SmartTranscript of House Healthcare - 2025-04-02 - 11:00 AM

[Chair Alyssa Black]: Well, let's get started. So welcome back. It is still April second, and we have joining us today, Catherine am I Bramhall? [Catherine Bramhall]: It is. [Chair Alyssa Black]: Bramhall. And you are in New Hampshire. [Catherine Bramhall]: Well, my first center is in New Hampshire. I actually reside in Barrie, Vermont. [Chair Alyssa Black]: Okay. Alright. And you're in Hanover? [Catherine Bramhall]: Yes, ma'am. [Chair Alyssa Black]: Hanover. So you drive every day from Barrie to Hanover or or when you need to be there, I should say. Yes. Great. So we're just gonna do kind of a virtual tour of your facility. And, you know, just because we do not have freestanding birth centers in Vermont, I think that, you know, we're we don't really have a frame of reference of what we're talking about. Yeah. So just sort of the hope of you could show us around a little bit. [Catherine Bramhall]: Yes. I'm happy to. So the name of my birth center is Gentle Landing Birth Center, and I have to be careful because somebody just walked in. Okay. I'm gonna start at the other end because hey. Hang on one second. [Chair Alyssa Black]: Can you [Allen "Penny" Demar]: go [Catherine Bramhall]: back into go into my office, actually, right there. Okay? Excuse me one second. Something unexpected just happened. [Chair Alyssa Black]: We know that business is the same. [Catherine Bramhall]: Hold on one second. Just go into the yeah. Right there. [Lori Houghton]: And can you please pose [Catherine Bramhall]: the door when you're in there? I'm grateful. Thank you. Hi. Sorry about that. That's okay. I'm gonna turn my camera around. [Chair Alyssa Black]: Alrighty. [Catherine Bramhall]: I think. I am going to turn my camera around. I don't know how. Hold on one second. I'm sorry to keep you waiting. Alright. [Allen "Penny" Demar]: You're just are you on [Chair Alyssa Black]: a phone or an iPad [Catherine Bramhall]: or on a phone. Yeah. Because you guys wanted me at [Leslie Goldman]: There's a little circular thing on the [Catherine Bramhall]: lower I wish I was I wish I was seeing it. It's alright. I'm just gonna turn my phone around. K. So when the so this is the birth center with this you this is when people walk in. It is handicap accessible. It is a it's licensed in the state of New Hampshire. So through the health Department of Health and Human Services, they come every year to inspect to make sure it's all, you know, fine with Internet security. Let's see. This is where people wait. I'm six tenths of a mile from Dartmouth. So the, you know, so the transport is pretty is pretty seamless. We train with the Hanover EMS guys and and with Dartmouth once a year. We have a an ADA bathroom. Can you guys all see this okay? [Chair Alyssa Black]: Yep. Perfectly. Thank you. Okay. [Catherine Bramhall]: This is the midwifery clinic that's attached to the birth center. We have a clinic bathroom. Again, it's ADA per the guidelines for the birth center. This is our laundry room and our sterilizing room, and that's as much as we just had a baby yesterday, so we're still doing laundry. Let's see. This is my office. This is not birth center specific. I'm just because I'm proud of it, I'm gonna give you this tour. You'll be fine. [Chair Alyssa Black]: Yeah. That's awesome. This [Catherine Bramhall]: is the other side of the birth center. This is another this is another treatment room, and this is the birth center. [Chair Alyssa Black]: So Can I can I interrupt you? [Lori Houghton]: Just visually, if you could slow down a little bit. I'm getting a little seasick with you. [Chair Alyssa Black]: Yeah. Take your time. We have lots and lots of time. [Lori Houghton]: You can read the video if the camera works slowly. [Catherine Bramhall]: I hurried through that because this doesn't apply to what you're talking about. Oh, that's okay. We're about to go into the birth center. So this is the entrance to the birth center. It is a it is a part of our facility that's a totally different area. So when people come in for labor, they come in here. We have a kitchen, which is pretty standard with all birth centers, you know, that you give a people a place to, you know, have something to eat and, you know, you they are encouraged to eat and drink in labor. Is this slowing down enough? [Chair Alyssa Black]: It's yeah. Better. Thank you. [Catherine Bramhall]: This is our this is the this is the sort of a cart where if things happen, there's you know, we have the things that are needed. We have a resuscitation station for the baby with a suction machine. The tooth this this and on the other side is oxygen for mom and baby should it ever be needed. All of the standard I'm gonna come back to me. All of the standard emergency things that you would expect and want when things go when things go south are here. They're actually mandated both for my licensing in I'm licensed in New Hampshire and Vermont, as well as in the birth center. So when the so every year, I have to make or all the time, I have to set rules and regulations that comply not only with the Department of Health and Human Services for the rules for birth centers, which is HE dash p eight ten, but also