►
Description
This is the fifth meeting of the 2021-2022 Interim. Please see agenda for details.
For agenda and additional meeting information: https://www.leg.state.nv.us/App/Calendar/A/
Videos of archived meetings are made available as a courtesy of the Nevada Legislature.
The videos are part of an ongoing effort to keep the public informed of and involved in the legislative process.
All videos are intended for personal use and are not intended for use in commercial ventures or political campaigns.
Closed Captioning is Auto-Generated and is not an official representation of what is being spoken.
A
Good
morning,
everyone
I
would
like
to
call
this
joint
interim
standing
committee
on
health
and
human
services
meeting
to
order
welcome
to
our
fifth
meeting.
We
will
call
the
role
first
for
those
members
attending
virtually.
Would
you
please
turn
on
your
cameras
and
respond
when
you
hear
your
name,
miss
rowe,
please
call
the
roll.
C
E
F
E
A
A
couple
of
personal
remarks,
if
I
may
about
today
in
the
subject
matter
we'll
be
talking
about,
I
think
it's
really
common
for
us
to
say
women
a
lot
when
we're
discussing
maternal
health
issues.
But
I
want
to
be
clear
that
the
intent
of
this
meeting
is
to
be
inclusive
of
all
birthing
people
and
people
seeking
care
for
pregnancy
and
for
children,
maternal
health
and
newborn
to
early
childhood
services
and
care
are
part
of
a
broader
system,
they're
impacted
by
systemic
bias
and
disparities
that
particularly
impact
our
impact.
Our
bipoc
community.
A
A
Additionally,
I
ask
our
presenters
on
the
zoom
call
today
to
leave
your
cameras,
often
microphones,
muted,
until
I
call
up
the
agenda
item
you're
under
or
ask
you
a
direct
question,
the
zoom
call
zoom
video
call
has
a
chat
feature.
However,
this
feature
is
only
to
be
used
for
technical
assistance.
Any
links
or
information
that
you
would
like
to
share
during
the
presentations
should
be
stated
verbally
on
the
record
and
can
be
shared
with
staff
agenda
items
may
be
taken
in
a
different
order
than
listed
two
or
more
agenda
items
may
be
combined
for
consideration.
A
A
If
you
wish
to
testify
in
person,
please
sign
in
at
the
table
by
the
door
and
leave
a
business
card.
If
you
do
not
testify,
you
may
also
want
to
sign
in
so
there's
a
record
of
who's
interested
in
a
particular
topic
and
in
the
event
that
the
committee
needs
to
contact
you
later
when
testifying
in
person.
A
Please
turn
off
the
microphone
on
to
speak
and
off
to
listen,
because
we
have
other
others
listening
to
and
viewing
the
meeting
in
las
vegas
and
online,
and
with
that
we
will
go
ahead
and
move
on
to
public
comment.
A
couple
of
notes
on
public
comment.
We
will
be
limiting
public
comment
to
three
minutes
per
speaker
to
ensure
that
there's
enough
time
for
all
folks
who
would
like
to
provide
public
comment
staff
will
time
each
speaker
during
public
comment
to
ensure
everyone
has
a
fair
opportunity
to
speak.
A
A
In
addition
to
testifying
in
person,
members
of
the
public
may
provide
public
comment
in
four
different
ways,
all
of
which
are
listed
on
today's
agenda.
We
will
start
with
public
comment
from
those
in
the
physical
locations
and
then
move
to
public
comment
from
anyone
who
has
called
in.
Is
there
anyone
in
carson
city
who
would
like
to
provide
public
comment
today?
A
A
G
E
Good
morning
my
name
is
leanne
mcallister.
I
am
the
executive
director
of
the
nevada
chapter
of
the
american
academy
of
pediatrics.
The
nevada
aap
currently
has
283
members,
most
of
whom
are
board
certified
pediatricians.
Both
primary
and
specialty
care
members
also
include
pediatric
nurse
practitioners,
physician
assistants,
pediatric
residents
and
medical
students,
all
of
whom
live
and
work
in
nevada
and
have
dedicated
their
professional
lives
to
the
health
of
all
children.
E
My
members
care
a
great
deal
about
all
the
topics
on
today's
agenda
and
I
thank
you
as
you
consider
creating
legislation
and
funding
programs
to
improve
the
health
of
pregnant
patients,
their
newborns
and
toddlers.
Although
our
colleagues
in
ob
gyn
are
the
experts
in
caring
for
pregnant
patients,
pediatricians
play
an
integral
role
in
partnering
with
families.
Caring
for
newborns
threats
to
family
preservation
come
in
many
forms,
including
inadequate
access
to
safe
housing,
food
insecurity,
gun
violence
and
lack
of
access
to
opioid
treatment
in
the
pediatric
medical
home.
E
Doctors
create
safe
spaces
for
families
to
ensure
all
of
nevada's.
Children
have
the
resources
they
need
to
thrive.
Nevada
legislators
must
also
help
by
extending
the
postpartum
coverage
period
for
individuals
who
were
enrolled
in
medicaid,
while
pregnant
to
a
full
year
after
the
end
of
pregnancy
and
by
supporting
robust
paid
family
leave
in
our
state.
E
Given
the
link
between
nutrition
and
health,
the
aap
is
a
leading
voice
in
support
of
strong,
science-based
nutrition
programs
to
help
promote
children's
lifelong
health
and
combat
food
insecurity.
Nevada
legislators
must
follow
the
successful
lead
of
others
and
impose
taxes
to
decrease
the
consumption
of
sugary
drinks
by
children.
E
E
Here
in
nevada,
we
are
fortunate
to
have
dr
steven
shane,
who
is
board
certified
in
both
pediatrics
and
obesity
medicine
under
dr
shane's
leadership.
The
nevada
aap
is
asking
the
nevada
legislation
to
fund
a
statewide,
proven
public
health
program
called
5210
to
promote
that
all
nevadans
consume
five
fruits
and
vegetables
a
day
limit
recreational
screen
time
to
two
hours
or
less
per
day,
engage
in
at
least
one
hour
of
active
play
and
drink
zero
sugar,
sweetened
beverages.
E
Good
morning
assemblywoman,
sarah
peters
and
the
rest
of
the
committee,
my
name
is
dora
martinez.
I
represent
the
nevada
disability
peer
action
coalition.
E
H
A
A
Committee
review
is
an
important
process
to
follow
up
on
bills
that
have
passed
in
the
last
couple
of
sessions,
but
we
will
not
be
taking
any
action
on
these
items
today.
I
will
ask
that
staff
introduce
these.
We
have
representatives
from
the
boards
that
are
proposing
these
regulatory
changes
and
we
will
take
all
of
the
regulation
or
all
questions
on
these
regulations
for
each
board
individually.
So
that
would
be
on
our
notes,
folks
item
a
e
and
f
together
and
item
b,
c
d
and
g
together
you
don't
mind
going
ahead
discussing
yeah.
B
B
I
believe
we
do
have
representatives
from
the
agencies,
although
I
know
we
had
some
issues
with
getting
lisa
from
the
board
of
psychological
examiners,
I'm
not
sure
if
those
have
resolved
themselves
yet
so
I
would
say
we
probably
should
start
with
the
board
of
pharmacy
regulations.
If
anyone
has
any
questions
on
those.
A
I
Thank
you,
madam
chair.
Just
for
clarification.
The
r013-21
has
already
been
adopted
by
the
alleged
commission
just
want
to
make
sure
that
that
was
the
one
that
was
already
adopted.
I
A
Thank
you.
So
much
are
there
any
other
questions
from
the
committee
on
the
regulations
presented
today,
seeing
none,
we
will
go
ahead
and
close
this
agenda
item.
Thank
you
all
so
much
and
move
on
to
our
next
agenda
item,
which
is
agenda,
item
4,
overview
of
maternal
morbidity
and
mortality
in
nevada.
A
As
has
been
the
tradition
in
this
particular
interim,
we
will
start
with,
essentially
the
data
we
have
at
hand
give
us
a
baseline
of
where
we
stand
today
on
this
particular
issue
and
then
move
into
topic-specific
presentations
from
the
experienced
folks
across
our
state.
So
I
have
miss
kyrah
morgan,
the
chief
biostation
in
the
office
of
analytics
here
to
present
on
this
today.
Please
go
ahead.
Miss
morgan
when
you're
ready.
E
C
Perfect,
thank
you
so
again,
I'm
kyrah
morgan
and
I'm
the
state
biostatistician
for
the
department
of
health
and
human
services
in
the
office
of
analytics,
and
I'm
just
going
to
go
over
quickly.
Some
data
related
to
maternal
mortality
and
severe
maternal
morbidity.
C
I'm
going
to
start
with
some
backgrounds
and
definitions,
we're
going
to
focus
in
this
conversation
on
pregnancy
associated
deaths,
which
really
is
the
widest
net
that
we
can
cast
related
to
maternal
mortality.
You
can
see
the
definition
here
that
is
deaths
while
pregnant
or
within
one
year
of
termination
of
pregnancy,
regardless
of
the
cause.
There
are
also
definitions
for
pregnancy,
related
deaths,
which
are
a
subset
of
pregnancy,
associated
deaths
and
then
maternal
deaths,
but
because
our
counts
are
just
so
small
in
nevada.
C
It's
really
hard
for
us
to
draw
conclusions
or
present
information
by
any
kind
of
demographic
subgroup,
and
so
we're
going
to
focus
again
on
pregnancy
associated
debts.
I
also
wanted
to
mention
that
the
information
I'm
presenting
today
is
part
of
a
report
that's
available
on
our
website
and
there's
a
link
to
the
full
report
on
this
slide.
The
data
in
the
report
are
a
little
bit
older.
We
updated
it
for
this
presentation
and
so
2021
data
throughout
my
slide.
Deck
is
preliminary
and
subject
to
changes
and
is
not
available
yet
online.
C
Also
wanted
to
give
you
some
background
definitions
on
maternal
morbidity.
It
really
is
a
continuum
from
middle
adverse
effects
to
life-threatening
events
or
maternal
death,
we're
going
to
focus
here
on
severe
maternal
morbidity,
which
is
the
second
tier
of
that
pyramid,
and
it
refers
to
conditions
and
diagnoses
that
indicate
potentially
life-threatening
maternal
complications,
including
unexpected
outcomes
of
labor
and
delivery,
resulting
in
significant
short
or
long-term
consequences
to
health.
C
So
we're
going
to
start
with
pregnancy
associated
deaths.
There
were
36
in
nevada
in
2021.
So
that's
why
we
focus
on
this
larger
category,
as
you
can
imagine,
if
we
drill
down
much
further
than
that,
we
get
a
little
bit
too
specific.
C
The
rate
of
pregnancy
associated
deaths
is
about
108
per
hundred
thousand
life
births,
so
it
is
fairly
rare
and
78
of
pregnancy
associated
deaths
typically
occur
in
our
county.
You
can
see
in
the
chart
here
the
trend
over
time.
Most
noteworthy
is
the
increase
that
we
saw
significantly
between
2019
and
2020,
where
we
went
from
21
or
a
rate
of
60
per
100
000
to
40
cases
in
2020,
with
a
rate
of
119
per
hundred
thousand.
C
C
Hispanics
had
the
lowest
pregnancy
associated
death
ratio
at
66
per
100
000
life
births,
they
accounted
for
22
percent
of
pregnancy,
associated
deaths
compared
to
36
percent
of
pregnancies
and
then
you'll
notice.
Throughout
my
presentation.
We're
suppressing
data
for
populations
with
two
too
small
accounts
to
have
any
kind
of
statistical
reliability,
so
that's
our
american,
indian
alaska,
native
population
and
anyone
who
is
reported
with
an
unknown
or
other
race
ethnicity.
C
When
we
look
at
pregnancy
associated
deaths
by
age,
you
can
see
you
know
hugely
disproportionate
ratios
in
our
individuals,
aged
40
and
older.
The
rate
for
that
group
is
405.
Nearly
per
100
000
life
births,
followed
by
35
to
39
year
olds.
We
tend
to
sometimes
combine
35
to
39
and
40
plus,
because
we
know
the
risk
factors
associated
with
that
that
age
breakout,
and
so
when
we
consider
those
in
aggregate.
C
We
can
also
look
at
the
underlying
cause
of
death
in
these
instances.
Interestingly,
in
2021
we
saw
that
the
most
common
cause
of
death
was
non-transport
accidents.
When
we
dug
a
little
bit
deeper
into
that,
we
actually
identified
that
all
of
those
non-transport
accidents
were
due
to
unintentional
drug
overdose.
C
And
now
I'm
going
to
transition
over
to
severe
maternal
morbidity.
Again
these
are
conditions
and
diagnoses
that
indicate
potentially
life-threatening
maternal
complication,
including
unexpected
outcomes
of
labor
and
delivery
that
result
in
significant
short
or
long-term
consequences
to
health.
I
did
include
a
slide
here
with
some
national
comparisons,
because
I
do
think
it's
always
good
to
have
a
benchmark,
but
the
cdc
is
a
little
bit
behind
in
in
their
national
data.
C
That's
available,
and
so
you
know
the
most
recent
date
on
this
slide
is
2014,
which
is
which
is
pretty
old,
but
I
did
include
it
because
it
does
show
a
significant
increase
in
the
10
years
nationally
that
were
shown
in
the
magnitude
of
200.
C
What's
maybe
the
biggest
takeaway
here
is
that
blood
transfusions
play
a
huge
role
in
that
and
if
we
were
actually
to
exclude
blood
transfusions
or
severe
blood
loss
or
hemorrhaging
from
severe
maternal
morbidity,
we
would
only
have
observed
a
20
increase
over
that
10-year
period,
nationally,
I'm
so
largely
driven
by
individuals
needing
blood
transfusions.
C
And
then,
although
this
is
dated
back
in
2014,
the
national
rate
for
severe
maternal
morbidity
was
144
for
10
000
deliveries
in
nevada.
We
are
only
trending
six
years
back
here,
but
if
you
compare
to
16,
which
is
the
most
relevant
compared
to
the
national
data,
nevada
actually
had
a
lower
rate
which
was
126.5.
C
C
When
we
break
this
down
by
maternal
race,
ethnicity,
we
find
similar
disparities
in
the
black
non-hispanic
group
also
for
this
indicator.
In
our
asian
pacific
islander
subgroup,
those
rates
are
279.5
per
10
000
deliveries
and
286.7
for
10
000
delivers
deliveries
respectively,
again
we're
suppressing
our
american
indian
alaska,
native
and
other
unknown
race
individuals,
because
we
just
did
not
have
statistically
reliable
information.
C
C
There
are
a
total
of
21
indicators
that
we
use
to
identify
severe
maternal
morbidity.
81
of
the
cases
represented
in
2021
had
just
one
indicator.
Present
11
had
two
indicators
present
and
eight
percent
had
three
or
more
indicators
present,
and
we
can
look
at
indicators
in
different
ways.
So
this
slide
is
looking
at
the
leading
diagnosis
based
indicators,
and
that
is
adult
respiratory
distress
syndrome.
C
C
We
found
maternal
age,
maternal
race,
ethnicity,
health,
insurance
status,
adequacy
of
prenatal
care,
charity,
method
of
delivery,
plurality
or,
if
you
have
twins
or
multiples
and
then
maternal
chronic
disease
status,
all
having
a
significant
impact
on
severe
maternal
morbidity,
and
that
is
the
end
of
my
data
presentation.
I'm
happy
to
take
questions
now
or
you
know,
at
the
leisure
of
the
committee.
A
Thank
you
so
much
miss
morgan.
Are
there
any
questions
from
the
committee
on
the
data
specifically
and
just
as
a
reminder?
We
do
have
experts
in
this
area
presenting
later
on
today
in
the
following
presentations,
and
they
may
be
able
to
answer
these
questions
either
through
their
presentation
or
in
the
question
answer
period.
I
do
not
see
anybody
raising
their
hands
for
questions
for
miss
morgan,
but
please,
if
I
miss
you
go
ahead
and
unmute
yourself
all
right,
not
seeing
any
questions.
A
A
We're
going
to
go
ahead
and
close
this
agenda
item
and
move
on
to
the
next
presentation,
which
is
under
agenda
item
5,
an
update
from
the
maternal
mortality
review
committee,
and
I
I
would
love
to
give
a
little
history
on
this,
but
I
don't
remember
the
specifics
and
didn't
get
to
dive
into
it.
I
believe.
