So we're going to call the meeting to order. And the first item on the agenda is the Executive Director's Report, Susan Barrett. Yes, thank you, Mr. Chair. Welcome, everyone, to the Green Mountain Care Board here on the road in Randolph, Vermont, with Gifford. I have a couple of announcements, and I thought I would save those announcements to the end and just start out by telling folks in the crowd and sharing with you who the board is and what we do. I see quite a few familiar faces, and I'm quite sure you know who we are and what we do. But what I thought we'd start out doing is just going down the row of board members and introducing each of you, just sharing your name, how long you've been on the board, and a little bit about your background. OK, I'll start. Hi, everyone. I'm Robin Lenge. I've been on the board almost three years. It'll be three years this fall. And my background is I'm an attorney by training. I also have a master's in health care delivery science from Dartmouth. And I worked at the legislature for a long time, and then with former Governor Shumlin as well. That's who I am and why I'm here. Hi, my name is Maureen Youssefer. I've been on the board just a little over two years. My background is more corporate finance. I was CFO for seven generations for four years, and then other financial positions in the private sector for 25 plus years. I'm Tom Pellum, a native of Arlington, Vermont. Been on the board for a year and a half, over half, so I can't claim that I'm the newbie anymore, just no excuses. And I was pretty involved in some stuff when I lived in the Boston area. But I came back to Vermont in 1989 and was a housing commissioner, a finance commissioner, for a Howard Dean, tax commissioner for Jim Douglas, a member of the legislature, and then deputy secretary of administration. So my name is Kevin Mullen, I chair of the board, and I've been a member for just over two years. Maureen and I started on the same day. And my background is primarily in small business. I did spend 19 years in Montpelier, four years in the house, and 15 years in the Senate. And I usually start off, but since there are so few people that I know in the room, but I'll do it anyways. Most of my career was spent as an exhibitionist. So I merely owned a movie theater. So that's hard to follow up on. So my name is Jessica Holmes, and I've been on the board for five years this fall. And while I'm not at the board, I also teach economics at Middlebury College, and I've been doing that for close to 20 years. And I teach classes in health economics, which is quite relevant to what we do. Micro-economics, public finance, did that for a while. I haven't done that in a while. Economics of sin, which is relevant to Kevin's formal work. And I guess that's got it. My name is Lynn Combs. I am the associate general counsel for the board, and I've been here for about six months. So I get to be the reviewer. And she came from California, which is really impressive. I've been in Vermont for about a year and a half. And I'm Susan Barrett. I'm the executive director. I've worked at the board for almost six years. Before working at the board, I was the public policy director for a bi-state primary care association, who they represent the federally qualified health centers. Before that, I did health law. And before that, I worked in industry for the vaccine rules. So welcome, everyone, and thank you. And before I forget, I just wanted to give a shout out to Ashley Lincoln for helping arrange today. This morning, the board and I separated. One thing about the Green Mountain Care Board is whenever we're off quorum, so anytime there's three or more folks on the board together, this needs to be a public meeting. So what we did is we separated folks out two by two, and we took field trips throughout the community this morning and learned about the great work that folks in this area are doing. And we'll hear more about it in our presentation this afternoon. But I did just wanna set up by giving a few more updates on what the board does, and also to set up the presentation we're gonna hear this afternoon. So the board is a five-member board. It's an independent board. So it's independent of the legislature. It's independent of the administration. So the decisions we make are very non-political, apolitical. The board members are appointed by the governor. They go through a very rigorous process through a nominating committee. That appointee also has to be confirmed by the full Senate. So we're very lucky to have this prestigious group on the board, and it's very stringent to get through. I wanna hit on the mission of the board because this will be related to what we hear today. So the mission of the board is the Triple A. So to reduce the cost of healthcare, while at the same time making sure that there's access to high-quality healthcare for all Vermonters. One of the things we are focusing on, and really the primary area of our focus in the last couple of years, has been an agreement with the federal government that it's an agreement between the state of Vermont and the Centers for Medicare and Medicaid Services. And this agreement is looking at ways to reduce the rate of healthcare costs and growth in the state, as well as looking at different ways to pay for healthcare. Right now, and I'm gonna try not to be too wonky, right now in our system, primarily providers are paid per procedure, per visit basis. This is often called fee-for-service. The move in this agreement that we've signed with the federal government is to focus on population health as well as value-based care. And you'll hear these terms moving away from fee-for-service and pay for quality and value-based care. And that is essentially what we're doing in terms of working on population health and prevention. You're gonna hear from folks today, from the Gifford community, about the things that they're doing to help us, the state of Vermont and the board, reach our goals with the federal government to reduce the cost of healthcare and as well as work on different payment methods. There are three overarching goals with the agreement we've signed with the federal government, and they are to reduce the deaths related to suicide and drug overdose. Second, to reduce the morbidity and the mortality of chronic disease, like diabetes or hypertension. And third, to increase access to primary care. And what we've asked Gifford and the accountable communities for healthcare in this area to share with us are ways they are addressing those issues in the community. So you'll see that in their presentation, they'll be addressing those areas as well as I think a few more because they do quite a bit down here. So we are really looking forward to listening and learning from all of you. We will have moments for public comment throughout the discussion and I am really looking forward to learning from all of you today. So I will turn it back to you, Mr. Chair, unless you have anything else. Oh, I've been reminded I have to read this statement because one of the, I didn't list out our duties. I think many folks in this room know that the board has overview of oversight of the hospitals in their hospital budget process. We also decide and review rates that are requested for the large market as well as for QHPs, qualified health plans. So we made a decision on a large group filing last week and per our statute, I must read it. So bear with me as I read the results of our decision. So the board has approved rates for the Blue Cross Blue Shield of Vermont and the Vermont Health Plan large group rate filings affected at the third quarter of 2019. On February 21st, 2019, Blue Cross Blue Shield of Vermont and the Vermont Health Plan proposed an average annual rate increase of 14.9% for their large employer groups affecting 68 large employer groups with approximately 14,600 covered lives. On May 23rd, the Green Mountain Care Board ordered Blue Cross Blue Shield of Vermont and the Vermont Health Plan to reduce their overall rates by approximately 0.3% to address the calculation error in the generic drug unit cost trend and by 0.5% to reduce the annual medical utilization trend and the impact of the administrative costs. The board approved the modified rate resulting in an overall average annual rate increase of approximately 14%. And then I will also send out a plug and a reminder that the board will be, has received the qualified health plan rates for Blue Cross Blue Shield and MVP. Those hearings will be held in Montpelier on July 22nd for MVP and July 23rd for Blue Cross Blue Shield. There will be an open public comment period as well as a public forum for folks to attend and all of this information is on our website. I'd encourage you to take a look at that. Will that suffice? That is wonderful, thank you. And now I can turn this back to the chair. Thank you, Mr. Chair. Thank you, Susan. The next item on the agenda is the minutes of Wednesday, May 15th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday, May 15th, 2019 without any additions, deletions or corrections. Is there any discussion? Seeing none, all in favor, signify by saying aye. Aye. Any opposed? And at this point, we're gonna turn the meeting over to the Gifford community. Thank you, Dan. And thank you for the great house development. Thank you. So good afternoon. My name is Dan Bennett. I'm the president and CEO at Gifford Health Care and Gifford Medical Center and also Gifford Retirement Community. And I want to take an opportunity to say thank you to the Greenmount Care Board. We have a number of different venues where we are presenting information to the Greenmount Care Board to help them do their job, their regulatory function here in Vermont. Typically that is around financial issues and we do also meet on a regular basis one-on-one as well. And we're very happy that they've taken this opportunity today to come to the Gifford community to learn what happens behind those numbers, what happens with the care we provide, what happens with the work that the Gifford people do on a daily basis, but also just as importantly, the work that we do with the partners that we have in the community, all toward the goals, I think the same goals at the Greenmount Care Board has to make our populations, help our populations stay healthy and to meet the aims of the all payer model. So we're very happy to have the Greenmount Care Board here today appreciate the efforts they made to come out and meet with our groups and two of them even went over some mountains and followed one of our excellent staff members with her driving and made it between here and Chelsea safely so we're glad that that worked well. So what we have for you today, we have in the room, we have our senior leadership team here at Gifford and you're gonna hear from a couple of them, I'll ask them to introduce themselves when they come up. As questions come up, we will call on whomever the subject matter expert is in that area to address the question and answer those questions. And I'd also ask that everyone please identify yourself when you do that. We are going to provide a summary of two of the three breakout groups that occurred this morning, to give you some context of what we talked about and some other information about the work that we're doing in the community. And again, the work that we're doing in the community with those partners that we have. And then the larger agenda item, we're gonna focus on our community health and community outreach activities. And we have some special guests from the community who are gonna participate in that as well. We think that is going to be a very enjoyable presentation. We do welcome questions as we go along. So please do feel free to ask