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Description
This is the seventh meeting of the 2021-2022 Interim. Please see the agenda and "Work Session Document" 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,
welcome
to
to
the
seventh
meeting
of
the
joint
interim
standing
committee
on
health
and
human
services:
let's
go
ahead
and
well
our
secretary.
Please
proceed
with
the
role.
C
D
F
A
A
Thank
you
so
much,
and
just
as
a
clear
notice
for
the
members
that
are
training
virtually
just
make
sure
that
you
have
your
cameras
on
and
throughout
the
duration
of
this
meeting.
If
you
can
respond,
whenever
you
have
any
questions,
we
have
members
that
are
joining
us
virtually
and
in
southern
nevada,
so
very
excited
to
be
here
today
up
in
carson
city
for
our
some
of
the
folks
that
are
attending.
I
just
wanted
to
give
a
clear
clarification.
A
We
have
gone
ahead
and
moved
the
work
session
to
our
following
meeting,
so
we
won't
be
doing
a
work
session
today.
A
Of
course,
please
mute
your
microphone
when
you
are
not
speaking,
but
you
can
continue
to
leave
your
camera
on.
Additionally
I'll
ask
all
of
our
presenters
on
the
zoom
video
call
to
leave
your
cameras
off
and
microphones
muted.
Until
I
come
up
on
the
agenda
item
under
which
you
will
present-
or
I
will
direct
questions
to
you,
the
zoom
video
call
has
a
chat
feature.
However,
this
feature
is
only
to
be
used
for
technical
assistance
and
any
links
or
information
that
you
would
like
to
share
during
your
presentation
should
be
stated
verbally
on
the
record.
A
Again,
there
are
some
situations
where
agenda
items
may
be
taken
in
a
different
order
than
listed,
and
the
committee's
meeting
materials
can
be
found
on
the
nevada
legislature's
website,
which
you
can
also
sign
up
to
receive
electronic
notifications
related
to
any
activity
on
the
committee's
website.
A
If
you
wish
to
testify
in
person,
you
can
please
sign
in
at
the
table
by
the
door
and
leave
your
business
card,
and
if
you
do
not
wish
to
testify,
you
may
also
want
to
sign
in
just
so
that
there's
a
record
of
who
is
interested
in
a
particular
topic.
When
the
committee
revisits
the
meeting
minutes
and
when
you
testify
in
person,
please
turn
on
the
microphones
on
to
speak
and
off
to
listen,
because
we
have
others
folks
in
virg
virtually
and
in
las
vegas.
A
So
now
that
I
have
completed
with
the
housekeeping
announcements,
let's
go
ahead
and
move
into
public
comment.
So
once
again,
public
comment
will
be
limited
to
three
to
three
minutes
per
speaker.
We
will
go
ahead
and
make
sure
that
everyone
has
an
equal
and
fair
chance
to
speak,
and
we
also
ask
that
you
do
not
repeat
what
the
previous
commenter
stated
and
again
since
we
won't
be
having
a
work
session.
A
Typically,
it's
just
encouraged
that
individuals
address
any
item
during
the
work
session
in
certain
public
comments.
So
just
wanted
to
make
that
clarification
for
folks
that
are
interested
in
speaking,
but
let's
go
ahead
and
begin
with
public
comment
for
those
of
us
here
in
carson
city.
So
please
begin.
D
D
As
a
matter
of
principle,
nami
nevada
is
in
support
of
open
access
to
all
safe
and
effective
medications
for
mental
health
conditions,
as
prescribed
by
qualified
health
care
professionals.
Access
to
meds
is
crucial.
The
state's
efforts
to
address
the
ever-increasing
costs
of
prescription
drugs
have
led
medicaid
to
join
the
national
medicaid
pooling
initiative
and
mpi.
D
D
D
Research
has
shown
that
prior
authorizations
and
denials
for
psychiatric
populations
results
in
poor
outcomes,
which
include
increased
utilization
of
ers,
higher
incarceration
and
a
higher
usage
of
mental
health.
Inpatient
hospitalization,
all
these
outcomes
cost
more
money
than
what
is
saved
in
prescription
costs.
Therefore,
it
is
very
important
to
ensure
that
the
current
pdl
is
maintained.
A
A
Thank
you
so
much,
and
is
there
anyone
virtually?
That
would
like
to
provide
public
comment.
G
H
G
Good
morning,
simply
sorry
good
good
morning
to
everyone,
my
name
is
dora
martinez.
I
represent
the
nevada
council
of
the
blind,
as
well
as
the
nevada
disability
production
coalition.
I
want
to
share
this
information.
It's
a
very
it's
a
great
news
for
people
who
are
low
vision
and
people
who
are
blind,
like
myself,.
G
G
It
will
read
you
the
directions
and
also
the
test
results,
and
these
are
all
free
to
people
who
are
visually
impaired
and
low
vision,
and
you
do
not
need
to
prove
that
you
are
blind
unless
they
ask
you
to
once
you
go
online
and
just
type
accessible
call
the
test
and
it'll
pop
up.
Thank
you
so
much
for
your
patience
and
have
a
great
session.
Thank
you.
E
E
E
I
am
excited
for
you
to
hear
today
from
dr
stephen
shane,
who
is
the
obesity
prevention
chair
at
the
nevada,
aap
and
a
leader
in
obesity
prevention
at
future
committee
meetings.
I
hope
that
you
will
call
on
other
nevada,
aap
leaders
to
share
with
you
ideas
for
legislative
action
that
could
greatly
improve
the
health
of
nevada's
children.
E
The
nevada
aap
currently
has
262
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.
Thank
you.
E
E
We
know
that
mental
health
concerns
often
present
in
primary
care
or
specialty
medical
care
settings
first,
so
the
emphasis
on
the
physician
shortage
is
necessary
to
address,
as
my
colleagues
will
share
today.
It
is
equally
important
to
respond
to
the
critical
shortages
in
mental
health
professionals
in
nevada,
to
ensure
that
our
medical
colleagues
have
someone
to
refer
patients
to
for
mental
health
care.
E
Good
morning
to
peters
vice,
chair
gennady
and
members
of
the
committee,
this
is
joanna
jacob
jacob
on
behalf
of
clark
county.
I
wanted
to
give
public
comment
today
on
agenda
item
6
on
improving
access
to
behavioral
mental
health
care.
We
thank
you
for
scheduling
this
item.
E
According
to
the
conversations
we've
been
having
with
the
state,
these
workforce
challenges
lead
to
a
difficulty,
maintaining
the
staffing
levels
for
them
to
be
able
to
care
for
these
kids,
especially
kids,
with
acute
behavior,
coupled
with
a
mental
health
diagnosis.
This
is
another
pattern
of
denial
that
we
have
seen.
We
need
to
address
the
needs
for
these
children
and
our
most
vulnerable
citizens.
Since
we
began
tracking
the
youth
that
have
been
surrendered
to
our
child
welfare
agency,
we
began
in
august
of
last
year.
E
87
children
have
been
surrendered
to
the
child
welfare
agency,
the
in
clark
county
for
unmet
mental
health
needs
only
40
of
those
parental
surrenders
have
been
since
january
of
this
year.
Parents
are
simply
surrendering
their
kids
to
our
system,
because
our
doors
are
always
open
and
they
cannot
access
care
in
any
other
way.
E
We
believe
our
child
welfare
system
will
benefit
in
any
effort
to
address
workforce,
but
our
needs
go
even
beyond
just
this
system.
Clark
county
administers
our
own
self-funded
health
plan.
For
example,
when
I
spoke
to
them
about
this
presentation,
they
told
me
that
we
are
seeing
this
significant
lack
of
children's
behavioral
health
resources,
specifically
facilities
serving
adolescents
needing
behavioral
health
care.
The
need
is
systemic
and
it's
impacting
our
employees,
the
staff
at
child
haven,
as
well
as
the
populations
we
serve.
This
is
a
very
serious
issue.
E
H
B
I
have
submitted
our
comments
via
email
as
well.
The
burden
of
cancer
is
great
in
our
state
as
it's
the
second
leading
cause
of
death
and
second,
most
costly
chronic
disease.
Only
behind
heart
disease,
world
health
organization
reports
that
between
30
to
50
percent
of
cancer
deaths,
could
be
prevented
by
modifying
or
avoiding
key
risk
factors
and
implementing
existing
evidence-based
prevention
strategies.
B
Chronic
disease
prevention
results
in
lower
health
care
spending
overall,
less
strain
on
our
health
care
system.
Fewer
bankruptcies
filed
by
families.
Who've
received
these
diagnoses
and
fewer
people
undergoing
treatment
that
leave
them
physically
and
emotionally
scarred.
So
imagine
nearly
8
200
nevadans
every
year
who
never
have
to
hear
you
have
cancer
and
imagine
saving
more
than
48
million
annually
in
medicare
costs,
so
to
truly
prevent
more
cancers
and
improve
the
early
detection
of
cancer
and
other
chronic
diseases.
B
B
So
here
at
nevada
cancer
coalition,
we're
truly
looking
forward
to
working
with
you
all
and
serving
as
a
resource
during
the
upcoming
legislative
session,
as
we
all
work
to
protect
and
improve
the
health
of
all
nevadans.
Thanks
for
everything
that
you
do
for
your
our
state
and
thank
you
for
your
time.
A
J
Interested
in
yes,
sir,
if
I
might
I'll
move
to
approve
the
the
minutes
from
the
24th
and
april
21st,
if
the
chair
or
assistant
chair
is
ready.
A
A
Thank
you
so
much
assemblywoman
peters.
We
have
a
second
for
the
motion.
Are
there
any
comments
or
discussion
on
emotion
before
you
vote
see
all
all
in
favor?
Please
say:
aye
aye,
yes,.
K
Thank
you
on
april
21st,
and
this
has
been
an
ongoing
question
on
page
60
of
the
minutes,
I
asked
a
question
about
reciprocity
of
the
compact
and
mr
mike
caluso
said
he
would
answer,
get
the
answer
to
the
staff
and
I'm
curious
when
we
ask
for
an
answer
and
we
get
the
answer
who
gets
the
answer,
do
we
all
get
the
answer?
G
For
the
record,
patrick
ashton,
legislative
council
senator
hardy,
I
can
look
into
this
and
see
if
we
can
still
get
this
follow-up
and
once
we
receive
it.
It
usually
goes
to
chair,
peters
and
then
is
uploaded
on
the
committee's
website,
but
I
will
make
sure
to
follow
up
with
mr
macaluso
and
see
what
I
can
get
you
for
you.
There.
G
For
the
record,
patrick
ashton,
senator
hardy,
it
will
be
included
on
the
bottom
of
the
meeting
minutes
and,
to
my
knowledge,
it's
also
distributed
to
members.
G
G
For
this
question,
we
did
not
receive
a
follow-up,
but
generally
when
we
receive
a
follow-up,
it
will
be
included
in
the
meeting
minutes
and
also
uploaded
on
the
website,
and
there
will
be.
Is
an
email
sent
out
that
there's
additional
meeting
material
for
for
the
meeting
coming
up?
For
this
particular
question,
I
do
not
I'm
pretty
sure
and
I
will
check
again,
but
we
have
not
received
a
follow-up.