A
In
the
last
couple
of
sessions,
we
stood
up
a
maternal
mortality
commission
to
look
at
what
were
the
causes
of
death
for
birthing
people
in
the
state
of
nevada
and
the
statistics
that
are
associated
with
those
and
then
come
up
with
some
solutions
for
us.
So
I'm
looking
forward
to
this
presentation,
seeing
what
we've
come
up
with
over
the
last
couple
of
years,
since
that
was
that
was
established,
have
with
us
today,
tammy
kahn.
D
Great,
thank
you
all
right.
My
name
is
tammy
conan.
I
am
the
section
manager
for
the
maternal
child
and
adolescent
health
section
within
the
division
of
public
and
behavioral
health.
So
thank
you
for
having
me
here
today.
I
will
be
providing
an
overview
and
an
update
for
nevada's
maternal
mortality
review
committee.
D
As
kyra
already
previously
mentioned,
within
maternal
mortality,
there
are
three
definitions
of
maternal
deaths
comprised
in
that.
D
So
pregnant
pregnancy
associated
deaths
are
the
death
of
a
person
while
pregnant
or
within
one
year
of
the
termination
of
pregnancy,
regardless
of
the
cause
and
then
pregnancy.
Related
deaths
are
the
death
of
a
person
while
pregnant
or
within
one
year,
from
the
end
of
the
pregnancy
caused
from
a
pregnancy,
complication
or
a
chain
of
events
initiated
by
pregnancy
or
the
aggravation
of
an
unrelated
condition
from
the
physiologic
effects
of
pregnancy
and
then
drill
down
even
further
is
a
maternal
death.
D
D
So
maternal
mortality
review
committees
or
mmrcs
across
the
country
review
deaths
within
one
year
of
pregnancy.
They
use
multiple
data
sources
to
obtain
the
data
with
the
goal
of
using
that
data,
to
drive
recommendations
and
actions
to
eliminate
preventable
maternal
mortality
and
to
address
disparities.
D
D
Cdc
does
work
with
mmrcs
nationwide
to
improve
the
review
processes
that
inform
recommendations
for
preventing
future
deaths
and,
like
I
said
most
states
are
moving
to
the
standardized
data
collection
system.
It's
called
the
maternal
mortality
review,
information
application,
otherwise
known
as
maria,
and
it
is
a
data
system
designed
to
facilitate
mmrc's
through
collection
of
data.
It
documents
collab
committee
deliberations
and
it
standardizes
the
data
indicators.
D
D
The
current
committee
members
for
the
nevada's
for
the
nevada
mmrc
is
dr
sandra
koch
and
she
is
the
chair,
dr
david
jackson,
erica
washington
from
make
it
work.
Nevada,
dr
james
alexander,
dr
jennifer
vanderlin
jolina
simpson,
from
the
kijiji
sisterhood,
dr
joseph
adashek,
dr
laura
knight,
melanie
rhee,
melinda,
melinda,
hoskins
and
natalie
nicholson.
D
And
then
there
is
an
additional
report
required
from
the
mmrc
biannually
and
it
is
an
even
number
of
years
it's
due
to
the
director
of
the
legislative
council
bureau
and
it
contains
incidents
of
maternal
mortality
and
severe
maternal
morbidity
during
the
immediately
preceding
24
months.
And
then
it
should
also
contain
any
recommendations
for
legislation
or
policy
changes,
and
this
is
the
report
that
truly
captures
the
recommendations
from
the
mmrc
itself.
D
So,
yes,
the
committee
was
established
in
2020,
so
we've
only
had
one
report
so
far,
which
was
in
2020,
and
then
we
will
have
an
upcoming
report
due
at
the
end
of
2022.
D
So
I
just
want
to
go
through
what
the
recommendations
were
from
that
2020
report.
So
the
committee
identified
substance
use
in
pregnancy
and
wanted
to
provide
adequate
substance,
use
treatment,
options
to
pregnant
people,
so
the
mmrc
recommended
educating
providers
on
nevada
substance,
use
disorder,
treatment,
options
that
already
exist
for
pregnant
people
and
then
removing
any
barriers
to
care.
D
So
I
did
present
to
the
gnome
advisory
committee
last
year
and
we
have
met
in
2022
and
we
are
ready
to
collaborate
on
the
2022
report.
That's
coming
up
so
future
opportunities
for
change.
Av-287
of
the
81st
legislative
session
also
made
changes
to
nrs
chapter
442
to
include
gender
neutral
language,
and
then
it
also
clarified
the
access
to
the
cancer
registry.
D
Like
I
previously
mentioned,
the
gender
neutral
language
changes
did
not
include
pregnancy
throughout
nrs,
four,
four,
two,
seven,
six
one
and
seven,
seven
four
and
those
changes
only
included
those
giving
birth
or
those
who
have
gave
birth.
So
it
would
be
important
to
add
in
the
pregnancy
language
into
that
nrs.
So
it
could
read,
persons
who
are
pregnant,
are
giving
birth
or
who
have
given
birth
as
used
elsewhere
in
ab-287.
D
And
then
I
wanted
to
provide
a
funding
update.
So,
as
many
of
you
know,
we
did
apply
for
funding
dedicated
to
our
mmrc
in
2019,
so
we
applied
for
the
enhancing
reviews
and
surveillance
to
eliminate
maternal
mortality,
a
race
mm
grant
in
2019
our
grant
application
was
approved.
However,
it
was
not
funded
at
the
time,
so
we
did
begin
our
mmrc
for
the
first
couple
years
without
any
dedicated
funding
so
july
2021.
D
We
were
notified
that
that
original
application
that
was
approved
but
not
funded,
was
being
funded,
which
was
great
news,
so
the
funding
began
late
september
2021
and
this
funding
has
allowed
us
to
hire
a
full-time
registered
nurse
abstractor.
D
Currently,
our
mmrc
just
has
one
part-time
nurse
abstractor,
and
that
does
sometimes
cause
issues
with
how
long
it
takes
to
review
cases,
as
one
case
can
take
up
to
just
20
hours
to
enter
in
the
data
into
the
application.
So
it
is
a
timely
process
and
we
want
to
make
sure
that
we
are
capturing
every
aspect
of
that
case
to
honor
that
person,
so
it
allows
our
hiring
of
a
full-time
registered
nurse
and
then
we're
also
partially
funding
a
data
evaluator
other
funding
opportunities
that
have
come
up.
D
Chronic
disease
prevention,
health
promotion
section
within
dpvh
has
provided
us
with
health
disparity
focused
funding.
This
funding
runs
from
the
beginning
of
this
year
through
may
2023,
so
this
funding
allows
for
the
hiring
of
two
mmrc
master
of
social
work
positions.
These
two
positions
will
be
conducting
informant
interviews.
Like
I
had
previously
mentioned.
The
committee
had
wanted
that
social
determinant
of
health
qualitative
data
being
collected,
so
these
informant
interviews
will
provide
just
such
rich
information
on
social
determinants
of
health
and
other
contributing
factors.
D
It'll
be
able
to
gather
anything
that
we
don't
see
throughout
medical
records,
and
I
will
just
say,
we've
been
able
to
hire
both
positions,
which
I
am
grateful
for
one
started
last
month
and
the
other
person
will
be
starting
next
week
and
we
do
have
to
create
protocols
begin
before
they
can
begin
the
informant
interviews.
But
we
will
get
there
soon.
D
Other
related
efforts
to
the
mmrc,
perinatal
quality
collaborative
so
currently
nevada
does
not
have
a
pqc.
It
could
benefit
greatly
from
having
one
it
can
be.
Another
implementing
body
for
mmrc
recommendations
serve
as
a
hub
for
our
other
program
alliance
for
innovation
on
maternal
health,
our
aim
program
and
would
work
on
other
perinatal
efforts
and
improving
birth
outcomes.
D
In
addition,
we
have
our
nevada
aim
program.
It's
a
national
data,
driven
maternal
safety
and
quality
improvement
initiative.
We
are
a
newer
aimsd
and
are
working
towards
the
fall
of
2022
launch
of
the
first
bundle,
which
is
on
severe
hypertension,
and
then
we
also
have
other
perinatal
health
initiative.
Efforts
to
address
key
contributors
to
mature
mortality
such
as
perinatal
behavioral,
health
and
here
are
just
some
resources
links.
If
you
wanted
more
information,
mine
and
vicki
ives
are
deputy
bureau
chiefs
contact
information
acronyms
and
that's
it
I'll,
be
happy
to
take
any
questions.
A
Thank
you,
miss
khan.
Are
there
any
questions
from
the
committee?
I
have
a
couple
of
clarifying
questions
and
I
believe
that
miss
gorilla
has
a
question
and
dr
titus
has
a
question.
I'm
going
to
start
with
my
clarifying
questions,
just
real
quick
while
we're
we're
fresh
with
the
information
presented.
A
First
of
all,
congratulations
on
the
new
hire
that
is
awesome
and
so
good
to
hear
we're
filming
we're
filling
state
positions.
Thank
you
so
much.
My
question
is
about
the
partially
funded
data
evaluator.
Can
you
talk
just
give
us
a
glimpse
on?
How
is
how
are
you
guys,
partially
funding
and
are
you
leveraging
with
another
entity
that
is
funding
the
other
part
of
that
data?
Evaluator
yeah.
D
Yeah
so
it'll
be
a
contracted
position
where
it
will,
just
due
to
the
amount
of
funding
we
receive
to
pay
50
of
that
position.
The
other
50
of
it
will
be
paid
through
money
from
our
alliance
for
innovation
on
maternal
health
initiative,
so
both
will
be
working.
Both
parts
of
the
funding
works
towards
mature
mortality
and
severe
maternal
morbidity,
but
it
will
be
a
50
50
split
between
the
two.
E
D
Thank
you
and
tammy
khan
for
their
record.
Yes,
you
are
correct.
The
femur
only
goes
over
one
county,
but
the
maternal
mortality
review
committee
reviews
deaths
in
the
entire
state
and
it
we
do
have
representation
on
our
committee
from
both
north
and
south
parts
of
the
state
to
make
sure
that
geographic
diversity
as
representative
great.
I
Thank
you.
Thank
you,
madam
chair,
for
the
question.
My
question
is
actually
along
the
same
lines
about
the
data
evaluator.
Looking
at
this
presentation
and
the
one
prior
we
get,
we
get
given
a
static
set
of
information
and
percent,
and
what
I'm
hoping
to
hear
next
time
or
get
some
follow-up
on.
You
is
that
in
the
previous
report,
we
had
to
click
to
clark
county.
I
There
were
36
deaths
in
2021
from
pregnancy-related
deaths
and
then
there's
several
slides
later
there
was
a
some
information
that
said:
30
of
deaths
from
pregnancy
were
drug
related
or
overdose
related,
and
I'm
just
wondering
is
that
to
assume
then
10
out
of
the
36
people
that
died
during
pregnancy
in
clark,
county
had
drug
overdoses,
and
so
could
we
tease
out
some
of
that
data,
because
what
I
really
am
interested
in
seeing
is
that
an
extraordinary
amount
of
deaths
for
women
who
are
pregnant
in
that
age
of
their
life?
What
so?
I
What
I'm
asking
is?
There's
many
different
ways:
reasons
that
we
die
pregnancy
can
be
one
of
them
associated
with
pregnancy,
but
at
that
age
group,
is
that
an
extraordinary
amount
of
women
dying,
pregnant
versus
women
dying
from
auto
accidents,
women
dying
from
accidents
at
home,
women
dying
from
overdose
that
aren't
pregnant.
I
So
I'd
like
to
see
the
spectrum
of
deaths
for
women
in
that
age
group
and
the
cause
of
their
death,
because
I'm
not
sure
that
that's
an
extraordinary
amount
of
deaths
based
on
what
what
you're
showing
me
and
how
many
people
live
in
clark
county
in
that
age
group.
So
hopefully
your
data
evaluator
can
get
more
of
a
picture
about
the
overall
death
rate
for
women
in
that
age
group.
So
thank
you,
madam
chair.
A
C
Sure
this
is
office
of
analytics.
I
can
surely
we
can
surely
get
you
that
information
on
total
debts
and
then
break
it
down
by
cause
so
that
you
can
see
kind
of
the
umbrella
that
that
falls
under.
So
we
can
provide
that
to
the
committee
as
a
follow-up.
I
Great
thank
you
because
I
really
think
that's
the
key
I
mean:
do
we
in
nevada
have
women
dying
way
over,
say
other
national
statistics
during
pregnancy
versus
maybe
that's
a
low
number.
I
mean
we
don't
want
to
see
any
woman
die
during
due
to
complications
of
pregnancy,
but
are
we
doing
good
or
are
we
not
doing
good,
and
so
I
don't
know
because
that's
just
one
point
in
time:
36
women
died
last
year
from
complications
pregnancy
in
clark
county.
I
A
C
C
Cairo
morgan
morgan
for
the
record.
I
just
want
to
clarify
that
that
number
is
statewide.
36
pregnancy
associated
debts
were
statewide,
not
specific
to.
I
Clark,
county,
okay
and
your
slide,
it
says
clark
county.
So,
on
the
what
we
got,
it
said
clark
county.
C
78
of
cairo
morgan
for
record
78
of
those
are
in
clark,
county,
okay,
very
good.
A
Thank
you.
I
also
asked
staff
to
make
sure
that
we
had
access
to
the
the
document
that
miss
morgan
had
mentioned
in
her.
In
her
presentation,
I
tried
to
click
on
the
link
and
it
seemed
broken.
So
if
you
have
problems
with
it
and
haven't
received
that
from
staff,
please
let
us
know
and
we'll
ensure
you
get,
that
maternal
mortality
and
severe
maternal
morbidity
report
from
2022
are
there
any
other
questions
from
the
committee
on
this
particular
presentation
item
go
ahead,
senator
donate.
E
Thank
you
so
much
chair,
peters
and,
of
course,
miss
khan
for
presenting.
My
question
is
in
regards
to
the
policy
recommendations
that
you
proposed.
J
J
E
D
Tammy
con
for
the
record,
I
would
not
be
able
to
answer
your
question
regards
to
what
is
required
for
nevada
licensing,
but
I
could
get
back
with
an
answer
on
that.
In
terms
of
our
committee
trains,
we
are
planning
to
provide
implicit
bias,
trainings
and
health,
equity
and
diversity
and
inclusion
trainings
for
our
committee.
A
Thank
you
for
the
question
and
I
believe
that
we
have
been
working
on
some
of
that
with
within
the
division
of
public
and
behavioral
health
and
their
licensing
division,
and
I'm
I'm
gonna,
ask
staff
if
we
have
anybody
who
potentially
is
coming
up
and
to
present
later
today
if
they
might
be
able
to
answer
that
question,
but
I
do
believe
that
there
are
existing
requirements
for
cultural
competency,
training
for
certain
environments,
but
I'm
not
sure
how
broad
that
is
or
how
specific
it
is
to
the
perinatal
space.
A
A
B
Eric
robbins
from
lcb
legal,
I
just
wanted
to
correct
something
that
I
said
about
r013-21.
B
That
regulation
has
indeed
been
adopted
by
the
board
of
pharmacy.
However,
I
had
thought
that
it
had
been
heard
by
the
legislative
commission
and
approved
it
has
not.
It
will
be
on
the
next
agenda
for
the
legislative
commission,
which
is
on
june,
10th
is
when
they're
scheduled
to
meet
so
the
the
regulation
is
not
currently
effective
and
has
not
been
approved
by
the
legislative
commission.
A
Thank
you
so
much
well
we're
under
this
agenda
item
I
know
miss
dr
titus
had
a
question,
so
please
go
ahead
with
your
question
and
we
we
may
have
to
try
and
queue
up
the
folks
who
can
answer
this
question.
I
And
thank
you,
madam
chair
I'll,
reach
out
to
them
after
this
meeting,
but
just
for
for
legal.
So
just
for
my
understanding,
if
it's
been
adopted,
they
can't
enforce
it
or
it's
not
an
official
regulation
until
ledge
com
approves
it
is
that
correct.
B
Yes,
that
is
correct.
The
the
regulation
does
not
become
effective
until
it's
approved
by
the
legislative
commission,
and
the
legislative
commission
does
sometimes
send
regulations
back
to
the
agency
for
further
amen.
Further
changes.
I
A
Thank
you,
dr
titus,
all
right,
we're
gonna
and
unless
there
are
other
questions
that
I
did
not
get
to
we're,
gonna
go
ahead
and
move
on
to
another.
Our
next
agenda
item,
I'm
closing
agenda
item
three
and
moving
on
to
agenda
item
six.
This
is
a
presentation
on
the
access
to
maternal
care
and
related
expansion
of
medicaid
coverage
for
women.
