Senate Standing Committee on Health and Human Services

Good morning, everyone. Welcome to this morning's informational briefing. It is Friday, March 6, 10am in room 329 in our beautiful state Capitol. As you all of you know, this is a joint informational briefing. On behalf of the House Committee on Health, I'm Greg Takeama.

And on behalf of my Senate colleague, Senator Joy San Buenaventura, who is Chair of the Senate Health and Human Services Committee, I'd like to welcome all of you and thank you for being here. First of all, I'd like to open with a bit of sad news.

We just learned this morning that our former colleague in the Legislature and former Congresswoman Colleen Hanabusa has passed away. So this is certainly sudden and unexpected and sad for all of us. I'd like us to observe a moment of silence if you. Anyway, thank you very much. Sure. She will be very much missed by.

All right, I'm going to keep my introduction brief. This, as all of you know, is a informational briefing on the Rural Health Transformation Grant. One of the few actually beautiful things about the big, beautiful bill is that it provided funds nationally for this program.

And here in Hawaii, we submitted an application which was apparently well received because we received almost $200 million for each of the next five years. Billion dollars. And that stacks up well, if not the best of any state of our comparable size. So congratulations to the Governor's office and all of you for your work on the application.

What we applied for and what we got, we're about to hear from all of you. So let me turn it over now to Lauren Kim.

Good morning. Chair Takayama, Chair of Sandboat, Concerned Members of House and Senate Committees. My name is Lauren Kim. I am the chief of the Office of Planning, Policy and Program Development, Legislative Coordinator, and as always, a proud resident of House District 34. I'm here representing the office of the Governor.

The reason for that is the artifacts of Project Administration for rhtp, or the Rural Health Department Transformation Program, are being run through the Department of Health. So the Governor has not stood up his dedicated RGP team.

And my proximity to the the documents, such as the special project and the position descriptions, affords me a little more insight than some of my other colleagues into the way the Governor's office is setting this up.

I'd also like to ask Mr. Ian Withy-Berry to introduce himself.

Hello, I'm Ian Withy-Berry, a policy assistant in the office of the Governor, helping out supporting Warren and here to answer any questions.

And so Ian will chime in as when he thinks appropriate, so very quick background RGP program was announced in June 2025. The state of Hawaii received $188,892,439.75. I am required by federal law to give you the specific and exact amount.

In short, our goal is to expand all of that in budget period one, including the $0.75 that I have here. So some lucky program is, you know, going to be able to buy chopsticks on. So it longs with, with that money. So we're looking forward to that. Thank you chair for mentioning that.

You know, we do have America's only sitting position, Governor. And Governor Green was the architect of the state's response. Being a physician living and practicing in a rural area was a clear advantage for the state of Hawaii.

Our physician Governor architect identified eight initial initiatives and farmed them out to agency leads who whittled that down and combined them into six proposals, including an oversight team for the office of the Governor.

At that point, when all proposals were collected and vetted, Governor Green sort of became the quarterback for the RHDP making the final decision on what would be sent to CMS. And on December 29th, our award of 188 million 75 cents was awarded.

For perspective, as Chair Takayama mentioned, the state of Illinois with a population of 12 million just got about 5 million into more dollars than we did. So in our state of 1.4 million, this is going to go a very, very long way. So what's the takeaway?

Well, you know, having being a physician Governor during periods of healthcare transformation is good work if you can find it. So recommendation, if you ever need to think about that in the future, I would like to before we get into some of the detailed implementations, before I turn it over to the initiative feeds.

We are celebrating this large amount of money, this windfall to this state of Hawaii. But we also need to remember at what cost that this windfall fell in our laps. And that's because the one big beautiful bill really eviscerated the long term funding for Medicaid expansion.

And going back a little bit more on the way back machine circa 2013 with the patient Protection and Affordable Care act, also known as Obamacare, funded Medicaid expansion to the tune of 9010. So, so states produce 10 cents.

Feds kick in up to 9090 cents to expand Medicaid rolls for economically disadvantaged and rural residents across the United States. And it was a game changer for many people who, you know, could go to the doctor for the first time, get a cavity filled Get a prescription filled without a $75 copay.

So we do celebrate this windfall, but we still need to think through as a public policy priority what happens after five years. And so the emphasis for RHTP and the Office of the Governor will be on transformation. Right. Just a little more background before I turn it over to my colleagues. This is a cooperative agreement, not a.

That is a type of federal program where the funding agency has substantial involvement. There are other kinds of grants where it's. And I'm being glib here is, here's the money gave us some good ideas. Tell us what happens at the end of it. No, CMS is heavily involved with this.

And part of the reason we don't have slides is because CMS is still debating and thinking through their communication protocols. So we are playing it conservatively. We do not want to get ahead of any CMS announcements while they're standing up their administrative infrastructure.