I
can
go
ahead,
follow
up
with
mr
macaluso
and
then
upon
approval
of
the
chair.
G
B
Thank
you
senator.
I
do
receive
those
follow-ups
from
staff
and
I
approve
like
within
a
couple
of
days
of
receiving
that,
depending
on
my
my
day
schedule
and
then
they're
really
great
about
following
up
with
that.
I
know
that
in
our
emails,
sometimes
things
can
get
lost.
B
I've
had
to
put
a
filter
on
my
email
to
make
sure
that
I
capture
all
of
lcd's
emails
as
they
come
in,
but
we
will
follow
up
and
make
sure
that
that
is
that
is
provided
back
to
the
committee
and
I'll
make
sure
that
everyone
gets
access
to
that
and
we
post
online.
We
do.
B
I
do
try
and
be
very
transparent
in
this
committee
and
make
sure
that
what
we
receive
as
follow-up
is
presented
to
staff
or
by
staff
to
our
committee
members
and
post
it
on
to
the
appropriate
meeting
page
as
follow-up,
because
I
think
that
our
questions
are
val
are
valuable
and
valid
and
those
follow-up
items
do
help
us
make
policy
decisions.
So
thank
you
for
bringing
up
that.
We
did
not
that
we
missed
that
follow-up
potentially,
and
I
hope
we
can
get
that
to
the
committee
members
in
a
timely
manner.
A
K
A
A
A
G
Yes,
so
for
this
agenda
item
we
have
three
regulations
for
the
consideration
of
the
committee
today.
Lcb
file,
r043-22
and
r048-22
are
both
from
the
state
board
of
health
and
r061-22
is
from
the
state
board
of
nursing,
and
we
should
have
representatives
from
the
two
different
regulatory
agencies
behind
these
regulations
who
are
available
either
virtually
or
in
person.
A
Thank
you
so
much,
mr
robbins.
As
a
reminder
to
the
committee.
This
is
informational.
Only
staff
have
informed
you
about
the
status
of
the
regulatory
process
of
these
regulations
that
we
are
considering
right
now
and
I
want
to
go
ahead
and
if
you
have
the
opportunity,
if
there's
any
questions
regarding
them,
we
can
go
ahead
and
proceed
now.
It
looks
like
assemblywoman
titus.
You
have
a
question
so
please
proceed.
J
I
thank
you.
I
have
a
question
regarding
the
regulation
r048-22
by
the
state
board
of
health
and
under
the
notes
that
we
received
that
apparently
has
not
been
scheduled
for
a
hearing
yet
or
or
a
vote
yet
through
the
ledge,
because
it
hasn't
gone
out
to
impact
statements.
Yet
is
that
correct
to
small
businesses?
G
G
This
is
latisha
for
the
record,
with
the
bureau
of
healthcare
quality
and
compliance,
we're
currently
undergoing
the
small
impact
study,
we're
expecting
all
the
responses
to
be
in
by
the
end
of
this
week
by
the
end
of
friday
and
start
the
analysis
next
week.
Okay,.
G
J
That
and
if
I
might
have
a
follow-up
question
on
that
on
actually
on
the
very
first
line
on
section
one
it
it
seems
like
it
expands,
the
chief
medical
officers
abilities
dramatically
with
one
kind
of
stroke
of
the
brush
and
I'm.
I
have
concerns
about
that,
because
it
doesn't
really
say
what
information
he
might
actually
request,
and
I'm
just
wondering
when
you,
when
you've
reached
out,
who
have
you
reached
out
to
on
this
impact,
because
it
doesn't
really
I'm
just
concerned
about
that.
J
That
amount
of
opened
ended
power
that
he
might
have
and
and
requesting
information.
G
So
far,
we've
sent
it
out
to
all
of
our
licensed
health
care
facilities
and
we
are
still
waiting
for
the
feedback.
We
have
not
send
it
out
beyond
that
that
I'm
aware
of,
but
I
will
definitely
note
your
concerns
and
bring
it
back
to
our
administration.
J
Right
because
the
word
says,
the
the
chief
medical
officer
may
require
any
person
or
any
or
entity
in
the
state,
and
so
any
person.
Any
entity
is
just
about
everybody
here,
and
so
I'm
just
very
concerned
about
that
that
language.
G
Yes,
I
will
definitely
bring
back
the
concerns
to
our
administration
to
discuss
that
and
also
review
the
analysis
and
see
if
we
get
any.
B
Feedback
on
that
section
from
our
health
facilities.
J
All
right,
it
doesn't
say,
limited
to
health
facilities,
though
that's
my
concern.
This.
G
So
I
just
wanted
to
note
that
nrs
233
b
.039
says
that
the
regulatory
adoption
process
does
not
reap
does
not
apply
to
any
order
for
immediate
action
included,
made
under
the
authority
of
the
state
board
of
health
in
the
discharge
of
a
responsibility
for
the
preservation
of
human
or
animal
health,
and
so
basically
the
state
board
of
health.
As
we
interpret
it,
it
would
have
the
authority
to
impose
reported
reporting
requirements.
G
You
know
immediately
to
respond
to
a
pandemic
anyway,
so
this
regulation
doesn't
really
as
we
would
interpret
it,
expand
the
authority
of
the
state
board
of
health
so
much
as
it
just
states
their
intention
to
to
do
that.
And
so
I
mean
again,
this
isn't
really
an
expansion
of
authority
so
much
as
a
restatement
of
the
authority
that
they
already
have
under
statute.
A
Okay,
thank
you
so
much
any
other
questions
from
any
other
community
members.
At
this
time,.
K
Thank
you,
mr
chair.
I
looked
at
this
and,
as
I
see
it,
and
this
is
going
to
go
to
the
legislative
commission.
Obviously,
if
the
chief
health
officer
determines
that
a
pandemic
exists
in
a
pen
or
a
pandemic
exists,
the
officer
may
require
any
person
or
entity
in
the
state
to
report
to
the
chief
health
officer
as
opposed
to
do
something
else.
And-
and
so
I
I
think,
the
reporting
process
of
that
is
probably
a
little
different
than
having
to
take
some
kind
of
action.
K
So,
for
instance,
if
to
dr
titus's
point
any
person.
So
let's,
let's
pretend
that
there
is
a
covid
issue
that
has
happened,
and
if
you
do
a
home
test,
the
that's
positive,
then
the
chief
health
officer
may
require
that
person
who
did
the
home
test.
That
was
positive
to
report
and
that's
how
I
read
that
this
could
happen
and
I
suspect
that's
what
they
meant,
but
we
have
a
lot
of
home
tests
right
now
that
aren't
reported,
and
this
would
create,
could
may
require
such
a
person
to
report
the
positivity
of
a
home
test.
K
G
Yes,
the
intent
was
to
be
able
to
do
something
similar
to
that.
I
don't
know
if
it
was
specific
to
that.
It's
not
necessarily
just
specific.
G
The
information
we
need
during
a
pandemic
in
order
to
be
able
to
carry
out
the
workload
of
the
you
know
of
the
of
the
division
and
so
early
on.
We
ran
into
certain
difficulties
with
reporting
or
reporting
from
laboratories
from
outside
of
the
state,
and
things
like
that.
So
yes.
G
That
there
was
a
need
to
collect
information
on
home
tests,
but
it
was
basically
limited
to
the
pandemic
or
epidemic
for
that
particular
reason
versus
making
it
at
any
time
to
help
facilitate
those
needs.
K
I'm
a
mr
chair:
please
proceed
so
what
I'm
hearing
is?
Yes,
the
intention
is
to
be
able
to
get
home
tests
reported,
and
the
comment
is
made
that
we
had
difficulty
getting
entities
outside
of
the
state
to
report
and
obviously
we
don't
have
jurisdiction
outside.
Nor
does
this
require
outside
people
to
report
because
it
says
in
this
state.
K
A
Thank
you
so
much
senator
hardy
again.
I
just
wanted
to
reiterate
that
for
those
of
us
that
are
interested
in
participating
in
the
development
of
these
regulations,
that
we
have
the
ability
to
do
so-
and
you
know
we
don't
approve
or
deny
any
of
these
regulations
before
today,
but
I
encourage
all
the
members
on
this
committee
to
follow
up.
A
If
need
be,
do
we
have
any
other
questions
at
this
time
from
any
other
committee
members
regarding
the
presentation,
seeing
none,
let's
go
ahead
and
continue
on
with
any
additional
agenda
items.
Give
me
one
second.
A
Great
okay,
so
let's
go
ahead
and
move
on
to
the
next
agenda
item,
which
is
the
overview
of
community
health
workers
and
medicaid
reimbursement
for
such
workers.
In
behavioral
healthcare
settings
we
have
jay
colbette,
which
is
the
program
manager
of
the
nevada
community
health
workers
association.
So
please
proceed
when
you
are
ready.
L
I
believe
we're
set
up,
so
my
name
is
jay
colbert
klossel
for
the
record.
Thank
you
for
having
us
here
again
to
do.
Follow
up
on
the
great
community
health
work,
legislative
effort
that
you
put
into
the
last
session.
L
L
So
just
a
quick
overview
on
what
is
a
community
health
worker.
So
community
health
workers
are
front
line
public
health
contacts.
They
help
bridge
the
gap
between
the
services
that
are
available
and
the
services
that
that
people
are
willing
to
accept
and
kind
of,
engage
and
learn
how
that
they
can
live
healthier
lives.
L
We
have
state
certification
for
community
health
workers,
they
take
an
eight-week
course
and
must
be
supervised
to
really
do
their
work
correctly
with
the
right
health
team
to
refer
people
to
they
reduce
er,
a
readmission
and
urgent
care
reliance,
and
they
extend
the
reach
of
our
licensed
healthcare
professionals.
L
Community
health
work
is
an
entry-level
place
for
many
people.
Now
our
students
range
in
age
from
18
to
97.
So
not
everyone
is
on
the
track
to
become
a
a
social
worker
or
a
nurse,
but
the
community
health
worker
is
a
place
that
you
know
anybody
can
kind
of
be
trained
and
bring
the
expertise
that
they
have
about
their
community.
L
Three
percent
of
our
students
are
american,
indian
or
alaskan
native
three
percent
are
hawaiian
or
pacific
islander
24
are
black
or
african.
American
31
are
hispanic
and
32
percent
are
rule.
So
you
can
see
how
these
are
the
people
we
want
to
incorporate
into
our
health
care
system.
L
Other
training
programs
across
the
state,
the
nevada
community
health
worker
association,
has
had
about
500
students
sign
up
so
far
this
year.
So
just
really
tremendous
growth
tmcc
has
an
online
program
that
they
operate
out
of
reno
csn
has
online
and
in
person
that
they
operate
out
of
las
vegas.
L
L
These
are
the
13
competencies
that
the
nevada
certification
board
has
adopted
from
a
consensus
so
in
social
work,
oh
yeah,
I
forgot
to
introduce
so
I
have
a
master's
in
social
work
in
social
work.
We
have
a
governing
body
at
the
national
level
that
kind
of
defines
what
things
are,
but
in
community
health
work,
it's
been
more
organic,
so
we're
all
voluntarily
moving
in
the
same
direction
where
we're
using
community
health
workers
in
the
same
way
and
growing,
depending
on
the
individual
states
and
environment
and
the
needs
that
are
there.