questions as we go. And again, I wanna thank Green Mountain Care Board for being here. We also have several of our board members who are in attendance today and one former board member as well. So appreciate the community participation as well. So with that, I am gonna turn the microphone over to Rebecca O'Berry, our Vice President of Operations, to tell you about the right to help group that visited. So I'm Rebecca O'Berry. I am the Vice President of Operations for Gifford. I won't say healthcare or medical center because it's both. And so I'll just go with Gifford. And today Dan just went over this and I was probably supposed to click ahead and didn't. So this is where we spent our morning and I was lucky enough to get to host a group of folks who are a couple of the Green Mountain Care Board members and our community partners. And Chelsea is our most eastern clinic. So we have clinics around in our communities and this is our most eastern clinic. We've been in this building since 2009 and it has these wonderful vaulted ceilings in the front, which is the waiting room. And we provide services here and as you can tell on the back on the bottom, we also host the Medicine Shop Pharmacy and Claire Martin Center. So the Medicine Shop Pharmacy was brought to the Claire Martin Center by the Claire Martin Board. And excuse me, I just messed that up. The Chelsea Health Center by the Chelsea Health Center Board and they have their own entrance, which is really great because they can then have hours that work for our patients. So they have some extended hours when the clinic might be closed, they're still open. And that's a great benefit. They're also trying to work on having a mail order for our folks that are in that area so that they can get their prescriptions sent to their homes, which is a terrific thing. We also have Claire Martin Center in there three days a week and I'll talk about that a little more in a moment. This is the original building of the Chelsea Health Center and as you can see, it's been there since 1953, which is pretty amazing. We actually had Starr Strong, who was Gifford's very first physician assistant in that practice, which was really cool. Today we have a physician, Dr. Barber. We have Rebecca Savage, a PA. And then we have nurses, an MA, and a couple of MA's and an LPN, who's the office manager. And then we have our blueprint representative there. So she's there a couple of days a week and supplies sort of those wrap round services for our patients and helps connect them to the other services that they might need to just help better their care. We're trying to promote the Chelsea Health Center because it is really kind of our mission. They're in a rural setting and we're trying to make sure that patients who need care get their care locally. And if we can identify needs that we can supply to them in their own community, that's better for all of us. So this is the Chelsea Health Center and Dr. Brewster Martin and Dr. Howell started this in 53, like I said, and we'll talk a little bit more about Dr. Martin's wife in a few moments. Another partnership that we have is with Health Hub. So Health Hub provides dental services. They're in 10 of our local schools within Orange County and they also provide services through that little trailer at the Chelsea Health Center, but also here at Gifford Medical Center out behind our OBGYN clinic. It started as providing school services, services to kids at school, which is where we can sort of capture them and make sure they're getting all of their screening services. And we've been really working hard with them to supply the same services to adults and then make sure that we are, you know, hooking them up with another dental provider if they need restorative care or additional work. And so here we are all over the place. These are the schools that they go to on a regular basis, but Janine, who is the hygienist, is really great at just going wherever it need be. If she's not busy at one of the schools and she's seeing that there's a need somewhere else, she sort of modifies her schedule and meets those needs. She'll make sure that folks are getting the services that they need, whether it's closer to their home or closer to where they work. She works with people on an individual basis to get them what they need, which is a great benefit because we need to make sure that people's oral health is taken care of. Another partnership that we have that was represented today is our house calls program, which is with the First Branch Ambulance. They provide 24-7 emergency coverage, of course, for our community. They're staffed each day from eight to five, seven days a week. After hours, it's by volunteer. They supply all sorts of regular services, but they'll also do just transport if we call them and a patient needs to get from here to there. They work with us on that. They also provide the service that can be really important to us if we have a patient who's an inpatient but needs a service we don't have. They will take that patient to another hospital and wait for them and then bring them back to us, which is terrific, because sometimes that can be a real problem. We don't wanna just drop them off there and then have to figure out how to get them back to us. So they have this house call program which provides these services, blood pressure monitoring, blood glucose, wellness checks, falls assessment in first aid. One of the other things that they do that is really a terrific benefit to us in the patients is they do some medication management. So if they go into a patient's home, they can call Dr. Barber or someone else and kind of go through, I'm looking at all these pill bottles and I'm not sure how they're taking them. Can we just kind of start from A to Z and make sure that they're taking their medications the right way or identify something else that they might need. They also do like the post-hospital checks. So if a patient's been discharged from the hospital, they'll go and check on them. They'll make sure that if something looks a little bit odd, that if they can make up that phone call and connect the patient to the care that they need. They also can, they're in the patient's home. So they can make an identification of like, this patient needs some other services and they can work with either our blueprint team or another local clinician or support services area to make sure that we get that patient what they need so that they can stay at home or that they get to the right care if there's a care need identified. So they've been doing this for about five years. They haven't had this agreement with us. This happened with us in September of 2018, but they've been doing this for five years and they've reached about 75 individuals. Some of these people they see every day. They'll see them five days a week. Some people they see once. Some people they go see once a week.  So Claire Martin. So Claire Martin was married to Dr. Martin. And she had a passion, she had for healthcare, for mental healthcare and making sure that patients are getting the care that they need. And we have them in the building three days a week. They also work with us on an individual basis. So a lot of times patients of a certain age if they're younger folks they need to be, they need to have that initial intake and they have to come to Randolph for that. That's a real problem for some people that live out in Chelsea in these rural areas. And so they've worked with us to identify that and come in whenever they need to. It doesn't work out all the time, but a lot of times it works out just perfectly. Or if they're in the building and we have a patient who comes in who might have an urgent need. If they're there, then they're available, they'll come out and take care of that patient in the moment or at least start the service and then get them set up with what they need. They're a great partner for us. I mean, throughout our community. They actually provide services in 10 locations which sort of mirrors what we do. And so it's a really good handoff. We have Washington County Mental Health for our Berlin area, but everywhere else, this is who's taking care of our outpatients as well as providing services for us on the inpatient as a patient comes in the emergency department. So that's a, this is a real big benefit for us. They have services at Chelsea include mental health, but they also do addiction medicine as well. So they'll take care of our patients there. We have take back envelopes in all of our clinics. And that's one of the, one of the, we've worked with them as our partner to sort of steer patients to that, to if you've got medications in the house you don't need, we can help you get those out of your house. It's our Chelsea Hall Center. Any questions? No? Okay, so I am going to be introduced to you, Monica Boyd, who is our Director of Quality and Risk Management. Good afternoon. So I have the pleasure of sharing with you some of our quality initiatives that we have going on this year. We have a, sure I'm sorry, Monica Boyd. We have an antibiotic stewardship program. With this program we really focus on the judicious prescribing of antibiotics. One of the challenges we face in healthcare are drug shortages and multi-drug resistant organisms. So the life-saving medications that we need are becoming less effective. So we really focus on having responsible prescribing of antibiotics for our patients. With this initiative, one of the things we've done is embedded an antibiotic timeout in our daily inpatient rounds. At the 48 hour to 72 hour mark, it allows us to ask and answer that important question of is this patient on the right antibiotic? With that and our quick reference guides that we have developed for our providers who are prescribing to help them start the patient on the right antibiotic, we have reduced our antibiotic therapy days by 50% over the last 18 months. Another quality initiative that we're working on is reducing readmissions. Our focus is on 30 day readmissions. And with this effort, we have a dedicated provider in our primary care clinic who will see a patient about a few days after they're discharged from the hospital. Provides a nice opportunity for them to check in, to see how they're feeling, how they've transitioned back home, to go over the medication regimen, find out if they have any identified any additional services that may be needed or additional referrals. Sometimes when patients are discharged from the hospital, care management will try to get services set up for them and patients and families decline those services while they're an inpatient. And after they're home for a few days, they may change their mind. And so this is a nice opportunity to kind of revisit that question. We also have a large focus here at Gifford on prevention, prevention of chronic illness and overall health. We have several initiatives related to this effort, the first of which is a colorectal cancer screening project and there we're really looking at the referral process from primary care to our specialty clinic to scheduling and getting the patient in for the appointment and then closing the loop after they've had their colonoscopy, what is the follow-up plan and what were the findings of that screening. We also have projects focused on diabetes and pre-diabetes. We have several self-management workshops that are spearheaded by our community health team and we also have a fantastic diabetic educator to work with folks after they have that diagnosis of diabetes. This is a project, these projects really focus on helping patients prevent the diagnosis of chronic illness and overall long-term health. We do have several challenges that we face as a community hospital. When