You know, we want to be the model state, do everything right, do everything well, and get the full, fullest amount of funds that we can get. In the up years, we have met the project officers. The lead project officer is a lieutenant commander with the Uniform Public Health Services.

And the backup is a long is a career civil servant with US DHHS budget period one's priority projects for funding were solicited from a variety of sources, including the governor's RHTP website, agency priorities that were in line with the governor's priorities, and reaching out to trusted community partners.

Although our overall application was approved, CMS needs to approve every line item going forward. How much of it is a formality versus actual scrutiny remains to be seen. It's probably somewhere in the middle. This is a significant amount of funds, after all, so we understand the the need for fiscal stewardship.

There will be a significant amount of reporting, not just on the money, but details on contracts and outcomes. And again, that's to be expected. We anticipate good news on our line item approvals, but we still do not have anything in writing.

So again, we are here to share what has already been publicly shared since that already received CMS approval. That being said, we anticipate a green light for whatever they approve, but prior to that, all state agencies involved in this are poised to execute or near poised to execute contract modifications, requests for information, requests for proposals.

So when we get the green light and the state accounting and financing systems are set up, we'll hit the ground running. We will not spend four to six weeks writing RFIs. They're already being prepared. And so we're just waiting to pull the trigger. And I've just got two large points before my time is up.

One, emphasis on the implementation strategy being deliberated by the governor's team. It's about transformation.

You're going to hear a few initiatives, specific initiatives, especially with Dr. Jack Lewin that will have transformational benefits after five years that have to do with electronic medical records and value based payment as well as leveraging the AHEAD grant which is more about global hospital budgeting. So you know, transformation is the sustainability plan.

And so our community needs to think through what transformation means. It could mean an emphasis on community based health, improving knowledge, attitudes and behaviors, helping communities be healthier through needs assessments, giving them some tools that they can sort of take more control over their, their communities, health destinies.

And really we all are interested in decompressing the acute care system and assuring as much care happens in outpatient before it escalates and in communities where people live 99% of their lives. So although there are specific proposals, we had about five weeks to turn around a complete application and turn it in.

So as I've mentioned, state agencies looked internally to invest in our own high quality evidence based work. So we funded ourselves, we reached out to partners who are reliable, who do good work. A lot of those funds scale existing programs. Programs are not necessarily transformative and that's not a criticism. This is what all 49 other jurisdictions did.

Who's reliable, who does good work, who's trusted in the community, do more of that good work. So what's critical when I talk about transformation is adjusting future budget years to maybe support less scaling and more true innovation and transformation. Again, the 10 or 15 years of Medicaid expansion money is unlikely to be there.

So where are we going to be and what is the legacy of the World Health Transformation project going to really mean for our communities? And one last component is evaluation. So compliance with CMS is absolutely critical. But this project is a healthcare continuous quality improvement intervention.

And so we need a hypothesis, a baseline and a rigorous evaluation process measures, outcome measures. You know, some of you may recall the Beacon Committed grant which is a first attempt to tie high tech health information technology not with process measures but with outcomes like A1C is under control.

Community probably quite wasn't ready for that much of a change. But we are in a much better position as some of the other speakers are going to tell you about. And so in summary, you know, $188 million $0.75. We're going to spend every penny of that, including those three quarters.

And we really need to think hard about what transformation means. I think we all this, this Committee in particular has come to the conclusion, like those of us who do this for a living, that we have a sick care system and this is a real opportunity to think through what a health care system looks like.

So, Ian, any comments? I don't believe so. Okay, so with that I'll turn it over to the first speaker, which I believe is Dr. Leeboy Kansei Holom to talk about the Home Run program.

Okay, Members, I'm going to ask the presenters to go through all their presentations to make sure we can have time to hear all of them because we have a stoppage time of 11am so please proceed.

Good morning, Chairs, Vice Chairs, Committee Members, I'm Lee Buenconsejo-Lum, I'm the Associate Dean for Academic Affairs at Jabsom and I'm joined by our Associate Director for our area Health Education Center, Erica Davis and also Claudine Chan-Naruse, who is our project associate. So homerun is our overall workforce development initiatives.

There's actually many sub initiatives and as Lauren mentioned, some expand what we do. Some in fact are new and all with the goal of community at the core and really helping make sure that the community is able to identify some of their priorities. And so I'm going to turn it over to Erica.

Aloha and good morning. So again, the Home Run is Pipeline to Practice. So I'm going to talk about some of the pipeline initiatives. With these grant funds, at least one healthcare certificate training program is going to be implemented and available in all rural schools with a connection to a local industry partner.

We will also be supporting HOSA Future Health Professionals, formerly known as the Health Occupation Students of America for all their travel. So all the students rural travel and then we're also going to be providing an academic tutor on each island for group and individual sessions.

This will be to support that health certificate training program and anything else the students need. These tutors will be on each island so they will have a contact there. Now I'm going to turn it over to Claudine. That's going to talk about the healthcare future and the current learners that we're going to have.