L
So
promotorists
actually
were
the
first
community
health
workers
in
nevada
working
out
of
rural
areas,
but
now
we
have
community
health
workers
across
the
state.
L
So
in
the
last
legislative
session,
ab-191
was
passed
with
unanimous
support.
It's
a
very
short
bill
that
just
empowered
medicaid
to
allow
reimbursement
for
community
health
workers.
One
important
thing
to
note
is:
it
does
not
exclude
behavioral
health.
The
fiscal
analysis
really
looked
at
well.
What's
what
narrowly
can
we
tackle
to
get
things
started
to
approach
this
new
reimbursement
and
service
model
conservatively,
and
so
the
the
fiscal
analysis
looked
at
chronic
disease
prevention
and
management,
and
that's
what
moved
forward?
L
The
chws
must
be
employed
and
serving
the
same
clients
as
the
physician,
physician
assistant
or
advanced
practice
registered
nurse.
All
of
this
infrastructure
has
been
developed
by
the
medicaid
office
and
go
ahead
and
hop
a
little
bit
so
with
medicaid
reimbursement.
L
I
jumped
ahead
a
little
bit,
but
those
settings
can
be
in
clinical
settings
or
community
settings,
so
the
chw
might
be
based
with
a
physician,
but
they
can
go
into
the
churches.
They
can
go
into
the
schools
and
other
community
centers
to
provide
services
and
work
with
clients
and
and
help
them
really
adopt
the
the
health
practices
that
are
going
to
lead
to
healthier
lives.
L
So
in
february
we
began
enrolling
chws
in
nevada
and
just
a
few
days
ago
july,
7th
the
cms,
I
think
it's
center
medicaid
and
medicare
services,
so
the
national
level
approved
the
state
plan.
Amendment.
L
The
chws
must
receive
certification
from
the
nevada
certification
board.
That's
also
where
complaints
would
be
moved
forward
and
the
chw
has
an
agreement
that
they
sign.
That
is
on
file
with
medicaid
on
the
scope
of
work
and
where
that
community
health
worker
will
be
providing
services.
L
So
challenges
and
opportunities
for
chws
in
behavioral
health
took
this
picture
in
out
in
tonopah
a
few
days
ago.
We
just
we
have
a
lot
of
areas
where
we
need
our
licensed
professionals
to
have
a
longer
reach
a
further
reach
and
and
to
spend
more
time
with
clients.
So
with
the
medicaid
reimbursement,
that's
an
extra
12
hours
per
month
that
the
health
system
gets
to
engage
with
the
client.
L
If
we
look
at
medicaid
funding
in
other
states,
no
other
states
have
it
restricted
at
the
level
that
we
do
with
physician,
physician,
assistant
and
aprns
being
the
only
supervisors
for
medicaid
reimbursement.
I
I
think
I'll
I'll
ask.
If
there
are
specific
questions
about
this,
we
could
come
back
to
it.
L
I
think
what
it
boils
down
to
is
that
state
licensed
behavioral
health
supervisors
will
enhance
chw
services
across
the
state
because
they
have
a
longer
history
of
supervision,
experience
with
chws
and
close
ties
with
the
community,
and
I
put
that
that
statement
on
there
because
we're
doing
a
lot
of
education
for
our
physicians,
physician,
assistant
and
aprns,
so
that
they
feel
comfortable
supervising
chws
because
they
hadn't
historically.
L
Let's
see
so
some
of
the
goals
today
would
be
to
increase
the
awareness
of
the
nevada
certification
board
that
also
oversees
peers.
Certified
prevention,
specialists
and
doulas
increase
this
employer's
scope
of
work,
knowledge
for
chw's
peers
and
other
paraprofessionals,
and
then
open
career
paths
to
the
diverse
chw
workforce
in
public
health.
So,
for
our
recommendations,
we'd
like
to
investigate
the
nrs
language
to
recognize,
chws
and
other
settings
and
with
other
staff
funding
mechanisms,
the
current
language
is
very
specific
to
medicaid.
L
But
we
have
chws
who
are
funded
in
other
ways
and
are
also
making
use
of
the
nevada
state
certification,
like
we
contract
62
chws
across
the
state,
through
the
cdc
health
disparity
grant,
for
example,
and
they
have
a
a
slightly
different
scope
of
work
than
in
a
medicaid
or
a
medical
setting,
specifically
also
that
we
have
evidence
now
that
appropriately
supervised
chws
will
reduce
the
cost
two
dollars
for
every
one
dollar
spent
in
nevada,
and
we
believe
that
that
will
apply
to
the
behavioral
health
setting
it's
working
at
renown
and
it's
working
in
our
justice
system
and
even
in
our
food
pantries,
when
those
chws
are
helping
connect
people
to
services,
we'd
like
to
look
at
the
legislative
authority
to
medicaid
so
that
they
could
include
other
qualified
supervisors
right
now.
L
Our
language
is
more
restrictive
than
any
other
state
in
who
can
supervise
a
chw
and
then
add
chw
certification
to
the
nrs
definition
of
community
health
workers.
Right
now,
certification
is
not
listed.
It
does
say
that
they're
not
a
licensed
professional,
but
it
doesn't
mention
the
certification
that
is
available
so
for
additional
information.
L
I
have
my
contact
here
and
then
we
also
have
the
references
for
where
a
lot
of
the
research
came
for
this
and
then
where
you
can
find
information
on
the
nevada
program
as
developed
by
the
medicaid
office,
and
we
have
an
abbreviations
page.
So,
let's
see
oh
centers
for
medicare
and
medicaid
services.
I
had
the
c
wrong.
L
I
and
I'm
now
available
for
questions,
and
then
there
are
also
people
on
the
line
of
like
dr
let's
see
woodard
and
let's
see
I
did
you
want
to
share
any
or
was
it.
A
Thank
you
so
much
jay
for
the
presentation
we
have
dr
antonia
capraro
who's,
a
deputy
administrator
in
the
division
of
healthcare
and
financing
policy.
If
there's
any
members
that
have
any
questions
or
are
on
the
reimbursement
or
medicaid
part
members,
do
you
have
any
questions
at
this
time?
Don't
see
any
answers?
Senator
hardy.
K
Thank
you,
mr
chair.
I
think
this
is
wonderful
and
I'm
grateful
that
it's
trying
to
expand.
I
I'm
not
sure
I
understand
the
mechanics
when
medicaid
covers
this.
Does
the
check
go
to
the
chw
or
does
the
check
go
to
the
supervising
doctor
and
the
doctor
pays
the
chw
or
does
the
doctor
hire
a
chw
and
then
bills
medicaid
through
the
doctor's
number?
G
Yes,
thank
you
so
much
for
the
question.
This
is
for
the
record
within
nevada
medicaid.
What
we
require
is
for
the
community
health
worker
to
be
enrolled
with
us
as
a
as
a
provider
type.
They
must
as
a
pta
89
is
their
provider
type.
You
must
enter
into
a
collaborative
supervisory.
G
I
K
Yes,
so
so
I
understand
that
then
so
the
licensed
provider
gets
paid
by
medicaid
and
then
that
license
provider
in
that
collaborative
agreement
has
agreed
with
the
chw
person
how
how
much
that
person
is
going
to
be
paid
either
as
a
salary
or
as
a
piece
meal
or
as
a
whatever.
Whatever
agreement
they
come
up
with.
That's
the
agreement,
how
the
community
health
care
worker
gets
paid.
G
Thank
you
for
the
questions.
This
is
dr
capraro
for
the
record.
Yes,
that's
correct,
just
as
we
would
reimburse
any.
I
K
What
is
the
the
usual
and
customary
wage
that
a
doctor,
for
instance,
would
pay
a
community
health
worker
so
that
we
can
say:
oh
they
make
x
number
of
dollars
per
hour
or
how
are
we
going
to
recruit
if
we
don't
know
how
much
they're
going
to
be
paid.
L
Hello,
this
is
jay
colbert
clauselle
for
the
record.
Thank
you
senator
hardy
and
through
you
chair
peters,
it
is
market
driven.
So
there
are
there's
a
lot
of
diversity
in
how
chws
are
compensated,
the
reimbursement
rate,
if
you
kind
of
conservatively
map
it
out
and
allow
for
non-reimbursable
activities
like
scheduling,
you're,
looking
at
about
48
000
per
year
available.
L
K
So
it's
what
we
call
a
good
job
that
will
save
money
for
medicaid
and
save
money
for
the
patients,
and
I
think
if
we
bring
this
up
that,
not
only
can
you
have
a
good
job,
but
you
can
make
a
good
wage
and
it
would
be
good
for
everybody.
I
I
think
we
have
to
have
a
pr
program
that
says
you
know.
Do
it
it's
a
good
deal.
A
Thank
you
so
much
senator
hardy
any
other
members
of
any
other
questions.
A
Seeing
none
thank
you
so
much
to
our
presenters.
Let's
go
ahead
and
move
on
to
the
next
agenda
item,
which
is
agenda,
item
six,
improved
access
to
behavioral
mental
health
care
in
nevada.
We
have
dr
woodard,
who
is
a
senior
advisor
on
behavioral
health
at
the
division
of
public
health
and
public
and
behavioral
health.
So
dr
woodard
please
proceed
when
you
are
ready.
M
M
M
We
have
updated
numbers
that
have
not
been
calculated
yet
into
a
mental
health
america
report,
but
these
numbers
I
do
think
reflect
a
very
high
level.
Some
of
the
elements
that
are
critical
to
determining
how
individuals
are
accessing
care
in
the
approximate
prevalence
of
some
of
these
issues
in
our
state,
so
these
numbers
are
specific
to
nevada,
and
this
was
produced
through
the
national
survey
on
drug
use
and
health.
M
This
is
an
annual
survey
that
occurs
across
the
united
states
and
typically
is
held
as
the
gold
standard
for
estimating
prevalence
rates
across
a
number
of
different
indicators
in
behavioral
health.
So,
according
to
the
survey,
they
estimate
that
in
2020
the
number
of
individuals
over
age
12.
So
this
is
age
12
and
up
in
nevada.
Meeting
criteria
for
a
substance
use
disorder
in
the
past
year
was
371
thousand.
M
Now,
if
you
look
just
below
to
individuals
needing
and
not
receiving
substance
use
disorder,
treatment
in
a
specialty
facility
and
specialty
facilities
are
classified
as
facilities
that
are
specifically
geared
towards
addressing
individuals
with
relatively
severe
and
acute
substance,
use
disorders,
those
needing
and
not
receiving
substance
use
disorder.
Treatment
in
a
specialty
facility
was
approximated
to
be
355
000,
so
you
can
see
that
there
is
a
very
significant
gap
between
the
number
of
individuals
that
are
presumed
to
have
a
substance,
use
disorder
and
those
needing
care,
but
not
accessing
that
care.
M
Similarly,
we
see
prevalence
rates
that
are
estimated
for
individuals
in
nevada
meeting
criteria
for
any
mental
illness
in
the
past
year.
Those
estimates
do
not
include
youth.
There
is
a
different
tool
that
is
used
in
those
data.
I
did
not
review
as
part
of
this
presentation,
but
for
adults,
age,
18
and
older.
