I'm Senator Ginny Lyons, I chair the Senate Health and Welfare Committee. And I'm introducing myself, and then I'm going to have Representative Lippert introduce himself. And we'll go around the table for introductions because I'm not sure that you know everyone. So. Good morning, Representative Lippert from Hinesburg Chair of the House of Health Care Committee. And Anaheim from Northfield, Vice Chair of House Health Care. Lori Houghton from Hinesburg Extension, Health and Welfare. Steven Durby from Chastnery House, Peter Reed from Bradford, on the House of Health Care Committee. And Woody Page, Brian Smith from Derby, Health Care Committee. I'm Senator Debbie Ingram from Chittenden County. Representative Lucy Rogers from Waterville. Rich Weston from. Inmarie Christensen from the Lotus Field and I'm on the House of Health Care. The corner I represent, like Derby, Mount Holly, all of Mr. Cameron. So terrific, and thank you for being here today. Well, yesterday we took a little dive, set the shallow end into the budget for one care. And today we're looking forward to hearing about quality metrics and how outcomes will be improved for providers, among other things. And some of the work that you've been doing. And well, as we did yesterday, I think we'll listen to your presentation, look at your slides, and then we'll stop and have questions. If there are questions of clarification, I think people will, you know, let us know. And just to clarify that, I understand the Senate has, we have to stop. We're going to come by 11.15 this morning. And so I'm going to just say that I'm very eager to hear about the quality and analytics and make sure that we have plenty of time. And if you know that you guys can stay here and listen, we'll let you do that. That would be incredibly generous of you, and it would allow us to use our notes. Okay, thank you. Why don't you introduce yourselves for the record, and we'll go from there. So thank you very much. It's nice to be back today. Vicky Loner, CEO of One Care Vermont, and I'm going to turn it over to my colleagues, Marisa Parisi and Sarah Berry to introduce themselves and give a little bit of history with our organization. Good morning. I'm Marisa Parisi. Thank you. I'm in charge of technology. Just very good to text support. Very supported by our leadership here. I'm Marisa Parisi. I'm the executive director of Rise Vermont, which will lead a primary prevention initiative out on Care Vermont. We also have a couple of other initiatives in the primary prevention portfolio. And I've been working for about two years helping our Rise Vermont initiative expand safety. Good morning. I'm Sarah Berry. I'm the chief operating officer for One Care Vermont. I'm fairly new to this role, but have been at One Care for four years now. Prior to this role, I was really responsible for all of our clinical programs and it oversold all our analytics. So it would be my pleasure to talk you through some of the great activities and the outcomes that we are working towards. All right, so I'm going to start off today. And I have a very light role for this portion of the presentation. So I can get a move rather swiftly. And we're going to move on to Marisa Parisi. He's going to talk a lot about prevention programs and our health aid programs. And then Sarah Berry will start the presentation on the quality portion as well as our clinical programs. And as always, we're happy to follow up with any questions or any additional data. And you know we're always willing to come back. So I think the main theme of today's presentation, if you look at Joe Lauer, who works at Bounce, got me through the blueprint program, is really what we're trying to do is start to work as a system together. And this requires us to collaborate across the system of care with primary care, our hospital systems, our communities to really improve the health and welfare of Vermonters. So a lot of the work that we do is grounded in that and looking towards meeting the goals of the health care model. I just wanted to highlight before we started this that we never were thinking about what our strategy should be, what our programs could be, really thinking about what are the goals of the health care model and what are we trying to accomplish. And the fairly lofty goals, as we've talked about in Vermont, when we go to your home for some of these programs. And increasing access to primary care, I think, is on the forefront of all of our lines. And as Senator Frigge-Wesmans pointed out the other day, it really is a workforce challenge in Vermont and something that we all have to be collectively paying attention to and how we can preserve that foundational body of work. Reducing suicides related to reducing gas related to suicide and drug overdose. Also a fairly large goal, working very closely and trying to partner with our mental health designated agencies. Doing a lot of work with SASH or in services at home in that arena. And then lastly, reducing prevalence in one area of chronic disease. That is one that really takes a kind of holistic team approach to be able to do better on that. Just a quick question. So these three goals that are here, are these the measurable outcomes that are embedded within the waiver between the state and the federal government? I think that needs to be made very clear. Yes. These are the high level goals as part of the health care model agreement between the state and the federal government. So what we try to do whenever we're looking at programs are one of those programs servicing funding supports that we could provide in furtherance of those goals. And as you know, they're pretty large goals. So what we have to think about are one of those process metrics and milestones that will ultimately get us to those goals at the end of the five year demonstration. Yes. I have a question on the goal. Do you ever test? Yeah, I think Sarah can answer that question. But we do. It is a statewide process that we are looking to test innovations. And so communities submit proposals to us. And they're evaluated by our Population Health Strategy Committee, which has representation from across the state. But I'll give in my position. Is this something that we'll be addressing as you go through your slides? Yes, I do have a specific slide where we'll talk about some of the variables of those. Thank you. Remember it. Yes. And we're also happy to provide you with a listing of what those initiatives are so that you can see what's happening throughout the state. So with that, I think I'm going to pass the microphone over to my colleague, Marisa Fisi, who is going to first talk about the rise of the online expansion and then go on to the dosage. Great. Thank you, Vicki. And thank you again for having us this morning. My role at OneCare Vermont, my title is the Executive Director of Rise Vermont. But our team based at OneCare actually oversees the whole prevention portfolio. Because the goal at OneCare is actually to have a plan for every person in our population. And actually, thankfully, the majority of our population are people who are healthy or may have an early onset of some kind of chronic illness. So the goal of our work is to really provide interventions in the community and in the environment. Because only about 20% of your health is access to health care and medical care. The other 80% is really about lifestyle, environment. Are there any toxins in your community? Do you have enough money to purchase fruits and vegetables that would keep you healthy? So our group is really out in the community working towards improving the health of the environment and the spaces where people live, including schools, work sites, municipalities, so that everyone has the opportunity for the best health in Vermont. So what I'd like to tell you in my time is more about the Rise Vermont work. That's the bulk of our work in the primary, critical, primary prevention team at OneCare. But we've also helped this year expand the Dulce program. And our work really falls under goal three of the All-Pair Model on the OneCare Vermont. But I do want to tease out just to share very briefly about a project we're taking on this year that falls under goal two around suicide prevention. So let me dive into Rise Vermont. For those of you who are unfamiliar with Rise Vermont, this is an initiative that started in 2015 in the northern part of the state as a partnership between Northwestern Medical Center and the Vermont Department of Health. And the goal was seeing that we're moving into new payment models. How can we actually help support people in their homes, community schools, work sites? Even if you're in your little park, how can we have messages to influence how we are every single day? So Northwestern worked with the Department of Health to build on an evidence-based model to create Rise Vermont. And what they started to do was put wellness