Good morning everyone. So for the future and current learners in Healthcare, homerun plans to offer education awards to cover tuition for everyone who commits to working in rural areas for five years. This includes tuition for both online and and in person training for all direct health care and IT personnel.

Further support will also include travel for training in rural Hawaii for All local students and residents in medicine, nursing, physician assistant programs, speech, language pathology, social work and other health professions training programs. To continue talking about this, we have data. Deepak.

Hi everyone. So as Claudia mentioned and I have come to you many times before, we know that it's really important for our learners to train on the islands and in rural areas. And so what was mentioned earlier is for the pre health. Right.

And the travel funds are going to help with the folks who are actually in health professions programs and schools. But what's very exciting is this gives us the opportunity to really plan and hopefully get some more rural training tracks. You heard me speak before about graduate medical education and residency programs.

And you know, Jepsom aims to increase the class size. If we don't have residency slots, then that's hard. Right. So this money is going to be very, very useful. And we are already planning for nurse residency training programs.

So again, that's kind of a transition from nursing school to practice in the neighbor islands, but also working hard with many of our neighbor island hospitals already looking at potential rural tracks or programs in primary care, internal medicine and maybe pediatrics, obstetrics surgery, psychiatry and family medicine.

So the other thing that is important with this workforce development is actually our current healthcare workers. We know that there's a lot of capacity building to be done.

Your committees here have spoken many times about how we want to change the healthcare delivery system so that more people can receive the care at home that's appropriate for them to receive at home and then really only need to transfer if they really have to. Right. So that's kind of that long term goal.

And so one of the initiatives here is actually dealing with newborn care. You know, sometimes we have a lot of high risk pregnancies in the state. Sometimes babies are delivered early, early.

And it's really important that all of the pediatric providers or the family medicine docs who deliver babies that they are able to care for those earlier sicker newborns and keep them well and stable and then determine if they need to be transferred. So that's an exciting program.

It also includes monitoring after if discharge from the neonatal intensive care unit and other things. And for the most exciting part, I'll turn it back to Claudia.

So another component of home run for current active and healthcare workers is provider incentive payments of up to $200,000. These will be one time payouts to healthcare workers who will commit to work in rural Hawaii.

In rural areas of Hawaii for five years, there will be support for health workforce conferences, community meetings and mini grants for health improvement activities statewide. There will be coordinated health care provider focused well being initiatives as well as the creation of a wellness calendar and activities to support retention. My comics have anything else to add?

Thank you very much. I'll be here at the end for questions.

Now we can bring on Dr. Jack Boone if you'd be willing to talk about two initiatives, the Rural Health Information Network and the Rural Value Based Innovation and Ahead Readiness Fund. Thank you. Ian.

Aloha chairs, vice chairs and Members. Jack Lewin here, administrator of SHPDA. We are honored and excited to be overseeing the implementation of two of the hubs. One is the Rural Health Information Networks and the other is the Rural Value Based Initiative. Let me start with the Rural Health Information Network.

This is about, this is over $45 million a year to work in several categories to improve healthcare services in General across the state. I might point out, it's important to note that this is a partnership with MedCare MedQuest division on, on these activities and with DoH and with others to, to succeed.

First, we're going to put electronic health health records out to those that don't have them and we'll be able to upgrade health electronic health records for those who have them that really aren't fully functional.

That's a big chunk of the resources and a big opportunity for us to be a state that has a total interoperability connection across all of our rural areas and our urban areas together.

That's a big challenge, but it's one that we think we can manage and we can get the money out pretty quickly and directly in very useful ways.

But in addition to getting the electronic health records out, we need to create interfaces with those records and the other end users and we need to train the people and the institutions in that the offices, hospitals and other facilities to be able to use these effectively. So that's all part of this program.

We're going to build another hub statewide which will coordinate quality of care and it will involve sort of turbocharging our health information exchange to be able to do that effectively. And that's, that's an exciting project for us as well.

Working with Medbus Division, we're going to have a dunder hub that works on bringing social determinants, health related social needs together with our clients and patients in a much more efficient, effective way.

We have a specific proposal for our dual eligible Medicare Medicaid beneficiaries who are, you know, in essence the folks who need health resources and spend health resources in the most significant way. We're going to coordinate those services better. We can do a whole, whole lot better with that whole population of people with their special health needs.

And we have another, another project that is going to try to bring together with data analytics the two major sources of data that we're using to understand how we're doing in healthcare. One of those is the All Payer claims database which is going to become functional as of this year in stages.

It doesn't include yet the data for Medicare Advantage patients and it will be lacking 250,000 commercial lives, but we'll bring those in over the next few years to the all period claims database that is not being funded by Rural Health, but it's a tool we'll use to connect to the clinical data and the health information exchange to kind of make more comprehensive observations about health and health care improvement.

So that's kind of a general summary of the Rural Health Information Network projects.