M
However,
they
used
data
from
the
2018-29
survey,
the
same
survey
that
this
data
comes
from,
but
a
couple
of
years,
older,
according
to
a
compilation
of
data
that
they
put
together
to
look
at
access
to
care,
adults
and
their
ability
to
access
care,
nevada,
ranked
40th
out
of
51
and
youth
and
nevada,
ranked
51st
out
of
51.
M
M
I
was
listening
actually
very
closely
to
some
of
the
public
comment
that
was
given
just
prior
to
the
presentations
today,
and
I
do
think
that
it
underscores
some
of
the
data
that
was
presented
and
certainly
highlights
some
of
the
work
that
we
have
been
working
with
clark
county
on
when
they
say
that
87
youth
have
been
relinquished
to
child
welfare,
with
the
primary
reason
of
parents
feeling
unable
to
meet
the
primary
behavioral
health
care
needs
of
their
children
with
40
of
those
children
just
being
relinquished
to
child
welfare
since
january
of
this
year.
M
Of
the
biggest
drivers
that
we
have
related
to
access
to
care
in
nevada
is
our
workforce
shortages,
and
I
cannot
highlight
enough
the
importance
of
addressing
some
of
these
workforce
shortages,
considering
that
nevada
has
94.5
of
the
state's
population
living
in
a
mental
health,
healthcare
professional
shortage
area
when
we
start
to
quantify
this
not
just
in
generalities,
but
when
it
compares
to
what
we
would
need
in
order
to
just
be
average
john
packham
and
the
nevada
health
workforce.
M
According
to
this
research,
in
order
for
nevada
to
just
be
average
for
the
number
of
clinical
professional
counselors
per
population
of
100
000,
we
would
need
1074
additional
clinical
professional
counselors
licensed
clinical
social
workers
are
estimated
to
to
need
18..
We
are
actually
meeting
and
exceeding
what
would
be
considered
the
national
average
for
marriage
and
family
therapists.
M
This
continues
with
an
analysis
of
our
school-based
behavioral
health
providers,
and
we
know
that
providing
behavioral
health
services
within
schools
can
certainly
help
to
provide
prevention
and
early
intervention
services
to
youth,
but
also
extends
beyond
that,
including
making
sure
that
we
are
adequately
identifying,
assessing
and
qualifying
children
who
may.
N
M
Criteria
for
a
504
accommodation
or
an
iep
for
any
kind
of
behavioral
health
disability.
So,
in
order
to
do
this
contrast,
what
has
been
identified
is
that
for
school
psychologists
we
would
need
3.7
times
as
many
as
we
currently
have,
and
what
is
most
startling
is
for
school
social
workers.
Based
on
the
current
nevada
ratio
versus
the
recommended
ratio,
we
would
need
35
times
as
many
school
social
workers,
as
we
currently
have
available
to
us
and
consistently
school
counselors.
M
M
Workforce
is
one
of
the
critical
issues
that
plays
into
access
to
care
and
I
think
it's
important
for
us
to
understand
what
exactly
we
mean
when
we
talk
about
access
to
care.
So
the
centers
for
medicare
and
medicaid
services
to
find
access
to
care
is
the
degree
to
which
individuals
are
inhibited
or
facilitated
in
their
ability
to
gain
entry
to
and
receive
care
and
services
from
the
health
care
system,
and
they
include
some
of
the
factors
that
drive
this
as
the
ability
to
have
geographical
distribution,
as
well
as
financial
considerations.
In
others.
M
We
also
look
at
accessibility
of
services,
so,
although
services
and
supports
may
be
covered
under
one's
insurance
plan,
we
look
at
some
of
the
issues
as
it
relates
to
accessibility.
M
So
can
the
individual
access
routine
care,
screening
and
preventative
services,
and
are
they
with
timeliness
able
to
provide
those
services
in
a
way
that
is
timely,
based
on
when
and
where
an
individual
needs
care?
And,
of
course
one
of
the
foundational
underpinnings
of
access
to
care
is.
Do
we
have
a
workforce
that
is
capable
qualified
and
culturally
competent
to
provide
those
services
that
are
covered?
M
So,
while
access
to
care
can
be
broken
down
into
its
four
primary
components,
none
of
these
components
can
exist
without
the
other
and
they
are
interdependent
on
one
another.
All
of
them
when
they
work
together,
can
work
to
support
a
system
of
care
and
access
to
care
that
promote
health,
equity.
M
Certainly
the
mental
health
parity
addiction
and
equity
act,
also
known
as
mapia,
has
been
a
primary
driver
in
ensuring
that
we
have
what
we
would
consider
purity
across
both
physical
health
care
services,
as
well
as
behavioral
health
care
services
within
any
health
entity.
That
is
providing
that
coverage,
and
there
was
work
that
was
done
through
nevada,
this
past
session,
to
really
work
to
identify
ways
to
monitor
whether
or
not
health
insurance
plans
are
actually
meeting
the
requirements
under
mapia
and
parity
states
also
have
the
opportunity
for
medicaid
expansion.
M
Nevada
has
done
that
and
what
we
see
is.
There
are
also
opportunities
when
available
to
expand
the
qualifications
for
beneficiaries,
and
sometimes
that
means
extending
coverage
or
changing
the
coverage
variabilities
to
ensure
that
we
have
greater
access
to
coverage
for
some
of
the
most
vulnerable
in
our
state.
M
Affordability
of
health
care
plans
is
also
an
essential
component,
while
people
may
have
availability
of
coverage.
The
affordability
of
that
coverage
can
certainly
impact
whether
or
not
people
are
taking
advantage
of
the
coverage
that's
available
to
them,
and
we
know
that
while
individuals
may
have
coverage,
they
may
not
necessarily
know
how
that
coverage
works,
so
transparency
over
what
is
covered,
but
also
ensuring
that
people
know
how
to
optimize
their
healthcare
coverage
can
go
a
long
way
and
so
health
literacy
promotion
is
an
important
factor
to
consider.
M
We
also
recognize
that
there
are
individuals
that
are
uninsured
or
underinsured
in
the
state.
Typically,
is
the
requirement
to
meet
the
needs
for
safetynet
services,
so
also
making
sure
that
those
safety
net
services
are
broad
and
expansive
and
can
help
to
meet
the
needs
of
individuals
when
and
where
they
need
coverage
and
then
also
considering
some
all
payers
coverage
requirements.
M
M
Our
fee
for
service
recipients
or
beneficiaries
do
not
have
that
same
level
of
coverage
and
when
many
of
the
inpatient
services
that
are
needed
are
in
private
institutions
of
mental
disease,
what
it
does
is.
It
creates
a
considerable
issue
around
access
to
care
for
those
fee-for-service
beneficiaries.
M
There
are
other
covered
services,
including
value-added
services,
that
individuals
who
are
covered
under
managed
care
have
access
to
that.
Our
fee
for
service
beneficiaries
do
not
utilization
management,
quantitative
and
non-quantitative
limits
can
all
create
variability
in
coverage
from
insurance
carrier
to
insurance
carrier,
and
so
as
we
look
at
parity,
making
sure
that
those
quantitative
and
non-quantitative
limits
do
not
produce
significant
barriers
for
individuals
to
being
able
to
access
care.
M
M
It
also
can
limit
the
number
of
available
providers,
and
there
is
some
new
research
coming
out
where
we
they
have
been
looking
at
the
number
of
providers
that
are
enrolled
under
a
healthcare
service
plan
and
those
that
are
actively
taking
patients
or
seeing
patients
under
that
health
care
delivery
service
system
and
what
we
see
is.
There
is
also
a
mismatch
there.
Well,
there
may
be
more
providers
that
are
enrolled,
relatively
fewer
of
them
are
actually
providing
services
under
that
eligibility.
M
Category
telehealth
coverage
certainly
we've
seen
an
expanse
of
telehealth
coverage
during
covid,
but
we
also
have
to
be
mindful,
as
we
look
to
leveraging
telehealth
coverage,
because
it
can
lead
to
either
to
even
furthering
disparities
in
access
to
care,
specifically
in
geographic
areas
that
lack
broadband
access
and
potentially
alleviating
the
opportunity
for
people
to
have
choice
on
whether
or
not
they
would
like
to
see
a
provider
in
person
versus
being
required
to
see
that
provider
via
telehealth
coverage.
M
Assisting
in
developing
behavioral
health
equity
standards
and
ensuring
that
we
are
addressing
social
determinants
of
health
can
also
identify
what
some
of
those
barriers
are
for.
Individuals
accessing
care
and
making
sure
that
we
can
address
those
barriers
as
facilitators
to
being
able
to
access
care,
also
offering
the
expansion
of
access
points
for
behavioral
health
screens
across
our
health
care
system.
M
Primary
healthcare.
In
healthcare,
integration,
also
navigation
to
care,
supports
you
heard
just
prior
to
this
presentation,
a
presentation
on
community
health
workers,
adding
community
health
workers
as
well
as
case
managers
and
peers,
allows
providers
who
are
licensed
in
behavioral
health
to
work
to
their
the
top
of
their
scope,
while
also
ensuring
that
we
have
a
network
of
other
providers
like
community
health
workers.
That
can
help
people
navigate
to
the
care
that
they
need.
M
Timeliness
is
another
factor,
another
one
of
those
components
and
so
some
timeliness
issues
to
consider
establishing
wait
time.
Standards
for
health
care
plans.
California
and
a
couple
of
other
states
have
moved
to
doing
this
because
again,
you
may
have
coverage
and
that
service
is
technically
available.
But
the
wait
time
that
you
have
before
you
can
access
that
service
is
is
far
too
great,
specifically
for
individuals
who
have
very
acute
care
needs.
M
M
Tracking
and
evaluating
wait
times
for
care
and
wait
lists
for
services
is
incredibly
important
to
understand
how
people
are
moving
through
the
system
and
how
quickly
they
can
access
the
care
that
they
are
seeking.
We
do
not,
for
example,
have
an
ongoing
ability
to
manage
and
monitor
the
number
of
youth
that
are
waiting
in
an
emergency
room
for
a
higher
level
of
care
and
so
being
able
to
have
insight
into
where
and
when
people
are
waiting
and
for
how
long
for
what
services
can
help
us.
M
Also
engineer
a
system
that
can
be
more
responsive
to
their
needs
requiring
behavioral
health
crisis
coverage
across
payers
is
also
one
policy
lever
that
can
be
considered,
knowing
that
individuals
being
able
to
access
care
when
and
where
they
need.
It
is
important,
investing
in
service
capacity,
prioritizing
geographic
regions
without
access
to
care
and
beginning
to
build
infrastructure
there,
as
well
as
providing
real-time
information
on
service
availability
by
providers
and,
finally
I'll
leave
you
with
some
as
it
relates
to
workforce.
M
Some
considerations
is
to
facilitate
the
integration
of
behavioral
health
providers
in
primary
care
and
medical
settings
and
remove
any
barriers
there
are
for
them
to
practice
in
integrated
settings,
expand
providers
that
are
trained
in
community
mental
health
services.
While
it's
great
that
we
have
providers
that
are
trained
to
go
into
private
practice.
M
Establishing
opportunities
from
practicum
to
fellowships
for
the
workforce.
