[0:40] Good afternoon everyone. Uh welcome to our September 9th, 2026 uh board of

[0:46] Douglas County Commissioners work session. We are joined here by um our

[0:51] community partners from H Heartland Community Health Center. We have um Bob

[0:55] Transky from staff who might be kicking us off with a a little bit of an intro.

[1:00] And just a quick uh reminder for anybody who might be new to work sessions. Um uh

[1:06] we do not take public comment or take any kind of action during work sessions.

[1:10] It's an opportunity for presentation for commissioner questions and discussion.

[1:14] Um we always have a business meeting that follows which will begin at 5:30

[1:18] and we always have a general public comment um period then and you're

[1:21] welcome to provide any public comments you might have about today's discussion

[1:25] at that time or write us later. Um and with that I will turn it over to Bob.

[1:31] » Thank you commissioners. Good afternoon everyone. Um, in 2018, before there was

[1:36] a mental health sales tax, before there was a TRC, a mobile response team, care

[1:41] coordination in the community, um, behavioral health partners like LMH,

[1:47] Bert Nash, H Heartland, H Heartland, Raak, DECA were convening and having

[1:51] conversations about what the gaps in our community were with respect to

[1:56] behavioral health. And even before we had moved forward on trying to go after

[2:01] this mental health sales tax as a group, um, one of the gaps that was identified

[2:06] was in the area of psychiatry and med services. And so collaboration between

[2:11] Bert Nash and Hartland and LMH resulted in and support from the county resulted

[2:16] in the creation of a psychiatric infrastructure workg group that was

[2:20] tasked with taking a look at what the needs are across our continuum of care

[2:25] and community with respect to psychiatry and med services. That effort led to a

[2:31] really pretty significant increase in the number of providers that came to

[2:35] Douglas County. And over the years, all of our partners, LMH, Bert Nash, and

[2:41] Hartland have worked to maintain, sustain, and expand um the capacity of

[2:46] our psychiatric infrastructure. That work group um has members on it. Both

[2:51] lead executive leadership and providers from Bert Nash Hartland, from LMH,

[2:56] Coffin, Logan, and KU have participated in that work group. The work group was

[3:00] instrumental in shaping the early drafts of the medical director position for the

[3:05] TRC in talking about how we should look at the costs of psychiatry and med

[3:11] services across the system of care and identifying issues that our partners

[3:17] might want to try to address collectively and cooperatively. And so

[3:21] that's kind of been the work of the psychiatric infrastructure work group

[3:24] over the last couple of years. There's been sort of periods where that work as

[3:28] a work group has been more intense and less intense. But one thing that hasn't

[3:32] happened for a while is we have not given you the opportunity to really hear

[3:36] from Hartland about how their uh behavioral health services particularly

[3:41] with respect to psychiatry and med services have evolved and are iterating

[3:46] and continuing to grow in Douglas County. And so that's why we are really

[3:50] pleased to have the team from Hartland here. Um, I'm going to turn this over to

[3:55] Rachel Hartford, but I want to make sure that before we start talking that we do

[3:59] some introductions. And Rachel, I will let you lead it from here.

[4:05] » Rachel Hartford. Thank you. Um, I'm the chief operations officer at the health

[4:10] center.

[4:17] » Amy Celiff. I'm the director of quality at Heartland.

[4:22] Julie Brandstrom. I'm the CEO at H Heartland.

[4:26] » Nicely. I'm the director of psychiatry and a board-certified adult and child

[4:30] adolescent psychiatrist. I've been practicing in the Panda building from

[4:34] like August um 2023 until now, primarily seeing patients that are like 26 and

[4:40] under.

[4:48] I'll kick us off really quick um for H Heartland's presentation. Um we just

[4:52] wanted to kick off by saying thank you so much um for participating today. We

[4:57] really appreciate the opportunity to engage with each of you um to kind of

[5:01] provide some data on H Heartland's psychiatry program and also I think some

[5:07] important narrative that will provide additional context about how H

[5:11] Heartland's uh psych services have grown over the last about eight years or so.

[5:16] Um I get the privilege of being at the table today but don't have to have the

[5:20] pressure of doing the presentation. So, um, Rachel and Amy, I'm sure, are going

[5:24] to do an excellent job of walking you through the data and providing context.

[5:28] And so, I will hand it over to Rachel. Great. Thanks. I also want to say thank

[5:31] you to, um, several of our staff, community partners that are in the room,

[5:35] including um, some of our community health or mental health advocates. Um,

[5:39] we extended the invitation so that community partners or our employees or

[5:43] board members could join us to hear firsthand and experience the work

[5:47] session. So, I'm thankful that you guys took the time to come out. As Bob

[5:51] mentioned, um, since 2018, uh, H Heartland Psychiatry model, we've really

[5:55] evolved in response to the community needs, um, the workforce availability,

[6:00] reimbursement structures, and our funding partnerships. Um, what began as

[6:05] a response to the growing demand for communitywide psychiatric services

[6:10] actually developed into a broader, more integrated approach to behavioral health

[6:14] and psychiatry. For us at the community health center, our priority has been to

[6:18] improve access, support the continuity of care, and to try uh to address the

[6:24] complexity of needs that are experienced by patients that um see Hartland out as

[6:29] their primary care provider. Your investment at the county level has

[6:33] played an important role from the beginning and throughout the evolution

[6:37] of that work. Um, as Bob mentioned, Douglas County has supported the

[6:41] infrastructure work and has allowed H Heartland to expand our ability to

[6:47] respond to developing community need. Um these investments have not occurred or

[6:52] existed in isolation but rather they've been able to be incorporated into a

[6:57] larger more continual change of systems um including providers programs care

[7:03] coordination internal infrastructure in our operation and a variety of funding

[7:08] sources. And so as our model has developed Hartland has adapted and we've

[7:13] evolved to change um in response to that. And so again, very grateful for

[7:18] the opportunity to share a little bit of that information. The purpose of our

[7:22] presentation today um and the narrative that was sent to you earlier is really

[7:26] to just try to provide that whole picture. Um it's been a lot of u

[7:30] movement over the last decade and so today we hope to hit some of those

[7:33] highlights and have a conversation as we go through the data. Uh more really

[7:38] importantly, what we want to note is that the current state of psychiatry at

[7:43] H Heartland reflects both progress, achievements, and opportunities to

[7:47] continue to work forward. Um, our role as the federally qualified health center