The Rural Value Based Initiative is important to note because it's an expression from CMS directly that the AHEAD grant model is something they value because this particular bucket is going to prepare hospitals, health centers and community providers to prepare for alternative payment models and, and the challenges of the ahead model.

And that is going to be $25 million a year. And we'll be putting direct services in facilities and across that spectrum to help them prepare, but also to really take advantage of funding opportunities we're not taking advantage of now. Medicare, for example, offers, you know, the NSSP programs where people can actually get paid for value based improvements.

Today we're not really availing ourselves of that opportunity very greatly across the state. So some of these things are going to really enhance the income stream of providers over time. So those are real. In essence, those are the two things we can get into detail if you have questions.

But it's, it's shipped Med Quest and DOH together on these projects. Certainly the Value based, well, preparation for AHEAD is really a true partnership between MedQuest and SHPDA. Thank you.

Now if Dr. Christina Higa would be able to talk about our telehealth initiative.

Good morning Chairs and Vice Chairs and Committee Members. Aloha. I'm Christina Higa. I direct the Pacific Basin Telehealth Resource Center at the University of Hawaii. It's one of 14 federally funded resource centers in the country and our center serves the state of Hawaii as well as the US affiliated Pacific Islands.

Our center has been working on trying to advance telehealth for the last 16 years and have seen a lot of changes, especially as you all know in the pandemic. We have had so much more adoption of telehealth from patients as well as providers.

And so I think this initiative, the Telehealth initiative of this rural healthcare transformation program comes at a really great time. Pili Ola is the name of our initiative, and we're going to keep the momentum going with advancements of telehealth.

So the telehealth initiative's goal is really to expand and strengthen telehealth initiatives in the state of Florida and in particular for the rural areas. As Lauren had mentioned in the beginning, you know, some of the programs did look for projects that could scale up existing programs, and ours is one of them. We're one of the smaller initiatives.

If you look at the budget, less than half of the most of them. But we really saw the past experience of some of these programs taking years to get to the point where they are now.

So this Fund is really going to help to expand them so to rural areas especially so they can get the care services they need. But a big part of our focus is really to match the rural healthcare needs with their telehealth and their healthcare needs.

And we want to stay aligned with the rural reality, you know, to understand what works and what doesn't work. Because in telehealth, we have seen many things in the past that did not work and so. And many things that have.

So a big part of our work will be coordination, understanding and listening to rural communities and their needs. And so we're building a stakeholder engagement framework. So there'll be a coordinating council and working groups that take agendas from the council and staff to move the agenda.

Policy, technology, training, clinical applications, for example, as I mentioned, many of the programs that were proposed have a track record and those will be scaled up. Another big component of the telehealth initiative is the workforce and training, especially in the area of supporting your community Members in getting access to telehealth and helping the patients.

So we will provide that so they have the best experience. So if I could just move quickly to highlight some of the programs. There are many different types. These fall under expanding access to care for where the patients are. So we have a telehealth access point and navigator project. Again, this was.

We had a very successful project in partnership with the Department of Health in libraries and telehealth. That was a CMS project that unfortunately was defunded and we had to close it down and let go of all the navigators. But it was very successful. So this funding will enable us to re establish it.

But we made some changes through lessons learned and we would use libraries, which is great. But when we did the project, we also found community centers, churches, homeless shelters, many other places in the communities that wanted to have these services actually brought people to our navigators. So we'll expand on that.

We have another one that's telehealth in the workplace. Working with employers to make sure they understand the benefits of telehealth for their employees. This started with an idea with the Hawaii island and the hotels on the west side where people take three hours to find us in to work.

And we had a health fair and we found so many people at high blood pressure that was unknown or untreated. So the idea was to work with employers to get up and get a space. These people have no time in their day and they can, you know, find telehealth and help them with, with employment wellness programs.

And of course we added state employees, government employees, biggest employer. There'll be kiosks in the communities, virtual chronic disease monitoring from home school based clinic telehealth services. Expanding to Molokai and Hawaii island to charter schools where they're currently not located and then moving on to the safety net services maternal telehealth program.

Expanding that, that program took a long time to get where it's at and now it's the stage two scale telehealth, mental health, behavioral mental health, infectious disease and econsulting where primary care providers will be able to get specialty consultation.

So in closing, I just wanted to say again, in comparison to the other initiatives, you know, our funding is, you know, less than half. But if you listen to the other initiatives, many of them have telehealth as components to it.

And so we will work across the initiatives and coordinate and help to have them plugged into our stakeholder engagement frameworks in the same way as us plugging into theirs. Because I think they're all connected. All initiatives are really connected to really truly transform healthcare.

And I think telehealth has a major so that will be our commitment to this program. Thank you. Thanks Christina.

Director Fink, if you would be able to talk about DoH's rural infrastructure for Care Access initiative.