specialists in towns across Franklin and Grand Island counties to really start helping the community mobilize those health efforts. And given that, they had a very successful few pilot years, seeing good results in schools, great responses from parents, from teachers. At one care we decided, wouldn't it be wonderful if our hospitals were a backbone of her encouraging this type of healthy behavior, healthy lifestyle, healthy environment everywhere in the state of Vermont. So our team started out of our care in 2018. We have a group of wellness specialists across the state. Our map here has shown our expansion which happened pretty quickly. So when we started in 2018, we created a toolkit based on an evidence-based model and the measurement tools we were going to use to start putting program managers for Rise Vermont at hospitals across the state. And we had a very, a really wonderful response from our hospitals. So in 2018, we added five new hospitals with Rise Vermont program managers. After that, this slide has things a little, so Brad O'Barrell said yes in December of 2018 and started in 2019 in January. So Brad O'Barrell started a little bit, we usually put them in the 2019 category, but last year we had three hospitals come on board and we're very close to being statewide. We have pre-commitments around Rotterdam Medical Center, from Northern County's health care to work in the Northeast Kingdom. We've been in conversation with Central Vermont Medical Center and the Brad O'Barre Memorial Hospital team is covering the Grace Cottage region. So we're very close to having a Rise Vermont presence in all 14 counties. And to just give you a sample of what Rise Vermont does and when they get started at hospitals, when we place a program manager at a hospital that is going to help work on Rise Vermont campaigns, what they do is they work with the community and mostly they work with the medical communities for health, which are representatives from across the community who are doing projects that are really to invest in what the community needs after they've done a needs assessment. So Rise Vermont is often the boots on the ground to be able to help move projects forward within an evidence-based model with the community to improve the environment for health. And you can see here on this slide. And I'm happy to tell you more and also I encourage anyone interested in Rise Vermont to look at our website. It's a very robust resource that does a lot of local stories, has a lot of local photos about the work that we're doing. Here's a few samples. The Rise and Walk program is one of our most favorite to share because one of the things that we feel like is really important with Rise Vermont because there's so much good work already going on in communities, Rise Vermont provides the connection to the medical community, getting out of the hospital, out of their offices and really into the, you know, in your town with the people. So the Rise and Walk program is something that started in Addison County where all summer long last year for I think it was about 16 weeks, there were physicians that walked with the community every single week and the walks were advertised. The physician will talk about their particular specialty or get to talk about things like ticks and Lyme disease or the importance of hydration. Simple things interventions you can do in your life and it makes a real difference when you care from a doctor locally or you get to meet that doctor locally. In Addison County, every time they hosted this walk they had the smallest walk was 40 people. They have between 40 and 90 people coming on these walks. So you could see that there was a real interest in getting out. They're not only meeting the community but having things that were sponsored and advertised in a rude plan. So that's the type of work. Well, it may seem simple. It's incredibly important to have those opportunities in your community because I don't know if this has happened to anyone here but it certainly happened to me. The day that my doctor said you should probably do these few things to improve your health, you feel alone or you feel like you have to have an expensive gym membership or do things that are hard. What we're really trying to do is create an environment where wood health is easy and fully wrapped around it and supporting you at all times. So I hope you'll check out our website to hear a little bit more about some of the other products we've listed here. So. Oh, we have a question. Please. Just to clarify because statewide because it's in every, saying it or will be in every hospital area but it's actually limited to 36 communities. So it's right now anyway. It's a lot narrower than it sounds. And by reading that. Thanks for that clarification. And I appreciate that. It is in 14 counties but you're right. You're not covering every town. And let me tell you a little bit how we select those towns because I think it's important. We realize that to do a really good job we have to have a certain ratio of population to the people that we have working in the communities. And when we started looking at Rice, Vermont and Northwestern Medical Center team of the Department of Health started looking at doing a primary prevention program. They looked at different programs around the globe that were really successful. And we modeled our ratio around a program that's very successful in the Netherlands and they used a ratio of one person. So one program manager for population of 10,000. So that's kind of where we start. But then what we do is we look at all the data in the health service area by town including things like poverty, food security, access to fruits and vegetables, transportation availability, to then choose towns we think would need us most but then we inquire with the towns that they would want us. Because there's a really important readiness factor as to whether or not you would like to work with a new initiative. So that in every town what we want also is to have them feel like Rice, Vermont was born there, right? That it's their unique initiatives and their choices, their work that we're doing. So you're right, thank you for the clarification. Is there a list of illness on which towns? Actually I have handouts with me. If members of the communities would like those after and it will solve the towns. So we have two more questions. Representative Rogers at that center comes. Yeah, thank you. My question is when we look at in rural communities who will come out to a community meeting, for example, there's clear demographic divides and for the community meeting, for example, it tends to be people who are more affluent and people who are more left leaning just as information that I've come across. And I'm wondering particularly with targeting communities that have like a readiness factor, I'm wondering how you're reaching everybody in the community and whether we're not putting money into something that's only serving a certain subset of the community. Yeah, I think that's a great question and thank you for that. Our program managers, their focus really is more of lower income communities and what we're trying to do is be in as many sectors as we possibly can be. So in some cases we may be at a senior center. In some cases we may go right to a school meeting or a school board meeting. Right now to give you a very specific example, we're helping the town of Huntington. They are looking to purchase a piece of land that would become part of the town forest and we're really going almost door to door to really help people understand the importance of that and find ways to get them to the meeting that is being discussed. To find success, because we talked about having a doctor come out and we had 40 people, well going out to walk with your doctor once in July and once in August is really not gonna make it healthy. So how do, I mean you have events and people show up but how are you, what do you consider success? Yeah, that's a great question as well. So we are looking at a number of different factors, measurement factors for the community itself at a population health level but also at some smaller or more micro levels. I also have a handout on this of all the evaluation measures we are using to define success and see how we're doing but a couple of the things we're working on right now. So Franklin and Grand El counties, when they got started what they really wanted to see as a prevention effort was to focus on childhood to be in line. So what they started two years ago and it's just repeated itself is a study that looks at BMI of first, third and fifth graders in all the schools in Franklin and Grand El counties. And what they're doing is they're going back to measure those cohorts every two years to really see if the impact that we're having in the community by improving the health of the community and improving the health of our schools