[7:53] is to serve as a preventative and ongoing health partner that helps to

[7:58] address behavioral health needs before they escalate to a crisis or to be

[8:02] available to provide continuity of care following a crisis or if there was a

[8:07] higher level of intervention needed. Um, we've said this often in the last year

[8:12] or so, but Hartland as the FQHC, we're not a crisis center. um we are not

[8:17] equipped to provide that emergency crisis response service like other

[8:21] partners in our community, but rather we see our role um within the continuum of

[8:26] care to provide accessible outpatient psychiatry or behavioral health services

[8:30] while aiming to strengthen that prevention and early intervention,

[8:34] supporting stabilization or recovery as embedded in primary care and to ensure

[8:39] that patients have a trusted health partner for ongoing care after the

[8:43] crisis or hospitalization. And I think this distinction is important as we

[8:47] define the value and the appropriate scope of H heartland's u program in our

[8:51] model of psychiatry at the health center. Again, our focus is on

[8:55] prevention, early identification, treatments, um stabilizing a patient um

[9:01] in primary care and then con continuing that care um as patients transition back

[9:07] into routine life um following a crisis and wanting to coordinate that care with

[9:12] community partners. So today we're going to talk we're going to have some data um

[9:17] and again I hope that this data is viewed as a continuum of that investment

[9:22] and the capacity building rather than just an isolated um measure or an

[9:27] isolated moment of success.

[9:35] So we talk about psychiatry at our health center and it we view it as um

[9:42] more than just a specialty clinic or a subsp specialty service um as an

[9:46] integrated safety net health center. We consider that H Heartland serves as a

[9:51] cornerstone of community health and we provide that psychiatric care but also

[9:55] connect patients to a broader network of primary care behavioral health services

[9:59] like therapy. Um, we also have embedded substance use treatments and medication

[10:05] assistant treatment, pharmacy, we've talked about over the years care

[10:09] coordination and other supportive services that have recently been offered

[10:12] by community health workers. And so again, we just want to call our

[10:16] attention to that psychiatry is best understood from our our model um as one

[10:21] component of that integrated system rather than an isolated service.

[10:26] Here is a brief snapshot or [clears throat] a timeline of our

[10:31] partnership. Um, you may recall that we received our federally qualified

[10:36] designation in 2012 and we began collaborating almost immediately, as Bob

[10:41] mentioned, with other community health partners to advance an integrated system

[10:46] of care. And this timeline shows what we would identify as some key milestones or

[10:50] initiatives and how we have evolved um our

[10:54] integrated care program at the health center. Bob mentioned the uh Proposition

[11:00] One that passed and and even during that time we were in exploratory

[11:05] conversations and executed agreements with our hospital partners and our

[11:10] community mental health center to try to attract um providers to our community.

[11:15] Um we wanted to leverage as the f the federal dollars that we could. Um we

[11:20] would share staff again contract staff back and forth really just trying to

[11:25] increase access at a rate that um our community needed. Um following a a

[11:30] period of organizational changes and uh challenges around that uh I would say

[11:36] you know 2021 2022 mark. Hartland, we really renewed our commitment in 22 and

[11:42] in 23 to increase psychiatry services. Um, again, we believe this is

[11:47] fundamental to the work that we do and and it advances the mission to welcome

[11:51] all who need care. And so in 2023, Hartland uh we welcome Dr. Nick to the

[11:56] community and that marked for us a very strategic step forward where we were

[12:01] developing uh in that program with um leadership and prioritizing how we could

[12:07] expand that uh physical or clinical capacity. Um since then we've increased

[12:12] our our capital footprint. We've increased the number of mental health

[12:16] providers and as you'll see later we've increased the number of patients that

[12:19] are being served. So I would say over the last three years this has really our

[12:24] renewed focus has allowed us um to offer greater stability, consistency, growth

[12:30] within psychiatry and mental health services at the health center. Um and

[12:33] the data that Amy is going to present um demonstrates that progression and and

[12:38] can provide a measurable view of what we've been doing. And really the the era

[12:44] of 2018 uh to 2023 or if you look at from 2023 to 26 um it's really it's no

[12:52] longer one of just growth but how we are building capacity and how we are aiming

[12:57] to sustain that capacity with the demand. So again um looking forward to

[13:02] hearing what Amy has to say. >> Take it away Amy.

[13:08] » Amy can you make sure you use the mic? completely forgot we were muted there.

[13:13] I'm going to dive in first to talk a little bit about the unique patients and

[13:16] the encounters. When it comes to access, health centers track unique patients and

[13:21] we track encounters to really look at how access is happening. They tell two

[13:26] different stories. They're both important. And then overlaid with each

[13:30] other really tells us what our patients are using for services. Unique patients

[13:35] is defined as the number of individuals in a period who received care. Um, in

[13:40] this case, we're looking at quarter by quarter. Each bar represents a quarter.

[13:44] The encounters are the total number of visits or actual interactions that the

[13:48] patients had with the health center provider. So, that might be in-person

[13:50] visit or it might be a telealth encounter. Um, those started to happen

[13:54] once COVID came around. [clears throat] One patient might have

[13:58] multiple encounters in a quarter. They might have multiple encounters in a

[14:01] year. This really tells us how much care is being delivered and how frequently

[14:05] patients are accessing it. If we serve 20,000 patients overall with 80,000

[14:10] visits, it's an average of four visits per patient per year. This kind of gives

[14:14] us an idea of acuity. It's one of the measures, one of our indicators that we

[14:18] look at from period to period. We look at really in relation to each other as

[14:22] they go up and go down. We want to know why. Looking at both of these also then

[14:28] reports out to our leadership to know whether are we expanding access or are

[14:32] we just serving the same patients more frequently. It's also something we

[14:35] really want to know. If our unique patients increase, it

[14:39] generally indicates that a health center is reaching more people and reducing

[14:43] barriers to care. However, if our patients increase, but our encounters

[14:47] decrease, it might not mean that we're giving patients enough visits. They

[14:51] might not be able to get in as frequently as they needed. If we see

[14:54] unique patients drop, that also means that we are not having open access

[14:59] points. So as these numbers go up and down by quarter later you'll see there

[15:04] there is a direct correlation between our clinical FTEES available.