Aloha. I'm Kenny Fink with the Department of Health. The initiative that was named the Rural Infrastructure for Care Access or RICA is the initiative for which Department of Health will have the lead.

As you've heard from these other initiatives, there really is a focus to increase access to care in rural areas where rural residents reside and we incorporate that too. One of our priority areas in this initiative is should they need to go somewhere else for their care.

So in light of recent tragic events, some work with our federal partners and the national medical disaster system. One of our four priorities under this initiative is really strengthening the EMS and trauma system statewide with centralized patient transfer.

So in the event that a large number of patients needed transport from medical care, we really feel the need to use this opportunity to invest in that statewide capability and system development.

So one of the four key focus areas within this initiative is to build out a medical communication center which would integrate kind of the hospital capacity system. We would use a technology called Pulsera which allows for again more telehealth.

In addition with the infrastructure is to upgrade ambulances and provide Starlink capability so that particularly remote areas care can begin on scene with perhaps consultation with a tertiary cautionary center as needed. So there's equipment investment in Amwens's Starlink infrastructure support. Other priority areas for this include increasing the trauma capability on the neighbor islands.

So for a couple of hospitals we look to invest in simulation equipment for training and to provide more training opportunities to be able to provide enhanced trauma care on site on those islands and to support our Level 1 trauma center to begin with telehealth neurotrauma support of those neighbor islands.

So again, this is a key area to strengthen our EMS and trauma system statewide. As we build out our EMS system statewide on a county level basis, looking to build that out and leverage that through community paramedicine.

So there are some areas where we have EMS capability that is not fully utilized based on the volume of responses that they have. So how do we leverage the resources that we have to do home checks? There may be people who are calling 911 repeatedly for non emergency reasons.

So how do we care for people in the most appropriate setting and then expanding those EMS programs with other resources such as community health workers or nurses to support more outreach into the community to increase access to care and again check on folks.

In addition to kind of that aspect within this theme of community paramedicine is also to invest in mobile medical clinic.

So having a medical van that would go around to expand access to care again on those neighbor islands we'll be starting intend to start on the Big Island for the community paramedicine because they have the most well developed program.

And as we invest and build that out, we'll get more lessons learned for how to spread that into the other counties for the Medical Mobile Clinic. We're looking to pilot that on Kauai and stand that up there. And for the trauma simulation equipment we'll be investing in Maui and also in Hilo to get those started.

Another one of our key focus areas is how do we expand the reach of primary care. So this is separate from the community. Paramedicine is kind of the next level and wanting to leverage what primary care providers can do and how to support them. So keeping people healthy is really the ideal state.

So we will be using this funding to increase activities in promoting nutrition and physical activity and healthy behaviors and continue to do that sorts of work. You know, I just actually came this morning from an event recognizing the volunteers for senior Medicare Patrol, the state health insurance system program. And it's the value of volunteers.

So shout out to them and those volunteers. But there's a tremendous capacity of volunteers and really want to acknowledge, you know, the gratitude for people who are giving back to their community. So there's a project that will be pursued to how to leverage volunteers to help support their neighbors and community Members. So that's an important effort.

Uh, College of Pharmacy has a program where they train pharmacists and community health workers to help with medication management and disease management and they can work with primary care practices again to expend expand that reach. So that's another focus area with those community health workers.

If we can expand the work of public health nurses, so using the CHWs as kind of expanders or force multipliers of our public health nurses again to get out more into the community, reaching people and servicing them. And then there's also a part of oral health. So within that oral health there's kind of two components.

One is working with the federally qualified health centers to do minor remodeling and add dental chairs to increase the number of people that they can serve through those FQHCs. And another aspect is to partner to increase access to oral health screenings and dental sealants through school based programs.

And then the last of our kind of the themes is behavioral health. So that's another focus area for us. I will be investing in expanding crisis mobile outreach to include peer specialists. So people with lived experiences are a critical part of those teams. To support those initial responses and support stabilization.

We'll be investing in mobile behavioral health clinics. We know there's a need to increase access and we need to reach people where they're at. So these mobile behavioral clinics will help increase access to services.

And it was already mentioned through that telehealth and another kind of linkage across initiatives looking to create a hub to provide behavioral health consultation to primary care providers. This was kind of piloted, I think with pediatricians on Maui, supporting their care of children who had mental health needs.

So kind of learning from that and expanding that to provide more telemental health support, particularly supporting primary care providers to care for their patients in those communities. So those are the four key areas.

There's other aspects, there's some evaluation components and strengthening our ability to assess how we're doing and assess what those needs are as we inform what we'll do in future years. Because this first year, I don't know that's been raised yet.

This budget period one, it was only 10 months and all the future years will be kind of 12 months. But those 10 months kind of started in January. We're already in March and don't yet have final approval in cms. So it's going to be a very short window for this first budget period.

So we really focused on existing contracts or things we could do through memorandum of agreement recognizing we need to obligate these funds because next year's funding will be based on our ability to expend kind of this year's funds. And that will occur each year.