Experience
providing
mentoring
and
competency
development
support,
working
to
retain
and
recruit
qualified
providers
in
our
networks,
developing
incentive
programs,
as
well
as
value-based
reimbursement
strategies,
helping
to
increase
diversity
within
our
behavioral
health
professions
and
increasing
culturally
linguistically
appropriate
services
recognizing
burnout
and
promoting
healthy
workplaces
and
continuing
to
help
individuals
grow
competencies.
M
M
What
nevada
has
not
done
yet
is
to
really
lean
into
the
availability
and
work
with
providers
who
work
in
those
behavioral
health
workforce
shortage
areas
to
qualify
as
a
national
health
service
corps
site
where
they
can
then
recruit
licensed
providers
to
be
able
to
be
eligible
for
loan
repayment,
as
well
as
establishing
some
loan
repayment
programs
specific
to
the
state,
assisting
and
building
that
pipeline
to
professions
through
k-12
education,
leveraging
interstate
compacts
for
specific
behavioral
health
and
health
care
professions
and
establish
not
exactly
sure
what
this
one
was
supposed
to
say.
M
I
think
it
is.
It's
established
transparency
for
licensing.
So
with
that,
I
will
take
questions
to
peters.
A
A
Doesn't
seem
like
we
have
any,
so
thank
you
so
much
dr
woodard.
For
your
time.
I
greatly
appreciate
it,
especially
thank
you,
especially
the
workforce
piece.
I
think
that's
very
important
and
we've
noticed
that
even
with
the
duration
of
the
cover
19
pandemic.
So
thank
you
so
much.
A
Let's
go
ahead
and
move
on
to
the
next
agenda
item,
which
is
a
presentation
agenda,
magnum
7
presentation
on
vaccine
preventable
diseases
and
vaccination
coverage
status
in
nevada.
We
have
two
presenters
for
this
agenda
item.
We
have
kyle
divine,
who
is
a
health
bureau
chief
in
child
family
and
community
wellness,
and
we
have
dr
duckworth,
who
is
the
executive
director
of
immunized
nevada.
So
please
proceed
when
you
both
are
ready.
C
C
Today,
I'm
going
to
briefly
go
over
the
nevada
state,
immunization
program,
vaccine
preventive
diseases.
Some
data
provide
challenges
as
well
as
some
best
practices
and
innovative
ideas.
G
G
You
just
hit
duplicate,
slides,
go
to
the
start,
the
slideshow
from
the
beginning.
G
We
are
currently
just
seeing
this
slide.
If
you
go
to
the
from
current
slide
icon
at
the
top
of
the
screen,
we
should
be
able
to
see
everything.
G
Unfortunately,
we're
still
just
seeing
the
slide.
Can
you
go
to
the
top
orange
bar
right,
where
your
arrow
is
and
just
click
on
that
icon?
For
me
start
from
beginning.
G
G
C
My
apologies
commit
members.
I
worked
through
this
with
rit
this
morning.
I
guess
we
set
it
up
incorrectly.
C
So
to
resume
my
presentation,
state
immunization
program,
works
with
and
supports
nevada's
local
health
districts,
private
providers,
hospital
schools
and
community
agencies,
so
we
really
take
on
a
supportive
role
for
the
most
part,
however,
we
also
do
administer
public
funded
vaccine
programs
as
well.
C
C
C
Currently,
we
show
that
we
have
1900
providers
that
are
representing
3
000
clinic
locations
within
the
system.
C
C
So
for
our
schools,
existing
law
actually
provides
broad
authority
right
now
for
the
board
of
health
to
create
policy
governing
vaccine
administration
in
the
state
of
what
you
are
seeing
right
now
is
a
list
of
the
current
vaccines
that
are
required
by
current
state
law
in
order
for
children
to
enroll
into
schools.
C
So
this
figure
shows
the
childhood
seven
series
vaccination
rates
in
nevada.
For
the
past
three
years.
We
did
see
an
impact.
What
we
believe
is
a
impact
from
kovid
as
between
20
20
20
2020-21.
C
This
is
another
depiction
of
of
that
information.
This
figure
shows
the
breakdown
of
the
seven
series
vaccination
rates
by
race
and
ethnicity.
C
It's
interesting
to
see
that
and
and
kind
of,
concerning
that
for
the
american,
indian
and
alaska
native
population
that
there
was
a
drastic
reduction
in
vaccinations
during
this
last
year.
C
Yet
it's
also
interesting
to
see
that
for
the
the
black
population
there's
actually
an
increase.
C
So,
looking
at
this
graph
here,
it
tells
you
the
percent
of
increase
or
decrease
in
the
vaccination
rates
and,
as
you
can
see
here,
the
american,
indian
and
alaska
native
population
shows
the
largest
increase,
for
instance
at
approximately
38
percent
and
then
once
again
in
the
black
population.
They
saw
a
small
rise
in
approximately
seven
percent
of
children
receiving
the
series
7
vaccinations.
C
C
We,
when
you
look
at
the
men,
ac
wy,
which
is
meningitis
there
are
new
policies,
were
put
in
place
that
now
require
children
entering
or
adolescents
entering
the
12th
grade
to
be
vaccinated
for
meningitis.
C
Looking
at
it
closer
by
race
and
ethnicity,
you
can
see
that
all
had
an
initial
decrease,
but
most
rebounded,
with
the
exception
once
again
of
the
american.
Indeed,
alaska
native
population,
the
black
and
hispanic
teens
have
higher
vaccination
initiation
rates
for
all
the
vaccines
than
any
of
the
other
races
or
ethnicities
and
hpv
vaccinations
is
the
lowest
amongst
asian
pacific
islanders,
and
why
teens.
C
C
C
C
C
C
We
by
technical
assistance
and
also
in
cases
we
can
provide
community
and
information
to
keep
the
public
informed
about
the
outbreak.
C
Also,
we
determined
that
having
a
core
group
of
staff
available
to
provide
technical
assistance
to
the
local
health
authorities
was
imperative
in
in
rolling
out
our
response
for
kovit.
We
initially
started
with
a
group
of
18
core
immunization
staff,
but
then
had
to
bring
on
very
quickly
approximately
40
temporary
staff.
C
C
That
to
have
an
adequate
amount
of
core
staff,
as
I
indicated
previously,
that
it
is
very
important
that
we
maintain
that
in
order
to
respond
to
any
future
outbreaks,
partnerships
are
a
must,
and
we
saw
a
lot
of
partnerships
strengthened
fruit
through
the
response
to
covet
community
based
organizations,
local
health
authorities,
the
board
of
pharmacy
all
stepped
up
to
the
plate,
and
we
all
strengthened
our
partnerships,
which
we
are
hoping
will
continue
further.
C
C
C
C
So
looking
at
best
practices
and
innovative
ideas,
one
best
practice
that
is
well
documented
is
that
having
the
ability
to
have
data
and
a
data
system
to
direct
our
planning
efforts,
as
indicated
before
nevada
uses,
web
iz
and
its
value
lies
in
a
large
part
on
the
data
it
receives
and
stores.
C
So
in
a
universal
purchase
program
a
vaccine
is
purchased
by
a
state
department.
So
that
would
be
us.
The
division
of
public
and
behavioral
health
and
those
vaccines
are
distributed
to
private
practices,
clinics,
hospitals
and
other
providers
to
administer
the
vaccines.
C
C
A
Thank
you
so
much
kyle
we'll
go
ahead
and
proceed
to
dr
duckworth
to
present
her
slide
and
then,
after
that,
we'll
go
to
questions
from
committee
members.
So
dr
duckworth,
please
proceed.
I
A
I
Good
morning,
thank
you
good
morning,
chair
peters
and
assembly
members.
My
name
is
taran
arita
and
I'm
the
community
impact
director
at
immunized
nevada,
I'll,
be
presenting
on
behalf
of
our
organization
and
just
a
quick
overview
of
immunized
nevada.
Immunized
nevada
connects
nevada's
communities
with
information
and
resources
to
getting
people
vaccinated,
and
we
do
this
through
the
completion
of
education,
outreach,
communications
and
advocacy.
I
So
through
our
work
in
the
community,
we
have
identified
some
of
the
major
issues
that
we
have
seen
that
impact
vaccine-preventable
diseases
and
negatively
impact
the
vaccine
uptake
which
overall
affect
the
health
of
nevadans.
I
We
are
hoping
to
continue
communications
and
outreach
to
ensure
that
those
socially
vulnerable
priority
areas
are
identified
and
have
culturally
and
linguistically
appropriate
messaging
for
vaccine
promotion,
as
well
as
developing
equitable
vaccine
distribution
plans
of
vaccines.
That
may
result
up
in
pop-up
vaccination
sites
to
address
this
issue,
and
this
has
been
clearly
identified
when
we
hear
since
our
community
health
worker
team
goes
out
into
the
community
set
up
these
pop-up
vaccination
clinics.
We
hear
when
people
get
vaccinated,
that
they
either
have
these
resources.
I
I
So
because
of
these
additional
costs,
they
may
charge
a
small
administration
fee
for
these
vaccines,
but
must
not
turn
away
any
patient
if
the
patient
is
unable
to
pay
and
when
this
happens,
providers
must
absorb
the
costs.
This
is
why
there
are
limited
dfc
providers,
leaving
the
only
options
for
underserved
and
socially
vulnerable
populations
to
get
vaccinated
at
health
districts
and
federally
qualified
health
centers
by
getting
more
providers
on
board
with
public
health
and
prioritizing
that
vaccines
are
a
preventable
effort
to
protecting
the
community.
I
We
can
increase
enrollment
and
increase
more
vaccine
access
points
to
be
more
available
for
all
nevadans.
Additionally,
some
of
these
locations
are
unable
to
open
up
their
practices
all
times
of
the
day
that
are
convenient
for
most
people,
so
take
las
vegas.
For
example,
many
parents
and
guardians
work
on
the
las
vegas
trip
at
odd
hours
of
the
day
and
may
have
days
off
to
take
their
children
in
to
get
vaccinated
during
times
that
providers
offices
are
not
open
and
this
delay
this
delays,
shot
schedules
and
access
to
getting
vaccinated.
I
And
lastly,
this
needs
to
my
last
point
that
immunized
nevada
has
tried
to
expand
the
access
to
vaccines,
and
we
have
done
this
by
working
to
onboard
a
community
health
worker
team
that
has
worked
long
hours
to
bridge
the
access
gap
to
provide
vaccines
to
nevadans
at
locations
and
times
that
are
outside
of
the
normal
work
hours.
We
currently
have
six
community
health
workers
on
staff,
and
it
has
been
very
beneficial
to
have
them
setting
up
these
clinics
for
all
nevadans
to
get
vaccinated.
I
This
process
to
get
the
chw
members
fully
trained
is
long,
but
once
they
are
ready,
the
chws
have
been
able
to
set
up
clinics
and
get
many
peoples
get
many
vaccines
into
people's
arms,
so
much
so
that
in
20,
20
21,
our
chw
team
hosted
and
partnered
approximately
533
covet
19
and
flu
vaccination
clinics
statewide,
in
which
23
518,
coven
19
vaccines
and
4165
flu
vaccines
were
administered
and
for
a
very
small
team
of
eight
chws
at
the
time.
This
was
amazing
work.
I
So
luckily
we
have
had
the
funding
to
be
able
to
support
our
chws
in
these
efforts,
and
without
them
we
would
not
be
able
to
get.