[15:09] [clears throat] The distinction is important because

[15:12] access isn't just about how many appointments are provided. It's about

[15:15] how many people are able to enter the system and receive care and have

[15:19] continuity of that care. Another way to say it is that unique patients tell us

[15:23] how many people we're reaching. Encounters tell us how much care we are

[15:26] providing. and tracking both helps us understand whether we are truly

[15:30] expanding access, meeting ongoing patient needs, and using our capacity

[15:34] effectively. For an FQHC like Hartland, it's important because the goal is not

[15:39] simply to increase the volume. It's not just more visits, more visits. We want

[15:44] to increase meaningful access to care for the community while ensuring

[15:48] patients can receive the appropriate level and frequency of services they

[15:51] need to meet their goals, improve their health outcomes, and prevent acute and

[15:55] crisis events. Here we are breaking our access down into the two eras. So as you

[16:01] see in this era, we're again fluctuating based on their FTE available.

[16:06] Next slide, Rachel. In this next period, we're looking at

[16:11] 2023 to 2026. You can see that since 2018, now in this period, quarterly

[16:17] psychiatry volume has increased from approximately 230 unique patients and

[16:22] fewer than 500 encounters starting all the way back in that first quarter of

[16:25] 2018 to regularly serving more than,400 unique patients and 2,000 encounters per

[16:31] quarter. This growth has remained consistent since 2023 with a renewed

[16:35] stratey strategy to increase access to psychiatry indicating an ongoing and

[16:40] sustainable need for outpatient psychiatric services rather than a

[16:44] temporary post-pandemic increase. >> Currently, our psychiatry providers

[16:48] average nine patients per day with a monthly average of a 19% no-show rate

[16:54] overall. The growth we see is a direct representation of that strategy to

[16:59] increase access by preventing expanding provider FTE as well as strengthening

[17:04] the integration pathways among our providers and patient self-referrals

[17:08] allowing continued growth for new patients and continuity of care for our

[17:11] existing patients.

[17:17] Our new patient demand has also remained remarkably consistent considering the

[17:22] changes over the years with approximately 200 to 250 new patients

[17:26] per quarter for nearly 3 years. This sustained referral volume reinforces

[17:31] that psychiatry is operating in environment of persistent community need

[17:35] rather than periodic surges. Regarding our no-show rates, a no-show, to be more

[17:40] specific, occurs when a patient is scheduled for an appointment appointment

[17:43] but does not come to that appointment and does not cancel in advance. And that

[17:48] is particularly important for federally qualified health centers because an

[17:51] unused appointment slot is lost access. It means lower productivity, but it also

[17:57] means that we have scheduled and committed resources that a patient is no

[18:01] longer going to be able to use. No-how rates are important access and

[18:05] operational metrics. They measure the gap between that capacity and then the

[18:09] actual care delivered. A high no-show rate can reduce provider productivity,

[18:14] can increase weight times for patients, and limit the number of patients who can

[18:17] access care overall. Understanding the reasons behind no-shows allows the

[18:21] health center to address barriers and improve utilization of available

[18:24] capacity and ultimately convert more schedule appointment opportunities into

[18:29] meaningful visits. As you can see in 2025, those quarters

[18:35] and moving forward, the no-show started to rise. Our pediatric no-show, just for

[18:40] context, is generally less than one in 10 patients. Adult no-show is generally

[18:45] higher, and our new patient no-show rate is even higher, which is closer to 25%

[18:50] sometimes more. That means one in four of every new patient in psychiatry care

[18:55] doesn't show up for that first appointment.

[18:59] This is not unique to psychiatry and is frequently seen across other services.

[19:03] Heartland's no-show rates are all below industry standards and generally

[19:06] observed rates um which are seen among other FQC's, community mental health

[19:10] centers and CCBHC's which are around 25 to 45%. Our goal is to always try to be

[19:16] below 20.

[19:20] » Payer mix is um the breakdown of the health center's patients or encounters

[19:24] by how their care is paid for. So at an operational level when we look closely

[19:29] at noshare rates or access uh key indicators payer mix is one of those key

[19:34] indicators for us at the health center. Um we know that payer mix matters

[19:38] because it's the mix of patients that um the health center serves that ultimately

[19:42] has a direct impact on billable revenue or sustainability and informs our

[19:48] ability to maintain or increase access. So an example is if a health center has

[19:54] a high number of uh patients that may not have health insurance that is going

[19:58] to be a high uninsured rate and we know that that will lead into some

[20:01] uncompensated care. Um that also we look at that type of information even based

[20:07] upon provider panels because that can also inform how we structure um our

[20:13] schedules or or how we allow for um panel management again so that those

[20:19] payer mix shake out so that those costs are covered. Um at H Heartland over the

[20:24] years um I know in this area this setting our PPS rate has been brought up

[20:29] as a federally qualified health center. we get enhanced reimbursement for

[20:33] Medicaid and Medicare. And our PPS rate is currently $35962.

[20:40] Um, and we know, and this is important because when we again when we look at

[20:43] panel management or we look at access points, that payer mix and that

[20:47] reimburseable uh revenue can impact our ability to increase access. So, for

[20:54] example, an adult uh a provider that has primarily an adult panel may look a

[20:59] little different than what a provider with a um primarily pediatric panel

[21:05] would. You can see our breakdown of payer mix in the chart. Um I'm sure

[21:10] we'll talk about that here shortly. But regarding our psychiatry services,

[21:15] um, currently and where we're heading, again, we mentioned this, but it's

[21:19] really evolved from a program that hasn't that no longer focuses on

[21:23] building capacity and expanding access, but really aiming to stabilize and and

[21:28] sustain what we've um accomplished. And so since again 2018, that quarterly

[21:36] volume has increased. And we throughout this process, we've learned um what it

[21:42] what it requires to welcome providers to our community and to continue to see

[21:47] them. We know that already in 2026 we've reached um almost 2,000 unique uh

[21:53] patients that are seeking uh psychiatric services at the health center and that

[21:58] ex that number um exceeds our entire last year by almost 2 and a.5%. So

[22:04] steady growth. Um we offer care through a variety of um inperson and telealth

[22:09] services. Again, trying to be flexible in how patients can access their

[22:13] provider. Um and so we again we know that it's not just a standalone

[22:19] specialty service, but really has truly integrated in the system of care at the

[22:23] health center and Dr. Nick is an example of what that looks like when we've

[22:26] integrated it into um the Panda Pediatrics location wanting to link arms

[22:33] between a pediatrician and a site provider. And so the next phase of um

[22:38] psychiatric access or improvement for the health center won't uh be merely

