recommendations for them to go forward. The PCP can always contact me through the patient's medical chart or directly to my cell phone or face to face if they have any follow up questions. In an indirect way of help sometimes primary care providers just contact me about a patient and ask for advice and I can review the chart and give advice or if I feel like I am not able to give a good recommendation without seeing the patient face to face I recommend they see me. And patients are easily getting into seeing me within a month. It's not a long wait because I see them just once and keep the system moving. So that's the outpatient part and on the inpatient consultation part I help the hospitalists manage primarily two types of patients. One are the patients admitted with a primary medical problem for which there's a significant mental health issue that's impacting the illness or the recovery from the illness and the other are for those patients who have a psychiatric issue but don't meet inpatient hospital level care but are awaiting a placement in a long-term facility or a nursing home. So for the medical patient if they're an MVRH primary care patient I'm able to reach out to the primary care provider and improve the continuity of the mental health treatment from the inpatient setting back to their medical home and this is usually in regards to medication changes that I might have helped advise the hospitalist to try and I'll be in the background following that. For patients awaiting long-term placement I help assess and treat the patient's mental health problems just as though they were in the residential or nursing home setting. Commonly I'm helping treat behavioral problems associated with dementia which cause significant disturbance on the general medical floor and stress on the nursing staff as well as to the patient. So my treatment recommendations include environmental adjustments and interventions to reduce the need for acute medication interventions in this vulnerable population. So that's a very brief summary of the outpatient consultation work I do and the inpatient consultation work I do and I'll leave it for more questions from you. Thank you. Okay so starting with one of the biggest risks that we role hospitals most of the hospitals in the heart are you know is recruitment and retention of staff. Right now we have an opening for a general surgeon called an OB-GYN physician and 11 12 nursing vacancies are in the nursing vacancies that we have at the college today. We have a number of nursing physicians as well and of course that is a risk to us. One of the other risks is any change the 340B program is talked about frequently changes are contemplated and the 340B program to NVRH is worth about $3.2 million a year between what we save and that for outpatients and with the retail pharmacy piece of the 340B patients. The 340B program is a huge risk to us. We are in a really good position of being busy patients are not driving by NVRH anymore we have strengthened a number of services at the hospital ED, neurology, neurology orthopedics we've talked about before and so we're seeing more patients in the hospital and the concern of course is increasing in part our revenue growth above the 3.2%. We recently made aware that our competitor in Littleton was trying to get into Vermont in a choir of physical therapy practice I'm sure with the intent of putting another pedic surgeon in our backyard which is in threats to us we are also now going to be pursuing that practice as well. We've talked about some of the new services and programs for patients with mental health and substance use disorder diagnoses those are opportunities we continue to look for lean like opportunities to improve efficiencies and to improve the patient experience we can collaborate that further if you'd like. We are looking at an alternative to the one here model that fits with our vision of our temple health community we'll get into that and put a bit more detail later on in the presentation and looking at the opportunity to join one care with some of their other projects as well still in the evaluation process. So now turn over to Laura Brooker to talk about some of the access time. In the interest of time I've chosen to highlight four areas two where we're doing rather well and two where we're struggling a bit our primary care access has increased we've been able to recruit a number of primary care physicians and we're currently fully stocked with primary care physicians so our access times are one week for a well check and two days maximum for a cute visit. Pediatrics we've rarely been struggling with finding a pediatrician to replace a pediatrician in the last fall. So unfortunately with that access issue we're at about 11 weeks for a well check and one week for a cute visit generally they get those patients in the day that they need to be seen but they have to do that like over bulking and the other things like staying late, working through lunch etc. Cardiology is a service that we contract with CBNC and with their ability to also recruit cardiologists, bi-cardiologists that replace the cardiologists that left we're really struggling in this area. It's taking us about four months to see a new cardiology patient in three months for a follow-up visit so that's been really tough on our community. Palliative care on the other hand we're doing really about both of our palliative care physicians that are super busy and we can get those patients in generally in the one week. I'm going to move on to the quality measures I chose to highlight the HD A1C measure both of our primary care practices quantum medical and kingdom internal medicine are busy participating in this statewide diabetes collaborative and they've actually chosen this measure to focus on in that collaborative. We've got physicians working in that group. We've got an ambulatory pharmacist that's helping with the project behavioral health nurses care coordinators so we've got a large group that's working on that right now. The third day follow-up discharge for mental health or alcohol and substance use disorder dependence treatment this is a measure that we actually had not been tracking we did really well with tracking when patients were discharged from the ER we had a really good follow-up system in place we do a great job of following up with the mental health or alcohol substance use disorder patients if we know about them when we saw this measure we realized that this wasn't something we were looking at closely enough so we reached out to Valley Vista right of our retreat to collaborate with Amor we've already had a representative come up and meet with us from Valley Vista to try to improve this process the percentage of reported PCPs this has historically been a really good number in our area but has increased even further with the collaboration and support of our care managers within our ED it's done a really great job of working with our PCPs getting people signed up for PCP Thank you, I'll talk about financial performance I've reproduced several schedules here for reference our operating market is going to be 1.7% internal we've targeted 1.5 to 2.25 to 2.5% operating margin to achieve every year and so within our target range for what we consider to be long-term financial health of the hospital our bottom line as you can see about 1.4 million is very consistent from year to year and that's what we're hoping to maintain going forward again it's about 1.4 million, 1.5 million bottom line and again about 1.3 4% percent of the operating margin I've highlighted some of the key changes from year to year I will highlight again we talked about our nursing vacancy position we put in extra salaries in the budget to help us can remain competitive for nurses and other health professionals but again with 11 or 12 nursing vacancies we're focused on being competitive we found that we were talking a bit and we're taking steps to correct that and get market competitive again for those key employees I will also highlight the fact that from since 2017 our disproportionate share of government has gone down about over $600,000 while the provided tax has gone up a bit looking at our balance sheet I just highlighted a base cash on hand at about $122,000 slightly higher than our peer group margin lower than all the provided benchmarks but if you focus on the critical access peer group we're just a little bit higher than our peers that service coverage ratio looks like it's going down significantly but in fact it's just the temporary borrowing that we have on the books of the end of 2019 we're planning to borrow some 1.20 billion or so we've got many capital projects that are hitting all at once we just did our birth center we're upgrading our computer system and we'll be putting in a new MRI so we have a one-year crunch we're going to borrow internally we'll borrow from a bank to ensure the term needs and then take it back in 2020 so that's just affecting that service coverage ratio looking over to PH5 again it's the you can see the cash flow statement there are included at 1.8 million of borrowing our capital budget is about 6.9 million that includes the 3.1 for the MRI replacement projects the project has recently improved by the Greenland Care Board we're asked to provide information on our in-state versus out-of-state payer mix and that information is provided here roughly five and a quarter percent of our capital revenue is from out-of-state so you can see it's about 8 almost 8,150,000 out of our 1,557 157,157 million dollars we talked about some of the expense drivers and our cost containment efforts the drivers are here I think I need to repeat them all in the interest of time cost containment efforts again and again it's a huge benefit to us well over 800,000 dollars we provided a reconciliation of our 19 just on the 18 budget to project that was part of our original budget submission it's in here again and again I would highlight the increase in the 340B revenue which continues to grow it's 676,000 dollars it's an estimated increase partially from having additional providers and partially some education about providers on the 340B program and how it can be beneficial to the hospital and to the patients the last thing I want to talk about is page 7 of the additional clarifying information to tell the hospital stories I won't go through all the calculus here but as you can see we presented our version of a roll forward from fiscal 19 that shows that our net page of revenue would actually be under the 3.2% cap of about 114,000 dollars and that's all I wanted to cover on financial highlights and happy to answer questions in a few minutes I'll turn it over to Laurel Ruggles so we like to engage with our community on ongoing basis but in really three years we're going to be doing a formal community health