We
would
not
be
able
to
set
up
as
many
clinics
as
we
have
had
to
address
the
access
gap
of
getting
people
vaccinated.
I
They
have
been
able
to
address
so
many
issues
such
as
setting
up
clinics
during
nights
and
weekends
when
it
would
be
more
well
attended
going
into
communities
that
are
unable
to
be
vaccinated
in
a
provider's
office
or
pharmacy
and
helping
patients
feel
heard
and
comfortable
when
addressing
any
vaccine
hesitancy
issues
that
may
arise,
and
it's
because
of
our
community
health
worker
team
that
I
have
been
able
to
that.
We
have
been
able
to
expand
access
vaccines
across
the
state,
which
is
why
I
strongly
advocate
for
their
work.
I
So
that's
the
issues
that
we
have
identified
at
immunized
nevada.
Thank
you
for
our
time
for
your
time,
and
I
will
now
open
it
up
for
questions.
A
A
C
A
Yep
that
would
be
greatly
appreciated,
and
then
my
follow-up
question
would
be
perhaps
it
could
be
either
for
immunized
nevada
or
for
yuko.
A
There
has
been
my
understanding
is
in
national
conversations.
A
They
there's
always
a
consideration
of.
Do
we
move
back
the
required
vaccines
to
earlier
stages
or
earlier
ages?
Is
that
something
that
has
come
up
in
your
conversations
statewide
or
are
there
modifications
that
we
have
to
make
to
the
current
vaccines
to
improve
access
or
outside
of
the
proposals
that
you
guys
presented?
Is
there
anything
else
that
we
should
be
considering.
C
Kyle
devine,
for
the
record
of
I
have
not
heard
anything
in
the
state
or
any
proposals
to
make
those
adjustments
doesn't
mean
those
conversations
may
not
be
going
on
nationally.
However,
we
have
not
been
looking
at
those
within
our
state.
A
Great,
thank
you
so
much,
sir.
Anyone
from
the
let's
go
to
assemblywoman
titus.
J
Thank
you,
mr
coach.
Here
I
have
a
number
of
questions.
First,
for
mr
devine,
you
mentioned
in
one
of
your
slides
that
60
of
the
folks
have
been
vaccinated
now,
for
I
believe
the
covid,
that's
our
rate,
and
I'm
just
wondering
do
you
have
a
percent
on
people
who
want
to
be
vaccinated
that
aren't
or
have
we
reached
that
nexus
now
of
everybody
who
wants
that
covert
vaccine
has
been
able
to
receive
it.
C
When
it
comes
to
the
code
that
covet
vaccine,
we
do
not
collect
the
data
on
the
people
who
want
it,
who
can't
get
it.
So
I
don't
have
that
information
at
hand.
What
we're
seeing
in
the
data
with
the
uptake
of
the
vaccine
as
it
was,
has
really
stabilized.
J
J
I'm
going
to
follow
up
a
little
bit
more
and
sorry
to
interrupt
you,
but
but
that
whole
access.
I
have
asked
questions
regarding
access
for
both
of
you
actually
during
the
pandemic,
and
we
reached
out
to
the
walmarts
the
cvs
pharmacies,
all
the
different
pharmacies
that
are
out
there,
walgreens
et
cetera,
and
we
know
the
pharmacist
can
administer
vaccines.
J
Why
would
are
we
going
to
continue
that
process
because
everybody
seems
like
everybody
goes
shopping?
Everybody
has
a
local
store
that
they
go
to.
Are
we
going
to
continue
that
collaboration
with
them
and
because
you
know,
there's
always
we'll
go
see
a
provider?
Well,
people
can't
get
into
providers,
and
that's
really
that
that's
the
block.
Half
the
time
are
you
going?
J
Are
you
looking
at
that
collaboration
with
the
local
stores
that
have
pharmacists
to
be
able
to
have
them
administer
these
vaccines
still,
and
then
that
seems
to
me
like
it
would
help
with
the
after
hours
folks,
especially
the
the
the
workers
at
night
time
that
get
off
at
different
hours
et
cetera.
Are
we
going
to
continue
that
collaboration.
C
Divine
for
the
record,
one
of
the
biggest
and
best
relationships
that
we
developed
through
the
code
response
was
with
the
board
of
pharmacy,
and
we
do
intend
to
continue
that
work
and
continue
to
work
with
the
pharmacies
for
the
covet
vaccinations.
So
that
is
something
that
we
are
projecting
to
continue
in
the
future.
J
When
I
started
practice,
I
received
state
vaccines
in
my
office
that
I
could
give
to
those
who
were
uninsured
or
on
medicaid,
and
ultimately
I
had
to
stop
doing
that
because
it
became
a
nightmare
for
the
those
that
were
insured
and
I
had
to
keep
those
vaccines
separated
couldn't
get
reimbursed
for
administration
costs
when
I
would
administer
the
vaccine.
Nor
could
I
get
reimbursed
from
insurance
companies.
When
I
gave
to
somebody
who
had
insurance,
an
insurance
company
would
pay
me
less
than
well
I
paid
for
that
vaccine,
so
it
became
literally
a
nightmare.
J
J
C
Mr
vice
chair,
through
you
to
assemblywoman
titus,
you
bring
up
some
very
good
points
and
I
do
think
exploring
the
relationship
further
with
the
pharmacists
on
some
of
these.
Other
vaccines
has
merit,
and
it's
something
that
we
can
look
into
moving
forward.
C
So
that
is
a
direction
that
we
would
possibly
like
to
go
if
the
policies
and
and
the
mechanisms
can
be
put
in
place
to
where
the
state
could
then
collect
those
fees
and
money
from
the
insurance
companies
and
therefore
the
provider,
they
just
have
to
worry
about
providing
the
vaccine
to
their
clients
and
not
where
they're
getting
reimbursed
from.
J
J
C
Kyle
devine
for
the
record,
the
state
does
have
some
limited
capacity
to
store
vaccines.
Under
this
model,
the
vaccines
would
actually
be
delivered
to
the
enrolled
providers,
who
have
the
equipment
in
order
to
store
the
vaccine
themselves.
C
J
And
and
I'm
sorry
coach
here,
I
for
more
questions,
having
lived
this
dramatically
in
my
career
in
these
vaccines
on,
do
you
know
in
these
federal
programs
and
purchasing?
Do
they
also
negotiate
that
return
in
the
vaccines
that
have
expired
and
how
that
you
recycle
these
things
to
make
sure
that
you're
not
having
them
sit
in
offices
and
then
they
expire
and
do
the
companies
take
them
back?
Have
you
gotten
into
any
details
of
that
nature?.
C
Once
again,
kyle
devine
for
the
record.
Yes,
we
keep
track
of
all
that
information.
That
is
one
of
the
things
that
utilizing
web.
I
z
allows
us
to
do
so.
We
actively
monitor
situations
where
vaccine
may
expire
and
then
work
with
providers
work
with
the
pharmacy
representatives
and
everyone
to
exchange
those
or
to.
J
And
last
question:
I
promise:
is
it
current
now
that
all
electronic
medical
records
have
the
interface
with
webiv,
because
that
was
one
of
the
other
hurdles
that
we
went
through
when
we're
trying
to
administer
these
vaccines
was
that
interface
to
get
onto
web
I-z
through
our
electronic
medical
records?
Are
they
all
communicating
now.
C
I'll
divine
for
the
record
that
is
still
a
barrier,
is
many
of
the
electronic
health
record
systems
have
not
employed
the
technology
to
be
able
to
be
interoperable
with
web.
I
z
the
mechanism
through
which
we
are
now
able
to
access
other
states
information
that
provides
the
technology
to
do
so.
So
we
just
need
the
electronic
health
records.
J
Has
the
state
offered
any
reimbursement
for
providers
to
sign
on
because
the
ones
that
we
use
it
was
going
to
cost
literally
thousands
of
dollars
almost
twenty
thousand
dollars
to
get
that
interface
through
our
emr
and
that's
a
huge
you
know
barrier
is,
is
the
cost
of?
Not
only
do
we
not
get
reimbursed
for
doing
the
shots,
it
was
going
to
cost
us
a
lot
of
money
to
to
be
able
to
interface
with
that
web.
I
see.
Has
that
been
resolved.
C
C
J
Great
I'll
look
forward
to
seeing
how
that
progresses,
and
thank
you
for
chair
for
the
questions.
A
And
some
assembly
women
titus
just
to
let
you
know
eric
robbins-
has
a
clarification
for
you
on
the
discussion
with
between
the
pharmacists
and
the
physicians.
G
Okay,
so
I
just
wanted
to
note
that
the
board
of
pharmacy
has
adopted
regulations
and
concerning
the
administration
of
immunizations
by
pharmacists
and
it's
the
relevant
provision
is
nac
639.2971.
G
J
All
right,
thank
you.
I
actually
had
that
with
my
local
pharmacist
in
town,
where
I
signed
them
off,
so
they
could
administer
that
and
that
was
already
pre-existing
before
kovid.
We
could
do
that,
but
the
question
is
that
I
had
was
this
association
with
the
state
providing
the
vaccines
to
these,
because
when
the
pharmacist
would
give
a
vaccine
say
I
I
took
my.
J
Not
checking
pox,
but
oh
my
god,
zoster
vaccine
through
the
pharmacist,
but
I
had
to
purchase
it
right
and
so
that
there's
a
difference
there
so
expanding
what
the
pharmacist
can
do
to
expand
access.
You
know
they
can
already
give
these
vaccines,
but
the
pharmacist
doesn't
want
to
buy
these
vaccines
either.
So
there's
there's
lots
of
obstacles
for
this.
Thank
you.
Thank
you.
A
E
Thank
you.
Vice
chair,
I
had
a
quick
question
on
slide
18,
which
was
talk
about
the
county
rates
of
mennococcal.
I
believe.
C
Kyle
divine
for
the
record,
those
rates
are
somewhat
comparable
to
other
the
other
two
vaccines
for
the
adolescent
population.
So
there
are
probably
multiple
reasons
for
that.
You
know
one
that
we
need
to
dig
into
is
access.
C
We
also
know
that,
having
you
know,
champions
within
communities,
which
I
believe
elko
has
a
local
champion
for
getting
those
vaccines
administered,
has
a
very
big
benefit
so
really
moving
forward.
We
need
to
research
that
further.
We
need
to
create
those
partnerships
with
those
various
communities
in
order
to
see
how
we
can
improve
those
rates.
A
I
don't
think
I
see
any
in
any
virtual
as
well,
so
let's
go
ahead
and
close
this
agenda
item
great.
Thank
you
so
much
for
the
presentation.
Let's
go
ahead
and
move
on
to
our
next
agenda
item,
which
is
agenda,
item
eight,
the
overview
of
public
health
prevention
and
wellness
initiatives
and
programs
to
address
non-communicable
chronic
diseases.
A
We
will
also
review
the
health
workforce,
applied
demand
and
its
implications
for
chronic
disease
prevention
and
treatment,
and
then,
finally,
we
will
hear
about
policy
considerations
for
chronic
disease
prevention,
given
that
we
are
getting
closer
to
our
lunch
time
period.