that I I can only do the things that are up to my personal license as well as the licensing for the facility. And so that's where the policies and procedures for this facility and my practice have to meet up and get reviewed every year. I can I can show I wish I I can't find the the circular thing to turn my camera? I'm so sorry. I'm not. This in my birth in my birth part, there are medications. Should anything go wrong, I can't show it to you because I can't make it work, and then I'm gonna take you into the rooms. Okay. The bottom line is is that so much of what happens here, you the vast majority of the times it goes right. When it goes wrong, that's what you wanna be set up for. And and and in birth centers, that's you just set that up. You have hemorrhagic medications, which, of course, are allowed in my license and in the farm and like, all the things. You have you have emergency transport stuff set up so that you never have to worry about it, and it gets reviewed and drilled on a regular basis. I'm happy to answer questions. This is birth room number one. [Speaker 5 ]: Oh, I'm Slice. [Catherine Bramhall]: So [Allen "Penny" Demar]: It's baby on the [Catherine Bramhall]: Yeah. When you come in, this is sorry. We we had to clean the stairs yesterday. This we had a baby in here yesterday. We had a baby, and this is our birth tub. [Chair Alyssa Black]: Let's see. [Catherine Bramhall]: I always tell people you're never gonna see this bedspread ever again because it's there to sell the room. It comes off when people come to have their babies. It's just a very homey place. Again, we have in these drawers, we have the things that you would hope we would have blood pressure cuffs and all the things, but I'm sure you guys are familiar with what we do. And if not, I'm happy to answer any questions. Then this is the bathroom associated with this first room. Let's see. There's their own bathroom and their own shower with lots of shower heads in case they need help and relief in in labor. The the the birth rooms were designed for code. So, you know, handicapped accessible so the EMS can come in and out their fire doors. Oh, that's awesome. Good. [Chair Alyssa Black]: Say that again? No. We we had a sneeze, so there were a lot of plush shoes. [Catherine Bramhall]: I'm gonna take you into the other birth room, and then I'm open for any questions you might have. This is our second birth room. It has a different feel to it. Let me turn the light on. Oops. Let me turn the light on again. So it has a different kinda feel to it, but, again, it's the same idea. It's a private room. That's a ladder to nothing. [Chair Alyssa Black]: That's a tub. [Catherine Bramhall]: It has its own birth tub. Let's see. And then it has a this is a bigger room. And then the bathroom. I'll just this is the bathroom to this first room. Has a nice big shower, all of things. And I think I I'll I'm gonna stop there. I'm annoyed that I can't turn it around and give you a proper tour, but I'm happy to revisit anything that you might need to revisit. [Chair Alyssa Black]: I have a couple, but I see we have some questions. So, Leslie, if you wanted to. [Leslie Goldman]: Yeah, thank you very, very much. Could you talk about your agreement with Dartmouth? I'm looking at the wrong place, I think. And how that gets initiated and renegotiated and how that works? [Catherine Bramhall]: We don't have an agreement with Dartmouth. We're an independent freestanding birth center. I'm a private facility, and I don't need an agreement I don't need an agreement with Dartmouth, and they've made it very clear that they would never give us one. There's a lie there's a liability question there. What we have though is an emergence so we have Dartmouth and UVM actually each have what's called a transport number. You guys probably know that. It's a number that any any provider can call from any practice or facility, in the state who needs assistance from a higher level facility, you know, like a tertiary care hospital. So if you go on to Dartmouth to UVM's place, you will see that they have a transport number. You call the transport number and say, I'm this is who I am. This is where I am. This is who I need to talk to. They then call you back with whoever it is that's most appropriate. Somebody from MFM, somebody from the OB GYN clinic or a NICU guy or whoever that is. And so so that is a standard that standard access for any provider in any facility in the state of Vermont and, well, in New Hampshire for me at Dartmouth. [Leslie Goldman]: So you if I may Yeah. So so you're not required to [Chair Alyssa Black]: have [Leslie Goldman]: a standing agreement that they will accept your emergent patients? [Catherine Bramhall]: No. Not at all. But but the thing is is it's not twenty years ago. So I've been doing out of hospital thousand eight, and, you know, a lot has changed since then. They now because of NEPQIN, the Northern New England Laurie knows what NEPQIN stands, perinatal quality improvement network or something. NEPQIN has been key to getting all of that changed. So now what we do is we meet a few times a couple times a year, and we have Zoom meetings for on topics that basically ensures that we all know that we can call the