we talk about mental health, one of our challenges is recruitment and retention of mental health providers, particularly for a pediatric population. We have six beds in our emergency room so as we have a mental health patient come in awaiting a placement in a mental health facility that takes incredible resources away from other patients and the community in general. As a way to combat this, we have a new contract with a telepsychiatry company who can have a Skype consult and work with our providers in the emergency rooms to maybe start a medication treatment plan for that individual while they're waiting in inpatient bed. We also have our community health team and others here at Gifford who are really focused on addressing the social determinants of health and helping to reduce the emotional stress that some of our patients are feeling and dealing with. And as we look toward the future, we're really looking toward integrating care some examples of this are surgical services in its proximity to the OR and also the proximity of primary care and behavioral health care in our clinics. We have identified some needs in terms of our facilities as they're aging, as we have in aging plants. One of the areas where we will need to renovate is our emergency room. That layout is really small and the flow does not work and is struggling to meet our communities' needs at this point in time. And then we also have some vacant space at our southern end of the building that we're looking to identify as the best way to serve the community in that area of our building. Questions about our quality initiatives? What is the research behind the 48 to 72 hour period on the antibiotics? Typically that is when the culture results are back so we can identify whether the patient is on an antibiotic that is sensitive to their organism. Great. Can you talk a little bit more about the talicyte? I'm intrigued by this, but I also recognize that part of psychiatry is the human to human interaction and through a screen and through a Skype. I'm just curious about your successes with it or other successes with talicyte. So this is a brand new service that we can offer and we have done a dry run of it but we have not actually used the service for a patient. We are hopeful that it will allow us to be able to offer some services and get patients started on a treatment plan while they're here. Josh, do you wanna add anything to that? Sure. Come up so you can hear me. Josh White, I'm the chief medical officer here. So specifically in regards to the talicyte. You're absolutely correct. That person to person interaction is critical to that relationship. The key here in understanding the value is that as is true in most emergency departments a lot of these patients are essentially being housed. They're in a safe place, they have a place to sleep and they get fed but they do not get acute treatment for whatever mental health condition that they're facing until they reach their designated receiving facility. So it's a problem that they're not receiving and care that they need. Having an available telepsychiatry consult addresses that and we can start to address that patient's need, if not as well as with the person in the room. And it also offers a potentially significant bonus in reducing the burden both on the local emergency department as well as the state services. The hope with these patients is that as they interact with the psychiatrist, the psychiatrist is able to provide a consult that will allow the emergency physician to provide medication based on those recommendations and time passes where the patient has the opportunity to decompress from whatever acute event triggered their suicidal status or what have you. Maybe relationship issues or loss of a job, something along those lines. That patient may improve and be able to go home and subsequently are no longer going to require inpatient care such that the whole state will benefit from this as our triage list gets smaller. So in addition to kicking off this telepsychiatry program we're tying quality initiatives to it and examining our length of stay from previous years to as patients receive this and can we reduce that amount of time they spend in the emergency department. Thank you, that's really helpful. It's also interesting. You might want to mention the psychiatrist because everybody on the board should be familiar with him because we've met with him at the Brattleboro Retreat that is doing the work. Yeah, so we're contracted with Dr. Mark McGee who started Alpine Telehealth. This was sort of his baby, so to speak in terms of his career goals and we did initially start the conversation while he was at Brattleboro. He left there to start this organization so the transition for us and engaging with them was fairly easy as that road had already been paved. That's great. Other questions? Okay, then I will turn it back over to Ashley. Okay, I'm gonna begin with a overview of our community outreach program but later in our afternoon presentation we're gonna take a deeper dive into some of our work. I would like to focus this morning on or this afternoon on our discussion we had this morning which really focuses on nutrition and exercise. We are very fortunate to work in a community that is actually throwing with the desire to be healthy. Perhaps some of you in the room are aware of RASTA which is a new program of developing both mountain biking and backcountry skiing. They are also developing trails so we're working very closely with them in a way to encourage our youth to not only participate in team sports but also individual lifelong sports knowing that that will hopefully create an adult that will be aware of exercise and healthy eating. So one of our very early on partnerships when we kicked off our community health program was with our Randolph Rec Department. And it was a win early on when we discovered that at their youth sport level, youth team level they did not have first aid bags. So that was a very easy gold star for Gifford when we could very quickly pull together what they needed for to make sure that all the kids were healthy and safe during a team sport. We also have a very active staff with both our providers and staff members that want to volunteer, they want to be engaged. You're seeing many of us as volunteer coaches. We may be reffing, we are at events providing medical support. So again, having Gifford's presence really brings a sense of calm to the parents on the sideline. So with our community outreach program this is where we started. And I think that you'll discover it's really grown over time. This summer we're gonna be partnering with the area rec camps and we're gonna have an eye on nutrition. Certainly during the school year you'll hear we've got some members of our school community with us today. But the kids actually are very happy during the school year because they're guaranteed two meals. They get breakfast and lunch. So while we think about kids being very excited when that end of the year school bell rings and they get to go home there's actually a sense of fear with some of our children because they don't have access to food. So again, we are working very closely with our area food shelves to try to combat that problem. In addition, we're gonna be down at the rec program teaching kids about healthy eating. I'm sure many of you see kids drinking a big gulp probably have an extra large bag of Doritos not the type of food choices we'd like them to be making. So we would like to work with kids and teach them other alternatives that taste good and in the summer months are readily available. So as I mentioned with the Randolph area food shelf this has been a really excellent partnership for the hospital. Again, earlier we talked to Rebecca O'Berry and Rebecca is actually the president of the food shelf. Bethany, who you're gonna hear from later she's the volunteer coordinator. We have another woman in our quality department who's the vice president of the food shelf. So I think all these 501C3s are actually pretty smart and they know where to go to find quick and active volunteers. But we are excited to partner with the food shelf and a project that we took on this year just actually in the last few weeks was we created a food staple bag. When we have patients come to the hospital for their primary care visits to have their diabetic check to have whatever sort of appointment here there's often could be another nagging problem that is creating a larger health issue. And clearly our doctors can dispense the best medical advice that we have available. However, there's also other social determinants that are bringing down that patient and very quickly we discover that access to food is often one of them. So what we have done with the Randolph area food shelf is we've created a staple bag. It's a Gifford green bag. So when patients walk out there's no, nobody knows what's in it but it has been filled with non-perishable items that we get at the food shelf that they can bring home and have access to that food. We actually have that as part of our inventory system. It's down in our materials management department. It goes to all of our outlying clinics and all we have to know is when they're dispensed and then we send another bag to replace it. So that's a program we're really excited about and we certainly have heard a lot of feedback on how positive it is. We also are working with Kimball Library every day after school that is a spot where we see youth going and the librarian reached out to Bethany and shared that there were food insecurities that she was hearing. So again, we had those bags stocked down at the library for kids to be able to take when they leave. Just this last, in May, which you say a few weeks ago, we kicked off Veggie Van Gogh. That is a program with the Vermont Food Bank. They will continue to be here at Gifford the second Thursday of the month from 1130 to one. It was a huge success. I will say that we were really pleased with the amount of people who came out to access the food but also the amount of collaborations we were able to highlight for our folks here. We had a lot of local 501C3s with a table. Another area that we've been focusing on are our senior centers. During November, it's Giving Tuesday and that's a very popular day in our country where folks ask for money for 501C3s. At Gifford, we decided to do it different and we decided to look at Giving Tuesday as our day to give back. So during the month of November, we collect food in all of our outlying clinics as well here at Gifford and we then deliver that to all of our local food shelves. We also serve free community lunches in all of the senior centers. So our chefs, for those of you who don't know, we have an incredible team of talented chefs here at the facility. They come on site with Bethany, myself, other members of our senior management team. We have doctors who come out and we serve lunch to the seniors for free. That gives them an opportunity to get to know Gifford differently. It gives us a chance to give back and it also allows us to have a finger on the pulse of what those communities need. I think a lot of us have ideas that we think we know what our neighbors need, but when you're actually sitting there serving food and engaging in conversation, you very quickly realize that perhaps what you thought was the issue may not be. All of these outreach opportunities are what have guided us to develop a very strong community outreach program. So before I go further, are there any questions on those pieces? I guess not. Okay, because I have more. Yeah. So our larger presentation for, I'm gonna speak for a few minutes and then turn it over to my colleague Bethany. For many, many