So that was one strong consideration, particularly for this first year, was how we could leverage kind of existing contracts and agreements that we already have. And like everyone else, we'll be available for questions.

And finally, Director Campos, if you'd be able to talk about the Rural Respite Network initiative.

And Ian, thanks for the promotion, but Deputy Director, we won't tell anyone.

Okay, good. Department of Human Services. So the initiative that the Department of Human Services is taking the lead on is the Rural Respite Network. It's going to be a network of five respite sites, two on Hawaii Island, one on Maui, one on Kauai, and then one in Waianae on Oahu.

It's basically going to be designed to provide short term residential care for individuals recovering from hospitalizations who lack stable housing or sufficient home supports. So this is designed to ensure that one, the success of Pula Ma Ola that we had what, two and a half, three years ago, you know, can continue.

I think that was a good model that showed it is successful in helping to reduce hospitalization costs as well as provide people the necessary places for them to recover in an appropriate manner. As Director Fink mentioned. Right. We are in budget period one, which is a shortened period of time.

So we're looking at two respite sites, one on Hawaii island and one on Kauai. And then the next fiscal year we will be looking at expanding the additional three west respite sites. And so basically that's a real quick version.

We're already at 1040, so I'll step aside and then you have to finish something and then we'll get questions. Thanks.

I just wanted to just an overview of kind of how the funding operates. So We've had our first year award of 188.9 something, something, something and we anticipate receiving so that's the dollars for the first budget period, all to be expended by the end of next September.

And then we anticipate receiving four additional awards, I believe each November and subsequent subsequent years. And the specific, you know, kind of size and amount of those awards is anticipated to be similar to our current one. But, but it'll depend on our compliance and our progress on our various initiatives.

So we'll be providing an annual progress report to cms. Each of these initiatives has at least four outcomes or targets that they are seeking to progress on. So we can demonstrate to CMS that, you know, not only are we putting these dollars to use, but we're getting outcomes and benefits from them.

And so, you know, we're working very closely with CMS on kind of finalizing those plans and we'll, you know, continue to work with them to make sure that we're delivering on these and that we get these federal dollars. Every single one of these dollars is coming from the Federal Government in subsequent years.

And we're also currently in the progress of standing up this oversight team which will ensure compliance and aid our initiative leads in executing their initiatives and also ensuring that all of these initiatives cooperate and work together because that will really get kind of the transformational potential of this program just as great as possible.

So that closes out our presentation. So now we can take questions for any of us here.

Great. Thank you, all of you for all of your presentations and thank you for your very timely presentations. Before we'll open up to questions, I'm sure we have tons of questions. Let me sneak in a real quick one. Define rural, especially as it applies to.

Yeah. So our, the definition of rule that our program uses is the one given to us by HRS for the purpose of federal programs. So that's HRS Section 1B1. And this it's the definition used for determining the area's rule status for the purposes of federal program that accepts state definitions.

So it includes all neighbor islands and includes large parts of Wahoo. I would have to. I could work on getting you kind of the map itself, but I believe it includes Waianae coast and then Wahooan, what's north of it and Ka'. Awa and what's north of it is the map is last time that I recalled.

But it is important to kind of Understand the kind of, the relevance and importance of what that definition means because it serves primarily two purposes. One is it provides a geographic constraint on these five year workforce commitments.

And so if you're going to receive an education award or provider incentive for committing to five years of rural service, CMS expects those years to be served in a rurally defined location.

The other, the other relevant component or function of this definition of rule is that it provides a reference points, a reference point for our metrics and targets.

So when we tell CMS that we're looking to get a certain number of a certain percentage of our rural provider sites to be interoperable, they will be looking at those sites within that, that definition that we gave them from, from hrs.

But CMS, you know, they recognize that rural health is not only benefited by investments directly into rural communities, and they also recognize that, you know, rurality exists on a gradient.

And so they don't, they don't have a strict restriction on expending these funds specifically in these, defined, in this, this defined rural area, with the exception of that five year workforce commitment, which they do expect to go to people serving.

Okay, Waianae, Coast Central, Oahu, Wahiawa, up, Waimanalo.

Yeah, Waimanalo is included.

Okay.

As well as Kaawa and.

Okay, that answers Rep. Marten's question.

Yeah.

Okay, Members questions. Let's start with House Members.

I have another question. Hi, Yan. Hi.

So when we talk about telehealth now, we're kind of thinking about zooms and stuff, but when telehealth started, before we had the advent of zoom, it was really much more high tech and you could have a lot of tools to do different on the ground examinations that could then be shared very high definition with people on the other end.

And I'm wondering, when we're talking about telehealth, are we looking at that model of more sophisticated applications that people can really be remotely doing real examinations inside the body, et cetera?

Yeah, that's a really good question because the technology itself has changed a lot. There's still certain applications.