the up leveled hospital for and that we all know who we are. And so it's already a built in thing to the system so that, in fact, I you know, we all who work out of hospital have apps pretty close to no risk for for any of our patients because they the UVM and Dartmouth, you know, the big hospitals built it in for safety for out of for private practices and out of hospital clinics. So as a CPM licensed in Vermont, I can call UBM anytime day or night and get hooked up with a consulting doctor who will then help me if I need a transport in. Just say we're ready for your transport and we fax records over. It's already built in. This isn't something that needs to be made. [Chair Alyssa Black]: Leslie, for you. Oh, oh, for not yet. Laurie? Thank you, Catherine. [Lori Houghton]: I'm not in Buffalo. And just, disclosure, I'm a registered nurse, and the UVM, well, the Vermont Hospital Association, and Vermont Medical Society are concerned about having some sort of transport, agreement. I don't know that it it's, like, the kind that they used to wish for twenty years ago. I think it's they're asking for something a little bit different. But to me, it transporting a person who is in labor, is no different than, EMS picking someone up at home and transporting them for something else going on. And they the hospital shouldn't require that that that patient or the EMS have a an existing transport agreement ahead of time. The transfer of necessary information is gonna happen in the moment, and it's different for every for every patient. It's different for every laboring person. So it's really helpful for me to hear you say this. [Chair Alyssa Black]: That's it. [Catherine Bramhall]: If I could answer to that, is that would that be okay? [Chair Alyssa Black]: Yes. [Catherine Bramhall]: So I have so, again, I've been doing this for seventeen years, and it did used to different. I wanna I wanna just really say to anybody who's concerned about the safety and the transport thing. Like, I'm an old woman now, you know. I've been I I used to be groovy and I used to do transports from a different place, and it was a different time. The the amazing thing is because of the perinatal outcomes that are so challenged in the United States now and because of the closing of all of the small hospitals, the [Chair Alyssa Black]: larger hospitals have actually just really [Catherine Bramhall]: like, there's just been this reach back and reach actually just really like, there's just been this reach back and reach forward between out of hospital, whether it's a private a naturopath, whether it's, you know, whoever's larger hospitals have built this in for better outcomes for all of us. It's part of the quality assurance, quality improvement thing that is been us. It's part of the quality assurance, quality improvement thing that has been necessary no matter what your what your specialty is. But especially, you know, like but for me, I can only speak to the out of hospital thing. It has changed profoundly so much so that it took me about two years to not be afraid to call the hospital because they would, you know, like doctors would have attitude or something that I was out of hospital. I don't run into any of that anymore. And so an agreement is actually it's I don't mean to repeat myself, it's not actually necessary because the hospitals have already built into what you were speaking to. It's just, like, it's no different than an EMS transport in. [Chair Alyssa Black]: I was gonna ask you if regarding the numbers, how many how many births you have a year? And I was also gonna ask you about Medicaid, but I looked you up, and you are actually a participating your facility is a a participating provider under Vermont Medicaid. So you accept Vermont Medicaid, and they pay you. [Catherine Bramhall]: Actually, I'm gonna correct you. So sorry about this. No. I I need you guys to pass this bill because actually, I am not my facility is not covered by Medicaid because medic because Vermont the state of Vermont does not license birth centers. When I get a Vermont Medicaid patient, they have to pay the facility fee out of pocket because you guys don't have anything built into the Vermont Medicaid, whatever you call it to cover a birth center because you don't have any birth centers. [Chair Alyssa Black]: Okay. Just see gentle landing midwifery. [Catherine Bramhall]: Right. Yes. Absolutely. I've been under I've been since since s, I think it was s twelve back in two thousand and twelve or something. I don't know what it was. When they when they started saying that that you need malpractice insurance, I got malpractice insurance so that lower income people or people who need a little who need public insurance would still have access to this model of care. [Chair Alyssa Black]: Lori, did you wanna just tell [Speaker 5 ]: me, Lori Foster, ACNM, and Vermont or Center Coalition. Just a one more just a clarifying point is I believe what you're seeing, and, Catherine, you can correct me if I'm wrong, is that Medicaid will pay the provider fee [Chair Alyssa Black]: Mhmm. [Speaker 5 ]: As it does for our home birth midwives, but not the facility fee. So this is that, you know, topic that came up with Blue Cross Blue Shield