H
Good
morning,
chair
peters
members
of
the
committee
and
committee
staff,
for
the
record,
I
am
dr
antonina
capuro
and
I
serve
as
the
deputy
administrator
within
the
division
of
healthcare
financing
and
policy.
We've
had
a
small
change
in
our
presenters
this
morning,
miss
aaron
lynch
is
unable
to
join
us
due
to
an
illness.
We
send
our
thoughts
for
speedy
request
recovery
in
her
place.
I'm
joined
today
by
miss
breeza
virgin,
who
is
the
social
services
chief
one
within
the
medical
programs
unit
of
our
division.
H
H
So
we
have
a
brief
presentation
this
morning
and
we'll
be
discussing
statistics
and
covered
services.
We'll
then
move
into
implementation
of
bills
from
the
81st
legislative
session
that
center
on
maternal
child
and
adolescent
health
and
then
provide
policy
recommendations
for
future
consideration
next
slide.
H
H
H
H
So
turning
back
to
births,
as
I
mentioned,
nevada
funds
55
of
the
births
in
the
state,
I'm
sorry
medicaid
funds,
55
percent
of
nevada's
person
in
our
state
and
we're
actually
higher
than
the
national
average
so
nationally
medicaid
covers
42
of
the
births
in
the
nation,
and
what
we've
illustrated
here
is
just
how
we
have
variations
in
region
for
that
coverage.
H
So
this
illustrates
this
is
this:
is
some
of
the
data
that
we
take
into
consideration
when
we're
making
policy
decisions
and
when
we're
working
to
improve
maternal
and
child
health
next
slide.
H
So
I'd
now
like
to
turn
the
presentation
over
to
miss
barissa
virgin
and
miss
lisa
suarenjen,
who
provide
information
on
medicaid's
maternity
care
services
and
implementation
activities
for
our
maternal
child
health
bills.
From
the
previous
legislative
session.
G
Thank
you,
dr
caprero.
Brisa
virgin
for
the
record.
Nevada
medicaid
covers
medically
necessary
services
that
are
within
the
state
plan.
Some
maternity
care
services
are
listed
in
these
next
two
slides,
but
the
list
is
not
all
inclusive
maternity
care.
Services
may
be
provided
by
a
physician,
physician
assistant,
nurse,
midwife
or
advanced
practice
registered
nurse.
G
These
services
may
include
prenatal
visits,
lab
work,
imaging
postpartum
visits,
pregnant
women
with
medicaid
maintain
eligibility
until
60
days
after
the
pregnancy
ends,
labor
and
delivery
in
the
in
multiple
settings,
so
hospitals,
home
births
and
freestanding
birthing
centers,
a
freestanding
birthing
center
is
a
facility,
that's
not
part
of
a
hospital,
and
it
provides
services
for
normal
uncomplicated
births,
both
home
and
freestanding
birthing
center
births
are
appropriate
for
recipients
with
low
risk
pregnancies
intended
vaginal
deliveries
and
no
reasonable,
no
reasonably
foreseeable
expectation
of
any
complications
and,
of
course,
anesthesia
services.
G
The
link
that
you
find
at
the
bottom
of
the
slide,
that
is,
a
link
to
our
recipient
booklet-
and
this
is
this-
is
a
booklet
that
we
update
and
we
are
currently
working
on
updating
to
include
the
new
services
that
nevada
medicaid
covers,
and
but
this
is
a
booklet
that
we
do
share
with
recipients
out
there
in
the
community
next
slide.
Please.
G
Additionally,
we
for
coverage
services.
We
offer
one
of
our
newest
services
that
we
cover
is
doula
services,
and
this
is
and
I'll
get
I'll
go
further
into
the
details
of
this.
But
this
was
passed
in
the
81st
legislation
by
ab256
and
so
doulas.
This
new
provider
of
doula
and
doula
services
became
effective
april.
1St
2022,
with
nevada
medicaid,
so
abdullah
is
a
non-medical,
trained
professional
who
provides
education,
emotional
and
physical
support
during
pregnancy,
labor,
delivery
and
postpartum
period.
G
G
Community
health
workers
are
trained,
public
health,
educators,
improving
healthcare
delivery,
requiring
integrated
and
coordinated
services
across
the
continuum
of
health,
community
health
workers
provide
recipients
culturally
and
linguistically
appropriate
health,
education
related
to
disease
prevention
and
chronic
disease
management.
To
better
understand
their
condition,
responsibilities
and
health
care
options.
G
Additionally,
we
have
dental
services
during
the
prenatal
period
that
we
cover,
and
these
can
include
cleanings
prevented
preventive
care
and
restorative
care.
Behavioral
health
services,
including
substance
use
during
pregnancy,
non-emergency,
medical
transportation
to
medicaid
coverage
services
and
emergency
transportation.
Again,
all
these
are
this
list
of
services
is
not
all-inclusive
next
slide.
Please.
G
This
bill
becomes
effective
july,
1st,
2022
and
medicaid,
and
it
contains
two
components.
The
first
one
is
medicaid
presumptive
eligibility
for
pregnant
women
as
determined
by
a
qualified
provider.
G
This
is
this.
Bill
is
requiring
a
state
plan
amendment,
and
so
both
the
division
of
health,
care
financing
and
policy
and
the
division
of
wealth
and
supportive
services
are
working
together
to
to
create
that
state
plan
amendment
and
to
submit
to
cms
for
review
and
approval
next
slide.
Please
assembly
bill
191.
G
This
is
again.
This
is
the
bill
that
allowed
nevada
medicaid
to
create
a
new
provider
type,
which
is
community
health
workers,
provider
type,
89
and
and
their
services,
and
this
policy
again
became
effective
with
nevada
medicaid
under
medicaid
services,
manual,
chapter
600,
physician
services,
as
of
february
1st
2022.
G
Additionally,
there
is
the
link
to
the
web
announcement
that
nevada
medicaid
provide
issued
in
february,
which
provides
which
allows
providers
some
information
and
guidance
to
how
to
enroll
with
nevada
medicaid,
as
well
as
as
well
as
trainings
that
were
available
as
offered
by
nevada,
medicaid
and
also
some
billing
guidelines,
and
we
are
currently
working
with
with
cms,
so
the
centers
for
medicare
and
medicaid
services
on
the
state
plan
amendment.
We
continue
to
work
with
them
on
that.
G
Some
of
the
covered
services
that
community
health
workers
offer
is
guidance
in
attaining
health
care
services,
identifying
recipient
needs
and
providing
an
education
from
prevent
from
preventive
health
services
to
chronic
disease,
self-management,
information
on
health
and
community
resources,
connect
recipients
to
preventive
health
services
or
community
services,
to
improve
health
outcomes
and
promoting
health
literacy.
These
are
just
some
of
the
services
next
slide.
Please
assembly
bill
256.
G
This
again,
this
bill
passed
our
lady
first
legislative
session
and
this
allowed
nevada
medicaid
to
create
another
new
provider
type,
which
is
doulas
provider
type
90.,
and
this
policy
also
resides
under
medicaid
services,
manual,
chapter
600,
physician
services
and
it
became
effective
april
1st
2022.
G
again.
There's
the
link
to
the
web
announcement
that
was
issued
in
april
that
again
provides
billing
and
provider
enrollment
guidance
and
again
we
are
working.
We
continue
to
work
with
cms
on
that
approval
of
that
state
plan
amendment
we
also
as
part
of
this
as
part
of
this
dhcfp
partnered,
with
the
nevada
certification
board
and
and
the
nevada
certification
board
has
has
agreed
to
become
nevada's,
doula
certification
body
and
the
hyperlink.
G
There
will
actually
take
you
to
their
website
to
the
dual
certification
website
of
the
board
and
what
they
did.
The
nevada
certification
board
is
that
they
put
out
a
request
for
professional
doulas
to
submit
applications
and
off
of
those
all
those
applications
that
they
received.
They
selected
a
group
of
professional
doulas
to
be
the
advisory
group.
This
advisory
group
started
meeting
in
january
of
2022
and
they
they
were
meeting
frequently
and
they
were
really
working
on
developing.
G
You
know
what
the
requirements
would
be,
that
the
board
would
require
so
what
skills
and
what
trainings
the
doulas
must
have
in
order
for
the
nevada
certification
board
to
certify
them
in
nevada,
and
so
they
began
accepting
applications
as
of
april
1st
2022,
which
aligned
perfectly
with
when
our
policy
effective
date
began.
Doulas
provide
emotional
support.
G
They
provide
physical
comfort
measures
during
labor
and
delivery.
They
facilitate
access
to
resources
to
improve
health
and
birth,
related
outcomes
and
doulas
provide
evidence-based
education
and
guidance
such
as
general
health
practices,
newborn
health
and
behavior
and
other
a
multitude
of
things.
Of
course.
Next
slide.
Please.
G
Thank
you
so
senate
bill
420,
this
senate
bill
contained
several
components,
but
I
will
mention
before
specifically
that
that
allowed
nevada
medicaid
to
include
in
the
state
plan
some
these
maternal
child
health
services,
but
it
is,
it
is
to
the
extent
funding
is
available.
That
is
the
language
in
the
bill.
So
the
first
one
is
the
medicaid
expansion
for
pregnant
women
by
increasing
the
federal
poverty
limit
from
160
to
200
percent.
G
G
Secondly,
increasing
the
reimbursement
rates
for
advanced
practice
registered
nurse,
which
are
our
provider
type
24s
certified
nurse
midwives,
which
are
provider
type
74s
to
be
equal
and
pay
to
physicians,
which
are
provider
type
20..
This
would
allow
equal
pay
for
equal
work
and
it
improves
access
to
care.
G
Aprns
can
fill
the
gap
as
there
are
not
enough
providers
nor
specialists
that
accept
that
they're
able
to
take
medicaid
at
the
time
and
then
the
third
one
is
creating
a
new
provider
type
for
for
international
board,
certified
lactation
consultants,
and
these
are
non-physician
health
care
professionals,
but
also
adding
coverage
for
breast
pumps
and
supplies.
G
Breast
milk
provides
a
baby
with
the
ideal
nutrition
and
supports
growth
and
development
and,
of
course,
breastfeeding
can
also
help
protect
baby
and
mom
against
certain
illnesses
and
disease
and
diseases,
and
fourth,
is
adding
non-invasive
prenatal
screens
as
a
coverage
service.
G
G
Medicaid
does
currently
cover
the
first
trimester
second
trimester
screening,
which
includes,
which
includes
these
are
technical
terms,
but
trisomy
18,
which
is
like
edward
syndem
syndrome
and
trisomy
21
down
syndrome,
whereas
nips
covers
these
in
addition
to
trisomy
13,
which
is
the
patel
syndrome,
along
with
sex
chromosomal
abnormalities,
so
nips
is
recommended
by
the
american
college
of
obstetricians
and
gynecologists
acog
as
one
of
the
options
for
prenatal
screenings
as
well.
Next
slide,
please.
H
We've
included
this
slide
in
the
policy
recommendations
section
as
the
division
recognizes
the
value
and
the
importance
in
implementing
these
services
should
budgetary
authority
be
available
in
the
next
legislative
session.
So
this
is
just
a
mirror
image
of
those
items
that
we
discussed
previously
next
slide.
H
So,
following
the
model
of
health
assessments
before
school
entrance
policies
in
other
states,
this
requirement
could
be
incorporated
into
a
broader
policy
that
includes
the
completion
of
a
medical,
mental
health
and
dental
screening
before
school
entrance
by
a
medical
or
dental
personnel
outside
of
the
school
and
as
listed
here.
Some
of
the
benefits
of
this
policy
concept
may
include
increased
access
to
health
care
for
students
that
may
result
in
better
attendance
and
more
engagement
in
learning
a
possible
cost
savings
measure
for
school
districts
by
allowing
the
nursing
staff
to
be
redistributed.
H
As
a
result
of
completing
the
current
health
screenings
by
community
providers
and
establishing
medical,
dental
and
mental
health
homes
for
students
next
slide,
and
our
last
policy
recommendation
is
a
12-month
continuous
coverage
policy,
the
american
rescue
plan
act
of
2021
has
established
a
new
state
option
that
extends
medicaid
and
chip
health
insurance
program
coverage
for
pregnant
women
for
one
year
following
a
baby's
birth.
So
under
current
law,
medicaid
and
our
children's
health
insurance
program
pregnant
women's
coverage
ends,
or
it
only
extends
until
60
days
postpartum.
H
So,
as
you
can
see
here,
this
was
went
into
effect
april,
1st
2022
and
it
extends
through
march
31st
2027
when
the
current
statutory
authority
for
this
extended
postpartum
coverage,
option
would
expire,
but
our
centers
for
medicaid
medicare
strategies
has
indicated
they
will
work
with
states
to
identify
other
options
to
maintain
this
extended
postpartum
coverage.
H
A
Thank
you
so
much
for
the
presentation
I
have
vice
chair
donate,
I
believe,
had
a
question
for
you.
Please
go
away!
No,
not
this
one,
all
right!
Sorry,
my
my
fault.
Are
there
any
questions
from
the
committee
on
this
presentation.
A
I
appreciate
you
coming
with
policy
recommendations
and
I
look
forward
to
continuing
having
conversations
around
the
funding
mechanism.
This
is
you
know.
A
We
are
not
limited
to
policy
bills
in
this
committee,
but
vetting
those
those
fiscal
asks
are
are
difficult
to
do
under
a
policy
lens,
so
I
think
we
we
could
consider
some
of
those,
but
we
also
need
to
to
digest
and
look
at
the
fiscal
imp
implications
and
where
those
would
come
from,
but
I
think
we
we
have
the
capacity
to
to
look
into
those
over
the
next
month
or
so
before
we
work
session
our
bdr
options.
I
No
just
a
follow-up
comment
on
that,
madam
chair
and
I
agree
having
you
know.
Both
of
us
has
sat
on
this
committee
for
a
long
time,
and
certainly
in
sessions
for
a
number
of
times,
and
it's
not
against
our
purview
to
put
through
a
policy,
and
then
we
see
if
it
goes
to
gets
a
fiscal
note
on
it
or
not.
A
That
is
correct.
That
is
correct,
and
I
think
that
through
medicaid,
because
some
of
these
are
extensions
of
programs
that
you
were
asked
to
implement
without
funding
last
cycle
would
be
interesting
to
see
if
you're
able
to
build
those
into
budgets
or
not
and
where
we
need
to
look
for
for
what
the
state
match
or
other
funding
mechanisms
may
look
like
so
look
forward
to
continuing
those
conversations.
A
Are
there
any
other
questions
for
medicaid?
On
this
particular
presentation,
I
have
others
related
to
some
of
the
work
being
done
around
evidence-based
services
and
care
and
continuity
of
care,
but
I'm
gonna
take
those
offline
with
you
all
and
see
where
we're
at
with
some
of
those
discussions
all
right.
Thank
you
so
much
dr
caprero
and
other
folks.
I
really
appreciate
you
being
here
for
the
committee
and
presenting
on
this
topic
area.
A
I
wanted
to
go
back
real,
quick,
so
we're
going
to
go
ahead
and
close
this
agenda
item
and
go
back
real,
quick
to
vice
chair
donate's
question
about
cultural
competency,
training
for
medical
providers,
our
legal
staff,
mr
robbins,
has
a
response
to
where
some
of
the
regulations
are
at.
Regarding
that
issue,.
B
Yes,
eric
robbins
lcb
legal
for
the
record,
so
there
are
kind
of
two
sets
of
requirements
I
want
to
talk
about.
The
first
is
nrs
449.103,
which
requires
cultural
competency,
training
for
employees
of
any
facility
licensed
pursuant
to
chapter
449.
So
that's
going
to
be
your
medical
facilities
and
facilities
for
the
dependent,
and
that
was
enacted
by
senate
bill
364
and
senate
bill
470
in
2019
and
pursuant
to
that,
the
department
of
health
and
human
services
adopted
regulation,
r016-20
and
sections
14-18
of
that
regulation
prescribed
the
cultural
competency
requirements.
B
The
other
requirement
I
wanted
to
highlight
was
from
assembly
bill
327
of
2021,
which
requires
mental
health
providers
and
nurses
to
receive
cultural
competency
training.
So,
specifically,
that's
going
to
be
psychiatrist,
physician
assistant,
serving
under
a
psychiatrist,
nurses,
psychologists,
social
workers,
marriage
and
family
therapists,
clinical
professional
counselors
and
behavioral
analysts,
and
they
would
have
to
receive-
or
they
have
to
receive
cultural
competency
training
as
part
of
their
continuing
education
for
renewing
their
license.