I
might
cut
us
in
half
with
these
presentations
and
break
for
a
little
bit,
but
let's
go
ahead
and
proceed
with
our
first
one.
So
an
overview
of
chronic
disease
data
program
and
the
2022
nevada
needs
assessment.
A
H
H
While
there
has
been
great
success
in
primary
prevention
and
public
health
over
the
last
100
150
years,
especially
in
tobacco
control
efforts,
public
health
still
largely
focuses
on
secondary
and
tertiary
prevention.
This
is
due
to
numerous
factors,
including
funding
requirements
and
a
focus
on
clinical
care
over
social
determinants
of
health.
Lifestyle
change
focus,
common
risk
factors
that
can
reduce
through
primary
prevention.
Efforts
include
physical
activity,
nutrition
and
smoking
status,
while
heart
disease
and
cancer
are
consistently
number
one
and
two
among
all
races
and
ethnicities.
H
Many
minority
communities
experience
additional
disparate
disease
burdens,
for
example
among
blacks,
american
indians,
alaskan,
natives
and
asian
americans.
Diabetes
is
the
fourth
fourth
cause
of
death.
Overall,
not
the
fifth.
As
indicated
on
this
table
for
hispanics,
diabetes
is
the
third
cause
of
death
overall.
H
H
This
means
that
prior
to
covert
19,
four
of
the
leading
causes
of
death
were
chronic
conditions.
Only
upended
by
the
pandemic
trends
have
remained
largely
stable
decreases
in
respiratory
disease
and
stroke
indicated
on
this
graph,
beginning
in
2019
may
have
more
to
do
with
people
dying
from
coped
sooner
than
they
were
able
to
pass
from
the
diseases
they
were
impacted
by
it'll.
Take
a
longer
time
to
study
this
early
reductions
in
chronic
conditions
have
been
evident
as
tobacco
control
policies
became
commonplace
and
smoking
behavior
was
reduced.
H
H
H
Regarding
cost
in
2021
net
payments
by
medicaid
to
providers
for
cardiovascular
disease
totaled,
over
168
million
for
cancer
payments
exceeded
96
million.
The
medicaid
recipients
represent
only
20
percent
of
the
nevada
population.
This
data
gives
us
perspective
on
the
burden
of
chronic
disease,
not
only
for
individuals
but
for
the
state
as
well.
The
magnitude
of
managing
chronic
disease
in
nevada
is
significant.
H
H
H
I
will
note
smoking
status
among
adults
has
decreased,
but
it
is
important
to
note
the
significant
increase
in
electronic
vaping
behavior
among
nevada
youth,
reflecting
the
national
trend
known
as
the
youth
vaping
epidemic
statewide.
One
in
four
kids
under
18
have
tried
or
are
currently
using
an
electronic
vape
product.
H
Looking
a
little
bit
at
funding,
pardon
me:
cd
php
receives
just
over
16
million
to
support
the
programs
in
the
previous
slide
of
that.
A
little
over
9.7
is
received
from
federal
grant
awards,
while
six
and
a
half
is
received
from
state
funds
specifically
to
support
the
women's
health
connection
program
for
breast
and
cervical
screening,
youth
prevention,
youth,
vaping
prevention
efforts,
tobacco
prevention
and
cessation
and
food
insecurity.
H
H
Economic
challenges
are
both
related
to
the
cost
of
care
and
the
secondary
cost
of
care,
such
as
missed
wages
for
appointments
or
inability
to
access
and
afford
child
care
to
attend
appointments.
Health
equity
and
equitable
services
was
identified
as
a
need
partners.
Also
identified
a
need
to
focus
on
prevention
in
order
to
truly
impact
health
and
quality
of
care.
H
Partners
noted
this
would
require
a
focus
on
primary
prevention
and
social
determinants
of
health,
as
well
as
integration
with
mental
and
behavioral
health.
To
support.
True
comprehensive
wellness
and
specific
challenges
were
noted
in
serving
rural
and
frontier
populations,
such
as
distances
to
services
and
the
additional
impact
of
provider
shortage
should
service
shortages
in
rural
areas.
H
Partners
participating
in
the
needs
assessment
also
noted
specific
challenges
experienced
in
nevada's
tribal
communities,
nevada's
tribal
communities,
experience
higher
rates
of
obesity
and
lower
access
to
nutritious
food
food
security
than
other
nevada
communities.
Overall,
the
following
resources
were
suggested
for
nevada's
tribal
communities,
infrastructure
and
capacity
related
to
public
health,
improved
insurance
systems
and
access
to
providers.
H
The
second
set
of
needs
identified
represent
those
needs.
Partners
have
to
deliver
services
to
nevada
communities.
The
first
and
largest
need
was
for
flexible
funding
that
can
be
used
to
address
prevention
and
wellness.
Additionally,
workforce
capacity,
especially
the
provider
shortage,
has
been
a
substantial
challenge.
A
A
Doesn't
seem
like
we
have
any
so
let's
go
ahead
and
thank
you
so
much
for
your
presentation,
ms
helser.
Let's
go
ahead
and
move
on
to
our
next
presentation.
Looking
at
community-based
obesity
prevention
and
wellness
promotion,
we
have
dr
stephen
shane
from
the
obesity
prevention
chair
on
the
nevada
chapter
of
the
american
academy
of
pediatrics.
So
please
proceed
when
you
are
ready.
O
Well,
thank
you
for
inviting
me
to
speak
today.
O
O
For
that
matter,
and
it's
also
a,
I
think,
a
smart
way
to
focus
on
overall
wellness
promotion,
since
really
everything
that
we
do
to
try
to
improve
weight
status
and
prevent
obesity
really
helps
us
prevent
a
number
of
the
other
chronic
diseases
that
we're
already
working
on.
O
I'd
also
like
to
make
a
case
that
you
know
the
state,
we
need
to
recognize
obesity
as
a
disease
and
and
properly
monitor
it,
which
I
you
know
currently.
I
don't
think
we're
doing
enough
in
regard
to
that.
So
what
I'd
like
to
do.
O
First
is
talk
about
exactly
what
obesity
is,
because
I
think
a
lot
of
us
just
really
don't
appreciate
that
is
it's
an
actual
disease
process,
not
just
a
condition
or
body
type,
its
true
impact
on
us
not
only
medically
but
economically,
and
then
you
know
just
how
pervasive
this
this
disease
is
in
our
population
and
that
we
need
to
do
something
about
it
now
and
then,
hopefully,
give
you
some
good
recommendations
on
policy
changes
that
we
can
work
on
as
a
state
to
improve
our
population.
Health.
O
So,
first
to
define
obesity,
it
is
actually
a
disease
and
defined
as
a
disease
process
in
2013
by
the
american
academy
of
for
the
american
medical
association.
This
is
a
definition
from
the
obesity,
medical
or
medicine
association
which
I'm
a
member
of.
You
can
see
it's
a
pretty
complex
definition:
it's
a
chronic,
progressive,
relapsing
treatable
but
not
curable,
multifactorial
neurobehavioral
disease
that
causes
many
metabolic
and
also
direct
mechanical
problems.
O
So
I'm
just
going
to
give
you
a
a
quick
patient
scenario.
This
is
an
11
year
old
patient
of
mine
changed
the
name
for
obviously
for
the
sake
of
confidentiality,
but
this
is
daniel,
who
I
saw
back
in
the
spring
first
time
since,
prior
to
the
beginning
of
the
coveted
pandemic,
30
pound
weight
gain
in
the
two
years.
O
So
I
think
most
of
us
would
agree
that
if
you
didn't
know
this
was
an
11
year
old,
you'd,
probably
guess
that
this
person
was,
you
know,
40
50,
60
years
of
age,
but
this
is
an
11
year
old,
not
even
in
puberty.
Yet
and
some
days
in
my
clinical
practice,
I
see
multiple
daniels
so
just
very
distressing
to
see
young
people
like
this
and
also
very
yeah,
just
makes
me
sad
and
I
just
feel
like.
We
need
to
be
doing
better
to
help
daniel's
in
this
in
our
state
in
this
world.
O
So
this
is
a
nice
cartoon
that
gives
us
a
good
idea
and
just
how
obesity
and
this
cartoonist
for
childhood
obesity.
Now
it
essentially
affects
all
parts
of
our
body,
all
organ
systems,
even
the
brain,
it's
associated
with
depression,
headaches,
anxiety,
poor
self-esteem
and
obviously,
bullying,
like
I
just
mentioned
with
daniel.
If
we
were
to
include
adult
issues,
it'd
be
pretty
much
the
same,
except
we
probably
would
had
cancer
there's
currently
13
types
of
cancer
that
are
associated
with
obesity.
O
Obesity
may
soon
overtake
tobacco
as
the
number
one
cause
of
cancer
and
there's
four
other
cancers
that
are
currently
being
entertained
as
having
a
positive
link
with
obesity.
O
So
just
looking
at
this
alone
makes
a
good
case
on
how
focusing
on
obesity
prevention
can
help
us
promote
wellness
in
a
in
a
global
fashion
and
to
prevent
many
of
the
chronic
diseases
like
cardiovascular
disease,
diabetes,
mental
health,
illness,
health
issues
in
our
population.
O
O
A
lot
of
the
data
collected
to
the
pandemic
has
been
slowed
to
be
published,
but
the
bottom
line
here,
as
you
can
see
for
children
from
the
70s
to
80s
until
the
present,
depending
on
the
age
group
younger
ages
on
the
bottom,
older
ages
of
kids
on
top
in
the
light
green,
the
prevalence
of
obesity
has
essentially
tripled
or
quadrupled,
and
this
is
you
know,
holds
true
for
adults
as
well.
O
And
then
this
graphic
from
the
state
of
childhood
obesity,
which
is
a
wonderful
organization
under
the
umbrella
of
the
robert
wood
johnson
foundation,
has
broken
this
down
a
little
bit
differently
and
we
can
see
children
on
the
left,
adults
on
the
right,
and
you
can
see
the
19.3
that
I
just
showed
you
in
another
graphic
they
did.
The
cdc
did
release
data
last
fall
when
it
was
shown
that
from
august
2019
to
august
2020
just
months
into
the
pandemic,
this
number
in
children
already
jumped
up
to
22.4
percent.
O
So
we're
already,
you
know
back
in
august
the
two
years
ago
we
were
already
looking
at
over
a
15
jump
in
that
overall,
so
more
than
one
in
five
kids
with
obesity-
and
you
can
see,
adults
essentially
is
double
that
and
then
you
can
see
some
ethnic
and
gender
breakdown.
So
you
can
see
in
kids.
O
Unfortunately,
black
girls
and
hispanic
boys
have
the
higher
highest
prevalences
and
you
can
see
for
black
women
already
over
half
of
black
women.
Adults
have
obesity
yeah,
so
I'm
looking
forward
and
and
not
because
I
think
you
know
more
current
data
with
impact
from
the
pandemic
is
going
to
look
pretty
disturbing.
O
And
this
is
just
more
detail
on
that
interim
data
that
the
cdcd
released
of
on
on
children
what's
important
here
is
this
slide
shows
that
younger
children-
this
was
actually
had
an
even
greater
impact,
essentially
the
rate
increase
in
body
mass
index
in
kids
doubled
during
that
first
few
months
of
the
pandemic,.
O
Now
I'm
going
to
go,
go
over
some
state
data.