as well. Is that right, Catherine, that you that you that they will pay the provider fee [Chair Alyssa Black]: for for for you at the birth center if you have Vermont? [Catherine Bramhall]: Medicaid will. Yes. But they no. Not for the birth center for my midwifery practice. I don't have to yeah. They [Chair Alyssa Black]: provide a fee. Yeah. They provide a fee. [Catherine Bramhall]: Be clear, and I'm not sure I heard you correctly. I apologize if I got it wrong, but Blue Cross Blue Shield of Vermont actually does pay both the provider fee and the facility fee and for birth centers. [Speaker 5 ]: For your birth center. [Chair Alyssa Black]: Yeah. Yep. [Leslie Goldman]: Leslie, so I'm looking at the bill and, it says a requirement for written practice guidelines and policies that include teachers for transferring a patient to a hospital circumstances warrant. And what I'm hearing you say that you're not you don't have those agreements and you don't believe that you believe that the system takes that into account. So is that what I'm understanding? [Lori Houghton]: That's different. [Leslie Goldman]: That's what I'm having trouble with. So that's what I'm looking for help. [Catherine Bramhall]: Can you can you please tell me what bill you're looking at? Like, what Alright. [Leslie Goldman]: So let me just help I I may not need to ask you this. So this is just that they have internal policy. Yes. Okay. Got it. Never mind. I'm good. [Catherine Bramhall]: So to be clear clear, if you were looking at the New Hampshire bill or the New Hampshire guidelines, in fact, I have a seven hundred and fifty page policy and procedure manual that covers every single thing that would need to happen to follow all of the rules and regulations that for both practice for both myself and any staff as well as any, you know, in perinatal perinatal stuff that happens around here. So yeah. [Chair Alyssa Black]: And how many how many births do you have every year there? [Catherine Bramhall]: So I'm only I've just started I've just finished my fourth year, and right now I have about seventy a year, and I'm on track for, like, a whole lot more right now. [Chair Alyssa Black]: K. And [Catherine Bramhall]: and your Your build [Chair Alyssa Black]: up. And so for four years, you've been you've been you've had the birth center portion. You've had your midwifery services there, but not necessarily the the birth center. [Catherine Bramhall]: Delivery. Sorry. I'm so sorry. It is really confusing, by the way, because because birth center sort of love lumps everything in. The birth center is a facility. It's a different business. It's just a hospital as it is you know, if you get a hospital bill, you get a facility fee, and that is different. So for four year we opened up January two thousand twenty one. We opened the birth center. So that was when our birth center license came through. So since January twenty first two thousand twenty one, I have been doing births at the birth center. I've been doing births as a midwife out of hospital and homes since two thousand eight. Okay. [Chair Alyssa Black]: Alan. [Speaker 6 ]: Just curious. Full time staff compared to part time staff, how many do you have? [Catherine Bramhall]: I have I have one I have a front desk person who is here for thirty six hours a week, and then I have birth assistants who are contracted contracted people. So that there's always people more that you know, there's always two to three people at a birth, but they're not on staff. [Speaker 7 ]: Now is this twenty four seven? [Speaker 6 ]: Do you have somebody at that facilities? [Catherine Bramhall]: No. If that's that is not first center's work, you know, but so but you have somebody according to the rules and regulations. You have somebody who will be able to be here twenty four at any point twenty four seven. And people are really clear. At the beginning of somebody coming into care, they're required to get an orientation and a tour so that they understand the parameters of everything that they would be signing it up for. Like, we don't have epidurals and that there's not somebody here twenty four seven, but that there's somebody on that you can reach twenty four seven, that this is a different model of care, blah blah blah blah blah. [Allen "Penny" Demar]: Yeah. K. Thank you. [Chair Alyssa Black]: You're welcome. But you do show up if somebody goes into labor at two AM. You're gonna meet them there. [Leslie Goldman]: On call. You're on call. [Catherine Bramhall]: Yes. Absolutely. And whether they're in labor or not, if they need a if they need a visit and it's not an ER thing, you know, the answer is is yes. And yeah. Clear. I actually have a home in Barrie, but I also have an apartment six minutes from here so that during really busy times, if it does if it isn't appropriate for me to be an hour away, I I have an apartment here. [Allen "Penny" Demar]: Answers my question. Oh, okay. I was just wondering. Going from Barry down to Dartmouth [Catherine Bramhall]: I for her for her. Times in the last year. [Chair Alyssa Black]: Any questions for Catherine? Thank you so much. Thank you. I know that this is yeah. It's beautiful. Absolutely beautiful. It's beautiful. [Speaker 6 ]: May I ask how