[22:44] measured and encounters, but the reliability, the timeliness of care and

[22:49] and those payer structures. We talk often um over the last few years

[22:54] too about increasing access and how we know we're increasing access. One key

[22:59] measure for us is net provider availability. Um this this refers to the

[23:04] amount of care that a health center has the ability to provide based upon its

[23:08] available providers clinical hours, appointment slots, and support

[23:12] resourcing such as the the staff that works around that provider. Provider

[23:18] retention. um that really refers to the organization's ability to keep providers

[23:23] over time. We know that transition or turnover can be disruptive to care. It

[23:27] can also be costly. And so, we're not only measuring success by how um how we

[23:33] can recruit or welcome providers to our community, but how can we keep them? Um

[23:38] hiring providers certainly increase potential capacity, but retaining

[23:42] providers is what's going to protect that capacity over time. So, we've been

[23:46] looking closely at that net provider availability and it's taken us years to

[23:52] determine, but we finally have um a clearer picture that right now Hartland

[23:58] would Hartland needs six full-time providers to offer the care based upon

[24:06] the current patient demand. Um and again over the years you've seen us have 0.2

[24:12] two FTE, 3 FTEE, then one FTE, but as this chart um indicates, we hit a good

[24:20] stride for three and since then, we've been able to increase. And when we look

[24:24] at provider uh or panel management um provider continuity and the current

[24:30] patient demand and um weight list, we know that six providers right now are

[24:36] actively responding to what is going to allow us to serve up to about 9,000 uh

[24:41] visits this year. So it sounds like significant growth certainly. Um, but

[24:46] the the goal here is to be able to retain providers and not have that

[24:49] turnover because again, it's not just enough to increase that headcount. Um,

[24:55] but we don't we don't want to see providers um move if they don't have to.

[25:02] » Can I ask a question? I noticed the previous slide your number of providers

[25:08] went up and then roughly in the same period of time your uh commercial

[25:15] billings uh went from 20ome to 40 something. Is

[25:22] that related because you had more providers or

[25:25] » Sure. And credentiing and privileging those providers, how payers are

[25:29] structured. Um we talk about that sometimes with those hidden costs of how

[25:34] um we welcome a provider and if if they're credentialed with certain

[25:37] payers. Um we also know that the welcoming of providers that are

[25:42] providing pediatric or child and adolescent uh services that is a payer

[25:47] there. And so um you're going to see that where we've increased our child and

[25:51] adolescent access that inherently has increased our our billable revenues.

[25:58] Um full disclosure, this was our list of uh providers that have been um at our

[26:04] health center uh since 2022. And and again, I think you know these are the

[26:09] licenses of our providers and their FTE. And why this matters is because um at a

[26:14] time when we want to again support that integrated network of care, we're

[26:19] grateful for the psychiatric nurse practitioners that offer care alongside

[26:23] Dr. Nick um in our clinics. And you can see whenever that provider, you know,

[26:29] maybe on average a year or two and then they would um perhaps move on. And

[26:35] noteworthy, we have uh welcomed pro providers from outside of our uh

[26:41] community line, but the providers that have departed our organization,

[26:46] some have just left the field of medicine altogether. Um we're seeing

[26:50] that when we talk about provider retention and well-being and and um the

[26:55] clinical burnout that providers are experiencing. Um so again these

[26:59] providers that have departed, they they have changed their field of practice or

[27:04] they have taken an administrator role and they've they've left that clinical

[27:07] care. And so we started the calendar year um with six providers and in the

[27:13] middle of this year we had we decreased down to four. again, those two providers

[27:18] um taking a different adventure, but we're we're thankful to welcome two

[27:24] additional providers um this fall that will return us back up to six. And so

[27:30] I'm going to have Amy talk about what does this actually mean for capacity.

[27:36] So at a high level right now with the trends that we've been following over

[27:41] the year for the last few years, we're projecting around 9,800 annual

[27:46] psychiatry patients to be served by the end of the calendar year. This really is

[27:51] just the baseline demand we are currently experiencing. This is not any

[27:55] sort of expansion. At the current productivity and utilization

[27:58] assumptions, approximately as Rachel said, six full-time equivalents would be

[28:02] needed to maintain adequate access to psychiatry care at H Heartland. Um, this

[28:08] 6 FTE represents that baseline. No expansion goal yet. If we do want to

[28:13] increase access beyond our current demand, we would need to increase staff

[28:16] above that 6ft FTE. and then respectively um if we're looking at

[28:21] pediatrics and adolescence versus adults potentially those who might specialize.

[28:25] This provides Hartland with a better understanding of what our capacity is to

[28:30] meet the current needs as well as trying to plan ahead. Um it also has really

[28:34] helped to inform that framework for determining additional staffing need.

[28:39] How big of a case load can a provider manage?

[28:46] I won't belabor the integrated services part or our community health worker. I

[28:51] know that you all have read a lot of that narrative over the years, but again

[28:55] this just is a demonstration of the number of patients that are accessing

[28:59] multiple services or programs at the health center. Again, much of this was

[29:04] included in that narrative and you you can see a correlation of increase as we

[29:09] opened and welcomed um Blue Stem Wellness as another location for our

[29:13] health center and continuing to just increase or uh strengthen our um SUD

[29:19] programming at the health center with MAT and our community health workers.

[29:23] Again, um this is a lot of information, but it it helps to visualize that

[29:30] patients um are utilizing multiple services and again it just champions

[29:35] that integrated framework or um helps to validate why it's important to have um

[29:41] that whole person approach and then again community health workers.

[29:46] I know that this group has read and heard a lot about that, but just a key

[29:50] advantage of embedding those community health workers is again just that

[29:54] ability to offer that comprehensive uh social needs assessment and and helping

[29:59] patients overcome barriers to care so that they can have that adherence to

[30:03] their treatment. >> Got a question. [clears throat] Um when

[30:07] you say psych plus one service, what does that mean? So that would indic

[30:13] correct me if I'm wrong, but that would indicate if um a patient also received

[30:18] primary care or they saw a therapist or a dental provider.

[30:23] » Okay. I was just wondering if somebody has a dual diagnosis,

[30:28] if you count that as maybe they have a SUD with

[30:35] mental health issues, [gasps and sighs] is that just considered one service?

[30:41] That would still just be one service. So yeah, like if it was, you know, psych

[30:45] plus three, then maybe they're seeing dental, primary care, and have a

[30:49] therapist. >> Got it.