needs assessment I got some copies for the board and a few other people but it's also the one for 2018 this is our year again to do a formal one it's also on our web page the implementation plan which is a companion piece to the community health needs assessment is still in draft form because it needs to be adopted by the trustees and we hope that they do that next week at their August board so I think to summarize our community health needs assessment we can't do it alone we work really closely with our community partners whether it's getting data from Vermont Department of Health we use the new community health information from VHS on their website this year council on engaging we are really instrumental in connecting us to people in our vulnerable population like voter room owners and women from families and so that's the way we work but people in the community have residents people who work provide services work professionally with people and also people in our community and that's how we give the information that we need so I wanted to because when we're talking to people we're always looking for solutions not just the problems and identifying the needs and the gaps so I wanted to tell you one little piece of information that we use in order to talk with why we use a pretty innovative solution that you'll find in our implementation plan so this problem is first identified by Mary Grant who is the CEO of our rural transportation rural community transportation organization RCT who do a super job with providing public transportation in our region but what she said today was you know where the rural area where the little gap is providing transportation to people to work particularly if they are working on evening shift or weekend shift or night shift to be able to use their services so we went to the reach out program which is the state program to prepare people and they confirmed that with us they said you know we can if you don't have that much of a problem getting to medical clinics to other essential services even to things like shopping but if you don't have a car it's really hard to get to work so to help figure out what's the best solution to that and when you talk to some people and they're like we have all this we listen and talk and they said you know the rule if we can find transportation we can arrange transportation for somebody for the first month month or two maybe in the first few weeks of their job then they can figure it out they find out that there's someone who lives near there they think the car pulled it or they find out that there is a bus route that they can take or another working so they can afford to get the car that was being broken or they can afford to buy a car now that they're working so they said that's why we can get them there and get them started and get them successful in their job they figured it out but they don't always have the resources to have the money to do that so I said well that's when the hospital can come in so that's what we're going to do we're going to start with our men's fiscal year we haven't worked out the logistics yet I'm not sure we're going to set up an account with our CTE we'll figure out how we're going to do it logistically but we're going to track it we're going to see how successful it is and we can report on it in the industry I'll next highlight some of the health care reform and investment programs that we've implemented in the past two years what is the endo authority pharmacist he's done a tremendous job working with several of our primary care practices we've heard Laura talk a little bit about these two with diabetes patients so he has done a lot to manage health patients manage their medications better thereby reducing avoidable admissions to the ED or inpatient services our California Essex Accountable Health Community we've heard a lot about I think this is the third or fourth year we've talked about it we're going to talk about it again as part of our future look at the future of financials I'll look for the hospital managers we've actually had to increase from 1 to 1.4 full-time equivalent care managers working in the ED they drew a tremendous job of referring patients who have presented our ED who need to connect with other resources in the community not only to primary care but to any other health service organization in the community they do a great job and Dr. Ryan has been admitted in our lab we have some of that as well we have one and a quarter palliative care board certified palliative care physicians in the community we're just partnering with the county's health care we're going to add another 0.5 nurse practitioner to our palliative care service as well tremendous program tremendously busy and putting resources into it to meet the community need apart of that I'm a psychiatrist I can sort to you if you want to work from so I don't need to elaborate on that and we're getting ready to implement the community care medic service as well about the specs of the touch on that also this briefly in terms of our ED care management program this is a program that we developed when I came on board three years ago and it has grown with the support of the administration huge success these care managers are totally helping patients schedule follow-up appointments both with primary care and specialty care and kind of navigating that communicating with care managers in the primary care practices but also we have them focused on very specific initiatives what I like to term is trying to best provide care to the medically underserved so looking at high utilizers of the emergency department trying to focus in resources on them and we're working as part of a care transitions team which is multidisciplinary within the system including primary care offices inpatient and ED to identify those patients to those needs services regarding the community paramedics service also termed integrated global health care program it's currently there have been a few delays just in terms of training we are working closely with our EMS partner and to develop training with the paramedics the target population for this program specifically are patients who have presented to the emergency department and are discharged from the ED or if they are inpatient with the diagnosis of COPD CHF you have a fall and the goal with those target populations is that we're going to transition those patients to outpatient services more seamlessly specifically looking at metrics to reduce post discharge by term failures looking at ED utilization after that discharge ensuring PCP follow up those are the kind of metrics we're looking at the paramedics will be passed with mainly medication compliance also fall prevention and fall assessment in the home and also identifying restrictions of care whether that be transportation whether like and then communicating that back to care management in practice moving back to our capital budget plans a couple of points routine ongoing capital needs 2.4 million dollars infrastructure the facility was built in 1872 we continued to upgrade infrastructure so we're planning on about 500,000 dollars for the HVAC system the electrical system to keep the infrastructure of current routine technology replacement for example next year we're planning to move our e-mail system to all of 365 new technology great service our current system is at risk with the service based on we have the aging and we're looking to go to the yellow 365 and the investment for us and our current birth center electronic health record is not linked to many tech through separate system centricity by name and it's difficult for our providers to jump back and forth between systems so we're able now to get our birth center system integrated into the rest of the many tech system what you see here at the 3.8 million roughly does not include the MRI this is non-CL1 spending only so as I mentioned before we've got to spend about 3.1 million for the recently improved MRI into a bit of a deep project our long range financial outlook we're going to have Laurel and Paul talk a lot about this what we're seeing is the future for most of your financing and really looking at our database to get at those social determinants a little bit quicker then we see the current ACO model where we stand right now is we're working with we've brought one care into the discussion and we're working on aligning our health community model with the ACO model and this has been done about other places especially in Washington state where they have aligned the two models pretty seamlessly we're kind of using that as a guide you can call it alignment or you can call it the real name the health community on top of the care organization model well I've been involved with the all-payer model like work for actually right from the beginning and in some ways before again we're interested in taking on risk but again my interest has always been on integrating services and not just medical services with medical services across clinics and things like that but they integrate services across most of the human services because what I saw living in the northeast kingdom is many of these different agencies are working with common clients and we're not working in the most coordinated way the ACO concept is one step in my mind in the direction, the right direction to integrate care but the accountable health community is one that has always fascinated me for a whole variety of reasons but I don't think my own personal opinion is we look out to the future we're really not doing health reform if we're just working on what I call stuff and you might consider this a crude opinion but yeah we can talk about telehealth we can talk about this, that and the other but what really impresses me is when the accountable health community people that means the community action groups the councils on aging the mental health system by the way I'm a trustee and a designated agency so I'm aware of a lot of frontline things that can be done and also then the medical system with the housing people and the food security people and economic security people and by the way Tonya Kristen is out here observing this the Green Mountain United Way is a key player too people don't really think of this generally speaking as part of a team that can really focus, find synergy and solve some of the problems that we face the idea that we have at least I've had for quite some time could I think align very well with the alternative payment model I think we've deferred past years to terms like lending and grading and funding so for the first time in quite some time I'm actually thrilled that we're having innovative conversations with the department of Vermont Health Access Michael Autastas coming out to visit with us tomorrow on some innovative payment alternatives that we put in place with