is having an impact on that BMI. So that's one more micro measure. So define BMI for everyone. That is, it's a calculation that shows the height that takes into consideration the height and weight of the children. So you're looking at childhood obesity. We're looking at childhood obesity and that the BMI shows overweight or obese. And we just put out a press release on what that second round of data showed. And right now it's flat, which we actually think is promising. So that means there was no change from first round of study to the second round and what we anticipated was growth. And the BMI said those kids and it's flat. So decrease it. No, absolutely. And so that's exactly the goal is to decrease it. And that's in the evidence based model that we use over about a 10 year period, there was a pretty dramatic drop off in communities that did this type of community intervention. But we're also doing key informant interviews within the communities of the researcher from UVM. We have what's called a dose calculation, which is different types of community interventions that you do in a portfolio that is shown to reduce the BMI of communities. So I'd be happy to share that handout with you. And we're also going to be at the green on care board with our researcher on February 5th, if anyone would like to be there to hear from the researcher and the methodology we're using. Any questions? One more. Yes, you mentioned purchasing land. Any one of your projects? Can you speak into the mic? So we can hear you. That would be great. You mentioned purchasing lands for one of your projects. Does your organization work with other state agencies in that purchasing of lands? That does the nature and services and things like that? So let me clarify, we're not purchasing land. We're helping them. Well, it was just me. Yeah, no, no. I completely understand your question and I, what is happening in Huntington to use that specific example of the town, the municipality, has been looking at a piece of private land purchase which is behind the school to provide public access. And yes, the trust for public lands has been involved, different community groups have been involved. And what we've done is really tried to help educate the town of how great this will be, not only from an environmental standpoint, but a health standpoint. And what we're able to do, and this is a great transition into a key piece of the rise from art model, is that we're able to help provide towns and community members with small grants to accomplish projects that they care a lot about that align with the CDC's 24 strategies of intervention of obesity and overweight. Which is another way how we measure success in communities. So in Huntington, if the town chooses to purchase the property and the voters choose to do that, what you're going to help do is provide signage for the trails right away to be able to have it accessible immediately. One of the things we've done, even though I think people think of us as the exercise people all the time, we want people walking on the trails, but many seniors often really want to do a small part of the trail and have a place to rest. So us providing ventures on trails across Vermont has been a huge access piece to just be able to get the older Vermont community out on the trails. So it's that type of work that we're helping them do. Okay. So thank you for that segue. Because now I can tell you a little bit about the grants that we provide. So because we have one individual per health service area, for the most part right now, there's quite a few more program managers in the Grand Elf County. We have two program managers in Chittenden County. But what's critical for them is to work with other partners because of all these communities we are working within, there's so much good work already happening. And what all they need is a few more resources to get the work going even further. And that might be schools, it might be libraries, it might be a local nonprofit. So we have an amplified grant pot of funds for each area that we're able to help fund special initiatives for each community. And since we started that one care with the state-wide expansion in 2018, we've given out $223,000 and $21 to local initiatives. This is everything from envibian crossings, which I wouldn't have thought of as a healthy activity. I would have thought of that as an environmental activity. It was hugely important to the at-risk youth who applied for the grant. And now they have this project there taking a lot of care, a lot of care. It's pretty amazing. Funding snowshoes at libraries, so that if you would like to enjoy the trails right now that are near, that are in your town, but you don't have the equipment to use those trails, you can go to your local library and check out a pair of snowshoes just like you would your library book. So that type of, that's the type of project an amphibiant can further. And again, when people apply for the Amplify grants, they have to show us how they are meeting one of the 21 or more of the 24 CDC strategies on this intervention. So while we are in those 36 communities doing the grassroots work, the real on the ground work, we do want to influence a broader cross-section of the population for health.  And you may have heard a little bit about our sweet enough campaign. So the sweet enough campaign is really to help Vermonters reduce their consumption of sweetened beverages. And the reason that we chose this is we did some independent research for the research firm and found that there are in Vermont, many Vermonters are drinking about three to six times more liquid sugar than they show on a daily basis, which is contributing to heart disease, diabetes, chronic illness. And we pulled Vermonters, we worked with the firm to pull Vermonters and they said, we would make a change in this health behavior if we knew what to change to and what would be a good alternative. So that's how we created this campaign, which targets three groups of Vermonters. So you may not have seen the campaign if you were not a young man, a young parent or are working at a shift job because those are the three groups of Vermonters that really, we really saw drinking a lot of energy drinks, a lot of high sugar sports drinks, and especially kids who are on sports teams. They're doing this great activity but then they're loading up with sugar after. So we've really tried to target these communities and but with messages that are specific to them. So it's highly algorithmic. So like I said, if you're not one of those folks, Facebook knows that and these ads have probably not popped up on your Facebook page. But you may have seen our ads in movie theaters or on some of our social media. So the sweet enough campaign will know if that's successful. We took a pre-measure of Vermonters about how much they were drinking and we have already prepaid for the post-measure. So after a year of the campaign, we will look to see if Vermonters are actually consuming much sugary beverages. So this is where a broader population than our small communities. So I think that that's everything for Rice Vermonters. Right now what I would encourage you to, I have additional packets and that will tell you more about our evaluation methods, a little bit more about our programs, give you a snapshot of one of our communities. But please look at our website to learn more about that because I would like to tell you more about the Dulce program. And I would like to acknowledge, I did not come up with the Dulce acronym because I think it's a very wonky acronym. The one thing I tell people about the Dulce program when they say what's that and what does it mean. I know hard time remembering what the acronym is. It's at the bottom of the slide here. But I always tell people to remember that the L stands for legal because this is what I think is extraordinary about this program. So very quickly, what the Dulce program does is it has a trained family specialist from the local parent child center embedded in a pediatric practice so that when a family has a newborn, that family specialist goes to every well child visit with the family as long as they agree to enroll in the program. And that most do in the sites where we have Dulce. The family specialist goes to all the visits, does an extensive social tournament screening and connects the family to resources, including legal. Now that is what I think is truly extraordinary because many remoteers who might be in this program will struggle with things like an eviction, meaning for protection, meeting certain small legal interventions that can make a big difference on the health and well-being of themselves and their newborns. So I have a separate handout. I'd love to share it about how Dulce has gone this year. In 2019, most sites started up in around September. We have timber lane pediatrics working with NCSS in the