[30:54] » And Rachel, I noticed that you were tracking human trafficking, but there

[30:58] was nothing indicated on the graph. So just kind of curious.

[31:06] » Yeah, take it. Yeah, I can speak more to that. Um, so that human trafficking is a

[31:10] new addition to our federal report, our annual uniform database system. It has

[31:16] specific criteria and diagnosis codes. So, we do assess that through our

[31:22] upstream drivers of health. We do not necessarily put that on someone's

[31:25] progress note. We don't want that going to someone's portal, especially if that

[31:29] might be sensitive information, but we do track that information.

[31:35] » Okay. So you are tracking it. So potentially you

[31:39] could have individuals that are uh coming forward with that information and

[31:46] if

[31:50] there is a need you are uh developing interventions and

[31:54] » connecting with absolutely coordination. >> Uh you would not be reporting that out

[31:59] to other agencies is basically what you're saying. We are not putting it on

[32:03] our federal report card primarily because that's captured in claims

[32:06] information. We don't want that on an potentially on a lot of our EOBS, things

[32:10] that might go to an address and might be sensitive information. So, right now we

[32:14] haven't used that as an ICD code. >> Okay. All right. Thank you.

[32:21] » Here's a little information about populations. again um I want to be

[32:25] considerate of time and allow for uh questions and conversations but Amy I

[32:29] don't know if you want to hit some of the highlights of the population data.

[32:33] » Yeah I think the biggest thing you can see is that change in 2023 uh really in

[32:39] 2022 and before that we were primarily providing adult psychiatric services. It

[32:44] was with the addition of Dr. Nick that we really were able to offer services to

[32:48] pediatric and adolescent populations and that's where you see that again

[32:52] increase. Um most of our patients who are pediatric age have seen Dr. Nick at

[32:58] least once and pardon [clears throat] me. Yeah, it was

[33:03] up through 2022 that it was about 85% of our patients were adults. Now that we

[33:08] have added some more pediatric and adolescent psychiatrists, now nearly two

[33:13] of every five are under the age of 18. And interestingly, it's actually one of

[33:18] every five patients in psychiatry is between the ages of three and 12. So

[33:22] it's demonstrating ongoing need of our school-aged children.

[33:29] So, we have important work happening now. We have important work on the

[33:32] horizon. And again, we're just grateful for the opportunity to join you for a

[33:36] work session to demonstrate what has occurred over the last um 8 to 10 years.

[33:42] And again, the investment of the county helped to provide that momentum and

[33:46] accelerate much of that work that's happened. And you can, you know, be

[33:50] assured that H Heartland wants to see psychiatric mental health services

[33:54] advance in our community. we know that there's opportunity to work alongside

[33:58] community partners and you um to make that happen. And so again, just really

[34:02] grateful for the time today and looking forward to a conversation.

[34:07] » Thank you everybody, [clears throat] commissioners, other questions top of

[34:11] mind. >> Yeah. Um this probably goes back two or

[34:15] three years. I'm not sure of my uh timeline, but I know uh when uh

[34:21] psychiatry services and mental health needs were

[34:26] uh constricted by the staff. I know my

[34:31] staff at both places. I know a lot of people would sign up at H Heartland and

[34:36] at Bert Nash and then they would take the first available

[34:40] appointment. Have you seen that die down now with your increased staffing?

[34:49] Well, I mean, we continue to get referrals from the community and from

[34:54] all over, whether that's private practice, um, like Lawrence pediatrics,

[34:59] um, LMH, emergency room visits, um, people that aren't able to get in to

[35:04] other places, um, patients that have had recent crisis visits, and I mean,

[35:10] really, it's it's coming from all directions. Um, so I think as we've

[35:16] continued to grow and been able to get I mean we prioritize urgent referrals and

[35:22] the number of urgent referrals especially for you know the under 18

[35:25] population is tremendous. Um you know if it's if it's your family, if it's your

[35:29] kid, you know you want them seen as soon as possible. Um and that's one of the

[35:33] big goals of being able to hire more providers is to cut down on the wait

[35:36] time. Um but yeah, we get referrals from all over and I'm really proud of that. I

[35:41] mean, you know, when pediatricians know they can do an urgent referral and we're

[35:44] going to prioritize that and get them in within a couple weeks because we, you

[35:48] know, read their notes that they sent over, um, you know, that's really

[35:52] important to me and that's really important to our staff. So, even like

[35:56] going back to the, you know, if somebody does cancel an intake 24 hours in

[36:02] advance, like we have urgent intake lists, we have urgent follow-up lists,

[36:07] we have regular intake lists, and we have regular obviously follow-up

[36:11] patients that are that need to be scheduled. And so, if somebody gives us

[36:16] 24 hours, like we're going to fill that slot. Um, if it's a follow-up and

[36:21] somebody doesn't show up, then we're going to try to switch it to teleahalth,

[36:24] even if it's like 10 minutes into the appointment. Like, we really try to

[36:27] value obviously getting people seen. And by doing that, it's going to free up

[36:32] time to get more urgent referrals in. So, it always feels good to get, you

[36:36] know, like a private practice therapist to refer, you know, an urgent patient

[36:39] because they know you're going to prioritize trying to get that person in.

[36:46] I appreciate you mentioning some of the greatest need uh because I heard you say

[36:50] under 18 and then I also heard you say between the ages of 3 and 12. Uh and so

[36:57] [gasps] as we think about that uh I'm kind of

[37:02] curious about some of the partnerships that you do have within those uh age

[37:08] brackets. So that kind of makes me think of the community health improvement

[37:11] plan. Uh but then that also makes me think of some of the partnerships that

[37:16] maybe we have across the county with our school districts and how are you

[37:20] partnering with the school districts? How are you partnering with some of our

[37:23] partners within the community health improvement plan? What do those linkages

[37:27] look like and how are those referrals working and those partnerships? And if

[37:33] those linkages are not built yet, completely fine. What does it look like

[37:37] to either build them and are is there interest if they're not

[37:43] built to complete them? Because we do know when we think about property taxes,

[37:48] right? Some of our largest property taxes are coming from our school

[37:51] districts. And so I think there's a great opportunity there to build those

[37:56] relationships and to ensure that those linkages back to our schools and from

[38:00] the schools to our behavioral health providers that that is a seamless

[38:04] continuum of care so that our kiddos are receiving what they need. And then when

[38:09] we think about the community health improvement plan that we have that

[38:13] linkage back to the community health improvement plan because we are here to

[38:17] improve our community. And I know that was a lot.