the Medicaid population in our area and I'm talking about geographic population not just the tribute but looking for some of those innovative relationships that Oral referred to that are happening reasonably well in certain markets of the country say out in the state of Washington but to be blunt I find the ACO model that we have right now in the contracts that we have in place they're too constraining in my opinion they'll maybe get us to where we need to go 5, 10 years out from now but I think there are some things that we need to do now I think a lot of innovation happens locally I'm aware of the global agreement that the state has with CMS I've actually read the thing and actually section 1 reads about state wideness it says to the extent possible this needs to work differently in different parts of the state so when I hear somebody and we give people an idea and I hear the word it can't that's not really part of how I think so the financing of healthcare is always going to be risky it can't possibly not be risky when it's much of the Medicaid population is supported by finances that are less than the cost of those services so rather than take up the rest of our time giving my colony most most of it the last section the last section we were asked to address is our compliance with the budget orders for the past two years you can see that track record has varied the big year of 2016 was the first year we had to be rebased because of all the business we were bringing back to Vermont from the Hampshire hospitals then rebasing did happen the next year in 2017 and you can see we came in under the 2017 2018 based on standard calculation over by about $700,000 but back to the alternative calculation that I went through talking about earlier were actually under the 2018 cap of $250,000 so that's a historical compliance and with that our presentation was ended and we'll turn it over for questions great thank you very much starting with member Robin thank you to hear your update around the accountable community for health and also very pleased to see that you're continuing to move forward including by working through the existing ACO program because I I hear you Paul but knowing you for as long as I've known you at this point I know you're vocabulary and all I can say to that is I'm glad I'm not your general counsel but I am glad to see so I think that's very good news from my perspective and I hear you about constraining and slow but I think I'm very happy to see that you're moving forward the one of the questions that I had for you related to your health care reform investments is in terms of your expansion of your palliative care your physician time and your palliative care organization are there any specific disease conditions that you're going to target through that program expansion or just is it a general expansion well we weren't very close to the Norris County Cancer Center norris so they work our palliative care positions two of them it's not like there's one in one quarter bodies of them they're both more certified palliative care positions they do have co-employment by by the hospital and the FQAC for example what is the hospice director so there is a continuity between the palliative care program and the hospice program but the referral referrals come directly from the community the cancer center the physician offices I assume even from the ER I don't know yeah and the inpatient service and it is an expanding program great thank you I just was curious about that another question I had around the ACO do's or investment in your new LLC because it looked like from the materials that it was in either or which makes me think that perhaps you're not a hundred percent yet on signing on the dotted line with one care so if I'm wrong about that I'd love to hear that but the question I had is if you allocated to the LLC how would you propose to report on how these funds are spent and how the investment more specifically relates to the state's health care reform goals well the short answer is well for starters we'll take it in layers yes there is we're uncertain about signing the document with one care of Ramont as it exists now in terms of one of my my opinions over time has always been because we started a lot of this work back before one care of Ramont even existed who are working on this regionally we already had systems in place that are functional and working reasonably well given the constraints that we have in our area which are primarily frankly economic there's things related to the rural nature of the area but so we already had systems in place investments that we've already made my thing is why should this region of the state be paying a fee to an organization that is not going to add value to what we do now that sounds like a very rude thing to say but I'm still trying to figure out how paying for example next year it said there's no fee but if you get into the nitty gritty of some of these agreement sections there is a withhold and as far as I understand from the map there is something yeah it's not called a fee it's not called a tax but it still involves 300 plus thousands of dollars invested in additional money to see in my opinion to what we already have in place so I'm happy to work with people I think that we're much more knowledgeable about where to invest the money the money basically you can see part of it figured into our very getting our toe in the water sort of investments in the budget that are related to our community health needs assessment implementation plan and we put our money where our mouth is over the past number of years say for example Dr. Swartz is not she was not included in our budget for the coming year that we're in right now but it would be pretty stupid of me to pass up the opportunity of getting something a skill and a person who's absolutely wonderful who's never had access to before to come work with us on our team a person who actually knows how to build systems with other systems people so we're investing literally hundreds of thousands of dollars in mental health related programs as you've heard we're also dealing with some of the what I would call backwash of things that are happening in the rest of the mental health non-system out there right now in fact you may have recall that in a crank pretty much all my professional life about the issue of spending way too much time focusing on inpatient beds rather than figuring out I mean we're doing work around with the symptoms we're not dealing in my opinion with what's causing all this stuff in the first place any things that I can see we could be doing with our designated agency to strengthen frontline operations both in terms of system building so that patients who want to get into the designated agency services don't have to get clogged up in the service because we've got people in their service who could be better served in the primary care so there are a lot of options out there in terms of how to spend that money better and by the way not waste a lot of money which I personally think we're doing as a state so I'd be happy to report monthly basis here's what we're seeing here are the kinds of improvements that we can expect this is a favorite topic the shorter answer is it also speaks to we have a commitment to become a health community model so we wanted to get that into our budget as I think many people at the state level will do as well but we're going to be starting the third round of the health community care learning rounds that started with the state innovation model brand and then we've done it the second time without really having any of that state money that the states putting their putting some resources into this as well which is really encouraging to us we just want to be ready when everybody else is so I guess just to follow up to that I would say first of all I always appreciate your bluntness Paul and I feel like it allows me to return bluntness back which is if I know through our accountable care organization review budget review process where withhold money goes and the kinds of payments it is used for to quite frankly shift dollars from the hospital sector to the primary care sector I don't know based on your description what the two hundred thousand dollars would be used for the LLC so before I'm willing to approve it for that purpose I would need to know with more specificity the use of those funds so I'll just put that out there for your information we can we can respond with specifics that would be great moving on to the rate increase of four percent I just had a couple questions around your commercial contracts or the majority of your commercial payer contracts percentage of charges I would assume yes and then what are your primary commercial payers blue prices are most the largest commercial payers again followed by thank you those are my questions well I don't have any questions the presentation is pretty straightforward looking at your your projections and your special projections are all inside your trends and you take it to a bottom line that is reflective of how you've been over the last few years so I have quick questions I am curious always is that how people project their Medicaid if you are increasing your six tenths of one percent how do you get to that number the increase of the Medicaid is basically just open volume growth we're not projecting any rate increases at all right I saw that rate increase in common the rate increases in fact I go ahead and key that I can see that I would say six tenths of one percent but it doesn't seem like such a financial number that's pretty much consistent with our volume growth and then just the other two things are looking at the reconciliation for other operating income on page 12 and you don't have to look at it now just to double check is that there you have a number of 3.7 million and in the staff analysis document the total other operating income 3.44 million so I think there is some noise there somewhere that might need to be corrected and the only other question was looking at the 340B growth last year in the budget we had the 1.5 million and now you're running at about 2.2 million and projecting 2.4 million for 2019 is so that was a big job from budget to budget and I'm just curious what might be behind that so part of this is getting new more providers into the program that are eligible those of education those of providers on the drugs that are eligible for the 340B versus those that aren't eligible for the 340B it will make no difference to the patients either the cost or the outcome having to go to the 340B ultimately thank you I have some disconnects between your revenue growth and expense growth so when we look in 2019 the budget your revenue is growing NPR of 3.8 million and rate is about 1.4 million of that and your expenses are growing 4.6 million