years, actually before it became a mandate by the federal government, we have been doing community needs assessments. And those outreach surveys, we actually have worked at our town meetings to have paper surveys. Again, we serve a lot of rural communities that don't have access to the internet. So we had to think creatively to find out how do we actually reach our population to find out what they need? And everybody still goes to town meeting. So we have paper surveys at town meetings. We do have online surveys. We have surveys within our clinics. And we take this opportunity to actually ask our neighbors and friends where their areas of focus are for this facility. That is again mandated by the federal government and it's updated every three years. This survey actually helps us also create our strategic plan. I give a lot of kudos to our volunteer board because they look at these results and they let this guide that decision-making process. And while a strategic plan is just a roadmap, it does help us stay focused on the prize at the end. Not always are we able to check off all those items as complete. However, I think we've done a pretty good job. And this information that we have today has really helped develop our community outreach program. No surprises here with what we've discovered with our community needs assessment. Our community is telling us, there's a problem with drug addiction. There's a problem with obesity, mental health issues and preventative health care. So clearly it goes hand in hand with what Susan shared, the direction that the Green Mountain Care Board is looking for all hospitals to respond to. These are the areas that we have latched onto and have been able to successfully get out into our community with education events. We've done a lot. Two years ago, we received funding from a donor, $25,000 per year, that allowed us to reinvigorate our community outreach program. At that time, we made the commitment that that would not pay for salary. It would pay for all the projects and all of the initiatives that we wanted to pull off within the community. So we hired Bethany Silaway, who will be joining me up here shortly. And we immediately said, what do we need to do? We did a lot in a short amount of time. But then we realized that we really needed to focus our efforts differently. So we are gonna take a moment and look back and talk about our outreach around drug and alcohol prevention. And then moving forward, it's really gonna tie in nicely with the nutrition and the recreation. Any questions for me? Okay, Bethany? I'm Bethany Silaway. I'm the Community Relations Coordinator here at Gifford, as well as the Rise Vermont Program Manager for Orange County. That's a pretty new role. So we're not gonna talk about that too much today. First off, thank you so much for being here today. I get the pleasure of talking about all the really awesome, fun things that we do here at Gifford. So I'm honored to get to do that with you today. I also wanna thank our administration for just constantly being so supportive of our outreach efforts and understanding how important that is to the community. I feel strongly that the more we educate folks and teach them about the preventative measures they can do, though I'm gonna spend some money doing it, it's gonna save us a lot of money in the long run. So it's just nice to hear that again. Reminds me of my efforts and what I'm doing. My goal with a lot of the outreach that we do is to keep Gifford top of mind for everybody all the time. How can Gifford help you live a better life, live a more comfortable life? Be supportive to a cause that you're trying to get going in your area. When I first took this over, a candidate didn't know where to start. We had our initiatives, but I needed to form those relationships in the community and see what they needed from us.  I'm gonna tell a story with one of our partners where that happened later on. I was really inspired also after watching the relationships with our local lead program, which I'm gonna talk about in just a few minutes, but we have officers that go into the school systems to teach the law enforcement against drugs. And we've done a lot of work with them, which is really wonderful. And one thing I get to see through all of that was the relationships that those kids were forming with these officers. And oftentimes, and I know for me growing up, being really friendly with your local police officers wasn't really something you did. It was more like, whoop, they don't know my name. And watching these kids have these relationships with these local law enforcement officers was just heartwarming. They hug them, they're excited to see them, they joke around with them. And all I could think is down the road someday when they're in trouble possibly or thinking about it or it could be in a situation where they need them, what an awesome thing.  So my goal was how do I form that relationship with our community members, with the kids, with all of us here at Gifford. I want people to look at our physicians as comfortable people to talk to. Comforting ear, a good place to be. That way if they're here with us in kind of a bad situation, they're really ill, kind of something scary is going on, they're comfortable, they're in a place, they're familiar with the faces and they're comfortable to talk to us about those kind of scary situations. So goals behind what we do. So we, like Ashley mentioned, we've done a lot of outreach, but what I'm really gonna focus on today is our efforts in education of prevention, drug and alcohol addiction prevention with our youth, and as well as the community and educating the community about why you become addicted, what happens when you become addicted, what are your treatment options? Is there hope for people after addiction? So that is our really big focus we had last year. So the first real outreach I got to do in my role was working with the LEAD program. So that's the law enforcement against drugs. And they are currently kind of all of our Orange County headed up in this area by the Orange County Sheriff's Department and they completely supported themselves. So Orange County Sheriff's Department has to raise money to be able to support this program and to be able to put these officers into the school system to work with the kids. They go in once a week for a six to eight week series with the kids and at the end, kids have homework and they have projects and they present and they do a graduation ceremony. So the first thing we did was bought them pizza. Those kids earned it, they worked hard for it. We got to go to the graduation and provide food for them, which all kids love pizza. So that was our first thing we were able to do for them and that just started a wonderful relationship with us and LEAD. So basically I kept saying to them, what can we do for you? What can we do for you? So the next thing we heard was, well, we don't have a middle school curriculum. Right now the only curriculum that they had was grades K through six. So after sixth grade, the kids weren't getting anything after that. So we said, well, obviously we're gonna buy you that curriculum. We need to do that as well as continued to support that in the schools. It's hard for these school systems to carve time out of their day to host these programs. And with Gifford getting behind it and being supportive of it, that encouraged them that that was important and they needed to do that. So we're happy to use our voice with the experts that we have to keep programs like that going. What else did we do? We also supported their end of the year celebration. They pulled in all the LEAD, graduating LEAD classes from the year and they had a big party down at the rec field. We provided food for them. We had a t-shirt designing contest with the kids. We picked a winning t-shirt and got those printed and were able to give those to all the kids at the end of the year. That was just really fun to be a part of. We also took one of their local officers that participates in it down to Washington DC with myself last year to go to the Big Prevention Conference, which I have to say I was very humbled and proud to be from Vermont because a lot of the things that they were presenting in these big presentations, I was like, Vermont's got this. Like, we are leading the way. And so when I came back and had to report out on it to my prevention group, they were like, so what did you learn? I was like, that we're awesome. So that was really exciting to feel that way down there and all these really smart, big groups that we're meeting. And I was like, Vermont is really doing a wonderful job. So I got to leave there very proud. I have a couple of folks in the room that have been a part of the lead program with me. Scott, can you join me up here? I know you're hiding back there. But with Lieutenant Scott Cluot from the Orange County Sheriff's Department, he's actually gonna be taking over the lead classes in this area this coming year. But I was just gonna give him a moment to speak to the benefits of us partnering together on this. Good afternoon. My name is Scott Cluot. I'm a Lieutenant with the Orange County Sheriff's Office and recently took over the supervisory of the lead program here in the Orange County community. And Gifford has really helped us out greatly with purchasing all the material for the kids for the lead program. Right currently we're doing classes in all of the Randolph schools and even on the other side of the mountain in New Bradford and in areas out there as well. And Gifford also is helping us out with that piece as well. Lead is a, it used to be DARE. DARE was that preventative program we back went and DARE kind of fell by the wayside and lead took its place. What lead is is, it teaches a lot more than just drug awareness. It also teaches tools for kids to use in regards to fully peer pressure and everything that they would need growing up. It's a really outstanding program and we've got a lot of positive feedback from all the students that have taken this program. And we see a lot of people coming back through, if they take the third grade, we'll take it again in fourth grade and all the other stuff, all the curriculum tailored to those classes. And they are more and more energetic with learning the new stuff year to year to year, which is really, with the hope that this stuff is taking place that we'll see a lot of reduction in regards to drug addictions, made better choices for our youth and things of that nature. He's gonna be around if you have questions. I keep him close by on it. Another thing that lead, I didn't mention this, but they also talk about bullying, being a good friend, being a supportive friend when you're put in a difficult situation. Maybe somebody's encouraging you to try drugs, how to be supportive and be there. So we are lucky to have a lead graduate here with us today, John Lincoln from Randolph Middle School, but he graduated from the lead program in Randolph Elementary School. And I'm gonna have John come up and just share a little bit about his experience and lead with us. So I'm John. Okay. You wanna hold it? I'm gonna just put it down. Hi, everybody. I'm John. I went to Randolph Elementary School. And during our fifth grade year, we learned about a new program that was coming into the schools called lead. So I don't know if you guys know that by now. Basically, it was about, first it was kind of just like a risk-taking and stuff like that, kind of different things. We could learn about that. We didn't really know, I didn't really know at first it was gonna be about like drug prevention and use and stuff like that. But since we were at a younger level, they kind of started with stuff