northern part of the state, two sites in Windsor Mountain Schedule Hospital and Autoclegee Health Center working with the sprinkled area parent child center and the failing place. And then timber lane, pediatrics in South Burlington working with London Family Center. So our goal last year was to help Dulce expand to three sites we were able to get into four in partnership with the Vermont Department of Health. And so far, 138 families and children have been screened in our part of the program. Of those 138, almost everybody's been screened and we have about 75% of that population being referred to services. So it's already going very, very well. And to me, this is the ultimate in prevention. We're capturing newborns before anything that can happen before food security can happen, before anything that could get that life off on the wrong foot, we are intervening then. So it's been a delight to see this program expand further and we are continuing to provide funding for the four new sites into 2020. So really pleased with that. And I know you wanna hear about qualitative measures. So I'll move it along and say one last thing. And I didn't, I don't have any handouts on this yet or any information about what it's gonna look like. So I'd love to come back if you'd like to hear more. But I have been very concerned as has my team since last year we attended an all field team meeting that was sponsored by the blueprint. And Dr. Delaney from Beechip and the Lawrence College of Medicine who reports on Vermont suicides or suicide rates were there. And we just felt so compelled and concerned about the data that was being put out there, especially for older male homeowners. And Tom Delaney at the time sort of casually mentioned a model, a prevention model that he had visited in the UK while he was on vacation called Men's Sheds. And Men's Sheds is actually an evidence-based model that started in Australia really to address the social isolation older males were experiencing because also in other countries people retire much sooner than we do in the United States and we're feeling very disconnected from their community. So they created these social clubs where men could actually come and have meaningful projects to complete on behalf of the community. And what they found at the Sheds in these other countries is that not only did it bring men together to do social isolation, but their health improved and suicide rate went down. So we felt like rise your minds out there. We have a great network. Could we create an evidence-based for this project and based on all the literature and really create a Sheds model in Vermont. And we start talking to the SIGNA Foundation about it who is very interested in the suicide rate and mental health. So they really liked the Sheds project and then have awarded a fellow, a SIGNA fellow, to actually go on a paid sabbatical from SIGNA as a SIGNA employee who worked with us for three months to create some Sheds across Vermont. So we anticipate hopefully next year having three Sheds and Dr. Delaney is actually going to do the measurement through T-informed interviews so that we can see some pre and post data. And so as you're talking about the innovations that you're doing, they sound very exciting actually, but one of the criteria or principles that we have in place within for the ACO is to access and utilize current community people and programs. So you're talking about a Shed, you're talking about hiring someone, are you talking about bringing in people who are already in the community who might have expertise in these areas? Thank you, that's exactly what we're talking about. The Sheds program would really be a granting program. What we often do through Rise Vermont is make connections between between people and provide resources. So the Sheds model right now, our team who has put it together is Dr. Delaney from VCHIP, our colleague Melissa Southwick from SAASH, myself and a team of one group who does care coordination. And what we're trying to do is find different groups in the community who would find our Shed master is what I'm calling it. I'm not sure if the other Sheds call it that, but those core volunteers who really wanna do this or a nonprofit organization that already has this idea and needs further funding, what we need to do is make sure that there is a model so that we can put it in place and measure it, but no, we're completely looking to get the community excited about this and provide them resources. I think as I'm listening as well, one of the, I think a question for some of concern is that one care not tried to become the agency of human services, if you will, in terms of what's the connection to the department of mental health, what's the connection to the initiatives that are already going on around suicide prevention so that there's alignment. I think one of the things we've talked about in our committee just in terms of budget adjustment is that so that there's alignment with already stated health policies and health goals and initiatives rather than there being a new set of prevention efforts that are not necessarily connected to work but it's already underway with other funding in the state agency. I'm not interested in being the agency of human services. Well, I was overstating it for effect, but in fact, I think, you know, Frank, there's concern, there's some concerns about that. Yeah, I'm sorry, but I just want to both strongly agree and say I think really what is important to know is that we are serving as an activator in four projects that are already planned by the community, which includes the agency of human services and includes the department of health. We just don't have enough activation or who's on the ground to move things forward or a little bit of extra money to move things forward. And that's I think the gap we are filling and we, every program manager for Rise Vermont works directly with the district director of the Vermont Department of Health who's working on the 3450 campaign that they set this beautiful model for reducing chronic illness and their work is to put policy in place our work is to mobilize the community around that policy which wasn't happening before. And that's why I think it's been so effective to actually have a person base at the hospitals to draw the medical community out and see the importance of this work happening in the community. I would just say that I think it's also, perhaps short term and long term, it's going to be important that the connections that you've articulated here to some degree of the direct, the underlying research or the underlying reason to support some of these activities is directly related to changing health outcomes in communities because it has the potential to simply sound like, well this is a great idea, we need snowshoes in our library so let's go to one care and get snowshoes and I think that actually is going to undermine the support rather than enhance it. So I think there's a messaging piece here that that's actually quite important. I just want to add a little bit to that in terms of us thinking about this as a really great public-private partnership. So we have been working with agency human services as the policy arm for a lot of these things and saying what are those goals that you're trying to achieve and how can we as a delivery system support you in those efforts. So I think about this as a good partnership and that we again, the overall goals are working together to be stronger and this is a real commitment to doing that and I think you'll see when you even look at some of our boards, we had the Commissioner of Health on our Population Health Strategy committed to be able to kind of bring these things forward as well. And so I'm going to ask if it's possible that we move on to quality metrics and analytics and we do that because the Senate needs to hear some of it and then we're going to leave and the House has got it. We're going to do a little shuffling right now. I'm sorry, I'm sorry, some of us are more aware. Good job. Again, I'm Sarah Berry, Chief Operating Officer for One Care and it's my pleasure to talk to you this morning about several components of the work that is happening through our provider network and by providers, I just want to remind us all we're talking about the whole continuum of care. So individuals that are supporting Vermont citizens, whether they be in a skilled nursing facility, utilizing home health services, able to be in their home, in the hospital or accessing primary and specialty care services. And so as you can imagine, that's a wide breadth of providers of issues and ideas that come up and part of our job is to listen to all of those perspectives and try to bring them together and organize the priorities and use the framework of the all-payer model and those three population health goals to really help guide the priorities and the work that