A
Thank
you
so
much,
mr
robbins,
and
I
think
that
the
standards
and
curriculum
for
those
training
programs
are
have
have
been
developed
or
are
in
the
development
process
and
being
negotiated
with
the
higher
ed
institutions
who
would
train
in
those
areas
so
vice
chair
donate.
Do
you
have
any
follow-up
questions
on
that
particular
item
before
we
go
ahead
and
move
on
to
our
next
agenda
item.
A
K
Thank
you.
I
just
I
just
had
a
follow-up
to
that.
I
have
heard
some
concerns
from
the
rural
communities
about
the
accessibility
of
the
training.
I
think
you
just
stated
that
the
higher
ed
would
kind
of
be
involved,
and
so
I
just
want
to
make
sure
that
we're
not
adding
an
additional
burden
of
you
know
days
of
travel,
we're
already
understaffed
in
the
rurals,
and
so
I
just
want
to
make
sure
that
there's
going
to
be
some
accessibility
to
the
rural
communities
for
this
training.
A
Thank
you
so
much
for
bringing
up
that
point
and
I
do
believe
that
that's
been
considered,
but
I
am
not
in
the
position
of
promulgating
those
regulations
and
developing
those
curriculums
and
process.
So
I
can
connect
you
or
have
staff
connect
you
with
the
folks
at
public
and
behavioral
health
who,
I
believe,
are
working
on
those
regulations,
but
I
do
believe
that
options
for
virtual
meetings
are
available.
I
I'll
just
add
that
I've
asked
that
question
many
times
making
sure
through
the
health
care
that
it's
online
and
even
last
time
when
we
met,
I
was
concerned
about
some
of
these
regulations
and
access,
and
they
assured
me,
I
think,
with
the
speech
pathologist
regulations,
I
said,
are
you
working
on
templates,
and
so
I
think
most
of
this
much
of
this
can
be
online,
and
and
so
it's
really
up
to
the
boards
that
are
requiring
this-
make
sure
their
members
have
it
online.
As
far
as
I'm
concerned.
A
A
A
Dr
hardy,
can
I
can
I
come
back
to
you
post
with
this
response,
or
do
you
have
a
comment
that
may
integrate
with
this
issue?
It.
E
May
integrate?
Okay,
please
go
ahead.
I
was
I
wanted
to
clarify
quote
it's
in
law,
but
until
the
regulations
take
place,
are
they
not
responsible
for
abiding
by
the
regulation?
Therefore,
the
law.
A
I'm
going
to
let
our
legal
staff
answer
that
question.
Mr
robbins,
please
go
ahead.
B
So,
with
regard
to
the
requirements
for
the
cultural
competency,
training
of
people
in
medical
facilities,
those
requirements
they're
in
law,
but
they
are
in
a
regulation
that
has
been
adopted
and
is
effective,
so
they
do
have
to
comply
with
those
requirements.
E
B
L
L
The
regulations
were
adopted
and
passed
by
the
state
board
of
health
in
2020
and
that
training
has
been
going
on
since
that
time.
There
are
currently
four
providers
that
are
available
to
anyone
in
the
state
to
take
that
training
and
that
can
be
found
on
the
department
of
health
and
human
services
hcqc
website,
including,
as
legal
said,
the
the
ability
and
the
avenue
to
apply
for
additional
trainings
to
be
approved
under
the
nr,
not
interest,
sorry
ab327,
those
regulations
are
still
being
developed,
and
so
that
is
not
been
completed
at
this
time.
L
L
This
training
is
provided
to
any
state
employee
at
no
cost
to
them,
so
anyone
from
the
state
can
take
that
training
that
meets
the
requirements
of
nrs449
as
well
as
327,
because
in
the
law
about
327
it
says
that
nrs449
will
cover
and
meet
the
requirements
for
that
and
in
looking
at
the
regulations
that
just
were
proposed
for
the
psychological
board.
That
also
includes
training
that
is
approved
for
449
will
also
meet
their
requirements,
so
all
of
these
avenues
have
been
sort
of
covered
already
and
that
training
is
available
and
online.
E
So
I
get
a
mixed
message
here.
I
hear
the
words
things
are
covered,
but
are
they
required
by
everybody
whether
or
not
they're,
in
a
hospital
setting
before
the
regulation,
or
is
the
regulation
still
pending
in
some
instances
and
therefore
they're
not
responsible
for
it
until
the
regulation
passes
everywhere
to
everybody.
B
So
the
regulation
for
medical
facilities
and
facilities
for
the
dependent
under
449
has
been
adopted
and
approved,
so
the
requirements
for
that
they're
effective.
They
apply
to
everyone,
so
everyone
who
works
in
a
medical
facility
or
a
facility
for
the
dependent
currently
has
to
take
this
cultural
competency
training
the
ab327
requirements.
B
As
mr
caferetta
said,
those
are
still
being
adopted
by
the
various
licensing
boards,
and
so
those
are
our
requirements
for
mental
health
providers
to
take
cultural
competency
as
part
of
their
continuing
education,
and
so
those
are
are
not
effective
yet
and
those
people
don't
currently
have
to
comply
with
them.
L
I
I
However,
what
about
the
rest
of
us
that
aren't
state
employees
that
we
are
mandated
to
do
this,
and
is
there
a
waiting
period
I
mean
just
have
so
you
can
sign
up
online,
so
that
would
so
fortu.
Hopefully
those
in
the
rules
can
sign
up
in
line,
but
what
would
be
the
cost
to
the
average
person?
That's
one
of
these
professionals
that
has
to
get
this
done.
L
Thank
you
for
the
question.
This
is
jay
cafarada
again,
so
currently
the
training
is
nine
hours
long.
It
is
available
asynchronously.
So
that's
for
anyone.
The
cost
is
one
hundred
dollars
which
is
about
eleven
dollars
an
hour
for
ceu.
L
L
When
you
look
at
327,
those
are
by
the
different
boards
and
those
requirements
are
by
each
board,
depending
on
whatever
they
decide
is
going
to
be
required.
Both
laws
well,
no
for
327,
says
a
minimum
of
two
hours.
It
doesn't
add
any
length
of
time
or
how
how
long
it
has
to
be,
but
it
does
have
a
set
of
topics
that
must
be
covered
and
in
327
it
adds
two
additional
groups
of
people
over
the
number
of
people
that
are
under
449
and
those
are
veterans
and
people
with
mental
illness.
L
L
L
It's
not
intended
to
just
be
a
check
the
box,
it's
intended
to
actually
change
behavior,
and
so,
when
we
look
at
adult
learning
principles,
we
understand
that
you
cannot
be
led
to
change
your
behavior
in
a
two-hour
period
and
cover
all
of
these
topics.
You,
you
can't
even
read
the
the
law
in
two
hours
and
cover
all
the
things
that
are
under
449.
A
I
appreciate
the
interest
in
this
topic
area
and
I
think
yeah.
No,
I
think
it's
it's
a
little
bit
of
a
tangent
for
today,
but
very
important,
and
especially
in
this
area,
where
we
are
understanding
the
really
dynamic
relationship
that
the
healthcare
industry
has
with
our
our
cultural
and
societally
encouraged
biases,
and
how
do
we
break
those
down?
So
I
appreciate
the
work
you
guys
have
been
doing
and
I
appreciate
the
interest
from
our
providers
who
who
are
responsible
for
taking
this
training.
A
As
a
side
note,
I
don't
work
in
the
health
care
industry.
I
work
with
potentially
hazardous
materials,
and
I
have
to
take
a
40-hour
initial
training
for
hazardous
material
handling
and
an
eight-hour
training
annually
after
that.
So
I
don't
think
that
this
is
too
much
for
professional
expectation
for
education
but
appreciate
the
interest
and
can,
if
you
would
like
to
continue
this
offline,
I
would
encourage
that
all
right
we're
going
to
go
ahead.
Thank
you.
So
much.
E
E
A
Thank
you
for
the
comment
we
did
just
for
the
record
say
at
a
minimum
of
two
hours
in
the
legislation,
so
it
does
not
exceed
that
to
to
the
extent
of
not
being
what
our
intention
was,
I'm
going
to
go
ahead
and
move
on
from
this
particular
item.
We
can,
if
you
have
additional
questions
or
comments,
please
feel
free
to
reach
out
to
public
and
behavioral
health
hq
seek.
Is
it
cq
hcqc
acronym
central
you
guys
and
and
discuss
with
them
the
expectations
for
for
that
training?
A
Also,
as
we
start
to
integrate
more
of
the
understanding
of
cultural
competency,
just
societally,
we
may
need
less
training,
as
people
just
inherently
understand
the
needs
of
a
diverse
body
of
people
such
as
we
have
in
the
state
of
nevada.
Okay,
we're
going
to
move
on
to
our
next
agenda
item,
which
I
believe
is
seven
great,
we're
on
agenda
item,
seven
rates
of
cannabis
and
illicit
substance,
use
during
pregnancy
and
neonatal
abstinence
syndrome
and
the
implications
on
child
welfare.
A
F
Great,
thank
you
so
much
okay.
Good
morning
my
name
is
alexia
benshuf.
I
am
the
bureau
chief
for
the
office
of
analytics
and
I'm
with
the
department
of
health
and
human
services
with
the
state
of
nevada.
Today,
I'm
going
to
be
presenting
on
prenatal
substance
and
marijuana,
cannabis
use,
neonatal
abstinence
syndrome
and
child
welfare
impacts.
F
To
begin
I'd
like
to
provide
some
background
data
on
self-reported
substance
use
in
the
general
population,
the
national
survey
of
drug
use
and
health
collects
self-reported
substance,
use
from
americans,
age,
12
and
older
and
for
a
question
asking
respondents
if
they
used
any
substances
within
the
last
30
days
in
2020,
13.5
percent
of
national
respondents
reported
using
illegal
drugs.
11.8
percent
reported
using
marijuana
and
1.9
reported
misusing
prescription
drugs
in
nevada.
The
behavioral
risk
factor
surveillance
system
collects
self-reported
substance,
use
for
citizens
aged
18
and
older.
F
It
asks
a
similar
question
to
find
out
if
respondents
have
used
any
substances
within
the
last
30
days
to
feel
good
or
get
high
in
2020
in
nevada.
According
to
the
brfss,
2.9
percent
of
respondents
reported
using
illegal
drugs,
which
is
lower
than
similar
national
data
and
19.4
percent
of
respondents
reported
using
marijuana,
which
is
higher
than
similar
national
data
and
just
0.8
reported
misusing
prescription
drugs.
F
F
Data
related
to
self-reported
substance
use
during
pregnancy
is
available
from
the
nevada
electronic
birth
registry
system,
and
self-reported
data
from
the
birth
record
may
be
under-reported
because
of
stigma
and
legal
implications,
and
so
for
context
out
of
33
139
births
in
2021.
Just
three
percent
of
mother's
reported
substance
use
before
we
get
into
the
data
slides.
There
are
a
few
definitions.
I'd
like
you
to
be
aware
of.
F
Select
substances
include
alcohol,
heroin,
marijuana,
cannabis,
methamphetamines,
opioids,
excluding
heroin
and
poly
substance
use,
whereas
illicit
substances
include
cocaine,
heroin,
methamphetamines,
opioids,
poly,
substance
use
and
other
unknown
illicit
drug
use,
and
in
this
category,
marijuana
cannabis
is
not
included.
F
Some
prenatal
substance
use
data
are
broken
down
by
geographical
region,
which
you'll
see.
I
just
want
to
point
out
that
these
regions
match
those
of
the
nevada,
regional
behavioral
health
policy
board
which
are
washoe
northern
rural,
southern
and
clark,
and
you
can
see
that
specific
counties
are
included
in
various
regions
and
just
want
to
point
out
that
the
southern
region
does
not
include
clark
county.
F
F
F
Most
recently
in
2021
they
had
a
rate
of
12.0
per
1000
live
births
and
in
2021
clark,
county
had
the
lowest
rate
of
6.7
per
1000
live
births,
and
just
a
reminder
that
illicit
substance
use
does
not
include
self-reported
marijuana
or
cannabis
use.
F
Now,
moving
over
to
prenatal
marijuana
use,
we
can
see
that
rates
of
self-reported
prenatal
marijuana
used
have
grown
statewide.
Since
legalization.
We
can
see
in
2021
that
the
regions
of
washoe,
southern
and
northern
had
higher
rates
of
self-reported
use
and
clark
county
had
the
lowest
rate
of
self-reported
use,
but
growth
is
seen
across
all
regions
in
nevada.
F
F
The
centers
for
disease
control
prevention
report
that
the
number
of
babies
born
with
neonatal
abstinence
syndrome
is
increasing
nationally
between
2010
and
2017..
Nationally,
it
increased
by
82
percent
and
increases
were
seen
for
nearly
all
states
and
demographic
groups
and
comparatively
in
nevada.
The
number
of
babies
born
with
nas
increased
by
152
in
that
same
time,
range
I'd
like
to
briefly
touch
on
the
methodology
we
use
in
nevada
for
identifying
infants
with
nas.
We
look
at
inpatient
hospital
billing
data.
F
F
F
F
The
number
of
substance
exposed
infants
reported
to
cps
agencies
in
nevada
has
increased
from
2016
to
2021
by
80
percent.
Although
the
number
of
infants
screened
in
for
further
cps
involvement
decreased
from
2018
to
2021,
and
this
is
likely
due
to
changes
in
screening
practices
after
plan
of
care
regulations
were
implemented
in
nevada.
F
Most
infants,
screened
in
for
a
cps
investigation,
were
determined
to
be
safe
with
their
family
of
origin.
This
is
an
average
of
72
percent
of
infants
between
2016
and
2021..
This
means
that
the
cps
case
can
close
and
that
further
child
welfare
agency
involvement
is
not
necessary.
F
A
F
A
A
K
Thank
you,
madam
chair,
and
I
I
might
have
a
couple
of
questions.
If
you
indulge
me,
my
first
question
is:
are
we
trying
to
do
any
education
for
upcoming
mothers
on
the
effects
of
marijuana
use
during
pregnancy,
mainly
for
preventative
measures.
A
Miss
ben
schuff:
are
you
available
to
answer
that
question?
Do
you
have
comments
on
that.
F
So
alexa
been
chief
office
of
analytics
for
the
record
again.
This
is
something
that
that
we
can
consult
with
program
staff
and
and
others
in
health
and
human
services,
and
we
can
get
back
to
you.
K
Okay
and
then
my
my
other
question
in
that
regards
is:
are
there
any
warning,
labels
on
the
marijuana
products
similar
to
tobacco
and
alcohol,
to
warn
people
of
the
potential
side
effects
of
use
during
pregnancy.
A
I'm
asking
our
legal
staff
to
look
at
what
we
put
in
the
rig
the
the
law
for
recreational
on
what
has
to
be
included
on
those
labels,
because
we
have
may
have
included
that
on
there.
I
think
that
our
provider
may
also
be
interested
in
answering
these
questions,
as
they
would
be
more
face
forward
with
patients
potentially.
So
I
think,
if
you
want
to
hold
on
to
those
questions
for
our
next
presentation
under
this
particular
agenda
item
that
might
be,
they
may
be
able
to
help
you
with
those
questions.
K
A
A
E
M
Wonderful,
you
know
I
was
seeing
a
challenge
prior
to
presenting
presenting,
so
I've
asked
andrea,
peterson
who's,
presenting
subsequently
to
me
to
have
it
ready
andrea.
Will
you
be
able
to
get
that
pushed
through.
N
Okay,
just
tell
me
when
to
advance
wonderful.
M
Thank
you
so
much.
I
love
technology.
I
love
to
take
care
of
babies.
More
importantly,
so
I'm
very
happy
and
and
very
thankful
for
having
this
opportunity
to
talk
about
something
that
clearly
is
becoming
a
huge
challenge
in
our
community.
I've
been
asked
to
talk
about
breastfeeding
and
cannabis
use
in
the
nicu,
but
yes,
I'd
be
happy
to
talk
about
the
nas,
because
that
is
a
significant
component
of
some
of
these
challenges.
M
As
mentioned,
my
name
is
deepa
nagar.
I
am
the
nicu
medical
director
and
the
chair
of
pediatrics
at
saint
rossian
hospital.
It
is
a
non-profit
hospital.
I
am
a
corporate
director
for
pediatrics
group,
which
provides
services
for
the
nicu
care
in
the
state
in
every
hospital
in
the
state,
except
for
umc
and
recently
we
have
started
within
our
own
group,
a
neonatal
collaborative
group
to
look
at
how
we
can
do
a
cohesive
presentation
of
care
across
the
state-
and
I
am
the
chair
for
that
committee
next
slide.