that people of our age would kind of deal with and then moved it on as we got older through drug use and prevention and risk-taking and stuff like that. And one of the things they tried to do was take what we learned about with like goal and setting goals for ourselves and then figuring out how taking a risk that might not be positive for those goals could affect us and the goals themselves. And they'd kind of work everything together with our homework and kind of figuring out and stuff like that. And I mean, I think that everybody that was in the program learned a lot about things that we're gonna encounter in middle school and high school and everything that we were taught. I think that we've definitely been exposed to. And now after learning about drugs and alcohol and things that kids are doing, we know not to do it and we know kind of what they're doing by taking a risk of vaping, drooling, drinking and all that kind of thing in schools. Yeah. And after sixth grade, we moved into the middle school and it was kind of, it was nice to have the health class. We still kind of continued that curriculum into health and learned about more of that stuff, kind of an ongoing program. And I wasn't in the semester where they had a health or they had lead in health. But I mean, there's still a lot of stuff that we were learning. We could learn about what was going through like the mind of someone and they were taking the risk to smoke or vapor drinks and like that, which all tied into what we learned beforehand. And it was nice to be able to have a chance to learn about that. So then we now are better educated on what's going on in the real world and not just in elementary school or middle school. So yeah, that's what I have about that. Are there any questions? Yeah. Do you see any drooling at your?  How young are kids starting? There's seventh graders, seventh grade, seventh and twelfth grade. And you'll see people go in and curds to go and try different flavors. And there's people that are like dealing out drool pods and different like the oils that are in the pods and stuff like that. You can walk into the bathroom sometime and you'll see people handing them out. Yeah, it's definitely a problem. And if there's action being taken in our school to fix that, we just don't really know how long it's gonna take right now. It's just kind of a hard thing to stop, I guess. It's taken over. Yeah, nicotine addiction is a pretty hard thing to beat. Yeah. Questions? We have a prevention, learned to prevent it and not break in the habits. Any more questions about the program? Cool. Thank you very much. Thank you. Thank you, John. He's our really great lead supporter. So after getting involved with LEED, we felt like we were doing a really good job in the elementary school to support that prevention effort there, but we needed to try to do something in the middle and high school. So I heard a story on the news about the Vermont State Police partnering up with the HELP program, which is the Heroin Epidemic Learning Program. It was started by Jesse Brooks and Jeremy Holm of the Middlebury United Way. Jeremy Holm is actually a movie star. He was in the Netflix series, House of Cards, and he had a dear friend, Diamond Overdose, and he lives locally in Vermont, and he reached out to Jesse at the United Way of Addison County and said, what can we do to try to help this movement here? So they formed this program. Jesse herself was the daughter of an addict. So this was near and dear to her heart as well. Jeremy having connections in Hollywood was able to form a program where they bring experts in this field in to talk to the kids. Each week they would bring paramedics. They would bring state troopers. They would bring in someone in recovery. Jesse herself would also speak, and then they would bring in a professional film crew to work with the kids on how to film their own PSA. So they would film a 30-second public service announcement. Was it 30 seconds or one minute? 30 seconds, I was right there. And at the end of the year, we showed all those, had a little celebration. There was a winning PSA, which did get pushed out nationally. So it was a great program. And it would pull the kids in with the whole film aspect of it. But also they walked away really learning a lot. I was fortunate enough to go sit in on many of the classes and the kids were very engaged and the speakers were just phenomenal. The great thing with that program, Gifford was able to sponsor that. And it was a cool moment when I went in to pitch this idea to Colin, who's in the back and I'm gonna have him and Ms. Larry join me in just one second. But I pitched the idea to him and he was like, so what's it gonna cost me? Or what do I need to do? And I was like, nothing. We're gonna do that for you. And he's like, when do we start? So he marched me right down the hall and we talked to Ms. Larry and she's like, yeah, we can put it in my class. And it was just awesome to see it all happen and be able to support them. So that has kicked off and Ms. Larry has been able to continue that program on her own in her classes this year, which is great. And she's also incorporated the lead into the middle school health programs as well. So she's a huge asset to us and our kids, as well as Colin. So I'm gonna invite Colin Andrzejek from RUHS who is the SAP. Am I so good, getting that right? And Deb Larry who is the health teacher at the high school. And I'm just gonna let them speak for a moment on their experience of this program. You know, Bethany's telling the truth. You know, is this gonna cost anything? Because you know, these conversations have to wind up in the principal's office. And as soon as she said, no, it's gonna be supported through Gifford. I was like, well, I don't even think we need to talk to the principal. I think we're just gonna go right down to the classroom where this is gonna dovetail right in, merge right in with our health class where we really do focus on prevention efforts. And so it was just really easy to make this program a part of the high school's curriculum. And you know, and having somebody, you know, and I could ask right who here has been affected by addiction or what not. I think most of our input go up. And of course Jeremy's connection was Philip Seymour Hoffman, right, the great actor. And again, just to sort of be willing to be public about the losses people have experienced, you know, my uncle was a heroin addict and passed away. Allows us to just embrace these topics so that maybe we can at some point get to a generation where not many hands would go up in a room. And so it would be the health program really being a creative endeavor, right, with a curriculum already established and in place that was engaging and asked our kids to sort of be creative, right. And work with somebody that maybe they'd seen before or if they told their parents, where you know, in the house of cards, it just really just, it took off, right. Do you agree, yeah? Mm-hmm, mm-hmm. Yeah. I'll keep talking right here. It was very popular and it was interactive. So there was, I would say immediate buy-in for the kids. Yeah. And they didn't have to listen to me. So that was really neat.  And then you also had Jesse who was one of the people who started this program who grew up with an addict. So he had real life people with real life stories that these kids could relate to. And then the film piece was really neat because they learned the skill of filmmaking. So they literally learned how to make a 30 second commercial PSA, which is very hard to do. So it was just an overall a great success. A great way to promote prevention, awareness, and a great way. And of course all of our children, all of us are growing up right now hearing about the opioid epidemic on a daily basis. And so sometimes our kids feel helpless in these circumstances, just hearing the stories or even in the family hearing the story at the table. And this gave them an opportunity to actually feel like they were contributing, offering a potential solution or just being part of that. And again, without your support in that, we're gonna try our best but to bring in this equipment and these heavy hitters was great and it allowed the students to maybe feel like, hey, I might help in this situation. So it was really good. And Jesse's booked throughout the entire state. She's hard to get a hold of. Her program is that well received and that popular. Thank you. Yeah, I appreciate it. So once we tackled that, we thought we should look into bullying. So Dr. White and myself went to the local schools and said, hey, we wanna create this bullying program for you. And we met with Jason Gringold who's the director of the Randolph area technical career center. And I just call RTCC, so I had to make sure I knew all the letters. And he said, thanks guys, that's really great, but that's not my problem.  Vaping. So we said, oh, okay. So we kind of pedaled backwards and thought, what can we do? Luckily, Dr. White had just attended a conference where he heard a phenomenal speaker on the dangers of e-cigarettes and vaping. And he said, we'll get right back to you. So sure enough, we did some networking and booked a whole entire day. Jason blocked out, blocked the periods with the kids for a day to have the New England Poison Control Center come in and do presentations on e-cigarettes and vaping. The big takeaway was these kids are lab rats. We don't know what is gonna happen to them because we don't have any studies on any of this. And I felt like that was heavy hitting. The kids knew a lot more about it than a lot of folks, which is frightening. At the end of the day, she also met with the teachers to be able to help them identify it more, become more comfortable, ask questions. And then we followed up with a parent night as well to, again, just raise that awareness. Parents have no idea what these things look like. They're easily hidden and that it's going on. So I'm gonna invite Jason up for just a moment to share his experience. Hi, everybody. I'm Jason Gingold. I'm the Director of Randolph Technical Education. Going into this fall, 2018, we were not prepared at all for the Juuling epidemic that has hit the state and our students. And I see some heads nodding. I see Scott's head nodding in the back and Colin who I work with every day. Just today, before I got here, I had to talk to a student and I got my Juul for the day. So to underscore to you all that this is a statewide academic for our students and their families, I hope you hear that message. It was great for Gifford and Bethany and Dr. White to come down and provide North Country boys into control. And the students really took that message to heart. They didn't feel like anyone was bagging their fingers. They didn't feel like they were getting lectured at. Really listened to the message of they don't know what's going into their bodies. However, that doesn't solve the problem. As you said, sir, it's an addiction. And what we're faced with at schools is disciplines not gonna, we're not gonna discipline the addiction of students. And so as we continue moving this in partnership forward, we're hoping we can get more counseling for the students and figure out ways that we can break this addiction. Suspension won't cure this. So we really need to work with our students and we work with Collin and the health class and the law enforcement agencies to help these students and their families. And then we offered the parent night and we're hoping to do all that again. And I also brought down on a weekly basis, I email all our parents, I do like a weekly parent kind of email and my file folder of the articles and information that I send home through emails getting thicker and