we're doing. So I think it's important when we think about first the quality, this is really how do we assess the impact of this work that is happening in healthcare reform through the avenue of an accountable care organization. And the way that we do that is to structure a systematic data collection process that happens by collecting direct information from patients. So surveys of patients across the state happen every year. In addition, we go in and we actually have to have some staff who collect information from medical records where the data aren't otherwise accessible, things like people's blood pressure or what their blood sugar level is so that we understand how well we are as a community are caring for and supporting individuals and populations. And then we also are able to collect information from the billing data, from claims that come through the system. And of course that would be our preference because from an efficiency standpoint it's much easier to then aggregate that information and have to go look for every single piece of data. But it's really important that all of that information come together into a lens or a perspective on how is healthcare being delivered in Vermont specifically and under the accountable care organization. And so as that occurs, that measurement happens every year and there are lots of kind of underlying caveats. I'm not gonna go into all of the details today but I do think it's important to recognize that one care is still growing. Every year more and more Vermonters are coming into this model which does from a measurement standpoint make it a little bit challenging in these early years to be able to compare kind of year one to year two. As we have more and more people and more and more communities in the program that in the future years will get easier to do year on year comparisons. So across the top of the slide, you can just see an aggregate what our quality performance looked like about 85% for Medicaid, 86% for the individuals on the Blue Cross to Shield exchange program. I do wanna note that 100% for Medicare is a technicality that is because it was the first year we were in the new ACO Medicare program which means as long as we submitted all of the data they asked of us we kind of got the check mark or the check plus. So we wouldn't expect that to be 100% as we look at the 2019 data. And in fact, if you think about the measures which we've just listed out and apologize for the small type but this is actually the totality of the measures that the providers are paying attention to right now. And they focus on things in childhood like our adolescents coming in for well care which is a good proxy to understand whether they're receiving things like depression screening whether their weight is being checked whether there's discussion of healthy behaviors and emphasis on their strengths. All the way through our certain types of cancer screenings happening for older adults. There's a whole host of mental health related measures as well. And one of the things that we've really been focused on in thinking about these quality measures is how do we help providers who as we know are very busy caring for patients and having to do their paperwork and serve in other community based settings how do we help them identify areas of opportunity? What are the gaps where maybe performance isn't as high as it could be and maybe there's an opportunity to improve. So when we looked at the data for 2018 a couple of the key things that stood out to us is that from a survey perspective patients reported that they felt that the communication they received from their healthcare providers was very effective. They felt that they actually had good access to primary care services and that the care that they received was well coordinated. So I think those are three really important perspectives from the voice of consumers, our Vermont citizens. We also saw that there's some variation. So for example, when we think about chronic disease management individuals with diabetes who have Medicare insurance actually are doing quite well. Their diabetes is well controlled and supported. But when we look at some of the other populations in the state that might be insured or other programs that might not consistently be happening. And so when we think about some of the gaps that's one of the areas we're drilling into with providers. How do we look at things like hypertension so high blood pressure, diabetes care and make sure that the high quality care that may be happening in certain areas really gets spread across the entirety of our provider practices across our communities. So we have a question here from Representative Donahue. I'm looking at the quality measures and sort of wondering where they come from because obviously if the bar is too low then success is not really success. And we tend to focus on things you know best about. And so I look at, somebody has had such an acute mental health crisis that they went to the ED. And it's quality if within 30 days after that ED visit there's been follow up. That to me is like stunningly not quality. Thank you so much for the question. I agree it's really important to understand where this comes from. These are not locally grown measures. They are all nationally validated measures that come from various sources so that they can be benchmarked or compared to other regional or even national populations. And that helps us understand are these the right measures? Because to your point, if we were getting high quality scores across all these measures then perhaps they're not the right things to focus on. And in fact, part of my early work at OneCare was to look at what was at the time a list of 70 different measures which providers found impossible to identify where to focus. And to really ask from a clinical perspective what is important to ask from a data perspective where are the gaps? And then to partner with the Agency of Human Services and say from a policy perspective as the all payer model is was being negotiated and then moving forward. What are those key focus areas? So you'll see there are five core mental health measures. Those really are process measures related to trying to get to that reduction in deaths due to suicide or drug overdose. In every one of these areas there is still significant room for improvement. If these were easy, we would love to have kind of checked them off and move forward. We see from a data standpoint that there's still tremendous variation across communities and that's a big part of what we're trying to use our data to highlight and to help communities improve by facilitating the discussion of, well if in Bennington this is going so well what are you doing that's different or unique and how do we share that with folks in Franklin County for example? And so you can segregate out by demographic. You can segregate out by private versus public. So all of our, we do monthly reporting on all sorts of what we would call kind of cuts for some populations of the data trying to understand where are their differences and then what do we do to get rid of those differences? So I'm probably gonna jump ahead a little bit but so when you have that information and you see that the patient that's with food class and flu shield is getting, is not having the outcomes that we're seeing with medicine. Then how do, how does that work? I mean it's an insurance company. They have specific outcomes themselves. How are you improving the quality of care within that private organization? And I ask that question because I know that we're trying to gather more attributed lives from our self-insured folks. And if it does, will this improve the outcome, outcomes for that group of people? Thank you for that question. A specific example I can give you related to your Blue Cross flu shield population question is that we have as we start to track who is utilizing or accessing primary care services in these different populations that we might define in this case by insurance, we know that it tends to be a lower use of primary care services for people who have their insurance through the health exchange. And so we had that conversation with leadership at Blue Cross Blue Shield and our clinical leadership at OneCare and we started to say, well, what can we do differently? Because, I mean, does it relate to the out-of-pocket and other deductible costs? It could relate to communication. Like do I know that my provider thinks it's important that I come and see them at least every year and that what's the value of that relationship and that connection? So because we are a provider-based organization, what we really looked at is how do we look both at financial incentive alignment with what we want for the clinical outcome? And we together with Blue Cross Blue Shield designed a program that we started piloting late in 2019. We targeted nine different primary