For example, the maternal telehealth application, it's a combination where they would do the teleultrasound, but the, the pregnant woman would have to go into a healthcare facility and then the connection will allow the scan so that maternal fetal medicine specialist can view it from Honolulu. But there's also other aspects of it where you might have fetal monitoring.

Instead of having to drive in and wait for your session and drive back home, they can do it from home. So there are Some of those applications, a lot of people have asked about primary care. Is that appropriate to use telehealth or if you need to listen to breathing, heart rate, etc.

And the grant does have very commonly used technologies now that's available for home and also has really good support so that the patient or a remote nurse or someone who's using it can get directions from the remote provider. So yeah, the technology is really increasing. The program itself will use a combination of all of those.

Thank you. Thank you. Chair.

I do have questions.

Rep Hartsfield followed by Rep Lee Loy.

It's a budget related question, so I'm assuming you're the person. Okay. So this five year program, the annual awards are going to be dependent on federal approval and performance. So my question is how often will CMS review progress and compliance?

Yeah, thanks for that question. In this first year. Well, our first official report to them will be our annual progress report submitted at the end of August.

We, you know, we'll be meeting, we meet with our project officers bi weekly at this point and update them on our progress and as they kind of develop these, these templates that we'll be using for these, these progress reports.

But our first annual progress report will be due August 30th to describe the activities, I think up through July and then subsequently every single year we'll have another annual progress report due at the end of August. But in the months in between, we'll have quarterly reports beginning after this first annual progress report.

So they'll be kind of very close oversight and working with cms.

Thank you, Chair. I have two more questions but I'll

have for all Members. If you come up with more questions, write them down and I'll make sure and pass them on. So. Okay, go ahead. Vice Chair.

Yeah, thank you. Thank you for the good work. I'm just really curious, like my colleague, you know, we have this incredible spend down and we'll have a number of assets. The question is then what? Right. And I know we, Lauren talked about there's going to be some planning for that.

When can we engage in that process and then as far as the repair, maintenance and upkeep of some of these assets which are absolutely needed on the Big island, how do we transfer that and or get those community readies to maintain them after these assets are deployed?

Yeah, thank you for that question. I think that's a great question. I think it's also one that I think every state is considering how they're going to make this truly transformational and how they're going to put these federal dollars to use and not just kind of make investments that will just fall off after five years.

Because unlike the cuts that came out of HR1, this is short term. This is five years only. I think, you know, we'll be each initiative lead as well as the oversight team that we're building out will be, you know, working on that, considering, you know, how we can ensure that these, that these programs are sustainable.

That was one piece of our project narrative. The final piece was sustainability narrative. And so, you know, we outlined kind of the overview and our hopes for the projects.

But I think it'll be, it'll be a task of this, of this oversight team and of each of our initiative leads to ensure that we're making these changes and making them transformational and also not, you know, leaving anyone on the hook for, you know, subscriptions and maintenance. That will be too much to handle.

But, yeah, when you guys get there, like, reach back out.

Yeah, yeah, yeah. I just want to. Then I'll turn add one real comment. As Dr. Higa mentioned, there will need to be a lot of listening to rural community health needs. And so we need to begin to think through some of what that looks like and to stand that up.

But, you know, this just can't be people in Honolulu figuring everything out. So rest assured that there will be a lot of listening and community engagement.

Okay Rep Amato. And then I'll turn it over to. Thank you.

Thank you, Chair. So I'm not really sure who to direct my question to. It's. But basically, I'm curious about an AI component. We've heard about telehealth in many different programs. Is there an AI component to this money? And if so, how is that going to be utilized in supporting physicians, bringing them up to speed with technology and

going forward for their patients?

I'm not. Yeah. Christina,

thank you. Another really important question with the development of technology, and we do in our, in our telehealth initiative budget, we have a small AI lab kind of work. It's not defined yet because when the proposals came in, there was so much agreement, you know, on what should be focused on.

So part of what the telehealth initiative we do through our stakeholder engagement framework is to identify this platform. There is one for the fqhc. There's an FQHC has been doing a lot of use of AI, especially for determining, analyzing social determinants of health and interventions and all of that.

They will continue that and we will see if that's a model that can be scaled to other FCs. Our other TRC said telehealth resources center side, we're doing, you know, programs on AI and safety just for people to get aware now on, you know, what you should look up, especially in healthcare and AI.

So we'll continue to put that into the industry.

Let me add just one component. As we get into the Rural Value based initiative. Physicians, practices, clinics, community health centers will have an opportunity to use AI tools as part of what they need to empower them to participate in the new models in the future.

So I think we certainly will involve those there as the practices want to adopt them. Thank you.

Okay, thank you. Senate. Do you have any questions?

No, you go first and if there's any time, I'll jump in. You first go.