M
So
before
presenting
some
of
our
data,
I
wanted
to
really
first
talk
about
what
are
the
recommendations
for
the
different
committees
that
are
out
there.
What
are
the
different
recommendations
across
the
country
so,
from
a
cdc
point
of
view,
use
of
marijuana
in
any
form,
edibles,
oils
etc,
while
breastfeeding
can
allow
harmful
chemicals
to
pass
from
the
mother
to
the
infant
through
breast
milk
or
second
smoke
secondhand
smoke
exposure
to
limit
the
potential
risk
to
the
infant
breastfeeding.
Mothers
should
be
advised
not
to
use
marijuana
or
products
containing
cbd
in
any
form.
M
Cbd
contains
contaminants
potentially
like
pesticides.
Heavy
chemicals
heavy
metals
gives
me
bacteria
fungus
and
can
be
dangerous
both
to
the
mom
and
the
infant
data
on
the
effects
of
marijuana
and
cbd.
Exposure
to
the
infant,
though
through
breastfeeding
are
limited
and
unfortunately
conflicting
and
that's
been
one
of
our
major
challenges.
M
Fda
also
has
similar
recommendations,
but
it
really
uses
stronger
words
like
fda
strongly
advises
that
during
pregnancy
and
while
breastfeeding
mothers
should
avoid
using
cbd,
thc
marijuana
or
in
any
of
these
forms.
The
u.s
surgeon
general
says
that
marijuana
used
during
pregnancy
may
affect
the
fetal
brain
thc
can
enter
the
enter
the
fetal
brain
through
the
mother's
breast
milk.
This
is
during
pregnancy
may,
increase
the
risk
of
newborn
with
low
birth
weight,
may
increase
risk
of
premature
birth
and
potential
stillbirths.
M
This
is
one
of
the
challenges
that
we
are
presented
with,
with
the
information
so
other
than
the
one
approved
prescription.
Drug
cbd
products
have
not
been
evaluated
or
approved
by
the
fda
for
use
as
drug
products.
This
means
fda
states
if
they
they
do
not
know
if
they
are
safe
and
effective
to
treat
a
particular
disease.
M
What
if
any
dosage
may
be
considered
safe
how
they
could
interact
with
other
drugs
or
foods
or
whether
they
can
be
dangerous
and
have
side
effects
that
can
have
safety
concerns
next
slide
because
of
those
statements
through
the
cdc
and
fda
acog
and
which
is
the
american
college
of
of
ob
gyns
have
similar
concerns.
They
recommend
that
obedient
should
counsel
women
against
using
marijuana
while
they
are
trying
to
get
pregnant
during
pregnancy
and
while
they're,
trying
to
breastfeed
and
american
academy
of
pediatrics
has
also
similar
concerns
about
avoiding
next
slide.
M
M
This
provides,
unfortunately
less
oxygen
to
the
baby,
and
maybe
one
of
the
reasons
for
the
smaller
children
and
potentially
preterm
labor,
but
again
not
clearly
defined
and
from
a
brain
development
problem
side
of
the
concerns.
We
have
problems,
solving
skills,
memory,
visual
perception,
behavior
attention,
executive
function,
impulse
control,
especially
as
they're
becoming
teenagers.
M
So
these
are
all
the
concerns
that
aap
has
stated
as
concerns
about
use
of
marijuana.
Another
concern
is
that
thc
concentrations
in
marijuana
have
actually
quadrupled
since
the
1980s
when
the
studies
were
initially
conducted.
So
these
concerns
may
actually
be
much
higher,
but
we
just
don't
do
not
have
the
studies
next
slide.
M
M
Unfortunately,
in
the
united
kingdom,
long
longitudinal,
development
and
infancy
study
that
was
performed
across
the
united
kingdom
found
that
most
pregnant
women
who
use
cocaine,
ecstasy,
methamphetamines
and
other
stimulants
and
other
illicit
drugs
usually
stop
using
it
by
the
second
trimester.
M
However,
due
to
the
potential
lack
of
information
and
or
beliefs,
48
of
previous
marijuana
users
continue
to
use
marijuana
as
well
as
alcohol,
which
is
64
and
tobacco
46
throughout
the
entire
pregnancy,
and
they
have
a
very
strong
belief
that
it
is
less
concerning
than
alcohol
or
even
marijuana
or
even
tobacco.
M
So
what
have
we
seen
in?
At
saint
rose
siena
hospital?
We've
looked
at
breastfeeding
rates
at
time
of
discharge.
One
of
the
concerns
that
we've
been
working
towards
is
trying
to
increase
breastfeeding
rates.
However,
we're
noticing
a
significant
drop
in
2020
maternal
breastfeeding
at
time
of
discharge
was
approximately
55
percent
in
2021.
M
It's
actually
a
little
bit
higher
at
58,
however,
the
ones
who
are
not
providing
breast
milk
when
we
are
able
to
stratify
the
different
patients.
We
see
that
approximately
23
percent
of
the
babies
who
are
not
given
breast
milk
are
due
to
some
type
of
drugs
in
mom's
mom's
use
of
drugs
during
pregnancy
and
in
the
breast
milk,
which
is
significantly
higher
than
14
that
we
had
in
2020
of
that.
M
60
percent
have
either
a
just
a
marijuana
exposure
or
a
concomitant
use
of
marijuana
with
the
other
substances,
so
the
infant
is
exposed
during
the
pregnancy
with
poly
substance
use.
I
apologize.
I
don't
have
the
20
20
numbers
for
thc
use.
However,
we
do
know
that
it
is
higher
than
the
60
that
I'm
presenting
in
2021
next
slide.
M
M
M
So
from
the
literature
we
have
decided
to
provide
exclusive
breast
milk
diet
to
babies
less
than
34
weeks,
and
this
means
that
the
hospital
with
their
own
expense
pays
for
donor.
Breast
milk
and
supplementation,
like
prolacta
and
other
calorie,
increasing
options
for
which
are
all
breast
milk
related
so
that
these
babies,
less
than
34
weeks,
are
getting
an
exclusive
breast
milk
diet
until
their
34
weeks
of
gestation,
we
have
had
several
babies
who
are
born
at
around
33
30
on
almost
34
weeks
gestation,
where
we
we
are
struggling
to
decide.
M
M
When
we
presented
her
the
information
about
the
recommendations
from
aap
and
the
rest
of
the
other
federal
government
recommendations,
she
still
felt
that
the
breast
milk
diet
would
be
best
for
her
baby
and
we
made
a
compromise
with
her
that
she
would
pump
and
dump
her
breast
milk
for
one
week,
and
then
we
would
check
her
breast
milk
to
make
sure
that
the
thc
was
not
in
the
breast
milk
anymore.
Once
it
was
safe,
then
we
would
provide
that
for
her
baby.
M
Unfortunately,
once
the
the
time
came
for
her
to
be
tested,
she
told
us
that
she
actually
had
not
changed
her
use
and,
despite
this
use
being
for
hyperemesis
gravidarum,
which
is
basically
increased
emesis
during
pregnancy,
even
though
she'd
had
the
baby-
and
this
was
no
longer
a
concern-
she
was
not
comfortable
stopping
her
marijuana
use.
M
This
did,
of
course,
create
a
little
bit
of
tension
between
the
medical
staff
and
the
family,
because
she
was
so
adamant
that
she
wanted
breast
milk.
We
were
able
to
convince
her
that
we
needed
to
use
formula
in
this
infant
and
proceeded
to
to
care
for
this
infant,
which
went
home
very
well
and
healthy
by
approximately
35
weeks.
M
However,
we
do
know-
and
she
mentioned
that,
once
the
baby
went
home,
she
was
going
to
breastfeed
again
another
infant.
This
was
a
term
infant
who,
unfortunately,
for
medical
other
medical
reasons
had
had
perinatal
stress
and
came
out
with
apgars
of
zero,
zero
and
two
and
subsequently
went
to
need
hypothermia,
meaning
this
apgars
basically
means
this
baby
came
out
with
no
heart
rate.
No
respiratory
effort
we
had
to
code
this
baby
chest
compressions
were
done,
epinephrine
was
given.
M
Despite
all
of
the
education,
including
neurology,
consult
and
subsequent
education
on
the
neurodevelopmental
effects,
potentially
from
any
of
these
exposure
from
either
the
thc
or
the
cannabis
and
the
contaminants
that
could
be
there,
she
was
adamant
that
she
wanted
breast
milk
to
be
used.
She
called
me
and
my
staff
four
letter
words.
M
They
told
us
this
was
legal
and
it
should
be
used.
We
try
to
explain
that
alcohol
is
legal.
That
does
not
mean
that
it
is
appropriate
for
a
baby,
and
the
studies
are
concerning.
She
told
us.
It
was
an
organic
product.
When
we
tried
to
find
out
and
have
asked
other
moms,
we
found
that
they're
not
getting
him
from
the
pharmacies.
They
are
getting
them
from
other
sources.
So,
despite
trying
to
have
education
in
other
places,
this
mom
again
said
fine.
M
Coming
to
a
24
week,
baby,
you
know,
as
I
mentioned
earlier,
there
are
significant
components
in
breast
milk
that
protect
a
very
premature
baby
and
help
with
their
development,
but
also
for
their
gi
tract,
which
can
absolutely
become
very
ill.
M
So
when
we
have
a
24
week,
baby
and
same
story,
mom
has
a
history
of
marijuana
use.
We
showed
her
the
the
significant
impact
on
on
these
babies
with
breast
milk
and
how
important
her
breast
milk
was.
She
decided
that
she
would
not
provide
breast
milk
because
she
could
not
stop
marijuana
use
for
for
her
anxiety.
M
This
was
not
a
prescribed
medication.
This
was
again
off
the
streets
and
she
felt
that
that
was
more
important
than
than
the
numerous
things
that
absolutely
have
been
shown
to
benefit
babies.
This
premature.
M
A
Thank
you
for
the
presentation.
Those
are
really
intense
examples
and
I
am
digesting
anyways.
I
would.
I
have
a
couple
of
questions
in
the
queue
I'm
going
to
start
with
dr
titus.
Please
go
ahead
with
your
question.
I
Thank
you
for
the
lives
that
you
have
saved
and
the
continual
engagement
to
to
help
these
a
very
vulnerable,
it's
very
vulnerable
population
that
we
have
my
my
questions
revolve
around
formula
and
the
the
donor
breast
milk
programs
that
you
have
wondering
how
accessible
that
is
to
your
infants
what
your
supply
looks
like
and
how
well
that
serves
you
and
it's
other
options
throughout
the
state,
because
the
next
question
I
have
is:
what's
your
supply
of
formula,
look
like
in
southern
nevada
right
now
we're
seeing
continued
articles
where
they're
empty
shells
where
it
comes
to
formula
I'm
just
wondering
what
your
situation
is
in
clark
county.
M
That's
an
excellent
question,
so
let
me
start
from
the
breast
milk
diet
component,
so
exclusive
breast
milk
diet
definitely
has
impact
on
the
outcomes
of
these
infants,
as
I
mentioned
in
multiple
organs,
but
especially
the
neurodevelopmental
and
the
gi
tract,
which
is
known
to
be
a
component
of
our
immune
system
and
also
has
a
has
the
the
connection
between
the
gut
and
the
brain
health.
M
So
we
believe
very
strongly
in
the
in
the
improvement
in
outcomes
due
to
breast
milk
because
of
that
dignity,
health
specifically
has
for
over
a
decade
been
providing
at
our
own
cost
breast
milk
from
a
california
blood
breast
milk
bank.
Thank
you
sorry
about
that.
A
breast
milk
bank
that
we
provided
and
then
we
are
providing
the
extra
calories
use
of
prolacta,
which
is
10
times
more
costly
than
formula.
This
is
again
provided
from
our
own
cost
because
of
the
increased
cost.
M
We
know
that
the
hca
has
use
of
a
donor
breast
milk
and
they
are
going
to
be
bringing
prolacta
soon.
The
valley
systems
does
not,
and
the
renal
system
does
have
donor.
Breast
milk-
all
of
that
is
of
course
provided
by
the
hospital
and
their
cost.
There
are
some
challenges
to
overall
breast
milk
donor.
Breast
milk
from
different
state
entities
and
limitations
are
there
because
of
this
higher
use
of
marijuana
and
risk
of
transmission
of
viruses.
M
So
the
the
testing
process
for
breast
milk
is
actually
more
impressive
than
even
blood
products.
So
we
are
very,
very
careful
about
the
products
that
we
get
from
a
formula
point
of
view.
We
are
seeing
challenges
in
the
supply
chain.
M
We
are
able
to
make
substitutions
between
the
different
formula
companies
and
have
the
support
of
that
and
recently
I
was
told
today
that
there
was
an
approval
for
similac
to
open
up
their
facility
again
and
but
there
will
be
a
probable
two-week
delay
before
that.
That
warehouse
is
up
and
ready
for
doing
producing
more
formulas.
M
M
That
is
a
concern
and
unfortunately,
there's
also
some
challenges
happening
where
they're
sharing
of
breast
milk
from
with
strangers,
and
that
is
a
very
high
risk
because
of
transmission
of
viruses,
drugs
and
potential
dilution
of
the
breast
milk,
which
can
cause
seizures
and
other
complications
in
babies.
So
we
are
recommending
to
parents
that
they
not
share,
and
we
are
trying
very
hard
to
help
support
this
lactation
process
without
making
the
parents
feel
inadequate
if
they're
not
able
to
provide
that
breast
milk
did.
I
answer
all
your
questions.
I
Follow
me
so
and
thank
you
for
that.
The
great
information
I'm
just
curious
if
there's
is
dignity,
health
or
the
clark
county
health
department
or
the
state
folks
doing
any
public
service
announcements
regarding
the
formula
concerns-
and
you
know
the
the
risk
of
sharing
breast
milk
and
those
kind
of
issues
at
all.
Have
you
seen
anything
that
our
state
is
doing.
M
M
More
and
more
physicians
are
leaning
towards
the
benefits
of
breast
milk,
outweighing
the
risks
that
are
potential
and
not
well
studied
in
some
of
these
studies
and
using
breast
milk
in
their
units
and
with
the
babies,
because
the
the
formula
concern
is
there
that
is
becoming
even
more
of
a
concern
in
the
hospitals,
despite
cdc
fda,
aapa
cog.
All
having
statements
like
this.
I
I
thank
you
for
that
and
certainly
a
concern,
but
what
I'd
like
to
see?
Maybe
madam
chair,
hopefully
our
state
folks,
are
on
board,
and
I
think
this
is
something
regarding
the
breast
formula
that
we
shouldn't
take
lightly
and
I'd
I'm.
I'm
thankful
that
you're
willing
to
do
and
the
news
media
has
reached
out
to
you
for
some
information,
but
I
think
our
state
is
something
we
should
get
on
board
sooner
than
later.
Regarding
this
this
formula
issue
that
we
have
seen
statewide,
I
think
it's
a
true
crisis.
That's
not
really
being
acknowledged.
A
Thank
you
for
your
questions
and
comments.
Are
there
any
other
committee
members
who
have
questions
assemblyman
hafen?
Would
you
like
to
come
back
around
to
your
question
regarding
labeling.
A
Have
I
asked
artly
excuse
me
our
legal
counsel,
to
to
look
at
the
regulations
regarding
labeling
and
he
has
an
update
for
you,
real
quick
before
we
go
back
to
dr
nagra.
B
Hi
eric
robbins,
lcb
legal,
so
the
labeling
requirements
are
spelled
out
in
nrs,
678,
520
and
currently
cannabis
products
do
have
to
have
a
label
that
says
keep
out
of
reach
of
children.
B
In
addition,
a
cannabis
facility
is
required
to
convey
to
each
purchaser
of
a
cannabis
product
in
the
manner
prescribed
by
the
cannabis
compliance
board
that
they
have
that
cannabis
should
be
kept
out
of
reach
of
children.
The
cannabis
product
can
cause
serious
severe
illness
in
children
that
allowing
children
to
ingest
cannabis
or
cannabis
products
or
storing
cannabis
or
cannabis.
B
M
Please
go
ahead
if
I
may
just
add
to
that.
So
when
we
antidotely
ask
the
moms
about
this
cannabis
use,
majority
of
them
will
state
that
they
do
not
go
to
any
of
these
dispensaries
it's
too
expensive
and
therefore
they
have
not
been
educated
on
it.