care offices that were interested in working with us. We provided them with a toolkit and we said, let's get a little creative. What are some newer different things that we might do for you as a practice to outreach to patients that aren't coming in and to help them understand what is the value, why is that important? And we don't have the final data yet, but my team has been tracking it really closely and it looks like we're starting to make a difference. That some of those individuals that traditionally were not connecting are now seeing a primary care provider. Now, this is a long-term game, right? Like this is we wanna create a relationship, we wanna establish trust in that provider relationship and then we wanna maintain it. So our intention is to take some of the early things we've been trying and spread them more broadly in 2020 and then be able to evaluate whether that strategy in particular is working. Other things just to highlight very quickly, this is a great example of where one care staff and blueprint for health staff work very closely together in supporting practices and identifying in this practice maybe we have a healthcare gap around diabetes care and in another practice maybe the issue is really around early developmental screening for young children. And so then there are targeted evidence-based approaches that we gather both nationally because there's a lot of work that happens across the country in these areas. And also to the earlier point I was making, really how do we find out what works in one local Vermont community and share that information? And so we have a whole host of things that we do to share that. We create one-page network success stories where we give people credit and say what is it that worked and what didn't work because we can learn from that as well. We host clinical grant rounds where we have people come together across the network to say this is how I've done it. These are the results that I've been able to show. Here's a patient or caregiver perspective on how this felt and what I appreciated and maybe what didn't work for me. And then we ask those people to go back and think about how that might be implemented. And we have some really nice examples starting to emerge of how some of those early stories that might have started in Berlin spread to Morrisville as an example or vice versa. So just briefly we started to talk about the data and that really is a critical cornerstone of ACO activities. I would say from my lens it's right up there at the top with thinking about how we support every individual in a population health approach. And so I do want to acknowledge and I understand there's been some conversation in previous days that the types of services we're talking about here are potentially things that hospitals could do, but that we believe and our provider network believes can be done more efficiently and with more sophistication and more efficiently when done centrally through an entity like the ACO. And that is because I will just say that the data that come in are complicated. They're often messy. They need to get normalized. So the data that comes in from one pair might come in in a different format than another and we have to make sense of all of that information. And then it's our job to meet the expectations of our network. And that means turning around data in a really timely fashion, making sure that it's actionable information. And I would say that's been really a focus area for us in the last year. And as we move forward, I'm really identifying not just how are we doing with cost or utilization or some of these quality measures you saw, but what can I do differently because I now have this information? And so one of the areas I will show you in a few minutes really relates to how we started to look at and track use of the emergency department for individuals that are high risk. And I think in part, along with other interventions we were putting in place, watching that data every month and saying, oh, what I'm trying is making a difference. These emergency room rates are going down or they're not. What else do I need to do? So Marissa did a nice job of really talking about our primary prevention activities but I wanted to put that in a broader context for all of us today to really recognize that from one care's perspective we do want to make sure that we are thinking holistically about how to care for the entire population that we touch. And the way that we do that is to try to break that very kind of overwhelming concept down into some structures and some ways that we can create language and priorities around the populations. And so we use, we call this our four quadrant model. This is our population health approach. And in it, what we're saying in the middle of the circle is that in general, we can use the data that we have to preliminarily identify and predict whether you are healthy and well or whether you might have a chronic condition but that chronic condition is pretty well under control and you're managing it with your healthcare provider. Those are those category one and two that you see at the top. And then in category three and four, these are individuals that in category three, for example, might be struggling with one or more chronic diseases. Oftentimes what we see is there is a very real intersection between physical health needs, mental health needs and social needs in this category. And so one of our former board members from a designated agency labeled this for us kind of the rising risk category and argued very passionately in one care's early days that this was probably the greatest area of impact that we could have. And that became a cornerstone of really thinking about how we define some of our interventions and specifically our complex care coordination program so that when you get to category four, that is a category that represents very acute needs. And those could be very rapidly changing. That could be somebody finds out that they need a liver transplant. Somebody has a really bad car accident or a bad cancer diagnosis that they go from yesterday thinking things are going well to today. All of a sudden I have tremendous needs and I need to draw upon resources really not only within healthcare but also oftentimes across the agency of human services as well. And so we have put as an accountable care organization tremendous focus on that population, what we call our top 16% that rising risk and that acute population. And if you just focus for a minute on the box at the very bottom, this is a brand new data that just came out for us this week. But we looked at within that 16% of the population and we saw that they account for 60% of all of the healthcare expenditures within the accountable care organization. So you say 16% or is it 6%? The population is 16%. So the errors in both ways are representing the top 6% to category four plus the 10. It's the two bottom. It is the two bottom. I'm sorry. Thank you. So within that 16%, which is, I don't have the exact math with me but I wanna say that's about close to 24,000 lives. Again, 60% of all of the healthcare expenditures within that population, 95% of them have more than one chronic condition and over half of them have a mental health condition within the last three years that has been documented through claims. So that doesn't even speak to those that might not be recognized yet. And so again, you can see they're complex issues here but this is really the overarching framework and the way that we connect all of our partners in the community across the healthcare system to say what are the strategies we need to put in place and how do we have a diverse portfolio so that while we're focused on, let's say hospice needs of a particular population we're not forgetting about prevention needs of another population. The care management of those two groups is must be complex. Complex, absolutely. So thank you, that's actually a perfect segue. So I talked about our population health approach. This is just a graphic to help illustrate our overarching care model and I'd like to start at the center because the center of the model is all of us and our families and our neighbors, we, the Vermonters that we are serving through this model and so we then need to think about what are the individual and group needs within that? What do I care about for my health and well-being and what is important to me? Not what does my healthcare provider think I need to do but it might be, you know, my goal, let's say after a heart attack might be to walk to the end of the driveway or to make sure I can get to that graduation. That could be very different from what a healthcare provider might give you as a statistic that you wanna achieve is let's say for your blood pressure. So the second, the middle part of the circle really represents all of those partners that we're bringing together through