so first there is a little bit of a disconnect on how high your expenses are growing in 2019 and second I kind of want you to help me get to a 3.2% increase rather than the 5% that you have because I look at you guys as you were ahead of your time you got rebased from 16 and 70 you were up 6% and 16 you were up 7% and 17 you got what you wanted in 2018 which when you came in here was over an 11% increase off of budget to budget and we gave you what you wanted last year so the revisionist to kind of look at it as a 5% is a redefined equals the 3.2% I don't buy into that so I really want to see how do we get you back to a 3.2% and taking your rate away gets us right there to a 3.2 but I think in that expense area some of the other things you can do because the remaining increase in 2019 is more than your revenue increase and it's significant over the prior year that's correct and it's made up by the increase in the 3.2 EP program so we're closing that gap but to get to your question about expense growth I mean we are constantly looking at expenses some of our expense growth began to mark competitive wages I was going to have to do over some of the expenses part of the additional costs that we've had to incur to comply with CMS regulations on how we're caring for patients in the hospital and EG and in the hospital patients with mental abuse and substance abuse disorders those are some of the costs why it was open to both and general inflation I think even the general inflation had about 1.6 million I mean it's about what we're going to have to try to get back if it's just one person but if we're going to the 3.2% because you guys are clearly above what the guidance was it seems to be in most all your lines so salaries are going 27.4 to 29 million range 8.5 to 9 million position fees 9.5 to 10.4 I mean all of your lines other operating 22.7 to 23.6 so I mean I don't doubt that you have expenses in there but when you look at your utilization you're only showing an under 2% utilization growth so the utilization is only a couple million dollars and your expense growth is 4.6 million so I think you guys may need to look at additional cost savings in order to get a lower number I'm almost talking about look at additional cost savings throughout the process given all the challenges that we're facing is the best we can do to our community we'll take another look at it right I mean it's 17 you're at 77.4 million your 18 budget was 78.6 your 18 projection is 79.8 and your 19 budget is 83.2 there's a schedule in you that does walk through those increases in the year so I like to challenge whether 2% inflation across everything which was given you 1.6 and then you have salaries and other things I just think you know I'm just trying to put out there that there may be additional cost savings or something to bridge a gap or in order to get to how do we get to a 3.2% yeah there's probably upwards of between $400,000 and $500,000 that are not bringing any new revenue in related to addressing some of the mental health related issues that show up at our doors and in fact I've met with some of our legislators talking about our concerns that there's a gap between what the regulatory requirement agencies are requiring of us and what not what we think we should need to provide to people arriving at our doors with mental health services so I wouldn't mind saving $400,000 to plus thousands of dollars I don't think I'm off on that number because you know what that bit of value has improved healthcare outcomes at all I'd love to do that but we're we're not going to be allowed to do that no matter what you say we're going to have to spend that money we've been told by the government so I guess I'm just going to echo a little bit of my college audience point that Budget Guidance is a 2.8 with a point for health reform investments you're coming in at 5 obviously well above our guidance which means you probably all have a little bit of work to do here and I just want to point out the alternative way of looking at your NPR I think it's on page 7 of your presentation and we don't have to go through this step by step but there's a couple of things that I think need to be reconsidered if you look at the fiscal year 2018 base that you used it doesn't align with what we approved for rebasing in fiscal year 2018 according to our Budget Guidance that is submitted in September and January I understand and that's off by that 800,000 the cardiology transfer I understand that you're it had been approved for partial year and you're upping it for the full year totally appreciate that even with that adjustment and the lab transfer adjustment the final base that I would come up with would be different than the final base that you would come up with based on what you're using as a fiscal year 18 base I'm using what the Board approved as the rebased fiscal year 18 base then the second layer I think there's some reconsideration is the approved growth rate for 2018-19 is actually 2.8 it's not 3.2 3.2 is inclusive of health reform investments 2.8 is the growth rate that we allow for the base so that the subsequent additions that you have down there may or may not be considered as health reform investments and could be in the 0.4 or not but I would just caution to say those are not definite add-ons and 2.2 is inclusive of approved health reform investments so can I address your questions? yes you certainly may have left it so you're right the 2018 base that you're talking about was approved is taking what we were allowed in 2017 and rolling that and that's a big difference if we ever produced revenue in 2017 so the big change is rolling the that's revisionist history right is to say well if you had approved that and given us 3.4 on top of the rebasing but actually if you take the rebase that we actually gave you in fiscal year 2018 and go from there the answer is no you rebased 2017 but rolled that forth what I'm saying is we rolled forward or we could have it in 2017 I understand it the second part is the 2018-19 growth rate we've identified other health care reform investments that do add up to the 24% one is the ACO fees and the other is the additional kind of care so then what we've shown here at the bottom recovery coaches and mental health DD phase 1 when the Green Mountain Care Board representatives came to visit us in April we made the point we wanted to invest money that they put us over the cap into services and we were told go for it make your arguments and put it in the budget so that's what we have, that's over above the 24% for the health care reform investments okay a simple question I have is in terms of non-operating revenue I believe that the only hospital that has to report to no zero non-operating revenue I want you to speak to that non-operating revenue is unrealized gains and losses on stocks in our investments I can't tell you what the stock market is going to see next year and whether we're going to have unrealized gains or losses so we just pledge a zero okay, you only have to look at that so I thought I was surprised by that you know, all the talk to me appears because they have a crystal ball of white dollars and then one of your health reform investments involves the health care program expanding it and I know that was a part of the 2017 health reform investments so I'm wondering if you can speak to one of the reasons for justification I think it's a very legitimate one is that it's going to reduce ED visits and other service visits and I'm wondering if you have been able to quantify the impact that it's had in the last two years we're putting the deal together and we're not going to be able to clarify it great, I think those are my questions thank you so the questions I have been asked have been answered but I have a couple of new ones since I listened to the presentation first of all you talked about the purchase of a PT practice and I'm curious about that as far as you currently have your own employed PT's, correct? so when you're referring out after somebody has been to your hospital do you automatically refer them to your own PT's or to some of them go to this private PT they can choose which physical therapy service to go to okay do you know when you will know whether or not you're going to be buying that practice this just came up Thursday afternoon so we're just taking the steps to move forward and we'll be putting a letter to the Greenmount Care Board and to all of my steps that might be taken I'll send them to the letter to the Littleton Regional Hospital last week okay great so the second question it really follows up on a question that I asked at one of your peer hospitals earlier today you started the presentation talking about a crisis in access and you mentioned that psychiatry was number one they didn't rattle off two, three, and four could you do that for me? I would say from an emergency department perspective most regularly as I said not in terms of the numbers because the numbers of psychiatric presentations aren't as high as some other disease processes but in terms of percent availability of resources I would say psychiatry is number one in Latin number two and then three I would say number two is critical medical patients and three is probably kind of your sub-critical that requires some level that we're either full and then varied to 25 in patients including patient requiring telemetry so I'm not sure trauma is not on that list trauma is the most always accepted although it's not always the long term so what possessed me to ask the question of your peer hospital earlier today is to follow up to our visit with you a few months back and I urge you to say cardiac and Dr. Cunin from Copley seemed to think that there was no issue as far as cardiac when they have somebody at that level they don't seem to have a problem you know getting that referral to the tertiary hospital so it's just conflicting testimony that we're hearing at times and it's hard to figure out what's the truth and what's the reality and maybe what we'll need to do is try to work with your colleague at VOS and try to get some type of survey out there to see you know what others are experiencing so we can get to the bottom of this because we certainly don't want to have an access issue on things like that so I completely agree with you I appreciate you carrying that concern and again my admission is going not only one state over but two states over to me Medical Center three hours away I think that speaks volumes it certainly does so Pat do you have questions really I have a couple of comments and questions first of all it sounds like this might be Paul Bexton's last hospital budget hearing at least as CEO of the RH so I just want to thank you for where I've sat over the last 30 years or so you seem to be quite an innovator and not only a doctor so thank you very much