[38:22] » A couple things. So, so like we see a lot of kids that have high high needs

[38:26] and they have SEDD waiverss through Burton Nash or other community mental

[38:30] health centers and they need, you know, they they might see us for medication

[38:34] management and therapy, but they still depend on the local mental health center

[38:38] to get, you know, SED waiverss that would allow, you know, case management,

[38:43] group therapies, respbit services. So, we do see a lot of um and obviously that

[38:49] qualifies them for Medicaid um if they have an SED waiver. So, we do see a lot

[38:54] of that population. Um as far as the to answer the question

[38:59] about schools,

[39:04] parents frequently will sign a release and needs the school might need some

[39:09] information. But in the world of child psychiatry,

[39:12] privacy is very important. And sending, you know, notes to schools, that's not

[39:20] something that we commonly do, right? Parents typically don't want that. Um,

[39:25] and the communication really, you were kind of caught in the middle

[39:30] sometimes with these conversations. So, the communication has to go through the

[39:33] parents. Um, sometimes we'll hear directly from the school and sometimes

[39:37] that will really, you know, upset the families. Um, obviously sometimes

[39:41] they're they're very much for that, but it's a definitely a um case by case

[39:47] situation and if we're able to talk to the, you know, school counselor or

[39:51] something like that, um, it can be really, really valuable, but we always

[39:54] have to go through the proper channels of getting a release information. And a

[39:58] lot of times parents really appreciate that. um if we're if if we talk to the

[40:05] school and we haven't gone through them or they haven't told us to do that, I

[40:08] mean that's just a not a good situation. And a lot of times they're voicing

[40:14] frustration. So I spend a lot of time educating parents on how do you talk to

[40:18] the schools about a kid that needs an IEP? How do you educate the parents to

[40:22] advocate for their kid? How do you deal with panic attacks? So I do a lot of

[40:26] education and talking um with the parents to how know how to address those

[40:30] things with the school system and I honestly I mean it would be overwhelming

[40:34] to contact schools all the time. I mean I don't have that time. So by educating

[40:39] the parents to be able to do that it's it's definitely

[40:43] the best route. So am I hearing then that

[40:50] maybe there's a gap between the schools and

[40:56] so there's a gap in the system maybe between the schools and our behavioral

[41:00] health, right? To then maybe bridge between parents.

[41:05] Maybe there's like a missing piece there or that education piece.

[41:12] I wouldn't I wouldn't necessarily say there's a missing piece. Um like I said,

[41:17] I think educating parents on how to address situations with the schools and

[41:21] if there is more of an extreme situation or suspension or something like that. Um

[41:27] you know there's communication when there needs to be.

[41:30] » And I would add I'm sorry. >> Yeah. One last thing.

[41:33] » No, go for it. >> Um community health work.

[41:35] » That's that's where I was going. That's where I was. That's where my brain is

[41:38] going that I'm trying to figure out if maybe

[41:40] » they're facing if they need to go to an IEP meeting or they need to, you know,

[41:45] help with communication and things like that. Yeah, that's a tremendous benefit

[41:48] for for our patient population. >> Yeah, that's exactly what I was going to

[41:52] say is having them embedded um in pediatric alongside our care

[41:56] coordinators. Um they're in and out of the schools and building that

[41:59] relationship. And so yeah, a lot of it is trying to relieve the burden that

[42:03] families may experience navigating and being educated on what the options are.

[42:07] So community health workers is that linkage for us.

[42:10] » Thank you. >> Can you address a little bit more on the

[42:15] wait times? So we talked about kind of wait times maybe being a couple weeks

[42:18] for an acute need. Uh that still seems like a long time for for a parent with

[42:23] with a child with acute need especially. Um what are the different weight times

[42:27] for different populations? So, a less acute need, when when would they be seen

[42:31] for a first visit? Um, and are there kind of industry standards?

[42:36] » Oh, I mean, I'm super excited that we're hiring, you know, two providers um that

[42:41] are getting ready to start, you know, this month and next month that are

[42:44] focused on 26 and under to really cut down on the weight times. Um, since one

[42:50] of our child providers went down to two days a week, I have basically um been

[42:54] seen on the child side like only urgent referrals since that time. And so

[42:58] unfortunately that means that there have been patients that have been on the wait

[43:01] list for you know several months. But I'm really optimistic but that by hiring

[43:05] these next two providers um it should address that in the coming months

[43:10] hopefully even by the end of the year because that is definitely a high

[43:13] priority of ours. >> And that goes back to that net provider

[43:17] availability. We know if we have six full-time providers we can stay to where

[43:21] that access is either at or below that industry standard. But again, the care

[43:26] coordinators around the providers, they they jockey those schedules. And so to

[43:31] Dr. Nick's point earlier, if there's a no-show or a late cancellation, they're

[43:35] working that list to try to get someone in or to recover that appointment, even

[43:39] if someone doesn't show up in person and they can make contact with that patient

[43:43] in the first 5 to 10 minutes. They'll flip that and try to um reserve that

[43:47] access. And that a couple of weeks for to get an

[43:51] urgent um first visit in is that pretty common within the industry?

[43:59] » Yeah, I mean across the US I mean it's there's an overwhelming need for

[44:04] psychiatric services whether it's adult or child. There's very few areas where

[44:08] they have you know an overabundance of child psychiatrist. Where I was trained

[44:12] actually they did just because it was a really popular place to live. Um, but

[44:16] that was part of why I wanted to move back to Kansas, just knowing that there

[44:20] weren't a lot of psychi child psychiatrists and wanting to serve the

[44:23] community. Kansas

[44:29] talked about no-shows and how they, you know, um, kind of disproportionately

[44:33] impact everybody involved um, for the the capacity and the access. uh in terms

[44:39] of like what what tools are there to try and reduce that because I've you've seen

[44:43] that the one of the goals is to you severely reduce the no-shows. It sound

[44:46] like you're already kind of better than the industry standard, but what are the

[44:49] tools that are available for that? Sure. We have a few things that we've

[44:55] tried and a few things that I think we are working on tweaking and perfecting

[44:59] if we can. Um so we do have a reminder call system. We have recently opted to

[45:04] change the language to be pro-social. So, it is uh a couple days out from your

[45:11] appointment. You get that phone call that says, "Hey, if you can't make this

[45:14] appointment, please give us a call to reschedule so we can give this

[45:17] appointment slot to somebody else in need." Um, we've learned that that is

[45:21] actually very effective in getting people to call sooner. We also know that

[45:25] when we have patients who aren't confirming those, we're able to give

[45:29] them a live phone call and try to confirm on the phone. Um, that's also

[45:34] one thing that's been helpful to make sure we all have reminder fatigue with

[45:39] portal messages, email messages, text messages, you get an AI phone call and

[45:44] so sometimes that live phone call can also make a difference.