thicker. And so we'll, we just go home with every grade report we used to just mail an envelope of a report card and now our postage fees and our envelope size has gotten a lot bigger because we're trying to educate our students but the parents about what's going on here. So we're in a dangerous situation. We feel more prepared for this fall but we could sure use your help. And then I just wanna give one more plug and Bethany didn't know this, but Collin, can you come up? Can I invite Collin? Yeah, absolutely. I'm gonna take a little one more minute of your time. Earlier when Bethany was talking about the food insecurity and the bags that they provide for their patients, I'd also like to thank Gifford and Collin can help speak to this. Randolph Technical Care Center on the last Friday of every month, we give every student who wants one what we call food for thought, a bag of food to go home regardless whether they want it or not. It's there, we deliver it to all the rooms, they're just green bags, but Gifford was nice enough to donate some funds. About $700 a month. Yeah, it's about $6 to $7 per bag and this way we didn't have, we give it to every student so we don't have to identify a student in need or ask a student to self-identify. So we try to sort of just erase the stigma and just say, hey, if it's on your desk when the school's empty this afternoon, we'll put it in our pantry. Right, but it's on every desk, so take it if you want it. So, great. Thank you for that partnership and donation as well. Any questions? Just one, do you think that the legislative approach this year of talking about increasing the age to buy jewels and also increasing the taxes to make them more expensive, are there other ideas from somebody who's feet are on the ground every day? What's interesting when I had to call the parent this morning about the jewel that I have, they were taking responsibility and willing to talk to their student, but they also, you know, the student's 17. So legally, that student can't go and buy, but we hear they do get it a lot from older students. So definitely raising the age would be helpful. I don't think it's the only answer. I think the marketing push that went on through Facebook and social media, no one was really prepared for that. What amazes me is you still hear the ads on the radio that talk about how it's a great cessation tool. Right. And it just, it's very frustrating. Unfortunately, no one knows really what's gonna happen yet. And I think these students that, you know, as John said, they're risk takers and they're learning, their brains aren't fully developed and they know that risk is okay. And so they don't fully believe in the truth of what might happen to them yet. And you know, for years, we had smoking prevention that really worked, but it took a really long time. And so now we're starting from square one again and it's gonna take a long time for this to catch up. Do you have any hope? I mean, in the sense that I have a daughter in high school in the beginning of this year, I came to a meeting and I basically just said, oh my God, there's a public health crisis that nobody's talking about because my own child was, you know, sharing with me what was happening in her school and the parking lots and the bathrooms and the classrooms under the desks everywhere and anywhere. Has the year has progressed? And again, this is just anecdotal. So that's why I'm asking you, you know, but she seems to suggest that the information barrage that the schools have responded with, maybe starting to take effect at the students at the beginning of the year had no idea, naive, didn't think it was harmful at all. Starting to, the message might be starting to sink in among some groups. I don't know if I can. I think there's two messages, right? There's the message of the information to students and families and we're more aware and here's how we can help you, right? You know, so when we work with a student, it's often a common then talking to that student. Are you understanding this? How can we help you? The second message is we as schools and administration or teachers, we're more aware now. You know, for a while it was like, why are there six students in one stall? I don't know what you're talking about. Now we're like, oh, I get it. Hand them over. Right. So I think going into the next school year, we're definitely more aware. We're training our teachers and our staff. They're more aware. Students who will be with us again are more aware. So hopefully that will keep minimizing. But also we want students to hear the message that they can come to us. One of the ideas that Khan and I have for next year is a amnesty day. So just turn it in, no questions asked. Sorry, Scott, we won't call you. But hopefully the thought is if we can get them out of the students' hands and out of the building, so to speak, maybe that will even help. To the extent that they are, some of them are rejected now. Can I just respond a little bit to the first piece about as the year progressed, are we seeing a change in students, right? And so what's been interesting is a lot. So I've been in the school's here for 20 years. And what's interesting is the students have been saying at the beginning of the year that they're not in it. And so what I've noticed specifically is students reporting health concerns, breathing issues as the year has gone on. And as we really discuss symptoms of addiction, especially related to nicotine addiction, you see a lot of like, I got that. And now that I'll bust open the DSM and be like, hey, I'm not here to diagnose you right now. But why don't we just go through some criteria about what a diagnosable addiction might look like. And that's helping them sort of see, oh, this thing that I wanted to feel in control of, that I thought I was in control of, maybe actually I'm losing control of. And so it's really sad when we're doing with like a seventh grader or an eighth grader. I mean, it's sad on any level. But we are seeing students sort of say, oh, I have to stop this, right? I don't think we're close to, on the down slope yet, right? But we are starting to see over the course of a year plus of like, we weren't ready for this.  And so the notion that safer doesn't equal safe, right? Is what we're really pushing. I guess that's a follow up to my, I mean, my question is a great follow up to that is, in the sense that an adult comes in with a nicotine addiction, you put a nicotine patch on or there are some types of remedies to help them alleviate that addiction. What does one do with a seventh grader, eighth grader who is showing the signs of addiction wants to have help, doesn't want to tell their parents. Right. Can't put a nicotine patch on. I mean, I'm just trying to figure out what are the solutions at that level with parents and... Right, and there's obstacles around confidentiality, right? Right, there's all these things that are in place for a reason, right? Because we're not sure how every family is going to react if we sort of said it's in your best interest to have your dad yell at you tonight, right? And so we have these obstacles. You know, ultimately it's great when you can get somebody who's addicted to anything, right? To sort of be ready to defold the struggle they're having, right? And so a lot of the focus becomes around that is, hey, you know, you're here talking to me, be the court organist, Mr. Gingold, who does a great meeting here, or Ms. Larry, right? Or Scott, you're talking to us because you trust this relationship and you're finding it beneficial. So we're starting there with this notion of, okay, after us, who else can we bring in to support this process, right? And so always trying to include family. But now and then as human beings and public institutions, we're aware that not every family might be the best support group, may even in fact be the provider with a good intention, but with really a lack of information, right? So we have to look at each case individually, but always try to bring in family.  And I'm gonna sit with the child and the doctor and the parents gonna wait in the waiting room because we're gonna talk to the doctor together. Right, and so we try to be creative and do anything we can. Thanks for your hard work on this, it's tough. Thank you. Thanks everybody. Thank you. I was just at a talk on prevention day and they said that part of the problem is kids are getting hooked by vaping, but then they're increasing the cost of them and they can't afford the upkeep cost. So they're just going back to cigarettes. So it's kind of reversing all the work we've done. We're gonna keep going at this. So we're not gonna give up on our bullying program. We are gonna continue work with the school system to create a vaping program that Gifford can bring into the school systems. That way it's more easily accessible for them. We can keep that moving forward and keep the expertise right here in our own house because we have it. We just need to create it. Because again, we're reacting just like they are to these epidemics that we're seeing. We're also working with the Vermont Department of Health to bring education series into the technical, our TCC program for parents and community members as well. One last thing I wanna talk about that we did, we were lucky enough to receive a Cures grant last year from the state. So we were able to fund a six week series on we called it a dose of reality. Our first series talked about how to effectively talk to your children about alcohol and substance use and signs and symptoms to watch for. The next one was the science of drugs. What happens to your body during addiction as well as how Narcan works when we're using that. It was completely fascinating. Our very own Jane McConnell from the pharmacy presented that evening as well as Dr. Chris Lacones. The next one was the impact on the community and prevention efforts. Then we had the path to recovery. We brought in someone to speak who was in recovery program. How can you help and how can you get involved as a community member? That series was a bit of a struggle like we talked about this morning, getting folks in the room that needed to hear all of that. There was a woman who attended several of the sessions that at the end of the path to recovery, one came up to Dr. Lacones and said to him, thank you. And he kind of, okay, you're welcome. And she said her daughter had overdosed a year ago, left some kids behind and she was crying when she told this story. And she said, thank you because for a year I blamed myself for her death and her addiction. And now I know that was not my fault. This was her choice. So I came back and I said to Ashley, I don't care if anybody else comes. I feel like we've made a difference and that's all that matters. So that's my just really great feel good story about that. That series wouldn't have been possible without Dr. Chris Lacones and the help of Matt Whalen from the Vermont Department of Health. So I'm gonna invite Matt up just for a moment to speak about our partnerships. Sure. Thanks Bethany. I love hearing about Gifford Hospital doing the vaping outreach for the community. Generation Z had the first opportunity to be the first nicotine free generation and then they turned it into a thumb drive and made it taste like cotton candy. And we were ready for that and no one really wasn't. The Department of Health really can't be everywhere at once. In my role I'm a substance abuse prevention consultant. Part of my mandate is to provide technical assistance to the grants that we have in the community and to build community capacity for prevention. And so it's really tough sometimes to translate what we're seeing at the epidemiological level down to strategy