When
we,
we
also
did
a
a
qi
study
where
we
asked
moms
if
anybody
had
educated
them
during
their
pregnancy,
including
their
ob
gyns.
K
I
I
do
they
thank
you
for
that
information,
but
I
wish
we
could
find
a
way
to
get
that
information
out
better,
as
I
believe
dr
titus
stated.
One
of
the
things
that
you
mentioned
in
your
slide
show
is
that
marijuana
use
should
not
be
used
when,
when
trying
to
get
pregnant,
pregnant
or
breastfeeding,
and
that
was
specifically
towards
women,
are
there
any
consequences
or
recommendations
on
the
male
side
of
this.
M
A
Thank
you
for
the
question.
I
had
a
follow-up
question
regarding
research.
Dr
nagar,
can
you
talk
a
little
bit
about
who
or
what
studies
may
be
occurring
around
the
use
of
marijuana
during
conception
and
pregnancy
and
the
implications
of
marijuana
in
breast
milk?
Are
there
studies
being
done?
I
know
it's
very
difficult
to
conduct
studies
on
pregnant
people
because
you
never
want
to
put
the
the
potential
child
at
risk,
but
what
what
is
going
on
in
that
space.
M
Unfortunately,
that
that
process
is
very
limited
and
and
as
you
mentioned,
the
ethical
implications
of
some
of
these
studies
have
really
limited
that
that
part
of
the
studies,
what
we
are
doing
is
looking
at
the
infants
and
the
nicu's.
M
M
So
we
have
a
very
robust
database
of
over
30
million
patient
days
and
we
have
been
following
the
increase
in
marijuana
use
and
exposure
to
the
infants
that
is
still
in
the
process
of
being
evaluated
and
we're
hoping
to
present
that
as
a
study.
But
obviously
the
important
part
I
want
to
emphasize
is
by
the
time
they
come
to
us.
M
Those
babies
have
already
been
exposed
and
we
can
only
see
the
potential
implications
in
the
nicu
and
may
not
be
able
to
do
the
developmental
process,
because
once
the
babies
leave
us,
they
may
not
be
part
of
our
system
anymore.
So
those
challenges
are
very
concerning
because
there
are
very
limited
focus
on
this
kind
of
studies.
Right
now,.
A
Thank
you
so
much
for
that.
Are
there
any
other
questions
from
the
committee?
I
have
additional
questions,
but
I
will
ask
them
offline
because
we
do
have
quite
the
agenda
to
get
through,
so
I'm
not
seeing
any
other
questions.
Thank
you
so
much,
dr
nagar.
I
really
appreciate
you
being
here
today
and
we
will
go
ahead
and
close.
This
agenda
item.
A
Next,
we
are
going
to
move
on
to
agenda
item
eight.
This
is
an
overview
of
programs
to
treat
substance
use
during
and
after
pregnancy.
I
have
dr
peterson
with
empowered,
I
believe
who
yep
please
go
ahead
and
introduce
yourself
and
begin
when
you're
ready.
N
Adam
chair
and
members
of
the
committee
for
the
record,
my
name
is
andrea
peterson
and
I
am
executive
director
of
the
empowered
program
with
roseman
university.
Thank
you
for
having
me
here
today
to
present
an
update
on
empowered
and
also
just
want
to
say
that
I'm
grateful
to
be
able
to
follow.
Dr
nagar.
I
had
the
privilege
of
working
with
her
for
12
years
in
that
nicu
that
she
was
talking
about,
and
we
were
great
colleagues
so
she's
also
the
co-founder
of
the
empowered
program.
So
I
would
like
to
acknowledge
that
as
well.
N
So
those
of
you
that
don't
or
are
not
familiar
with
roseman
university
wanted
to
provide
just
a
brief
amount
of
information.
We
were
founded
in
1999
in
henderson
nevada.
It
is
a
non-profit,
private
institution
of
higher
learning
that
is
focused
on
the
health
professions.
We
do
have
a
college
of
medicine,
college
of
dental
medicine,
college
of
pharmacy,
nursing
and
graduate
studies.
N
We
have
campuses
that
have
been
campuses
that
are
established
in
henderson,
nevada,
las
vegas,
nevada
and
the
summerlin
area,
and
then
also
in
south
jordan
utah,
and
we
are
regionally
accredited
by
the
northwest
commission
on
colleges
and
universities,
and
I
will
say,
I'm
a
product
of
roseman.
I
attended
pharmacy
school
there
and
graduated
from
there
in
2008.,
so
at
roseman,
when
we
are
in
the
classroom,
we
do
something
called
active
learning,
and
so
I
want
to
do
something
with
you
today.
N
That's
an
active
learning,
and
so
I
want
you
to
look
at
these
pictures
and
I
want
you
to
look
at
what
you
think
these
moms
and
babies
have
in
common
and
for
those
of
you
that
know
me.
I
know
there's
a
couple
of
know
me
for
several
years.
You
might
know
where
I'm
going
with
this,
but
I
want
you
to
really
look
at
the
faces
of
these
moms
and
these
adorable
babies.
N
So
you
know,
as
you
look
at
these
women
you're
gonna
see
women
that
might
look
like
your
sister,
your
friend
a
co-worker
when
you
go
to
the
grocery
store
today,
you
might,
you
know
see
one
of
these
faces
to
let
you
know
what
they
have
in
common
they're
all
program.
Participants
of
the
empowered
program
and
the
empowered
program
supports
pregnant
and
postpartum
women
with
substance
use
disorder,
and
so
all
of
these
women
are
in
various
stages
of
recovery.
Some
act
are
still
currently
experiencing
substance.
N
Use
disorder
are
navigating
that
and
all
these
infants
that
you've
seen
today
when
they
were
born,
were
at
risk
for
neonatal
absence
syndrome.
So
I
think
it's
really
important
to
be
able
to
put
faces.
You
know
to
the
information
that
we're
talking
about
today
when
we
talk
about
substance,
use,
disorder
and
pregnancy
and
and
neonatal
absence
syndrome,
and
what
it
looks
like
it
looks
like
these
women
and
substance
use
disorder
does
not
have
a
face.
N
I
wanted
to
touch
briefly
on
some
nevada
trends
and
we've
had
some
great
data
today.
This
came
from
the
overdose
data
to
action,
grant
that
is
through
the
state,
and
this
is
specifically
suspected
drug
overdose,
related
ed
visits
from
january
of
2018
to
november
2021,
and
the
reason
I
wanted
to
point
this
out
is
because
everybody
is
always
curious
about
you
know
what
did
kova
do.
We
know
that
covet
impacted
mental
health.
We
know
it
impacted
substance,
use
disorder.
What
did
it
do?
N
Moving
on
to
look
at
another
nevada
trend,
this
is
the
annual
rate
of
suspected
all
drug
related
overdose,
ed
visits
again
from
january
of
2018
to
november
21.
That
is
specific
for
that
women
of
childbearing
age,
and
so
you
can
see
that
percent
change
from
2018
to
2019
was
actually
negative,
4.6
percent
and
then
2019
to
2020
jumped
9.5
percent.
So
again
you
can
see
the
impact
on
the
specific
population
with
overdoses
and
to
kind
of
cap
it
off.
There
was
some
data
that
was
released
by
this
team.
Again,
it
was
just
last
week.
N
N
So,
essentially,
everybody's
done
such
a
great
job
today
talking
about
this,
but
the
problem
is
that
drug-induced
deaths
are
the
leading
cause
of
death
for
reproductive
age.
Women
in
the
us
it's
higher
than
motor
vehicle
accidents
gun
violence.
Homicide
is
drug-induced,
so
we
know
that
this
plays
a
huge
role
nationally.
We
know
that
this
is
playing
a
huge
role
locally
in
nevada
as
well.
The
effect
of
this
is
that
infants
who
are
born
to
these
mothers
are
going
to
be
at
risk
for
neonatal
absence
syndrome.
N
So
essentially,
that's
withdrawal,
symptoms
that
are
seen
in
infants
born
to
mothers,
who've
used
drugs
during
pregnancy
and
just
to
give
you
an
idea,
a
large
percentage
of
these
births
are
funded
by
medicaid,
it's
reported
to
be
82
percent.
When
we
look
specifically
at
the
empowered
program,
we
found
that
90
percent
of
our
moms
did
have
medicaid.
N
So
how
do
we
identify
someone
with
a
substance
use
disorder?
We
saw
those
pictures,
we
saw
those
moms
again,
I
don't
think
any
of
us
would
look
at
them
and
in
line
you
know
the
grocery
store
and
identify
that
they
have
a
substance
use
disorder.
So
that's
going
to
occur
through
a
process
known
as
expert
it's
an
evidence-based
process
and
it
identifies
individuals
with
a
substance
use
disorder
and
those
were
a
risk
for
a
substance
use
disorder.
N
N
We
had
a
lot
of
success.
We
had
275
patient
encounters
during
that
time
and
I
won't
go
through
each
of
these
statistics,
but
you
can
see.
42
did
receive
referrals
for
medication,
assisted
treatment,
44
for
prenatal
care,
we
assisted
with
transportation
84,
and
what
we
found
is
that
when
we
assist
with
that
transportation-
and
we
have
high
rates
of
recovering
women,
do
well
26
need
assistance
with
housing,
and
we
also
learned
a
lot
through
that
process
and
we
made
some
observations
so
with
regards
to
overdose
deaths.
N
Women
of
childbearing
age
continue
to
be
at
a
very
high
risk
of
developing
substance
use
disorder.
Screening
by
all
healthcare
providers
is
absolutely
imperative,
and
I
want
to
just
highlight
that:
it's
not
just
women,
it's
not
just
you,
know,
individuals
of
childbearing
age.
This
should
be
everyone,
everyone
that
is
seeing
a
provider
should
be
screened
for
substance
use
disorder.
N
We
also
noted
that
patients
with
substance
use
disorder
need
strong
support
networks.
They
need
strong
home
visiting
programs,
they
need
wraparound
services
for
the
entire
family
to
fully
support
mom
and
baby,
and
I
just
want
to
remind
you
kind
of
back
to
that
data
that
I
presented
in
the
in
the
beginning.
N
So
our
solution
to
this
was
the
empowered
program
at
roseman
university
of
health
sciences.
We
were
able
to
work
with
dignity,
health,
to
move
the
program
to
roseman
and
we've
been
able
to
expand
services,
so
we're
able
to
support
that
mom
during
pregnancy
and
that
postpartum
period
we
support
them
with
peer
recovery
and
advocacy.
Specific
treatment
and
resource
provision
divine
designed
around
their
need
is
very
patient,
centered
and
person-centered,
because
none
of
us
have
the
same
needs
and
when
we
meet
with
them,
we
identify
what
is
their
most
urgent
need
for
their
recovery.
N
Those
our
mission
statement
is
that
we
develop
and
unleash
the
power
of
expectant
and
recent
mothers
with
opioid
and
stimulant
use
disorders
to
be
active
in
managing
their
health
and
partnering
in
their
care,
and
this
really
is
my
favorite
part,
because
it's
from
recovery
through
stabilization
to
resilience,
because
we
really
want
to
promote
that
resilience
piece
and
I'm
so
excited
to
share
that
we
have
women
who
are
getting
jobs.
We
have
somebody
graduating
high
school
this
week,
we're
having
such
great
outcomes
because
we
don't
want
to
just
have
them
survive.
N
We
want
them
to
be
able
to
thrive.
This
again
is
accomplished
through
iterative
assessments,
personalized
patient-centered
care
plans.
We
have
counseling
services,
including
individual
and
group
therapy
when
needed,
health,
education
and
then,
of
course,
the
facilitation
of
those
referrals
and
care
coordination.
N
It's
just
a
picture
what
our
patient
journey
looks
like,
so
once
we
have
enrollment,
we
do
that
comprehensive
assessment.
I
just
want
to
note
here
that
many
of
our
program
participants
do
present
in
crisis
so
whether
if
they've
just
delivered,
sometimes
they
lost
a
child.
You
know
a
child
or
they
had
them,
separated
with
the
department
of
family
services,
sometimes
they're
worried
about
that.
So
we
help
support
them
in
that
crisis
we
stabilize
them
through
that
crisis
and
then
again
develop
that
individualized
patient-centered
treatment
plan.
N
We
manage
those
interventions,
provide
case
management
and
continue
to
follow,
follow
them
through
pregnancy.
In
that
postpartum
period.
N
Our
goal
is
event
to
leverage
the
capacity
and
strategic
processes
of
roseman
to
deliver
enhanced
services.
So
again,
we're
now
able
to
offer
that
individual
therapy
and
that
household
centered
home
visitation
program
we
provide
access
to
care,
support
and
advocacy
for
participants
have
those
educational
counseling
services
with
individual
group
therapy.
We
manage
the
social
determinants
of
health
of
program
participants
and
their
families,
and
we
support
them
from
their
recovery
through
stabilization
to
resilience
and
just
to
kind
of
show
you
what
this
looks
like.
N
We
had
a
patient
case
this
this
week,
who
has
been
involved
in
our
program.
She's
lived
in
nevada
for
more
than
a
year,
she's
separated
from
her
child,
and
she
has
no
id
and
to
be
able
to
engage
in
a
lot
of
services.
You
have
to
have
a
government-issued
id,
and
so
we've
been
helping
her
with
that
process,
and
just
this
week
we
were
able
to
provide
her
with
transportation.
N
We
paid
the
p
for
the
fee
for
her
id
and
she
was
able
to
go
to
the
dmv
with
our
peer
and
was
able
to
leave
the
dmv
with
a
government-issued
id
and
she
called
our
care
manager
afterwards
and
just
said
this
is
life-changing
for
me,
so
it's
just
so
humbling
to
think
you
know.
Everyone
again
is
just
in
various
stages
of
the
recovery.
Everybody
has
different
things
that
are
impacting
them
to
be
able
to
make
a
successful
recovery,
and
sometimes
it's
as
simple
as
an
id
and
we're
able
to
help
provide
that.
N
I
wanted
to
briefly
touch
on
some
barriers
to
treating
substance
use
disorder
in
nevada
and
one
being
that
collaborative
care
codes
are
not
covered
by
medicaid.
A
second
is
that
behavioral
health
is
not
included
as
a
chronic
health
condition
addressed
by
community
health
workers.
So
I
believe
earlier
today
there
was
a
presentation
on
that
is
so
wonderful.
N
Now
that
we're
able
to
have
you
know
community
health
workers
as
a
reimbursable
program
in
nevada,
but
behavioral
health
is
not
included
in
that
and
then
superior
support
services
are
not
reimbursed
in
health
care
settings,
and
I
just
really
want
to
emphasize
the
importance
of
those
community
health
workers
and
peer
support
in
treating
substance
use
disorder.
N
The
last
thing
that
I
wanted
to
point
out
is
access
to
buprenorphine,
so
those
of
you
that
aren't
familiar
with
the
medications
that
are
available
to
treat
opioid
use
disorder,
there's
methadone,
which
probably
a
lot
of
people,
are
familiar
with,
there's
also
buprenorphine
among
others.
The
buprenorphine
is
a
life-saving
medication
that
is
used
in
medication,
assisted
treatment.
N
I
want
to
specifically
point
out
that
neonates,
who
are
exposed
to
buprenorphine
in
utero
have
significantly
lower
rates
of
nas
and
shorter
nicu
stays
compared
to
methadone,
and
I
know
that
dr
nagar
would
agree
with
me
when
I
say
that,
for
the
most
part
infants
who
were
admitted
to
our
nicu,
who
were
exposed
to
buprenorphine
in
utero,
did
not
experience
nas,
they
did
not
experience.
Withdrawal,
health
and
human
services
recognized
the
importance
of
this
medication.
N
They
recently
expanded
access
to
buprenorphine,
so
they
revised
their
practice
guidelines
to
allow
practitioners
to
treat
up
to
30
patients
without
having
to
obtain
certain
training
related
certifications.
So
it
was
great
one
of
the
barriers
that
we're
seeing
is
with
regulation,
nac
639-748
and
that's
where
it
requires
a
current
and
valid
form
of
id
issued
by
a
federal
state
or
local
government
agency
that
contains
a
photograph
and
so
again,
just
many
of
the
program.
N
Participants
that
we
have
are
lacking
this
government-issued
id
and
it
takes
time
to
be
able
to
get
that
id
and
it's
really
important
when
somebody
wants
to
engage
in
treatment
and
they
want
to
be
able
to
make
a
change.