[45:49] » And then I would add the recovery of the slots. Um, again flipping the

[45:53] appointment. You know, perhaps the family's running a little late and they

[45:56] can't make it in person, but we flip that. Um and we don't um we try really

[46:01] hard not to block a provider's schedule. Um that's the other thing is um really

[46:05] preserving that clinic facing time and again of care coordinators suggest

[46:10] alongside providers to reshape that schedule to allow you know we look at

[46:15] what's the maybe the trends in the no-show like what what time of day is

[46:20] most likely to be no-showed well then we that can help us inform how we structure

[46:25] that schedule. Dr. where you can say something.

[46:29] » It's some um help again from the community health workers. If somebody's

[46:32] consistently not been able to make their appointments, getting them involved to

[46:35] try to problem solve, you know, what's the issue? Is it transportation? Is it a

[46:38] certain time of day or something like that that can help them make sure their

[46:41] next appointment's successful? I have another That's right. Um we

[46:47] looked at your payer mix and how that's been changing over time. Um and and a

[46:50] larger percentage of the payer mix was Medicare, Medicaid. Um, is that because

[46:54] of do you suppose a changing demographic being served or is that because of the

[46:59] ability to kind of get people signed up for Medicare and Medicaid as they need

[47:02] as they require it? >> I had a same question and just want to

[47:06] tack on similarly um has there been support with enrolling

[47:11] more patients onto commercial and marketplace insurance if they're not

[47:15] because both those numbers seem to have gone up. So curious if you can point to

[47:19] any strategies around that. >> I'll say something kick it your way. Um

[47:21] I think we I think Mr. Dorsy uh mentioned this but yes the the welcoming

[47:27] of child and adolescent providers have impacted our payer mix because uh the

[47:33] number of children that have Medicaid or covered insurance. So that's one key

[47:38] indicator that we know that by increasing child and adolescent

[47:41] psychiatry access or capacity that inherently has impact our payer

[47:46] structure. We also have several of our CHWs who are

[47:50] certified to navigate that marketplace too. So we are proactively running

[47:55] reports looking at patients who might have expiring Medicare, Medicaid,

[47:59] looking at patients who might be eligible for marketplace and trying to

[48:02] reach out and getting them enrolled >> or if there's a gap in coverage. Um our

[48:07] pediatric teams work alongside those community health workers to try to scrub

[48:11] those list to make that contact with families.

[48:19] Other questions, commissioners?

[48:23] And one quick one. Um, and and Rachel, you mentioned it and I didn't quite

[48:26] catch it. You told me you said how many uh patients per day typically your

[48:30] providers are at. >> Um, about nine.

[48:36] I mean, if you want to really know Dr. Nick's schedule, I'll tell you.

[48:39] [laughter] >> See up to I mean, you can see 15

[48:41] follow-ups in a day. >> Yeah. Um, and that's one thing I really

[48:45] appreciate appreciate about H Heartland. Um, the support from the administration,

[48:49] but also just I mean, we have to have time with our patients and having time

[48:52] for that initial visit is really important. Um, so I really value that. I

[48:57] mean, we're not doing 15-minute med checks. That's not our mission or goal.

[49:02] » Yeah. And that that number is the average across the department. And so,

[49:05] if you were to look at Dr. Nick's schedule, he can typically see 10 to 11.

[49:10] again not just met checks but um hour or so appointments

[49:20] » and you did mention the PPS rate earlier as well.

[49:22] » I did. Yeah. >> Okay. Uh go ahead.

[49:24] » Um >> yes and it's a narrative. Our PPS is

[49:28] 359. >> Uh we will this is something that Sarah

[49:33] and I were talking about earlier, but we'll probably potentially be seeing

[49:36] changes coming in 2027. Uh are you all tracking to maybe some of

[49:41] the changes that we might see in the future?

[49:44] » Yes. Yes. >> Okay. Uh yeah, we are um actively

[49:50] monitoring what the [clears throat] impacts would be to our state and at a

[49:54] local level as well. >> Okay. And so as you're monitoring some

[49:57] of those potential changes coming down, uh what are some of your thoughts?

[50:03] » Oh, dear Julie. >> Yeah.

[50:08] Um well, we're concerned um clearly um and that's also why I think um ensuring

[50:15] that we have adequate support with community health workers that are

[50:19] working on that um intake and enrollment for our patients is really important. Uh

[50:24] and we will continue to add staff there um because we know that it will be

[50:28] needed. Um but we are concerned and currently working on trying to project

[50:33] what the fiscal impact impact will be um with you know knowing that there will be

[50:38] likely a reduction in the number of patients that we will be seeing with

[50:41] Medicaid. >> Yeah. So in pra in practical terms the

[50:46] community health workers are we're trying to increase um the number of our

[50:50] IE team members that can help navigate some of those changes. We're doing some

[50:55] worst case scenario planning um you know running those worst case budget but also

[51:00] um trying to take advantage of some of our technical assistant trainings

[51:05] through our national and state association. Obviously we're not going

[51:07] to be the only ones impacted by this. And so when you run those scenarios and

[51:12] you run those different plays, what does your infrastructure need in the

[51:15] organization and trying to maximize what we can um and leverage where we can, but

[51:21] also being very realistic in what's a boundary line for us in terms of what

[51:26] could be lost or what could be gained. And um for our community health center,

[51:31] I think an example of that is how we're engaging um valuebased strategies into

[51:36] the workplace and into the clinic. And you know, we don't just talk about our

[51:40] quality care, but putting that into action and seeing payers um respond to

[51:46] that in positive ways is very helpful. We see that as an opportunity as an

[51:50] FQHC, but nonetheless, it is worrisome and I know that it keeps many of us up

[51:55] at night, but at the end of the day, we're trying to take the the best step

[51:59] forward knowing what we know today.