in the community and we rely on partners like the community outreach team at Gifford to get us to that point and to help us have that anchor in the community and to help us translate what we're seeing into strategy and to help us have relationships in the community. Because we can't be the energy everywhere but we can provide that technical support. We can help them with the data piece. We can let them know what we're seeing in the Youth Risk Behavior Survey or the Behavioral Risk Factor Surveillance Survey. And a good example of that is with the safe disposal efforts. We knew looking at our data that the number one place that people were accessing and misusing prescription medications for the first time was in the medicine cabinet of their home, friends, families, neighbors. And so we had a huge push, a huge take my push to establish safe drop boxes for unused meds and we even now have prescription drug mail back on Gifford has been a local champion in that having, can I say overflowing? Is that a bad word to use? But a highly used kiosk here at the hospital. Oh, I mean you heard about the mail back envelopes being out the satellite offices even out the Chelsea Health Center. And so that's a great example of a community partner helping us help the community and really leveraging the resources that we have to provide a much needed resource in the community. I'll also just say that it's being a part of the six part opioid series that took place was great for me to be able to come and tell Randolph about its own data what's actually happening here on the ground to level the difference between the perceptions of use and what people have in their mind and to also highlight some other problems like alcohol that are being a little bit overshadowed in the time of opioids. And it's so great to see Dr. Chris Laconis and his team and Ashley and Bethany really serving as local advocates and anchors for prevention. And it's an invaluable partnership for me and my office. Thank you. Thank you, Matt. So as Matt alluded to, I applied for a grant to receive a take back kiosk for us to place here in the hospital and with the help of the Orange County Sheriff's Department I was able to convince everybody here that that was a good idea. There was a little bit of hesitancy in fear of folks coming to try to remove things from that kiosk, but they assured me that's not where they were gonna go. The state told me that I would probably empty the kiosk four times a year because there is a cost associated with that. It's $150 every time I package up one of those boxes and send it out. So I thought, oh, that's no problem. We'll cover that, not a big deal. I empty that box every two weeks. Wow. So much that sometimes we have to come at night because it's so full. Scott and I have our tricks of how we get it out now without it going over the floor, which is a really great problem to have. I sometimes have to close it because I have to throw my whole body into it to keep it locked up. So it's working.  And I think people just weren't comfortable with that. So that's been a huge success as well as our mail back envelopes in our clinics. Also wanna boast about our Narcan distribution site that we have at our Kingwood facility and a big piece of our work is to educate folks on why Narcan is a good thing. And I'm gonna let Dr. Lacoma speak to that. That is all for me. Does anyone have any questions? So it's my pleasure to introduce Dr. Christopher Luconus who's the head of our addiction medicine program here at Gifford. He's been with us for three years and he's brought a whole new level of awareness regarding addiction medicine to our organization as well as the state. So thank you Dr. Luconus. Thank you for having me. Right. Thank you for the opportunity to speak with you. So, there's been a lot of community interaction in all of these talks and you might be wondering a little bit about how the addiction medicine program might play into that. An addiction medicine program is something that's not common in a rural hospital but it really becomes part of the fabric of the community and the degree of interaction support we have with our patients. So some of the basic background for our program is that we have a team that works in our Burling Clinic in our Kingwood site. Kingwood site's right up the hill near the McDonald's, exit four. And our team is composed of myself, a licensed alcohol and drug counselor, two nurses and an administrative assistant. So some of the basic philosophy of our program is that every door is the right door for treatment. For addiction. And that is Matt reaching out to various satellite clinics and to primary care to make sure that they understand that we're always available to take patients in and care for them. The other part of the philosophy is that addiction is a treatable disease. That we have medication and we have counseling that can help people change the trajectory in their life. And what we base our program on is that teamwork as it increases success, not only with our nursing and counseling staff and myself, but also by actively reaching out to the primary care providers and our other community partners, which is another essential component. So what kind of services do we provide?  I think about medication. So medication comes first on the list, although it's not always the most important thing. But we provide medication for opioid use disorders, including buprenorphine, which comes in sublingual form, suboxone, or more recently, something we're offering is supplicate, which is a every 28 day injection of buprenorphine underneath the abdominal skin. So for patients who may not be able to safely handle medication, we also offer naltrexone treatment. Naltrexone is an opioid blocker and that can be taken orally, or again, that can also be given in an every 28 day injection. So people who don't want to be on something, like a control substance like buprenorphine could be on naltrexone. We also realized pretty quickly, although our program started a couple of years ago focusing on opioid use disorder, that alcohol use disorder was far more prevalent, probably causing much more subtle, but serious long-term damage in the community. So we also began offering a few different medications for alcohol use disorder, camp role, you don't have to worry about the name so much. Naltrexone can help people manage cravings in health drinking, as well as ant abuse, which is kind of a dinosaur of a medicine for people who really want to stop drinking completely because it makes you violently ill if you do drink on it. And then just importantly, we've been offering psychosocial interventions. So we have individual counseling. Patients can actually come see a counselor and not have to even see me. They can directly see the counselor and not have to be on a medication. Often patients do show up that way saying, well, I might have a problem with that. And then the counselor eventually convinces them that we might have medical care to offer as well. We are in the process of planning group counseling, which some people benefit from more. And we also have extensive case management. So we have the MAP nurses, I'm not sure if you're familiar with the MAP teams, but the medication assisted treatment nurses act really as case managers. They're not just getting blood pressure or doing PHQ-9 screening for depression. They're helping people who are homies. They're helping people who have food crises get things in order. Okay, so back here, I mean, the nice thing about the Gifford community is that we can also integrate our behavioral health services into our program. So it's extremely simple for us to call up when I have a patient, for instance, who's struggling with depression, not making it to their appointments or their opioid use disorder, and get them in to see our behavioral health department. We can quickly get people in for primary care. Most of the patients we see in our program actually transfer to Gifford for their primary care if they're not here already. And then things that are simple, but so extremely important, important like birth control. I can meet with the patient for the first time and that same day I can get them to our OBGA. I want an OBGA in office to get their double shot. So we have a few strategies here at Gifford that try to get people into treatment as quickly as possible. So our goal is to medicate, particularly opioid use disorders if it's appropriate for a person beyond medication within 72 hours. I think the theory in the past was you sort of screen people. You have them see a counselor. You try to gather all of this data and the patient drops out. They get bored. All of that stuff can be gathered later. So our new way of looking at it is that really the important thing is to get the patient into treatment and then you can figure out whether they're at the correct level of care or whether they may need referral for additional support. So part of that initiative that I worked with Central Vermont Medical Center on and we're trying to adapt now to Gifford is providing rapid access to medication-assisted treatment in the emergency department. So what that looks like is a person comes in saying, I'm in heroin withdrawal. Or they come in and they have an access from injecting heroin. Being able to actually screen them and if appointment is not available that day to see me or one of our community partners treating opioid use disorder to provide them with Suboxone to take home for a few days to get their appointment. We've also established our own walk-in hours in our addiction clinic and our community partners in Central Vermont have done that on the days that we don't have walk-in hours available so that we can see patients who might decide that this is the day that they won't treat them. And that really all ties into the whole concept of rapid assessment, not needing to get an entire history of your first meeting with someone. I think another unique aspect that shows the coordination within the Giffer community is that we provide consultation for primary care doctors who may be prescribing chronic opioid prescriptions. So something might happen, you know, like, well, Mrs. Smith lost her oxycodone prescription or somebody's not showing up for appointments like they should. Where we heard that there was a DCF report that there might be neglect and perhaps drug abuse going on in the home. The primary care doctor that Giffer can refer over to us and we can assess more carefully and either sort of sign off and say, you know, we don't really see a problem with this prescription. It looks like you're providing good, safe care or we need to give the patients recommendations for opioid use disorder treatment. So I think you already heard, we have the free Narcan overdose reversal kits. Not only is that provision of a service to the community, we're getting people to come into our office to get a kit. So it might be, well, I'm here to get a kit for my friend. Like, well, you don't have to go into any details. You can fill out the paperwork. Maybe you want to bring them up a brochure or about what our program is about. And we've got a fair number of people. So the other initiatives that we're currently working on is we've had over time a number of our primary care providers who may not have been as interested in opioid use disorder treatment decide that they may want to start doing that themselves in our satellite clinics. So I believe in our baffle clinic, our MAP team is gonna be helping a provider there start to treat a select group of individuals who would definitely benefit from being seen at one of our satellite clinics. And then finally looking at some of our other initiatives, I've worked in central Vermont in