It's
really
important
to
be
able
to
support
them
with
that
in
the
moment
and
not
to
have
it
bogged
down
by
the
id
and
so
with
them,
lacking
this
id
oftentimes
when
they're
able
to
go
and
get
a
prescription
for
buprenorphine
they're,
not
able
to
pick
their
pharmacy
or
their
medication
up
from
a
pharmacy.
N
So
just
wanted
to
bring
awareness
to
this
issue.
Some
of
you
may
be
familiar
there's
a
clarity
card
which
is
a
homeless
id
that
is
not
recommended
or
not
recognized
at
this
time
as
a
government
issued
id.
So
it's
very
easy
to
be
able
to
get
that
homeless,
id
or
that
clarity
card,
but
very
difficult
to
get
a
government-issued
id,
and
I
will
open
it
up
for
questions.
A
A
I
am
not
hearing
any
questions
at
the
moment,
but
I
have
a
question
about
what
we're
doing
around
stigmas
that
exist
for
birthing
people
who
use
drugs
and
how
are
they
offered
care
and
treatment?
You
discussed
some
of
that,
but
I'm
just
wondering
if
you
can
talk
about
some
of
the
efforts
to
reduce
bias
and
stigma
in
within
the
treated
populations,
but
also
within
the
treatment
system.
N
That's
a
great
question
and
something
for
the
record:
this
is
andrea
peterson,
I'm
not
familiar
with
specific
efforts
around
stigma.
I
know
that
we've
had
this
with
a
group
that
I
participate
at
the
state
level.
That's
the
nevada
reproductive
health
network
that
this
is
something
that
is
needed
really.
What
I
am
familiar
with
is
that
expert,
which
is
going
to
be
around
screening,
which
is
that
screening
brief
intervention,
referral
treatment,
it
is
evidence-based
and
does
provide
guidance
around
how
to
have
those
conversations.
M
Hi
this
is
dr
nagar
just
to
add
to
that.
The
screening
process
for
the
expert
is
universal,
and
that
is
one
of
the
importance
of
not
having
biases
with
certain
populations
and
only
asking
questions
in
those
populations.
M
So
the
recommendation
absolutely
is
to
be
universal
in
these
questions
and
seeing
what
at
risk
for
patients
are
present.
The
second
thing
I
wanted
to
just
emphasize
after
hearing
these
presentations
across
the
board.
M
What
I
hope
you
guys
are
seeing
is
the
impact
of
the
support
during
pregnancy
can
absolutely
impact
the
life
of
that
mom
and
the
baby,
and
because
of
that,
having
a
cohesive
plan
for
the
state
that
looks
at
the
perinatal
quality
collaborative
is
one
of
the
key
components
to
make
sure
that
we,
as
a
as
a
medical
community
and
as
a
state,
are
looking
at
the
care
in
a
continuum
instead
of
just
having
silos,
realizing
that
there
are
issues
but
not
having
that
continuity
in
place.
M
Their
process
of
withdrawal
is
significantly
improved,
because
moms
have
shown
that
they
are
getting
this
care
during
pregnancy.
They
have
followed
appropriately.
They
know
we
can
now
say
yes,
that
baby
and
mom
together
our
safe
pathway.
Instead
of
separating
the
mom
and
baby,
we
can
work
on
breastfeeding
with
them,
which
again
improves
not
only
the
the
connection
between
the
mom
and
baby.
But
we
know
that
these
women
are
more
likely
to
not
fall
off
the
wagon.
M
A
Thank
you
so
much.
I
appreciate
your
perspective
in
that
point.
I
also
want
to
take
a
moment
to
just
highlight
the
statistics
around
transportation
and
the
increased
success
of
treatment,
and
I
think
that
this
is
kind
of
across
the
line
when
folks
have,
when
barriers
are
removed
from
accessing
care.
People
are
more
likely
to
seek
treatment
and
to
complete
treatments,
and
this
isn't
just
for
behavioral
health.
A
So
I
appreciate
the
statistics-
and
I
look
forward
to
to
bringing
those
forward
and
talking
more
about
what
we
can
do
as
a
state
around
public
transportation
to
ensure
that
that
barrier
is
diminished
for
most
people
in
our
state.
Are
there
any
other
questions
folks
have
on
this
presentation
in
the
committee
for.
N
The
record
this
is
andrea
peterson,
and
I
would
just
say
that
it
that's
really
where
the
social
determinants
of
help
come
in.
It
is
essential
to
be
able
to
identify
the
social
determinants
of
health.
You
know
in
those
underserved
populations
and
those
at-risk
populations
to
be
able
to
identify
their
barriers
to
accessing
care
because
you're
right
when
you
remove
them,
they
do
engage
in
in
care
and
treatment,
and
and
have
really
great
successful
outcomes.
A
Thank
you
so
much
dr
peterson.
I
do
not
see
any
other
questions
or
comments
from
committee
members,
so
we're
going
to
go
ahead
and
close
this
item
and
move
on
to
our
next.
Thank
you
again
so
much
for
the
presentation
and
for
being
here
today.
A
Our
next
agenda
item
is
agenda:
item
nine
and
the
need
for
a
nevada,
perinatal
quality,
collaborative
or
professional,
sorry,
a
professional
network
to
enhance
the
quality
of
care
for
mothers
and
babies
and
other
considerations
to
improve
obstetric
outcomes.
I'm
very
excited
for
this
presentation.
I
think
one
of
the
things
as
a
mom
of
three
kids
that
I
would
love
to
see
more
of
is
really
the
overlapping
of
care
and
services
and
making
sure
that
we're
looking
holistically
at
family
health
metrics
and
not
isolated,
maternal
and
baby
health
metrics.
A
J
Great
great
well
I'd
I'd
like
to
thank
everybody
for
welcoming
me
back.
I
spoke
before
you
in
january
of
2020,
and
I
also
like
to
thank
dr
peterson,
dr
nagar,
for
being
my
straight
persons
for
me
and
many
of
the
things
I'm
going
to
be
presenting
here
today.
J
The
last
time
I
was
here
was
in
january.
2020
is
quite
a
different
time.
Then
I
presented
several
things:
moving
forward
about
a
support
for
prenatal,
collaborative
change
in
the
poverty
threshold
for
medicaid
coverage
for
pregnancy
to
provide
one
year,
postpartum
coverage
which
we're
still
trying
to
get
to
to
support
different
types
of
payments
for
behavioral
health
in
offices.
J
It's
a
sport
payment
systems
to
screen
for
medication,
assisted
treatment,
the
we
were
successful
in
some
of
these
things,
but
not
on
others
and
part
of
the
reason.
Why
probably
was
right
after
january
2020,
we
kind
of
fell
into
the
coronavirus
issues
that
that
came
on
in
our
society.
So
I'd
like
to
bring
forward
a
little
bit
of
this
data
that
we
talked
about
in
the
past
and
then
move
forward
to
why
it's
so
important
to
move
forward
in
the
future.
J
Now
that
we're
coming
out
on
the
other
end
of
the
chronovirus
epidemic
or
pandemic
within
the
united
states,
our
maternal
mortality
ratio
is
one
of
the
highest
in
the
world.
I
think
it's
like
57th
or
58th
now
and
we're
last
in
developed
countries.
As
you
can
see,
the
maternal
mortality
rate
is
the
death
of
a
pregnant
woman
within
48
days
of
the
termination
of
pregnancy
or
six
weeks
postpartum,
and
it's
expressed
over
a
hundred
thousand
people
or
a
hundred
thousand
births.
The
us
had
the
highest
rated
17.4.
J
J
Cdc
thinks
that
this
is
mainly
due
to
variations
in
healthcare,
pre-existing
underlying
conditions
that
are
maybe
exacerbated
from
inability
to
to
gain
access
and
then
also
structural,
racism
and
implicit
bias
within
nevada
itself.
We
have
we've
been
seen
seeing
us
where
the
blue
blue
bars
here,
we've
seen
an
uptick
in
our
perinatal
or
our
maternal
mortality
rate.
This,
I
think,
is
partially
due
to
how
they've
been
counted,
but,
as
you
can
see,
there's
been
a
rapid
uptick
in
where
kind
of
nevada
is
kind
of
shadowing.
J
What
the
rest
of
the
country
is
doing
right
now,
when
you
look
at
it,
you
could
actually
see
this
increase
from
2016
to
17.
This
is
a
different
graph
on
pregnancy-related
mortality
rate.
Pregnancy-Related
mortality
rate
is
not
six
weeks
postpartum,
but
up
to
a
year,
postpartum
from
any
cause
related
to
or
aggravated
by
the
pregnancy.
J
The
issues,
though
again,
are
are
really
highlighted
further
by
the
the
disparate
nature
of
how
this
affects
our
populations.
The
black
and
non-hispanic
population.
Their
prenatal,
related
mortality
rate
is
63
asian
populations,
55.8
white
non-hispanic
18.4
in
the
states
that
take
their
data
and
show
it
by
race.
J
Our
black
non-hispanic
perinatal
related
mortality
rate
is
the
highest
in
the
country
right
now
and
although
I've
been
pre
focusing
a
little
bit
here
on
maternal
mortality
rate,
I
really
think
the
unknown
story
of
this
is
the
severe
maternal
morbidity
rate
and
not
only
the
the
medical
health
of
this.
But
the
cost
of
this
severe
maternal
mortality
is
thought
to
be
60
times
greater
than
that
of
maternal
morbidity
is
thought
to
be
60
times
greater
than
that
of
mortality
and
there's
dramatically
increased
costs
from
that.
J
And
so
where
do
we
go
from
this?
I
think
one
of
the
clear
answers
here
is
a
perinatal
quality
collaborative
the
cdc
thinks
that,
and
I
think
the
data
does
show
this
as
well
from
maternal
mortality,
review
committees,
that
up
to
about
60
of
all
maternal
deaths,
are
preventable,
and
that
would
probably
also
lead
to
you
know,
maybe
as
high
as
a
60-fold
decrease
as
well
and
the
maternal
morbidity
rates.
We
really
need
a
collaborative
to
increase
our
quality,
improve
outcomes
and
decrease
cost.
J
We
can't
have
multiple
people
reinventing
the
same
wheel
over
and
over
again,
we
need
a
coordinated
statewide
team
to
be
able
to
improve
the
quality
of
care,
for
these
pregnancies,
use
data-driven
research,
funded
processes
to
improve,
to
improve
our
care
and
utilize.
These
methods
to
make
change
we're
one
of
only
six
states
in
the
whole
country
without
a
perinatal
quality
collaborative
beyond
the
development
stage.
There's
the
other
44
states
already
have
a
collaborative
and
we're
one
of
only
two
states
in
the
country.
J
J
Perinatal
quality
collaboratives
really
work.
If
you
look
at
them,
one
of
the
initial
examples
of
success
for
a
perinatal
quality
collaborative
was
the
california
collaborative.
And
if
you
look
at
the
red
bars,
that's
the
increasing
maternal
mortality
rate
in
the
country
and
if
you
look
at
the
prenatal
quality
collaborate
for
california,
when
in
a
place,
I
believe
in
around
2007-
and
you
could
see
the
dramatic
driving
down
of
maternal
mortality
rates
within
california.
J
They
didn't
also
just
decrease
the
return
mortality,
though
they
decreased
their
maternal
morbidity.
By
21,
they
decreased
elective
deliveries
which
lead
to
increased
nicu
problems
by
55
percent
and
the
illinois.
Perinatal
quality
collaborative
decreased
the
time
to
treatment
for
severe
hypertension,
which
is
recommended
in
the
us
anywhere
from
between
30
and
60
minutes.
They
that
also
decreases
maternal
death
and
they
showed
in
their
study.
It
decreased
severe
maternal
morbidity
and
hence
has
a
major
cost
savings.
J
J
The
cms
has
adopted
two
maternal
morbidity,
structural
measures
that
need
to
be
reported
a
does
your
hospital
participate
in
statewide
or
national
pqc
and
has
your
p?
Has
your
hospital
implemented
safety
practices
or
bundles
related
to
certain
conditions
during
pregnancy?
J
When
I
came
here
in
2020,
we
were
one
of
only
14
states
without
a
perinatal
quality
collaborative
now,
as
I
said,
we're
one
of
only
two
states
and
one
of
only
six
states
either
within
the
process
or
progress
of
forming
one
or
don't
have
one
at
all.
We're
really
in
the
don't,
have
one
at
all
game
right
now.
J
What
does
it
take
to
form
a
pqc?
You
need
a
director
website
with
video
capability
data
capability.
I
believe
we
do
have
red
cap
now
in
the
state.
This
was
my
older
slide
from
the
last
time
I
was
here.
You
need
a
meeting
capability,
travel,
training,
education
and
marketing.
How
do
you
do
this?
You
need
some
initial
government
funding.
Maybe
some
grants-
maybe
some
user
fees
which
I'll
get
to
in
the
next
slide
and
and
and
then
go
from
there,
but
how
much
money
do
you
need
again
from
the
cdc?
J
J
I
believe
nevada
would
need
probably
250
to
300
000
per
year
for
two
years
and
then
run
based
upon
user
fees.
Possibly
for
this,
I
think
if
you
did
a
smaller
collaborative
about
100
to
200
000
a
year
we
could
probably
get
by,
but
not
get
ourselves
up
to
speed
like
the
rest
of
the
country.
I
think
you
can
also
later
incentivize
perinatal
quality
collaborative
work
by
linking
pay
for
deliveries
to
hospitals,
giving
a
plus
two
percent
possibly
fee
for
delivery
for
participating
in
a
collaborative,
possibly
disincentivized.
J
Non-Non-Participating
hospitals
by
decreasing
pay
by
about
five
percent
require
modules
of
participate.
Participation
for
physicians,
so
physicians
participate
in
this
and
all
providers
participate
in
this
and
they
get
disincentives
or
payments
or
minuses
and
payments
when
they
don't
participate
in
the
collaboratives
or
you
could
just
fund
this
later
by
fees
to
overall
hospitals
overall
that
are
not
related
to
payment
systems.
J
I
think
this
really
needs
to
be
done
and
really
needs
to
be
done
now.
Maternal
mortality
and
morbidity
is,
as
I
said,
60
of
the
cases
are
preventable.
We
really
have
a
dramatically
high
health
care
and
equities
issue
the
highest
in
the
country
on
who's.
Recording
it
right
now
for
our
black
populations
and
putting
something
like
this
into
place
saves
money
as
well.
J
If
you
decrease
early
deliveries,
you
decrease
subsequent
nicu
care
and
you
also
decrease
the
cost
of
severe
maternal
morbidity
cases.
I
think
we
need
to
concentrate
our
efforts
on
improving
care
to
prevent
these
unneeded
or
un
or
preventable
catastrophes,
and
really
reduce
costs
of
neonatal
care.
J
And
that
kind
of
adds
or
ends
why
I
want
to
go
with
it
forward
with
a
collaborative
and
hopefully
that
convinces
you,
but
also
we
have
some
other
issues
that
I
want
you
to
look
at
and
if
you
see
the
spending
in
pregnancy,
I'll
be
able
to
kind
of
maybe
put
it
together
for
you
in
a
in
a
way
that
is
more
understandable
within
the
u.s
about
42.6
of
births
are
covered
by
medicaid.
J
J
Next
people
think
physician
fees
are
things
that
are
problematic.
Physician
fees
have
only
increased
over
the
last
15
to
20
years,
maximally
by
cola
increases
and
and
many
times,
not
even
by
cola
increases
the
loan.
Almost
all
the
increases
in
cost
now
to
the
system
are
dominated
by
hospital
increases
and
costs.
J
If
you
look
at
it
by
the
billions
hospital
fees
are
in,
the
brown
here
are
about
52
billion
a
year
in
the
united
states,
ob
provider
fees
are
about
18
billion
per
year
in
the
u.s
nicu
fees,
which
only
treat
about
10
of
the
patients
being
treated
or
10
of
the
pregnancies
is,
is
also
18
billion.
J
It's
equal
to
the
entire
amount
of
ob
provider
fees
overall,
ob
anesthesia,
which
takes
care
of
a
pregnancy
for
several
hours
during
delivery,
is
seven
billion
around
the
united
states
in
comparison
to
the
nine
months
and
the
delivery
spent
with
obstetrical
fees
and-
and
this
is
a
big
problem
in
nevada-
I
mean
we
have.
Overall.
If
you
looked
at
this
study,
it
was
from
last
year
we
have
the
highest
ob
gyn
shortage
in
las
vegas
in
the
whole
country.
J
This
leads
to
people
running
to
different
hospitals,
not
being
able
to
spend
as
much
time
on
the
care
that
they
need
to
on
patients,
because
they're
busy
and
they're
and
they're
basically
understaffed.