many square feet your building is? [Catherine Bramhall]: It's a different that's a that's a different question than how many square feet my facility is. My facility is thirty one hundred square feet. I'm in an office park. [Allen "Penny" Demar]: Oh, okay. Okay. Great. [Chair Alyssa Black]: Well, you're in an office park? [Catherine Bramhall]: I am. [Allen "Penny" Demar]: Oh, shoot. [Catherine Bramhall]: I have sound canceled technology in the floors. [Chair Alyssa Black]: Thank you. Thanks so much for joining us. [Catherine Bramhall]: You're welcome. Can I actually, can I just end with saying one thing? [Chair Alyssa Black]: Yes. Please. [Catherine Bramhall]: What I wanna say is that it makes a lot of sense to me, people wondering about the safety and about, it's really hard because, number one, only two percent of people in the United States have babies out of And this isn't a this isn't a very well known model of care. What I want you to know is that is that setting the rules and regulations that are set up in the state of New Hampshire for opening a birth center through the Department of Health and Human Services actually are the thing that keep this really, really safe. It isn't whether it should be or shouldn't be. Those when when I was setting this birth center up, I slept with those rules, h e dash p eight ten. I swear I could actually I've memorized them. By the time I was right finished writing the policies and procedure manual, seven hundred and fifty pages, and and there was a doctor at OB who at at DH who reviewed them for me. He was just like, you just wrote a PhD. What you should know is whatever that you can say yes. The reason you can say yes is because the policy the the rules and regulations that you set up are the guidelines to keep this safe, and you don't need anything big and fancy. Like, you don't need you don't need all sorts of things. What you need is to make sure that when this is when the Department of Health and Human Services and when the licensing is done, that you've covered everything, and it doesn't have to be hard. I recommend that you read the the eight HE dash p eight tens as a reference point because New Hampshire has had, birth centers for decades and the and the safety and look up the safety statistics of birth center births in the state of New Hampshire. And I recommend that as you're, you know, debating all of this, do it from a reference point from your neighbor that has that has a pretty similar population for, you know, for what you're looking at. And my collaboration with Dartmouth is I was I was my collaboration with Dartmouth could not be better and because it's already set up, and UVM has a very similar setup. So that's what I wanted to say. Just please please consider this and let because women come families come from Vermont, from Northern Vermont to have their babies with me wishing they didn't have to make that drive before when they're in labor and then wishing they didn't have to make that drive after their after they've had their baby or get a hotel room until the next day. It yeah. So that's that would be what I would wanna say. [Leslie Goldman]: Leslie, I was just hoping that you could say that regulation New Hampshire slower, so if we wanted to find it or maybe you could send it to us or something. [Catherine Bramhall]: I'm never gonna send it to you. I hope I'm never gonna remember that. Yes. And I I know that I know this I know this rule better than I know my daughter's names. It's h e dash p eight ten. The New Hampshire rule, h e dash p eight ten. [Leslie Goldman]: Thank you. [Catherine Bramhall]: Yeah. It's really, really great. It's everything from what you need beforehand as how to set it up, and then how you what what you're allowed to do and what you're not allowed to do, blah blah blah. It's incredible rule. And it keeps me safe. Every time I I literally, every time somebody comes into care, I make sure that I check the rules of that those rules as well as my own rules to make sure that when I say yes to somebody, it is clinically and legally accurate for me to say yes to them. [Allen "Penny" Demar]: Just out of curiosity, in Central Monet, you know, we have a pretty good hospital. I'm wondering if by living here and being in the community, do you do you see a birthing center might be in the in the in the cards? [Catherine Bramhall]: I'm not sure what in the cards means. Can you clarify that question? [Allen "Penny" Demar]: It's that it may may one may come here and prize. [Catherine Bramhall]: Yes. I see that. I think that I do. I I can easily see that because women want it. And women are the ones having the babies, and so we should probably listen to what they want too. And make and keep it smart. You know? I can I can see that? Yes. [Chair Alyssa Black]: Thank you for that last statement. Appreciate that. Any other questions? Thank you. Thank you for your time. Thank you for the tour. [Catherine Bramhall]: You're welcome. Good luck, everybody. Thank you. Okay. [Chair Alyssa Black]: I think we can [Lori Houghton]: go off of slides.

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SmartTranscript of House Healthcare - 2025-04-02 - 11:00 AM

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