various settings for a while now. So I've had the opportunity to work with, initially with Wixar, I know it's not a good acronym. The Washington County Substance Abuse and I'm a used abuse back then response program. And that was started up at CBMC by Mark Deppman, initially, and the emergency department to really think about how do we all coordinate in central Vermont. And at that point I was working with Mark and Berlin. But I kept up my work with that organization since Wixar, since I do practice a bit in Berlin as well. And we share a lot of patience with Band-Op even though it's a difference in County lines. That initiative led to the CBMC RAM initiative that I talked about, the rapid treatment in the emergency department and what we're trying to adopt here. And I wanna point out too that we also, Clara Martin also provides psychiatric services in the area. They also have a small MAT program and sometimes their community is better suited to care for people who have more severe mental health problems since they're a community health center. So we're able to refer people back and forth to each other and we actually meet with them. I think it's every other month at this point. We all get together the MAT teams, Dr. Buchanan and our MAT teams to talk about how we can better serve the folks in our area. So I think it's time to answer questions. Questions. Can I ask a question? Sure. Are you seeing any decreases in addiction, opioid crisis? Are you seeing any differences at all? Just seems like there's been so much more awareness to this. And maybe, like you said, we're really aware for other addictions like alcohol abuse, but are you seeing any changes? My sense is that we're starting to see an improvement in at least people accessing treatment. I think that some of the initial data showing that there's been a decrease in overdoses is related to people accessing treatment. We're really big in our program on saying, hey, you're doing great in your treatment now, but people are still pestering you to buy drugs or sell you drugs and just tell them to call us and they can come see us and we'll let them know whether we can be helpful to them or not. No obligation. Yeah, I mean, really word of mouth is probably the best way. I mean, the title kinds of media strategies and things like that and they don't tend to be too fruitful. I was intrigued by, I hadn't heard about the injectable buprenorphine. And so I'm just curious about whether or not, if it's every 30 days, is that increasing the success of maintenance of folks that are on it versus taking pills? And also what is the impact that people worry about the black market, right, for buprenorphine pills? So I'm wondering if it's injectable. And so I'm just kind of curious about the success of that as a delivery method. Yeah, I mean, there are some pluses and minuses. I mean, the first minus that gets focused on a lot is it's quite expensive, of course, because it's a new patented novel formulation of buprenorphine. The other surprising minus, maybe I should be starting with this positive screen. The other surprising minus, it may be harder to get people to engage in treatment. I mean, I don't like to use a prescription as a carrot, but in all reality, that's what it is. If I want to see you again in one week, I write the prescription for a week and you have to come back. If I give you an injection and it's 28 days, if you don't show up for 28 days, probably by day 28, I'm gonna be like, oh, but you really should still be honest and we'll just give you an injection and tell them to please come back next week. Yeah, if there are concerns of diversion, it's great. So if you think that somebody may be injecting their buprenorphine prescription, you probably don't want to give them a prescription so they can run and do that. If you think they might be selling it for other drugs or that perhaps family members may be stealing it from them, this is some way to make sure that only they get it. Other questions? Thank you. So Dan, I know that you said there were a number of your board members in the room. Would you have them stand and just introduce themselves because we want to thank them. Yeah, I'm just gonna turn so I can see them. So me right here, Matt Ponsonite is our board vice chair. Peter Nallin, one of our board members. Lincoln Clark is our board chair. Peter Reed over here, a board member as well. And I'll play Westbrook's in the back, you can play, you can see him in. One of our board members. Paul Kendall is a former board member as well that acted with Gifford on behalf of Gifford in healthcare reform activities as well. So it's a volunteer board, very engaged and very instrumental in all of this and supportive in these efforts that were engaged in. And I'm just hearing today, sitting in the crowd, again, chance to sit in the crowd and hear of all the good work and great job by everybody who presented. And thank you to all the partners who are here today. It's really a tremendous effort. But if you were to go to a hospital 10, 15 years ago and said, okay, tell us what you're really focused on. We're still focused on inpatient care. We're still focused on surgical care. We're still focused on providing all of those needs in the community. But to see that change and that turn, to now be looking at prevention, to be looking at those efforts where we're reaching out to partners to say, all right, what are the problems we're seeing in the community and how together are we going to attack them? That feels really good. And I think it really shows that we're focused on the correct things. I applaud you for being partners in that. Sometimes you have to nudge a little bit. And I feel like we're being nudged in the right direction. But I also hope that you see the leadership that there is in this community, whether it's people who are getting a paycheck from Gifford, people who are partnering with volunteers, people in the community. So a lot of great efforts going into this. And again, I wanna thank you for taking the time to hear about this because we think it's incredibly important. I know you think it's important. And hopefully now you have more information on what's going on on the ground here and what you want more focused on. So thank you again. Well, thank you. And I just wanted to say to the board members that it's great whenever I have my monthly conversation with Danny, he always talks about, he has a great board that's actively focused on what's happening and that's such an important role that you're playing for your community. And I know on behalf of all the board, we wanna thank all of you for what you're doing. And it's a very serious role that you have for your community. And the enthusiasm that we see this afternoon in this room, I just say some of the smiles are so infectious. And how could you say no to not wanting to do the prevention and wellness? And one of the things that we did a couple months ago, Robin Lunge put together a panel on the health of rural hospitals and 102 hospitals across the country have closed in the last 10 years. And we don't wanna see any hospitals from Vermont in that category. And seeing the commitment here this afternoon, I know that this hospital is gonna be around and thriving for a while. And just thank you for all that you're doing. Thank you. Thank you. Anything else, Susan? I don't know if there's any old business or new business. Is there any old business to come before the board? Is there any new business to come before the board? Is there a motion to adjourn? We should probably do public comment. Oh, yes. I was kind of assuming that people would raise their hand and ask for questions from public comment. But is there any public comment? Well, easy enough. So is there a motion to adjourn? So moved. So moved and seconded to adjourn. All those in favor signify by saying aye. Aye. Thank you, everyone.


Matt Damon is attempting to improvise an analog local atmospheric pressure sensor on the side of a Martian rover but needs to figure out how big it needs to be. Luckily for him, he knows that the gravity and average atmospheric pressure on Mars are 3.7101 meters per second squared and 610.5 pascals respectively. Calculate the height of the mercury column in a barometer on the Martian surface in millimeters. Remember from thermal 1 that we had come up with an equation, the PAH equation, to relate the pressure change across the height of a column of fluid to that fluid's density, the acceleration it's experiencing, and the height difference between the two points that you're relating with the pressure difference. In this case, the barometer is relating pressure difference between the top of the barometer, which is assumed to have a pressure of about 0 pascals, and atmospheric pressure, and the height difference between these two points is how we determine what that atmospheric pressure is. So we are saying P bottom of the barometer minus P top is equal to the density of this barometer's fluid, which is going to be a mercury column. So we're saying the density of mercury times the acceleration experienced, which is going to be the gravitational acceleration on Mars multiplied by the height of this column, which is what we're actually solving for. P top we know that's 0. P bottom is atmospheric pressure, gravity of Mars we know, and the density of mercury we can look up. For these sorts of lookups, we're going to be using the back of our textbook. The appendices contain, among other things, tables that have physical properties of a variety of fluids. The table that is going to be relevant to us here is table A3. This is going to be properties of common liquids at one atmosphere and 20 degrees Celsius. Now, of course, the mercury on the Martian surface isn't actually at one atmosphere and 20 degrees Celsius, but this is the best property that we have available to us. We don't have mercury tables for Martian atmosphere conditions. So we're going to be assuming that this property is close enough to the density of mercury for the purposes of improvising an atmospheric barometer, and we are using this 13,550 kg per cubic meter density. So from table A3, the density of mercury is about 13,550 kg per cubic meter. At this point, everything in our equation is known except for h. So we can solve for h, that would be P bottom minus P top, which is just P bottom, divided by the density of mercury times gravity. P bottom is the atmospheric pressure, which is 610.5 Pascals. The density we just looked up, 13,550 kg per cubic meter. And the gravitational acceleration on Mars, which is 3.711. We want an answer presumably in millimeters, because the problem asked for that. So I'm going to write 1000 millimeters in one meter. And I'm going to need a little bit more room. I'll scoot this over. And then to get the units inside of the Pascale to cancel, I will break that apart into its component pieces. A Pascale is a Newton per square meter. Newton is a kilogram meter per second squared. So Pascale cancels Pascale. Newton cancels Newton. Meters, meters, meters squared cancels cubic meters and meters, second squared cancels second squared. And kilograms cancels kilograms. That leaves me with just millimeters in the numerator. So by pull up my calculator here, we should be able to coerce it into doing stuff for us. 610.5 multiplied by 1000 divided by 13,550 times 3.711. That's 12.141. So the mercury column required to indicate Martian atmospheric pressure would be rather small. Note that for atmospheric pressure on Earth, it's about 760 millimeters tall. We could come up with that number by using the atmospheric pressure on Earth, about one atmosphere, or 101,325 Pascals instead of 610.5 and a gravitational acceleration of 9.81 instead of 3.711.