They
can't
have
the
ability
to
to
deliver
as
high
quality
care
that
we
want
them
to.
J
So
I
would
ask
that
we
need
some
increases
in
payments
to
providers
to
decrease
this
under
this
under
supply.
Global
payment
increases
are
kind
of
needed
urgently.
At
the
same
time,
I
think
the
physicians
should
be
responsible
for
payments.
If
we're
going
to
increase
payments,
we
should
make
payments
for
value
and
to
for
true
quality
care.
We
should
encourage
our
payers
to
develop
systems
to
decrease
and
sensitive
care
unit
stays,
and
we
should
disincentivize
providers
that
don't
follow
care
standards
by
giving
disincentive
payments
to
them
to
offset
their
global
payments.
J
And
then
I
don't
like
solely
recommending
changes
in
payment
on
outcomes.
I
think
in
doing
that,
it's
it's
pennywise
and
pound
foolish
in
those
instances.
What
you
get
is
you
get
providers
that
will
then
cherry
pick
patients
that
have
less
problems,
and
if
you
do
that,
you'll
probably
exacerbate
disparities,
maternal
morbidity
and
also
mortality,
and
then
one
interesting
payment
system
is
being
done
in
north
carolina
and
what
they're
doing
is
they're
increasing
payments
for
patient-centered
pregnancy
homes.
J
As
dr
nagar
and
dr
peterson
stated,
we
would
like
to
again
ask
for
medicaid
coverage
threshold
payments
and
postpartum
payments
during
pregnancy.
I'm
very
happy
that
we
increased
from
138
of
the
poverty
level.
Last
legislature,
I
believe
to
165,
but
still
the
u.s
payment
for
medicaid
for
pregnancy
is
200
of
the
poverty
level
200
to
205
percent,
and
although
we
improved
these
are
the
areas
that
hurt
the
people
with
disparities
the
most
and
since
we
do
have
the
highest
level
of
a
black
non-hispanic
perinatal
mortality
rates.
J
J
This
really
allows
for
increased
chances
for
follow-up.
I
think
it's
like
the
numbers
are
as
much
as
40
to
50
percent
of
people
because
of
the
increased
problems
that
they
have
with
transportation
and
the
increased
stresses
of
a
new
baby
do
not
make
their
postpartum
follow-up
or,
if
they
don't
do
it
in
time,
they
have
a
disruption
in
their
healthcare
coverage.
This
affects
our
marginalized
populations,
the
most
and
hurts
treatment
of
things
like
postpartum
depression,
getting
contraception
space
deliveries
a
little
bit
better.
J
These
people
lose
their
opioid
use,
cover
or
use
disorder
treatment,
or
their
mat
treatment
and
and
fall
out,
and
hence
get
overdoses.
J
Again,
treatment
of
these
people
for
the
postpartum
gives
a
two
generation
advantage.
55
of
all
children
living
below
the
poverty
level
have
a
mother
with
some
sort
of
depression.
J
Having
treatment
for
them
afterwards
for
up
to
a
year
would
help
alleviate
problems
with
depression
that
hurts
the
mother
child
bond,
which
has
implications
on
early
brain
development
and
one
in
five
people
that
women
in
poverty
are
or
even
higher
than
that
have
depressive
systems
symptoms
and
regardless
of
income.
J
Even
one
in
five
overall
treatment
also
gives
you
smoking
cessation
treatment
after
pregnancy
and
gives
you
time
to
put
that
in
a
place
which
would
decrease
the
risk
of
sids,
and
if
you
could
stop
people
from
smoking,
it
stops
the
next
pregnancy
from
problems
with
pre-term,
birth
and
low
birth
weight
and
then
also
postpartum
contraception.
J
One
year
gives
time
to
ensure
that
the
child
is
is
doing
well,
it
improves
birth
spacing,
and
this
is
super
important,
because
fifty
percent
of
all
births
in
the
united
states
are
unplanned
and
eighty
percent
of
them
are
in
people
with
substance
use
disorders.
J
Dr
nagar
talked
to,
or
dr
peterson
talked
about
collaborative
care
models.
What
are
they?
That's
when
you
take
services
and
place
them
into
a
regular
medical
care
office?
So
you
might
have
a
mental
health
treatment
into
a
primary
care
office.
Patients
with
publicly
funded
insurance
have
increased
challenges.
We
just
talked
about
that
with
transportation.
J
They
may
have
decreased
cell
phone
services.
You
want
to
have
things
in
one's
one
area,
so
they
have
one-stop
shopping
for
maternal
or
I'm
sorry
for
medical
and
mental
health,
and
this
also
decreases
the
stigma
of
treatment
of
mental
health
disorders
and
decreases
the
stigma
of
opioid
use
disorder
treatment
right
now,
one
in
11
people
below
the
poverty
level
have
extremely
severe
depression
and
only
30
percent
of
them
seek
help
if
they're
going
to
a
medical
visit.
This
allows
an
opening
of
that
door
for
treatment
for
these
people
overall
and
then
again.
J
J
Opioid
use
disorder
like
we
said
people
get
problems
of
of
overdoses
after
delivery.
We
really
need
to
have
behavioral
health
for
after
delivery,
but
also
during
delivery.
J
Our
office
runs
the
mother
program,
which
is
the
maternal
opioid
treatment,
health,
education
and
recovery
program.
We
treat
with
buprenorphine
and
we've
only
had
a
five
percent
nes
rate,
where
the
national
rate
is
55
to
60
percent
having
we
work
by
a
behavioral
health
model.
That
is
a
collaborative
care
model,
but
we
can't
bill
for
it
because
we
can't
pay
for
it.
Thank
er
to
to
pay
for
these
services.
I
mean
we
can't
bill
for
them.
We
have
been
lucky
enough
to
receive
grants,
but
grants
are
only
a
temporary
stepping
stone.
J
We
need
to
be
able
to
pay
our
care
managers
and
recovery,
support,
counselors
collaborative
care
models
really
integrate
these
services
overall
and,
like
I
said
they
decrease
the
stigma
they
build
on
existing
provider
relationships
and
they
decrease
the
social
determinants
of
health.
By
creating
one-stop
visits,
we
really
need
to
have
collaborative
care
paid
for
by
medicaid
one
of
the
last
side
side
notes.
I
would
tell
you
that
I
think
would
probably
be
unexpected
to
you.
J
Is
we
have
a
very
de-regionalized
system
of
care
within
nevada
in
clark
county,
eight
of
our
nine
hospitals
that
deliver
that
do
deliveries
have
level
three
nicu's
or
above
this
is
way
too
many,
and
when
you
have
way
too
many
higher
level
of
care
hospitals,
what
happens?
Is
you
decrease
the
experience
of
each
hospital,
especially
when
we
have
a
healthcare
worker
shortage?
J
Another
article
showed
that
as
many
as
one
in
30,
babies
that
delivered
a
low
volume
nicu
dies
unnecessarily
from
from
not
having
the
higher
levels
of
care
in
the
from
experienced
people.
Another
research
article
showed
a
risk-adjusted
odds
of
adverse
outcomes
such
as
severe
breathing
problems
bleeding
into
the
brain.
Blindness
was
16
to
55
percent
higher
at
among
infants
at
hospitals,
with
lower
than
50
very
low
birth
weight
deliveries
per
year
within
reno.
We
have
a
third
hospital.
J
Hence
a
majority
of
them
are
doing
less
than
50
deliveries.
A
year
which
is
probably
leading
which
will
probably
lead
to
worsening
outcomes,
are
hospitals.
How
do
you
solve
this?
Do
you
look
at
a
volume
indicator?
Do
you
look
at
the
very
little
birth
weight,
mortality
very
hard
to
say,
but
hospitals
in
the
highest
20
percent
of
mortality
usually
tend
to
stay
there
and
the
ones
in
the
lowest
20
percent
usually
tend
to
stay
there,
and
you
might
want
to
make
judgments
based
upon
that.
J
So,
overall,
my
final
ask
is
for
funding
for
perinatal
quality
collaborative
urgently.
I
think
we
got
sidetracked
last
time
because
the
coronavirus
outbreak-
and
I
would
urge
urge
you
to
help
us
move
forward
to
help
our
patients
within
nevada.
J
I
think
we
need
changes
in
global
pregnancy
funding
to
help
reverse
our
shortage
of
providers
in
nevada.
I
would
ask
for
a
medicaid
coverage
threshold
to
be
increased
more
towards
the
national
average
of
200
percent,
which
would
assist
our
our
mothers
with
social
determinants
of
health
or
and
other
disparities.
J
I
would
ask
for
expansion
of
medicaid
coverage
to
one
year
to
help
with
birth,
spacing
help
with
treatment
of
mental
health
disorders,
help
with
treatment,
opioid
use
disorder.
I
would
implement
policies
or
ask
for
implementation
of
policies
for
behavioral
health
services
and
ob
gyn
offices,
maternal
fetal,
medicine
offices.
I
would
ask
that
you
mandate
state
medicaid
to
pay
for
collaborative
care
services.
J
Then
I
think
we
have
to
look
at
this
explosion
of
level
three
and
level
four
nicu's
in
our
state
that
de-regionalized
care
helps
to
produce
more
worsening
outcomes,
dilutes
health
care
experience
at
each
center
and
exacerbates
position
shortages
and
that
I'll
end.
A
Thank
you
so
much.
That
was
a
a
lot
of
information
and
really
appreciate
that
summary
slide
at
the
end
summarizing
the
asks.
Are
there
any
questions
from
the
committee?
I
have
dr
titus
up
here,
who
has
a
question
I'll
go
ahead
and
start
with
you.
I
Well,
thank
you
for
the
presentation
and
totally
unexpected
information
that
you
presented
at
the
the
last
slide,
especially
regarding
the
excess
and
facilities
diluting
care
and
maybe
worsening
outcomes.
I'm
going
to
ask
a
question
about
that
in
a
minute,
but
first
I
would
like
to
go
back.
You
didn't
have
any
numbers
on
your
slides
and
I
was
wondering
about
that.
One
statement
that
and
just
a
clarification
that
I
heard
correctly.
J
I
Okay,
thank
you.
Thank
you
for
that,
and
then,
let's
go
back
to
the
your
closing
statement
there
regarding
the
number
of
facilities
in
nevada
in
in
the
healthcare
realm.
We
have
something
called
a
certificate
of
need
when
you're
applying
for
licensure,
and
you
have
so
to
prevent
the
excessive.
I
Applications
like
ct
scans,
mris
care
flights,
etc
even
hospitals.
I
thought
there
was
some
limitation
on
who
could
get
licensure
based
on
this
certificate
of
need
can
just
any
hospital
when
they
put
in
put
in
a
nicu.
I
did
training
as
a
family
practice
doc
in
the
nicu
in
saint
mary's
inn
at
washoe
at
the
time,
because
I
was
doing
deliveries
and
needed
that
experience
to
save
them
out
in
real
nevada.
J
What's
needed,
is
you
need
a
certain
volume
of
deliveries
to
be
able
to
apply
for
a
nicu
increase
in
level
of
care?
The
thing
is,
is
all
you
have
to
do
is
show
that
you
have
certain
equipment
and
a
certain
personnel
to
be
able
to
open
a
nicu
at
a
certain
point
in
time
and
those
are.
There
is
a
lot
of
burden
to
do
that.
J
So
I
don't
want
to
underestimate
that
there
is
a
lot
of
burden
to
do
that,
but
the
certificate
of
need
overall
for
the
community
from
a
community
standard
is
really
not
the
case
that
really
doesn't
hold
and
doesn't
move
forward.
As
you
can
tell,
I
mean
just
from
the
very
low
birth
weight,
babies
alone,
I
could
you
could
show
that
that
need
isn't
there,
and
what
I
would
say
to
you
is:
is
it's
because
of
a
of
a
profit
incentive,
I
believe
for
care
of
neonates?
J
So
there's
a
financial
incentive
to
open
a
nicu,
but
at
the
same
time
this
is
creating
other
other
sorts
of
problems
along
the
way-
and
I
can
see
dr
nagar
wants
to
get
in
here
quickly
because
she
got
back
on
her
camera.
So
I'll.
Let
her
do
that.
M
I
can't
agree
more
with
dr
erie
about
the
importance
of
quality
care
being
the
the
importance
instead
of
quantity,
of
care.
Similar
pros
challenges
happen.
When
increase
the
nicu
level.
M
Three
nicus
are
in
place
because
for
level
three
nicu's
the
physicians
stay
in-house,
so
the
shortage
also
continues
to
be
a
challenge
for
the
neonatal
world
to
provide
that
in-house
coverage,
24
7
and
then
have
this
dilution
of
care
because
of
the
limited
services
not
only
in
the
hospital
but
also
sub-specialty
coverage
across
the
board,
with
anywhere
from
gi
surgery,
neurosurgery
neurology,
every
single
one
of
them
are
having
to
go
to
multiple
hospitals
and
it
does
dilute
that
care.
I
Follow
up
on
that,
madam
chair,
so
just
again
just
to
be
clear
if
we
have
11,
nicu's
or
potentially
11
nicu's
with
these
three
new
ones
coming
in
reno,
they
can
only
get
licensed
to
do
that
if
they
can
staff
those
nicu's
and
so
and
which
means
they
would
have
to
either
bring
doctors
in
or
share
doctors,
but
again
they
can't
be
licensed
if
they
can't
be
staffed.
So
why
would
we
want
to
limit
accessibility
to
health
care
when
we
know
across
the
board,
we
don't
have
enough
docs
in
nevada.
I
So
I'm
just
curious
about
that.
My
first
question.
Second,
one
on
that
one
is:
are
all
these
that
have
the
the
nicu's
soon
to
be
11,
medicaid
reimbursement
ones
already,
or
are
they
just
all
private
facilities?
Do
you
have
a
breakdown
on
that.
J
They
all
have
set,
they
all
accept
nicu
in
one
way
or
except
medicaid
in
some
one
way
or
another.
Some
institutions
only
accept
certain
certain
forms
of
medicaid,
but
all
of
them
accept
one
or
another
form
of
medicaid,
and
most
of
them
accept
all
all
the
medicaid
hmo
plans.
J
In
regards
to
the
staffing,
the
staffing
numbers.
Just
say,
you
need
a
certain
number
of
personnel.
It
doesn't
tell
you
how
experienced
that
personnel
is.
It
doesn't
tell
you
how
they
keep
their
experience
by
dealing
with
more
intense
severe
cases,
all
the
time
it
doesn't
tell
you
the
nursing
experience
or
quality.
It
just
tells
you
numbers,
so
you
can
get
by
that
by
by
being
able
to
be
able
to
hire
personnel
and
train
personnel
for
those
positions,
but
it
doesn't
mean
you
have
already
trained,
experienced,
high-level
care
at
each
institution.
A
E
Thank
you,
madam
chair,
and
it's
good
seeing
you
again,
dr
erie.
Some
people
might
not
realize
we
already
have
some
maternal
child
health
coalitions
and
advisory
committees
already
in
the
state.
So
could
you
talk
a
little
bit
about.
J
They
they
would
really.
They
would
really
be
the
the
organization
that
puts
together
and
solidifies
the
marketing,
the
education,
the
data-driven
response
and
the
implementation
from
a
research
perspective.
J
As
I
showed
what
perinatal
quality
client
care
collaborative
done
when
set
up
in
this
fashion,
have
really
decreased
morbidity
and
mortality,
and
you
really
need
a
centralized
structure
to
be
able
to
do
that.
Those
structures
are
usually
assisted
by
an
organization
called
nietzsche
or
or
nnpqc,
which
is
neonatal
perinatal
quality
care,
collaborative
society
in
the
united
states
and
those
are
federally
funded
organizations
that
that
put
these
programs
together,
make
sure
that
they're
run
at
a
high
level
and
utilize
educational
and
research
perspectives
that
are
are
basically
best
practices.
A
Thank
you,
assemblywoman
gorlo.
Anyone
else
have
questions
for
dr
erie,
I'm
not
seeing
any.
Thank
you
so
much
for
the
presentation
again,
really
appreciate
it
and
your
time
and
we'll
go
ahead
and
close
that
agenda
item
at
this
time,
we're
doing
pretty
good
on
time.
Y'all
we
are
going
to
take
a
lunch
break
30
minute
lunch
break.
There
is
food
in
the
grant,
sawyer
building
there
for
y'all,
and
we've
got
some
up
here.
So
you
shouldn't
have
trouble
getting
to
that
and
we
will
see
you
back
here
at.