for your service to follow up on Robin's question about the Accountable Health Community I think it would also help the board to know not only how the dollars are being spent but some ideas if you can give us about metrics that we or you might use that's the admin that you have time to pursue to evaluate the success of the Accountable Health Community so it looks like Laura might have an answer so right now through the Accountable Health Community we have what we call the results checklist and I can always send that to you where we have some identified metrics the real quick way to get us and pick at them is in our implementation plan the population and all the measures they pretty much match up with what we're looking at and then we use the results list of accountability format looking at these population health measures which are typically particularly to see a difference and they're also the ones that you need lots of collaboration with lots of partners to get to and then within each program or service or each admission in we also identify the performance level measures and that's how many people were served how many kits you had those types of things and then we look at how you can evaluate the service or initiative we have whenever we do any kind of evaluation we have to struggle with we don't have a lot of academic medical centers and we only have so many people that can do that but we really think it's very important we don't want to spend our time on something that's not working and we kind of see with this alignment with the ACO they have their quality measures their population health level measures and we see having to meet those as well but we'd also like to layer on these really more true population level measures real social and public type measures as well with the kind of community. I can comment on that because there are efforts that we use to and will use to measure five categories of work which are physical health and mental health food security, financial security and safe and secure housing so and there are metrics that we've generated defined with the UVM office of rural development and so we also follow the University of Wisconsin county health rankings more specifically and we have projects working right now. It's interesting that Robert Wood Johnson people sought us out so that they could work with us on building again and continuing to build systems that raise all boats so to speak in a general area which is again one of the three poorest counties in Vermont so that's what we're working with say for example we're interested in seeing the number of people who are spending more than 30% of their monthly income on housing Housing is affordable housing in our area even though it's a low income affordable housing is still a real problem and those are just a couple of examples. What I like is to see the agencies working among themselves to solve some of these and yes we're interested in not wasting money we're interested in controlling the taxes but we'll save more for more specific responses Thank you Following up on the expanse question I was wondering if you could give an example of a lean project you mentioned in your own narrative some of the efforts you have around lean projects and just give an example. Sure We had an inefficient system of registered patients for our laboratory diagnostic imaging services. Patients set to make several jumps to get registered and then get to the right place to get the lab drawn for example. So we have a point of service registration person now in the lab so that the patients don't have to jump from office to office to get their lab work done to get registered for and then get their lab work done so that much greater patient can use some labor costs for their registration. Thank you Pat. I just wanted to say that for a short period of time I've known Paul I can't picture him riding off into the sunset. At this point we're going to turn the questions over to the health care advocate, Julia and Eric. Thank you. I have a question I want to thank you. Of course, for those of us earlier this summer who are hospital and second for providing written answers to the questions that we said last week that well hopefully we'll get some help out of here a little bit sooner so we appreciate that. So I don't want to start by asking well as we know the Office of the Health Care Advocate represents her monsters in health care policy and we also work with individuals or monsters who help with accessing health care. So one of the things that's frequently raised with our office is affordability issues for accessing health care services whether it's somebody with a medical plan or no insurance or someone who's not qualified for financial assistance programs with their local hospital. I'm wondering if you can talk a little bit about your hospital's experience about affordability challenges and whether or not you agree that affordability is a major concern for our hospital. As Paul mentioned, we're the third force county in Vermont so affordability is a challenge for us. We try to keep rates as low as we can to qualify for our patient assistance program wherever possible and when that's not possible those patients in between can go over too much to qualify we have a very generous interest free long term treatment program for the health services. Thank you. I can comment on this interesting topic and it's going to be really interesting to watch where this goes but meeting with our health benefit exchange navigator which is just outstanding. One of the things that we're observing is that when people come in and look at the affordability even if the plan is on the exchange they'll they'll take a look at what the cost is for them to find that benefit plan and then they'll match that against what our financial assistance program will provide them if if they had a medical event they had to use our services and some people interestingly enough are started to say no I can't afford the X amount of dollars a month on the health benefit exchange plan will use your financial benefit program instead so they find that our financial benefit program is more affordable. You want to mention that you have two sort of like navigators for the health benefit exchange so they help people they are busy. Can you talk about how you assess her mother's ability to pay when you're studying her prices? Well again to keep the prices as low as possible so I don't know specifically think about people's ability to pay to think about keeping the prices again and again qualifying patients for our assistance program very possible giving those that don't qualify a long term plan to be paid. Thank you. So when the board approves a commercial rate for your hospital do you consider that to be a set rate or do you see it as a starting point for negotiations? We see it as a starting point for negotiations with insurance companies so it's not a set rate we're negotiating we haven't agreed to negotiate with Blue Cross for example. And then I just wanted to give you how many of you answered in your analysis that I wanted to give you an opportunity to talk about the harm reduction services for substance you're just a community you're just an agent. Sure so we have quite a few so we're getting started. Are you talking about needle exchange now? I'm just going to get the exact wording so first as I said the easiest one to describe is we provide rent free space for the Ramacuse program, the needle exchange program so we don't operate the program but we provide space for those to do to do so on free of charge and then we have a nurse practitioner whose all her time is spent on harm reduction services so she's screening patients for hep C and HIV she's got her own patients with HIV that she's working with she's got patients with hep C that she's been able to get the vaccine get the virus clear from their system so again it's 24 hours a week this person spends just on harm reduction services Thank you That's all my questions This time we'll open it up to the public for any comments or questions. Stay up Speak loudly Neil Yeah This room is part of what we're hearing The woman that first talked It's Dr. Schwartz Yeah, it's her Well there even the shadow over there you can't even see faces or anything it's just like there's a shadow there's a shadow Do you by chance I heard you say you meet each person once but do you look for things like weight gain caused by the medications measuring that because I know that can be a significant issue in terms of side effects and it's one that actually most people I was surprised aren't even aware of unless they're actually taking it which is weight gain from meds The second part would be the out-of-pocket expenses clarification on is the problem the out-of-pocket expenses related to an under-insured plan a bronze plan or the purchase of a plan that really doesn't do much for you or is the problem what's not covered as far as not covered at all and you've got to absorb the full cost of the whole thing on top of all the co-pays and everything else I was just looking for clarification on that The third one would be this is an opinion I want to express I don't think they should be under one care I think they should be regulated somewhat and given a chance to be if they want to be the pilot group for creating change as they want to do and learn from them the same way rise for mom got into one care because they were created I think this group is very creative and I think they need more ability to express that creativity and I think Vermont will benefit from it that definitely has to go down as I think so I answer the first question someone else answer your second question so the first question was about monitoring, waking obviously when I see a person one time I'm not doing the ongoing monitoring I consider one of my tasks is helping get established a system where there is an ongoing mental health monitoring going on both in terms of the improvement of mental health as a result of treatment but you're absolutely right there are side effects to some medications that have a standard of care for doing the monitoring and that can be implemented particularly when you have a good robust electronic medical record for monitoring those parameters on a regular basis of course I always talk about waking people come to me already often having been on medications I assess what it's a personalized approach what is their biggest concern about waking if they have it, others say that's not the big deal I just want to feel better it's a very personalized approach but it is certainly a concern and I do address it and it's factored into my recommendations to the primary care doctor with instructions to monitor specifically for that thank you okay other questions or comments from the bottom I'm not sure we answered the second question the