the ACO. So you can see, I've mentioned the blueprint, our mental healthcare providers, our specialists caring for individuals with some of those chronic conditions, our hospitals, SASH and so on. Every one of them are integral to this model and to its success. And then around the outer rim, this is really the backbone support that OneCare, as an accountable care organization, provides at the request and to help support the activities that that center ring, all of our healthcare providers are delivering. And so that consists of education, tools, the data we were talking about, funding opportunities, whether they be for innovative ideas to be tested or amplify grants in local communities. So to the earlier question about innovation funds, in 2019, OneCare's board set aside roughly a million dollars to listen to the ideas of community members around where there were, what I consider to be kind of the sparks of great ideas that just needed some funding and an evaluation to test whether these ideas had the potential to improve care, to improve costs and very importantly to our population health strategy committee that oversaw this. Do they have the potential to be sustainable and scalable? Because there could be a wonderful project out there that frankly has no chance of going anywhere after its funding period and that was not something that the population health committee or OneCare's board felt like was the right and responsible use of funds. So some of the projects that were two rounds of funding and a open request for proposal process that again was led by our population health strategy committee, they made recommendations to OneCare's board and the projects for 2019 have now all been funded.  Some of the things that the committee prioritized in and set out in that initial RFP were things like we want to see collaboration. So if you're asking for a larger amount of money, you need to have partners coming together in this common vision for how the work would be accomplished. There was a focus on mental health, a focus on chronic disease management. And again, critical questions about how would we know if this is successful? Do we think it could be scalable and do we think it could be sustainable? And so just briefly, one of the ones that I personally am just so excited about is the Youth Psychiatric Urgent Care Model. This is down in Bennington. It's actually got an acronym called PUP right now. And this really came about because physicians in the emergency department at Southwestern Vermont Medical Center were identifying that while they had received some training to provide trauma-informed care in the emergency room for children, that they remained very concerned that that was not the right setting of care for children with mental health needs. These in particular were kids that were being transported from their school to the emergency room because the school couldn't deal with it any further. That there were really significant concerns. And when they shared the data with us in one quarter that they had tracked it, I believe there were close to 300 kids that had been transported in just a three-month period. And so they came forward. Who was transporting them? Oftentimes the police. I was just going to say that the school would call the police. They would give us that whole area of the world. And so our job was to really look at one segment of this through this proposal and it was to look at how could a partnership with a local designated agency, so the mental health care services help eliminate the need to bring those children into the emergency room. When I went down to visit, one of the most shocking components of that to me is that most of the kids, they weren't adolescents. They were elementary school age. And so this program has been up and running since the beginning of the school year. And it was intended to start just in one elementary school to pilot it. They've already spread it to additional because they are seeing the impact so quickly that is happening. They have developed a child, that lessen family-friendly area where the individuals can receive one-on-one services and supports. They often have ancillary things that they do. They bring the family in and do cooking classes together as part of this. And the goal is to get that child back to school as soon as they're ready. And to really have the mental health care providers in collaboration with the family evaluate that. So early days, that would be funded over the course of 2020 as well. But really excited about that is one example of the types of work we're doing. We do have another handout that we could provide you and follow up that goes into more detail about each one of these programs. How long has this been going on? 2019, so the first round was funded in May of 2019 in the second round in September. So when you're getting the data. We are. So we have reporting requirements and evaluation metrics written into the contracts for each one of these. And so the story I was just telling you about the program in Bennington comes out of there reporting to us around what they're doing. And they do have counts for us of how many children have been supported through this program. It'd be kind of neat to see a longitudinal analysis of the kids. The program is one thing. I mean, just the kids over time. Absolutely. And we might not have a full lens into that. But the thing that we've committed to partnering in the evaluation framework is to say, okay, if we are keeping these kids out of the emergency room because that's not the right setting of care, then we can look at cost go down and see is this the way to make this a sustainable program? Is a long standing partnership between the hospital and the mental health agency the right way to move resources around to provide better care and outcomes. And that is really the underlying framework for a lot of these projects. Okay, so I wanna share with you just some early data that we have. This improvement story comes out of Central Vermont, the Berlin Health Service area. And in particular, this is thinking about our quality measure performance. So we talked about diabetes care and the fact that there's some variation across different communities. This measure, just to decode it for you, is looking at how many patients who have a diagnosis of diabetes have had the right blood sugar test in the last year. And that is a measure that from a data and a systems perspective because that requires a lab test to do, we can then track how long that's happening. The graph is really important. This is an example of some of the ways we provide data to our provider network. And so what you're seeing here is that the dots represent every month. And if you look vertically, that shows you the variation from health service area to health service area. So if you looked at April, 2019, you can see that one health service area might be performing about 82% or 83% and another up at 94%. And so that's part of what we try to do is identify, again, that variation and try to narrow that down as appropriate. So the green dotted line represents one care's average, our providers on average. And you can see that this is something they've been paying attention to and so you're seeing that graph go up. But the blue line really interestingly is the work that is happening in Berlin. And you can see not only is it going up but it's consistently above that of the one care average. And so we said to the team, this happened to be through CBMC, the local hospital, what is it that you're doing specifically that you think is impacting these rates? And they came back and said, we're doing two very specific things. We're doing something called panel management. And what that means is that there is a staff or multiple staff members who are going ahead of time and looking and saying, who has diabetes? Who hasn't been in for a visit? Who hasn't had their lab test? Can I actually set up a process to get those labs ordered and call that individual up and help them understand why they should get that test and help the doctor read it? So that was one component. And the second, from more of a financial perspective, is they said as a hospital system, so looking at the employed primary care providers, we want to align our provider incentives. So there's actually a financial structure associated with the pay that the doctors receive associated with achieving higher performance in this measure. So just one example of the types of activities that are going on. So, and we can take a stoplight. So when you gather this data, for instance, from Berlin, I wanna make sure I'm understanding this right. Are you then going to the other HSAs throughout the state and saying, hey, this is what Berlin is doing and this is what we're seeing. This is your panel of people and this is how you could increase your numbers. Absolutely. And so every month, graphs that