[52:06] Well, community partners from H Heartland, we appreciate the

[52:09] presentation. Uh, I think my my final question, and I I would welcome you all

[52:14] chiming in on this um as well, but um really it goes back to Bob just to sort

[52:18] of um put this conversation and all of this specific data and context about uh

[52:25] how things have evolved at H Heartland in the the sort of greater context of

[52:30] the psychiatric psychiatry infrastructure work group. Um, so if you

[52:35] could just give us a little bit of whatever context you think is helpful in

[52:39] terms of where this uh conversation exists now and sort of what we uh what

[52:44] we might see coming forward in terms of um any recommendations or or

[52:51] considerations for for changes. >> I think one of the changes is in the

[52:57] convening structure of that group. So for a long time Dr. Dodson and I were

[53:01] the co-conveners of the psychiatric infrastructure group. Um we are

[53:06] fortunate to have a retired psychiatrist with quite a bit of expertise in the

[53:11] community who is also a member of the crisis system advisory group. Dr. Coup

[53:15] is here and I think you've had a chance to meet him. So Dr. Coup is going to uh

[53:20] co-f facilitate that group now with Dr. Nick. So will be some change there. uh

[53:25] and I think really bringing that group back together to look at the landscape

[53:30] that has shifted and changed and to ask you know what are the priorities that we

[53:34] should be looking at collectively and collaboratively um to meet the community

[53:39] needs as those change as payer structure changes the system is constantly fluid

[53:45] and the fluidity the pace of the fluidity and change happens kind of

[53:50] quickly so I think that's one piece and you know I I I just think that some of

[53:54] the progress that's been made on addressing no-shows and cancellation

[53:58] rates. I think we could point to all kinds of examples where Bert Nash and

[54:02] Hartland have collaborated together to be looking at these things and to

[54:06] experiment with how their scheduling practices are are implemented. Um, I

[54:10] think we can learn from each other and we can learn with each other. Um, and

[54:15] and and that's really the purpose of a work group like that. I know that Rachel

[54:19] and Ryan Storch from Bert Nash um collaborated on that focus area of the

[54:24] the behavioral health plank of the chip on improving access to care. So, not

[54:28] just looking at visits and volumes, but also looking at quality of care, patient

[54:32] satisfaction, willingness of of patients to stay engaged with a particular

[54:37] provider or a particular agency, I think are some of the thoughtful discussions

[54:42] that we could we could have coming forward and we look forward to that

[54:45] time. Thanks, Bob. That's helpful. Julie,

[54:50] Rachel, Amy, Dr. Nick, do you have anything to add?

[54:54] » Um, again, we just want to thank you for your um active participation in the

[54:59] conversation today. It's really um important to us and uh we're hopeful

[55:03] that the um data that's been presented has uh been informative and also

[55:08] demonstrates I think uh the impact and the value that Hartland brings um around

[55:13] access to psychiatry especially with continuity of care and um just the

[55:19] ability to provide preventive care as well. And um so we would welcome uh the

[55:23] county's continued partnership and support um when especially when we have

[55:28] conversations around uh parity of the investment um between uh funded agencies

[55:34] that provide uh care to people in our community that need access. So again we

[55:40] just appreciate the time. Can >> I just say one thing that I thought that

[55:43] I didn't add? Um I think we both I think both Bert Nash and Hartland have

[55:48] experienced this challenge which is you know you want to bring a new provider

[55:54] but you don't know when that opportunity is going to present itself and in the

[55:58] budget cycle and the way that the budget cycle operates um there have been a

[56:02] number of opportunities where we have had to scramble and so I think having

[56:06] some conversations about how to be prepared to receive an opportunity and

[56:10] to be ready to act on it when one agency or another um has something that they

[56:15] would like to move forward on and they might not be able to in the absence of

[56:19] funding. I think that's a conversation that we might want to look at because

[56:22] we've seen that happen on several occasions at both agencies.

[56:29] » Great. Thank you. That's really helpful context for me and uh I wonder if any

[56:33] other questions for commissioners. Go ahead.

[56:34] » Yeah. And so I'm just asking uh cuz I think Bob you are uh make or making that

[56:40] comment in regards to like out of budget cycle correct having these conversations

[56:45] out of budget cycle between now and potentially uh 2027 budget cycle is

[56:51] maybe what what you're saying. So if an opportunity or a need, a gap arises,

[56:57] you're desiring for these conversations to happen, uh iterating around what that

[57:02] need might be or potential project out of budget cycle.

[57:06] » This was easy when both agencies were saying we would like to add one

[57:09] psychiatrist and one APRN to our panel of providers. And now it's more fluid

[57:15] and the challenges come and go as there's turnover. So being prepared to

[57:19] have to be able to act if we're ready to act. um and to have conversations that

[57:24] maybe are not annual conversations. I don't know, you know, there's no way

[57:30] to predict what the need is, but we have seen this on several of occasions and

[57:34] because we have acted um I think responsibly responsively um we've been

[57:41] able to have the the benefit of some really talented providers. I mean the

[57:46] talent that's in this community is significantly higher and the result is

[57:50] that more people are being seen by the provider that best meets their needs.

[57:56] » Thank you. I just appreciate you raising the need uh and mentioning that so that

[57:59] we can be proactive and having these conversations and bringing partners

[58:03] together to address that need and starting to have the conversation with

[58:06] you.

[58:11] » All right. If there are no further com uh questions from commissioners, um I

[58:16] will bring us to a close and thank you again for your time and for all the uh

[58:19] work and effort put into giving us this data. It is um it's nice to see

[58:26] accumulation of many decision points and many uh it iterative changes and and

[58:33] growth capacity. It's it's nice to be able to see it all in one place um for

[58:37] your [clears throat] organization and to uh see that as a holistic story I think

[58:41] was really um helpful to me. I think it'll be helpful for us as a commission

[58:45] moving forward with these conversations and I really do look forward to sort of

[58:49] the reconvening um and um contemporary assessment from that workg group about

[58:55] what the total landscape looks like and what some strategies moving forward um

[59:01] can be based on lessons learned so far. But um thank you for your commitment to

[59:06] continuing to uh increase capacity and hold capacity and and work on all of

[59:11] those metrics that help make access to care um possible in our community and at

[59:16] a higher standard than many other communities enjoy. So appreciate your

[59:20] work. And with that, we are um recessed until our 5:30 business meeting. Thanks

[59:25] y'all.

Board of Douglas County, KS, Commissioners Work Session on Sept. 9, 2026

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