insurance piece well I would put there again this is a heavily subsidized program and we're doing it because the population needs it you know it's part of that additional expense without the additional revenue correct that's about the simplest way I can explain it me too thank you any other questions or comments from the public seeing none I'd like to thank the team from North East Paul I don't think this would be the last time we see you but you never know I've got a lot of other interest I like you but I'd like to I'd like to take a couple of quotes it's not a narrow suffer we're we're dealing with some of the same issues and many of Vermont's policies disadvantaged providers along the Connecticut River and you know I think I heard you use the word coaching one time with respect to people marketing to get into each other's markets we within the state of Vermont what I've watched over the years especially when it comes to health care and retail is that trade balance between New Hampshire and Vermont has continued to grow advantage New Hampshire I might actually be interested in getting more involved in economics because quite frankly I'm not sure people understand that economic dynamics of health care along the New Hampshire border I hope I'm wrong about that but we'll continue to work on that I love the people who live in our area and our community where as interested in is not overly spending I frankly I think to be to Dale's point I would say you know give this a chance it's not known for wasting money it's known for being prudent, wise investing in things that work and it has some considerable headwinds that it has to walk into so personally in my personal interest I'll probably spend a lot more time looking at issues related to the aging population of people with intellectual challenges if I stay paying attention to that I've got many other personal interests that I think need very happy to have nothing to do with health care so with that thank you very much for the invitation enjoy the rest of the day


gonna be famous this guy's gonna be famous what shoes are you in ultra Olympus the Olympus I gotta get your opinion on ultra once we're back in the car yeah yeah I got my first pair yes it is the net yeah two different ones yeah the they don't call it fly mesh what do they call it I think just mesh yeah something like yeah yeah but it's more a little bit more rigid yeah and it looked comfortable it was comfy I got a lot of thoughts on it yeah intriguing it's not a it's not necessarily a ring endorsement yet right no yes definitely not yeah but you know the funny thing is though I've had shoes that I've you know hated out of the box yeah come back to them yeah and then it's like oh this is nice different times you never know honestly I I think they're gonna be well I got a lot of thoughts but my place is somewhere in the quiver my P my PF felt amazing yesterday after wearing the the Torrens the day before okay so there's a lot of a lot of debate out there about the zero drop and your Achilles and yeah like how it's all linking together yeah and the plantar fasciitis so but I will say I did feel amazing yesterday are they all there they are Russell I got what is the name of this running group Castle Rock Run Club they're Castle Rock Run Club you guys are crushing it these guys wake up at like the blue way before the crack of dawn freeze your butts off and thanks for the invite hey man appreciate it so this guy rallying the troops all the time that's right oh man it's cold though it's cold one joy yeah and we'll do it again sounds good man yeah every week I try to do them every Wednesday Friday but Wednesday Friday don't sometimes okay them all yeah but anyway good trails and Castle Rock everybody good trails but don't tilt too many ladies and gentlemen ladies and gentlemen I'm at a 2 out of 10 on the pain scale for the PF I don't know what's going on I don't know what's going on I ran in the peg 35 this morning and 6.4 miles basically since I ran in the tour in two days ago things seem to be trending in the right direction I'm not trying to get too excited I know there's ups and downs with plantar fasciitis but right now it's feeling better and I'm a little I'm a little confused as to why because I did mile repeats last night pretty hard go check that vlog out so I've just tried to figure it out I'm trying to figure out why why do I feel better why am I walking around basically pain-free not quite but basically alright quick shout out to Jen one of the runners this morning if you are local in Colorado there's a winter series of running and just go to PPR run.org PPR run.org this is put on by the Pikes Peak Roadrunners Google it and they have a winter series and Jen is involved with organizing this winter series all right we're packing we're getting ready to go out a little a little vacay a little vacay up in the mountains so I'm excited yeah but first I'm gonna reply to your comments oh my goodness keep them coming keep them coming here she comes this is the way I like it at least three drinks at once hey y'all Vail here we come Vail here we come celebrating true love's birthday this weekend okay okay here we go made it to Vail made it to Vail for true love's birthday and in the next 20 seconds two cards are gonna pop out in the upper right hand corner and those are gonna be links to videos from this past summer where I ran two races here in Vail did pretty well but anyway upper right hand corner if you want to watch old running race videos click on those and I think you'll enjoy the the beauty of Vail and some good racing all right here we go family is asleep family is asleep taking a nap and so yes I'm gonna double up today I'm doubling up two runs in one day haven't really done this in a long long time and I'm doing it in the ultra torrents for the second run gonna go three to four miles easy bopping along nine minute pace but the key word of the day is fun and the question of the day based on the title of today's video is running fun is running fun and before you answer that though you have to define the term fun how do you define fun so I will be frank in high school running was very very fun I was good at it and so that helps but in college I had a lot of injuries I had stress fractures lots of stress fractures I'll talk about that in another video but in addition I was trying to keep up on the CU Buffalo's cross-country team with future Olympians and so it was kind of stressful like I was in distress a good amount of the time with the injuries and then also just like the pace of the workouts was a little intense for me I did pretty good sticking in the top you know let's say six to nine position on the cross-country team but it was not always fun because I was always kind of worried about keeping up with everybody so as you're thinking about answering this question there's no right answer alright and listen I know plenty of runners I know plenty of runners that don't do running for fun in fact they kind of don't like running they despise not despise running but they don't enjoy it and they do it simply and strictly for the benefit of their health so that's a big question it's open-ended I'd love to hear your thoughts down in the comments I is running fun to you and if not like what is perhaps running to you I know again you know you got a hit pause on this video and stop and think for a second how do I look at running and maybe guess what you may not have an opinion and that's fine too on this alright let's go bop around Vale Colorado even though I'm gonna go nine minute pace we are at 8,000 feet above sea level so you know it'll be a little bit of a workout but bottom line I'm doing today's second run because it's fun and I enjoy it and it's I love it I love it so I'm just gonna go bop around Vale for three miles because it's fun fun fun oh get me going guys get me going again alright buddy 8,200 feet yes that was fun oh man just bopping around at 8,000 feet finding a snow-making machine and just exploring just exploring it's a good thing man to disconnect from the phone disconnect from social media go explore and go have fun while running and it was fun good right you do go I am tired this runner needs to go to bed it was an early morning let's just put it that way I think I was up at 415 yeah 415 so the family's asleep I'm gonna edit this real quick and I didn't call it a day thanks for being here thank you for commenting on the question of the day the keyword and that yes I did run in the ultra again today in Vale Colorado three miles not too shabby it wasn't really long enough or intense enough to give you my thoughts on how it performed today it was just it was just did fine it did fine it did fine love you guys thanks for being here all right all right we'll be here tomorrow we'll be here mom see beauty work hard


Hi all and welcome to this video about sub-stages in Ecamm. This video is meant to quickly talk about the concept of sub-stages because they make up the structure for entering data into Ecamm and also because the concept can be a bit confusing at first. Basically a sub-stage is represents one process of a water system. So the inventory, like you'll probably know by now, is split into water supply and sanitation, each with three different stages. Then in order to enter information about a stage, you actually create a sub-stage. So it's not possible to enter specific information about, for example, abstraction until you've created an abstraction sub-stage. You can also create multiple sub-stages. This basically means that there are then processes that are happening in parallel. So this would be three different abstraction systems, and you can then enter data that's different about each of them. Anything that's not entered in a sub-stage won't be considered in your evaluation. So if I want to evaluate, for example, three different abstraction methods, one treatment plant, and two different distribution systems. For whatever reason, I would have to enter data into all of these different areas individually. That is about it for the basic concept of sub-stages, but just to reiterate, you use them to enter all the data that's actually about the process itself and they can illustrate process in parallel. The other thing that you could use them for is also processes that happen after another. So, for example, if you have multiple treatment processes that aren't already included in ECAM, as separate treatment processes, you could also illustrate those with sub-stages as well. In the results section, they are then lumped together, so abstraction is seen as one contribution to GHG emissions as well as treatment and distribution and the other stages. Okay, I hope this video was helpful to you all for understanding sub-stages and that you all check out other videos. If you have more questions, happy assessing.