Lauren, come on up. So I'm a bit disappointed. The whole idea behind the Rural Health Transformation Program is to help rural communities weather the effects of OBV, which means 6%, 6 to 7% of the population is going to be uninsured. I didn't hear anything about how we're going to help the uninsured.

That's a very legitimate question. And it goes back to some of my opening comments about, you know, loss of federal funding for Medicaid down the line. We'll certainly take that back into consideration.

$188 million to be spent in one year. What are you guys going to do to help out the uninsured? I mean, are these telehealth going to be directly for the public who are uninsured? Are they going to be able to like pick up a phone and ask for medical consultations? I didn't hear that.

So I heard the medical risk. I heard the telehealth being expanded and maybe AI and it's a lot of shock and awe, but nothing for the regular people who are uninsured that they're going to be facing. They're going to be losing medical care this year.

What are we going to do to help them?

Correct.

Well, certainly in conjunction with some of the safety net programs, we'll be coordinating responses. So many of the interventions that have been proposed at a high level here, here are not just based on a fee for service or reimbursement. You know, healthcare financial transaction.

You know, it is entirely conceivable that respite or telehealth or community outreach and community paramedicine will be able to accommodate and should be able to accommodate those without insurance. So reimbursement from a third party payer should not be a barrier to certain uninsured individuals receiving the benefit of this program.

That doesn't really answer the question. Okay, you haven't actually answered how an uninsured. Because we're looking at an unprecedented amount of uninsured because of the ACA premium credit expiring as well as the Medicaid and disenrollment requirements. How are they going to be able to sit to go get medical care?

Can they just pick up a phone and ask for consultation? I didn't hear anything like that. Can they just go to a doctor with a voucher and say, hey, the Rural Health Transformation Program is going to ensure that I'm going to be able to get medical care with this voucher? I didn't hear anything like that.

So. Correct. So I'm going to, I guess restate something I said earlier is that, you know, the thinking behind this wasn't how do we maximize insurance, we improve, it's how do we fill gaps in the community. I didn't think medical in Greenberg understood. And so that's getting at persons who are uninsured.

So this wasn't built with okay, how do we just make insurance pay for this or that? This is truly needs based. And so the listening that we're going to have to do will elevate and prioritize some of those issues.

But again, it is entirely conceivable that many of the projects that our colleagues have presented will be available to those who are truly uninsured.

Very purpose the Rural Health Transformation Program was to was to alleviate the effects of OBDA and not to create new stuff.

Well, I'm actually, I think that might not be fully the case. They did include within the Rural Health Transformation Program a specific cap on provider payments which are things for the services for the uninsured. And they put that cap at 15% because.

Because they did not want this funding to just go towards undoing for a short period of time what they did in the same Bill. So they specifically created this program, it came out of the same Bill to do things different than what they had done before. And they put on us this specific constraint, 15%.

So nowhere near the 189 million for the first year that, you know, if we go over that, that would be violating, you know, our agreement with cms. And so we are capped. The program itself caps us at what we can do, the specific amount of dollars that we can give for services for the uninsured.

So but where's the 15% then? What did you do with the 15%? I didn't hear anything.

Well, it's spread across the various initiatives. We don't have a specific initiative that is just going towards, you know, this initiative, the very specific initiative, its purpose is just to serve the uninsured. Instead, we're trying to build systems and and include within that components in, in each of these initiatives to serve the the uninsured.

Chair May I please go ahead. We got to get out of here. So really quickly, these will be answered via letter. I counted 1234 Washington D.C. lobbyists on these, these groups that are supposed to guide this. Why are they there, what are they doing there and who's paying them for their time?

Number two is I could look at this and I see a lot of places where you could argue that you're supplanting funds. How are the bright lines going to be established to ensure that that argument is thrown? Here's the bottom line. You got Administration, previous administrations. You could count on certainties through Cms.

There's a lot of uncertainties going forward. This future monies may not show up. There may be little restrictions. CMS may demand what's being spent on immigrant immigrants. Okay.

So we're investing a lot of resources to represent from the big islands point in these communities without a guarantee that there's going to be continued funding to support their continual operation. RNM and everything else which all fall back to us. And to chair's point, we're facing an insurance nightmare of people losing coverage.

And when they don't have coverage, they need to know where they can go and get that coverage. So that 15% should be front and center to the whole plan. So anyway, letters in writing and finally the RFP process for the equipment. I've heard that it sounds like our decisions have been made on what they're going to require.

When was the RFP process engaged? And we have an RFP process. So if you guys can get back to me with a letter on that, I would greatly appreciate it. Appreciate you guys. Times. Thank you. Continue work on this and mahalo. Yeah.

Before we leave. Thank you. Senators, just want to ask Members if you do have questions, forward them to me me and I'll be the collecting point. Yes. And make sure, make sure that we distribute. Well, I'll send them to Lauren and and Yuan, you folks. I'll distribute the. The responses. Okay. Thank you so much. Okay.

Thank you very much.

And we're adjourned. Thank you so much.