look like this come out in a report. They're shared within anyone who is contracted with one care. So home health gets to see this in Berlin as well, for example. And then what we do is we look for who are the really high performers and how do we highlight and share that and then who are the low performers and that's often where our staff will go in. So an example there was in one community, we had a large practice join us last year and we saw that they had a much lower rate of adolescent well care visits than anyone else around. And so there was no accusation that we came in with curiosity to say, what's happening here? And it turned out there were some system issues within the office where in part they were doing things that weren't well documented so we could fix documentation. And then we had some really good conversations about, well, who do you consider to be patients in your practice? Who do we consider to be patients in your practice and how do we come together in a more holistic way to think about the support of the community? So primary care are really important cornerstone of the entire framework of the ACO model and certainly as we think about how we want to provide access to services for all our monitors. So in this snapshot, what we're showing you is on the left when we survey individuals, we ask the question, how satisfied are you that you're receiving timely access to primary care? And the Medicaid surveys came back and said usually parents or adolescents who are old enough to report on the survey themselves, 94% replied that they were satisfied with that access to care. And you can see for adults, we gave you both the Medicare and Medicaid rates. We also really want to focus on the high and very high risk population. So if you go back to that four quadrant slide and we're talking of those bottom two categories, those are individuals that we know have high needs and you would assume that if we have high needs that they probably need primary care more often or they need to help coordinating services. And so we just took a snapshot and we said, well, what did it look like for individuals with Medicare insurance who were in those high risk categories in June of 2018, which was very early days in our complex care coordination program compared to June of 2019 and we see about a 6% increase. That makes sense to us because of the interventions and activities that we are really promoting in our local communities. And that includes things like having a sash wellness nurses check and make sure that clients in their congregate housing are actually seeing their provider every year. It includes thinking about how home health is communicating with primary care about when there's a specific need or an opportunity. I think it'd be really helpful together to also be looking at those percentages, the access issue for commercial insurance because that's where we see the people who have really high deductibles because they're, yeah. Yeah, I just, I underscore that that when you think about the issues of affordability and I think the, you know, Office of the Healthcare Advocate is releasing, you know, just an analysis of the comments from people in terms of the hearings at the Greenmount Care Board. And I mean, affordability is the issue that is layered over on top of access if you don't have affordability, you don't have access. And so I'm looking, well, Medicaid, affordability. Yeah, these are not surprising. Not an issue, Medicare, less an issue, private insurance, huge issue. And so I think there needs to be some kind of understanding of how this all fits together as well. And I would say that I think that there'll be a great opportunity for us to look at this year because as you've seen in previous years our number of commercially insured vides has been relatively low. So we could really evaluate that a lot further this year with MVP coming on and us expanding our pro-prosperity shield. It's a great comment. So the Senate is just about to leave. So keep going and then we'll leave individually as we feel. Perfect. This is actually a great note. Okay. You have to depart to leave. I would love you to leave these two numbers in mind. So we can talk a lot about our complex care coordination program and how we're supporting individuals, but it's also our accountability to look at the population that we're supporting that agreed to engage in this program and what is their care and what are their outcomes looking like? This is a first snapshot when we had individuals that had been in care coordination for at least six months, we said, what is it looking like in terms of their utilization of the emergency room? Because that's one of the first things we would hope would improve before we see costs go down and other things. And so what we saw is that there was a 33% reduction in utilization of the emergency department for those who were in the care management program with Medicare insurance and a 13% reduction for those with Medicaid. And I do wanna note that those are statistically significant changes because sometimes you have to think about, well, is the population big enough to really say these are impactful and in fact they're quite pre-dramatic differences in those rates. We continue to track these as well as other measures on an ongoing basis and we'll be happy to share more information about the program or about the outcomes that we're starting to see. Final slide here also related to care coordination is around a pilot program that began with UVM network, Home Health and Hospice. They used some of the funding that we provided them through the care coordination program and they developed what they call a longitudinal care program and what they saw with a small group of patients, this is roughly about 30 individuals, is that by continuing to provide home health support after a typical episode of care would end, so normally they would have lost their ability to access home health services. Instead through one care funding, we extended that for very frail and particular conditions. What they saw is a 30% reduction in cost, so about $1,150 reduction per member per month in that group, a 26% reduction in admissions to the hospital and about a 20% reduction in ED utilization. This was so impressive to us in a short period that this is one of the uses for delivery system reform funds that we are hoping to invest in in 2020 to be able to spread this to other rural areas of the state and see whether they can achieve these same outcomes. And as we see these reductions in cost and utilization, utilization resulting in cost reduction, what are you looking at in the future? How can we look at this, I guess is a better question. How can we look at this as cost reduction to the individual patient? I mean, right now we're looking at the overall system and the public health, but how can we look at this as a benefit to the patient to reduce out of pocket or deductibles and the copay whole piece that is so problematic for folks. In the big picture, what we're doing here is the hospitals are pre-investing about $10 million in 2020 in this program in order to support the 700 plus individuals across the continuum of care that are providing these services. But as services go down, as they stay out of the hospital, there should be a corresponding reduction in some of those out of pocket expenses. That's kind of the first layer of where we might see it. And then the next question becomes, how do we start to change other aspects of the way that care is organized and delivered? And I think that's where new creative thinking needs to happen, frankly. Oh, we've got it. Well, thank you for that. But it isn't that you're not thinking about that. I mean, this is important for, I think, us to understand. One of our focus areas this year is to really look at all the programs that we're investing in because they're pretty stable portfolio right now and evaluating those core metrics of success. And that'll be part of the performance dashboard that we're developing in collaboration with the Green Mountain Care Board to understand what those metrics are and how we are moving the dial towards those loftier goals of the LKM model. Before I start using people, I just really want to thank both the Senate and the House for allowing us to have so much of your time over the last few days. I hope that you found this helpful. And I think, as you know, we're all available. If you ever have any questions or things come up, or if you want any of us to come back and do a deeper dive or if we're happy to do that. So thank you so much for your time. Thank you. Thank you for your time and all your staff. I mean, I know there are others who haven't spoken or are here and we're very appreciative of the time you've given us. Thank you. So I think we're going to wrap it up for the House as well. Okay. Yes, we've done. Okay. Thank you. Thank you. Safe trips.