This algebraic geometry lecture will be a rather informal review of classification of algebraic curves. So we're going to look at algebraic curves and we're going to do it over the complex numbers just to simplify things a little bit. So there are three ways of viewing algebraic curves over the complex numbers. First of all, we can view them as algebraic curves. If you've got an algebraic curve, this is birational to a complete curve because you can just embed it in projective space and take its closure. And as we will see later, if you've got any algebraic curve, you can actually desingularize it. So it's birational to a non-singular complete curve. So these are all birational to non-singular projective curves. And there are two other ways of looking at non-singular projective curves over the complex numbers. They're more or less the same as compact Riemann surfaces. So if you've got any projective curve over C, you can look at it underline complex manifold and that's a compact Riemann surface. Conversely, if you've got a compact Riemann surface, it's a fairly deep theorem that it does actually come from a non-singular projective algebraic curve. The difficult part of this theorem is showing that a compact Riemann surface has at least one non-trivial meromorphic function on it, which requires some quite serious analysis. The third way of looking at curves is they correspond to finitely generated fields over the complex numbers of transcendence degree equal to one. So to go from a non-singular projective curve to a field, you just look at all meromorphic functions on it. So this just takes meromorphic functions. If you want to go back from a finitely generated function field to a non-singular algebraic curve, this is discussed in detail in Hawke-Schuln's book on algebraic geometry in chapter six. So I won't be discussing that in too much detail because it's already done. And of course, you can go backwards and forwards from compact Riemann surface to finitely generated fields. Sorry, that shouldn't be meromorphic functions. That should be rational functions. To go from here to here, you take the meromorphic functions. So there are three ways of looking at the same object. An analyst would talk about compact Riemann surface. An algebraist would talk about finitely generated fields over the complex numbers of transcendence degree one. And a geometer would talk about non-singular projective curves over the complex numbers. And they're all more or less the same thing. So let's look at how they're classified. The main invariant is the genus. Defining the genus for an algebraic curve and for a field is a little bit tricky, but defining the genus for compact Riemann surface is really easy because a compact Riemann surface is a topological surface and it's orientable. So it has a genus, which is the number of roughly speaking, the number of tori you have to stick together to get the surface. So here we have a surface of genus zero, which is just a sphere or one or two or three and so on. Defining the genus over for algebraic curves can be done, but it involves a little bit more work which we've maybe doing later. So the genus is the basic invariant of a curve. For each genus, there's a family of curves of that genus and there's something called a modular space whose points correspond to isomorphism classes of curves of that genus. So it's a modular space of curves of genus one which classifies curves of genus one and so on. And it's a very fundamental problem in the theory of algebraic curves to try and understand this modular space which is more or less equivalent to classifying all curves of a given genus. So genus naught is easy. The only curve of genus naught, we're talking about non-singular projective curves is the projective line. So the modular space is just a point. Genus one is an extremely interesting and important case. These curves are called elliptic curves. So we discussed these briefly in an earlier lecture. If you're thinking of them as Riemann surfaces, any elliptic curve can be obtained as C modulo elatis L. So L is elatis consisting of all the points M plus N tau for some non-real complex number tau. And as we saw, if you've got a complex number, if you've got C modulo elatis, you can use the Weierstrass function which satisfies this differential equation. And this maps C modulo L to an algebraic curve Y squared equals four X cubed plus B X plus C. So over the complex numbers, the elliptic curves of C modulo elatis. Writing a curve of C modulo elatis is a very non-algebraic operation. Lattices often can't really be defined in algebraic geometry in some sense. And this is certainly not an algebraic function. It's a very transcendental function. So over fields other than the complex numbers, it's rather harder to handle elliptic curves. Anyway, if you look at this, the elliptic curve maps to the X plane or rather the X line. Unfortunately, there's always a problem whether algebraic curves are called curves or surfaces because an algebraic curve is one dimensional when considered algebraically. But if you consider as a Riemann surface, it's two dimensional as a topological manifold. So there's this constant confusion about whether these things should be called curves or surfaces. So this is the X plane or the X line depending whatever. And this is a two to one map from the elliptic curve to the X plane. And it's ramified at four points. So if we draw the X plane, there are going to be four points where it ramifies. That means it sort of branches out a bit. So there's going to be one point at infinity and three points that are the roots of this equation. So what you can do is you can sort of join these up by lines. So this goes off to the point at infinity. And you can construct this surface by taking two copies of the plane, cutting along these lines, and then you sort of get some scissors and sticky tape and join up your two copies of planes by copying tab A in one plane to tab A in the other plane and tab B in this plane to tab B in the second plane and you do the same thing here. So you sort of join up, you cut along this line and then if you've got two surfaces, you join part of this surface to part of the other surface. And you end up constructing the surface as two sheets of paper with two cuts in each two sheets and then you stick them together in the right way. So in general, if you take any four points in the projective line, you can do this trick of joining up the points and pairs and forming an elliptic curve out of them by gluing them. Alternatively, you can look at the equation Y squared equals X minus A, X minus B, X minus C, X minus D, where A, B, C and D are the four points that are ramified. So the question is, when are two elliptic curves the same? Well, if you've got any three points on the projective line, there's a linear fractional transformation, tau goes to A tau plus B over C tau plus D, taking any points, lambda one, lambda two, lambda three to zero, one infinity. So if you've got four points, lambda four is going to go to some point lambda. So any elliptic curve over the complex numbers can be defined by giving a point lambda and you're then looking at the equation Y squared equals X, X minus one, X minus lambda. However, two different values of lambda can sometimes give the same algebraic curve. For example, there's a group of order six permuting zero one infinity, which takes lambda two, lambda or lambda one minus lambda or one over lambda or one over one minus lambda or there's one more that I can never remember, lambda over lambda minus one, I think, one, two, three, four, five, let me start one other, one minus one over lambda. So these form a little group of order six isomorphic to the symmetric group on three points. And this acts on lambda and any two lambdas that are equivalent under this group of order six give the same elliptic curve because you're just permuting these four points. And it turns out the modular space is the affine line parameterized by lambda modulo, this group of order six. So in order to take the quotient of the affine line by this group of order six, we just want to find the invariance of this action. And as I think I mentioned earlier, there's an invariant called the J invariant, which is 256 times lambda squared minus lambda plus one over lambda squared times lambda minus one squared. The factor of 256 makes things work well in characteristic two in case you're wondering where it comes from. So this is the famous J invariant of an elliptic curve. If you've got elliptic curve given like this, is J invariant as just this? Well, we also said elliptic curves could be given as C, the complex numbers modulo lattice one tau. So given tau, there should also be a corresponding J invariant. And this is actually quite difficult to write down. Q is equal to e to the two pi i tau. Then the J invariant turns out to be Q to minus one plus 744 plus one nine six eight eight four Q plus 21493760 Q squared and so on. And there's a whole theory of elliptic functions about these sorts of functions. This is the basic example of an elliptic modular function, as I think I mentioned in an earlier lecture. The coefficients of all sorts of rather bizarre properties, for instance, one nine six eight eight four is one more than the smallest dimension of the smallest representation of the monster simple group. And there are all sorts of other strange properties. So elliptic curves are more or less classified. Two elliptic curves turn out to be isomorphic, if and only if they've got the same J invariant. So the modular space, which is this lambda line minus S three is more or less isomorphic to the affine line A one. Actually, the modular space for elliptic curves isn't really the affine line A one because it's not really a variety at all. Strictly speaking, the modular space is something called an algebraic stack. And there is a problem caused by the fact that elliptic curves have automorphisms. And when things have automorphisms, it always turns out to be a bit iffy writing down a modular space for them. So there's a generalization of varieties called stacks. And I'm not going to give you the definition of a stack because although I've read the definition half of dozen times, I've probably forgotten it immediately afterwards each time that the definition is notoriously difficult to remember or work with. So that's genus one curves. They're pretty well understood. Now let's take a look at genus two curves. Well, you can write down genus two curves in a similar way to the way you write down genus one curves. You can just look at the equation y squared equals x minus a one, x minus a two, x minus a three, x minus a four, x minus a five, x minus a six. So what we're doing is we're taking six points in the complex plane and taking a curve that is ramified to order two over all of these six points. In general, if you've got y squared equals x minus a one up to x minus a two n, it's not very difficult to work out what the genus of the corresponding curve is. You can take this surface and chop it up into cells and you find there are two two cells and you can have two n zero cells and number of lines you need is going to be two n minus one times two. And if you work this all out, you find this Euler characteristic is two plus two n minus four n plus two, which is four minus two n. That's the Euler characteristic. So the genus is related to the Euler characteristic because the Euler characteristic is two minus two g. So the genus is just n minus one. So in particular, if there are six points, the genus is two. Incidentally, this shows there are curves of any given genus because you can just take a sufficiently large number of these curves of this form are called hyper elliptic curves. And in fact, in genus two, it turns out that all curves are hyper elliptic. So this construction gives all of them. Then you want to classify them. And the classification turns out to be equivalent to the problem of taking six points in the projective plane, so in the projective line. But then you've got the group PSL2C of all matrices A, B, C, D, acting on the projective line by mapping tau to A tau plus B over C tau plus D. So what you want to do is to have the problem of finding six distinct points of the projective line, modulo the action for group PSL2C. Well, taking six distinct points of the projective line is more or less the same as classifying binary forms of degree six. So we'd be looking at forms A naught x to the six plus A1 x to the five y plus A to the six y to the six. Modulo the action of the group SL2C. And this is the old problem of classifying invariance of binary quantics. And this problem has been solved, although it's quite difficult. The final answer you get is that this looks like A3, the affine plane, modulo the action of a cyclic group of order five over five z with the group of order five acting as x, y, z goes to zeta of x, zeta squared of y, zeta cubed of z, where zeta is a fifth root of one. So in order to find this space, you need to find the set of invariance of this and the set of generators for the invariance is given by x to the five x cubed y, xy squared, y to the five x squared z, xz cubed, z to the five yz. So you see there's an explicit description of the modular space of hyperliptic codes of genus two, but it's a bit messy. I mean, in higher genus, as far as I know, there's no similar explicit algebraic description of the modular space. It just starts getting too complicated. Well, what do genus three curves look like? Well, genus three, there are two sorts of genus three curves. There are the hyperliptic ones, which are given by y squared equals x minus a one up to x minus a eight. But not all curves are hyperliptic. Another sort of degree three curve are just degree four non-singular curves in the plane. In general, you can work out the genus of a degree D non-singular curve and single plane curve. And the generic degree D plane curve, you can think of as a default cover of the line and generically it will only have two-fold branch points and it will have D times D minus one, two-fold branch points from which it's not too difficult to work out that the Euler characteristic is two D minus D times D minus one, which is equal to two minus two G. So we find the genus is equal to D minus one, D minus two over two. For example, when the degree D is two, we get zero if it's degree three, we get one if it's degree four, we get three if it's degree five, we get six and so on. So the only possible genus of a non-singular plane curve, these triangular numbers zero, one, three, six and so on. So it's actually quite unusual for an algebraic curve to be a non-singular plane curve. There's in fact a six-dimensional family of degree four non-singular curves in the plane. The reason is the space of polynomials has dimension 15.  And then you subtract another eight because there's a group PSL2, 3C acting on this. On the other hand, the hyper elliptic curves form a family of dimension five. So in some sense, most genus three curves are in the six-dimensional family and the hyper elliptic curves form a five-dimensional family. We can give you just one example of a genus three curve.  So what's the point of this rather bizarre curve? Well, a degree four non-singular curve in the plane generally has 28 bi-tangents, which are lines meeting the curve twice. And the question is, can you find an example of a curve such that you can see all these 28 bi-tangents at once?  I'm not very good at drawing beans, but it ends up looking something roughly like this. And then you can see the 28 bi-tangents because first of all, each of these four beans is a bi-tangent that looks like that. And secondly, there are six ways to choose a pair of these. And if you've got any pair of them, it turns out you can find four bi-tangents, two going between them and two going like that. So this is a particular example of a genus four, so a genus three plane curve where you can draw all 28 bi-tangents explicitly. If we go to genus four, these can't be obtained as singular plane curves. It turns out genus four turn out to be the intersection of a cubic and a quadric in three-dimensional projected space. Genus five can all be given by intersection of three quadrics in P four. As the genus gets bigger and bigger, it gets more and more and more complicated to describe what the curves look like. I think people have pushed this sort of a script not to about genus 10 or 12 or something. I'm not sure what the current record is, but it really gets very difficult to describe these curves. Representing curves of high genus is quite difficult. You can embed them into a projective space using things called canonical embeddings. The trouble is that embeds them into a rather high-dimensional projective space. You can embed it into a plane with singularities such as double points. You can represent those branch covers of the plane. You can represent them as quotients to the upper half plane by discrete groups.