This
is
the
nevada
kindergarten
health
survey,
which
is
done
annually
by
the
nevada
institute
of
children's
research
and
policy
out
of
unlv
school
of
public
health
directed
by
amanda
habush
de
loy,
and
she
does
they
do
a
great
job
of
providing
self-report
data
from
parents
on
children
entering
kindergarten
each
year
throughout
our
state.
O
So
it's
a
great
sample
of
clark,
county
washington,
county
in
in
the
rural
areas,
and
you
can
see
already
in
these
young
kids,
who
are
you
know,
four
or
five
years
of
age
already
have
a
significant
proportion
of
being
overweight
or
having
obesity,
and
these
are
the
kids
that
we
need
to
be
impacting
at
this
age
or
earlier,
because
we
know
that
by
age,
five
or
six
weight
status
is
probably
not
going
to
change
too
much
throughout
the
lifespan.
O
So
we
really
need
to
be
making
a
difference
in
these
kids,
probably
before
they're
surveyed.
At
this
point,
I
do
want
to
point
out
that
this
is
self-reported
data,
which
you
know
has
some
problems
in
regard
to
accuracy
compared
to
measured
data.
But
it
is
good
self-reported
data
and
it
provides
us
some
trending
you
know
year
to
year
and
how
worried
we
need
to
be.
This
is
some
more
data
from
the
state
of
childhood
obesity.
O
I
don't
want
to
mention
this
is
a
great
resource
for
all
of
us
to
use,
to
look
at
up-to-date
national
data
and
also
state
specific
data,
and
also
ongoing
policy
work
and
policy
recommendations
for
preventing
childhood
obesity.
O
So
if
you
look
on
the
left
here,
two
to
four
year
olds,
participating
in
wic-
this
is
11.7
percent
is
probably
if,
if
not
the
best
one
of
the
best
health
metrics
for
the
state
of
nevada,
so
51
is
the
best
we
are
47th
and
this
is
from
2018
data,
so
11.7.
O
This
is
measured
data.
This
shows
us
that
the
wic
program
is
effective
and
actually
nationally
over
the
last
decade
and
37
states,
including
nevada,
there's,
been
a
significant
decrease
in
body
mass
index
in
this
age
group
of
kids.
So
this
is
a
program
we
need
to
really
work
with
recommend,
including
the
state
of
childhood
obesity,
expanding
services
of
this
program,
and
we
need
to
do
a
good
job
as
a
state
to
make
sure
that
we're
appropriating
funds
and
getting
individuals
who
qualify
for
this
service
are
participating.
O
O
So
we
have
to
take
that
with
a
grain
of
salt,
so
to
speak
so
for
children's
10
to
17,
16,
so
21
out
of
50
warren,
so
not
as
good
as
the
wic
participants
and
then
high
school
students,
12.3
and
I'll
show
you
very
shortly.
That's
probably
very
much
under
reports
actual
data
when
we
measure
high
scores
so
39
out
of
51.,
and
these
two
have
been
trending
upwards,
just
like
adults
that
that
we
just
heard
from
the
last
speaker
from
lily
helser.
O
This
is
the
most
recent
published
data
from
washoe
county
school
district,
so
this
is
measured
data
and
you
can
see
here
in
the
purple,
in
the
pie
chart
on
the
left
that
those
with
obesity
is
18.8
percent,
so
you
can
see
and
when
we
know
that
as
you
get
older
as
a
child,
your
prevalence
of
obesity
goes
up,
so
high
schoolers
usually
have
the
highest
prevalence
of
obesity,
and
we
just
saw
that
12.7
percent
that
self-reported
and
this
overall
number
of
eighteen
to
eight
point
percent
for
fourth,
seventh
and
tenth
graders-
shows
us
that
self-reported
data
probably
doesn't
give
us
the
true
picture.
O
The
incredible
difference
between
title
one,
schools
in
the
red
on
this
bar
graph
on
the
right
compared
with
non-title
one
schools,
so
just
pointing
out
the
the
differences
we
see
in
social
economic
status,
which
also
equates
with
certain
ethnicities,
and
obviously
this
is
not
only
holds
true
for
our
state,
but
for
you
know
our
country.
O
O
I'm
sure
if
this
same
modeling
study
was
done
today,
it
would
look
much
worse
considering
what
has
occurred
with
the
covet
pandemic
and,
as
I
mentioned
a
couple
slides
back
with
the
kindergarten
health
survey,
we
really
need
to
be
impacting
kids
early
and
we're
probably
even
perinatally
infants
toddlers
before
they
get
into
kindergarten
first
grade,
because
their
weight
status
by
that
time
is
pretty
much
set.
O
So
how
do
we
get
to
this
point?
This
is,
I
mean,
obviously,
these
photographs
depict
some
common
habits
in
our
in
our
society
today
that
have
led
to
increased
chronic
disease
burden
as
well
as
obesity,
but
it's
more
complicated
than
this.
It's
more
than
just
sitting
around
on
a
better
couch
playing
video
games
and
eating
fast
food
and
drinking
soda.
O
This
is
a
a
more
comprehensive
breakdown
of
the
factors
that
go
into
weight
status
in
chronic
disease
and
we're
learning
more
and
more
about
genetics,
which
accounts
for
about
40
to
70
percent,
or
at
least
has
some
part
in
obesity,
but
obviously
there's
a
lot
of
other
factors,
including
mental
health
issues,
food
quality,
food
quantity,
environment,
how
much
physical
activity
you
have
and
so
forth.
O
So
it's
a
complex
process
and
it's
a
biologic
process.
As
I
had
mentioned,
it's
not
a
matter
of
willpower.
O
And
then,
obviously,
you
throw
in
a
number
of
factors
that
have
been
amplified
during
the
pandemic,
including
disrupted
family
and
school
routines.
Sleep
dysregulation,
reduced
physical
activity,
increased
time
on
on
the
screen,
stress,
stress,
causes,
stress,
hormone
increase
and
this
adversely
affects
metabolism
and
leads
to
weight,
gain
food
insecurity,
increased
mental
health
problems
and
decreased
health
care
access.
O
So
what
can
we
do
about
this
as
a
community
as
a
state,
as
we've
already
just
discussed?
Obesity
is
a
very
complex
issue.
This
is
from
the
milken
institute.
Other
organizations
such
as
the
american
academy
pediatrics,
the
state
of
childhood
obesity,
pretty
much
concurs
with
this
perspective
and
it's
going
to
take
solutions
that
will
that
are
going
to
require
complementary
actions
from
federal
and
local
authorities,
as
well
as
leaders
in
public
and
private
sectors.
This
is
going
to
take
health
care
businesses.
O
O
This
is
a
very
interesting
study
called
the
healthiest
community
study,
which
was
published
just
four
years
ago,
and
this
was
looking
at
what
communities
do,
how
much
and
what
intensity
they
do
in
regard
to
trying
to
improve
policies
and
environments
for
communities
to
improve
weight
status
in
young
children,
and
this
study
was
a
big
lift
and
a
lot
of
effort
went
into
this
study.
O
So
we
have
good
body
mass
index
data
on
the
on
the
kids
from
these
communities,
and
this
top
graph
shows-
and
basically
these
were
all
scored,
depending
on
the
the
reach
of
the
policies,
the
strategy
and
the
intensity
of
these
policies
impacting
communities
and
behaviors,
and
what
you
can
see
is
over
time
over
this
10-year
period,
like
most
things
as
time
goes
with
practice,
things
get
better.
So
these
overall,
the
community
scores
intensity
scores
increased
as
you
can
see.
O
So
just
this
goes
to
show
us
that
working
together
in
a
multi-sector
fashion-
as
I
just
mentioned
from
that
milken
institute
report-
can
work.
But
it's
a
heavy
lift.
It
takes
a
lot
of
work,
a
lot
of
people
and.
O
So
I'm
just
going
to
throw
this
up
real
quickly,
I'm
not
going
to
go
through
all
these,
obviously,
for
the
sake
of
time,
but
this
is
from
the
state
of
childhood
obesity
policy
recommendations
that
this
organization
has
earmarked-
and
you
know
a
lot
of
these-
are
federal
a
lot
of
them.
You
know
some
of
them
are
purely
state
and
obviously
a
lot
of
them
are
a
combination
of
federal
funding,
working
with
state
appropriation
and
administration.
O
One
of
the
recommendations
of
this
think
tank
is
to
expand
services
and
and
also
making
sure
that
those
who
qualify
get
these
services,
because
we
know
that
it
can
work.
I
also
know
recently
that
the
finance
committee
just
approved
for
some
gap
funding
for
reducing
food
insecurity
in
our
schools
over
the
next
year.
So
that's
wonderful
with
providing
free
school
lunches
for
all
over
this
next
school
year.
So
another
good
example
of
where
state
policy
hopefully
will
make
a
difference
in
reducing
chronic
disease
risk
and
obesity
in
our
children.
O
The
american
academy
of
pediatrics
has
a
number
of
policy
recommendations,
including
considering
ways
to
reduce
sugary
drinks
being
consumed
by
our
children,
so
considering
excise
taxes
looking
at
marketing,
which
the
state
of
childhood
obesity
also
recommends.
There's
research.
It
shows
that
there's
been
a
lot
of
preferential
marketing
towards
certain
ethnicities,
such
as
hispanics
and
blacks,
and
they're
sure
that
our
federal
assistance,
food
programs
are
providing
healthful
food
and
beverages
and
discouraging
consumption
of
sugary
drinks.
O
Also,
we
need
access
to
credible
and
also
understandable
nutritional
information
for
families
making
healthy
beverages
that
default
in
in
a
wide
variety
of
settings,
even
fast
food
or
restaurant
settings
and
in
his
healthcare
settings,
including
hospitals.
We
need
to
be
role
models
for
the
populations
that
we're
taking
care
of
so
a
lot
of
good
policy
recommendations
from
good
organizations
that
have
done
a
lot
of
research.
O
In
this
arena,
so
I'm
going
to
throw
up
here
the
most
recent
behavior
that
has
been
collected
by
the
youth
risk
behavioral
surveillance
system.
O
That
is
done
every
two
years
by
the
cdc
for
our
state
unr
school
of
public
health
contracts
with
the
state
to
collect
this
data,
and
it
gives
us
nice
snapshot
every
two
years
on
how
well
healthy
habits
or
behaviors
how
prevalent
they
are
in
our
populations,
and
this
is
in
high
schoolers.
It's
self-reported
data.
O
As
you
can
see,
you
can
see
that
under
reported
self-reported
bmi
number
that
we
talked
about
a
few
minutes
ago.
But
I
think
this
slide
is
more
important.
Looking
at
the
room
for
improvement
in
regard
to
impacting
behavior
behaviors
that
we
know
that
can
help
reduce
chronic
diseases
such
as
cardiovascular
disease,
diabetes
and
obesity,
so
eating
sufficient
amounts
of
fruit
on
a
daily
basis,
as
well
as
vegetables,
quite
abysmal,
12
and
5.
O
These
have
been
trending
downwards
over
the
last
few
years
and
I'm
sure
you
know
when
we
get
data
that
includes
experience
of
the
pandemic.
This
may
look
worse,
excessive
screen
time,
60
and
then
only
about
one-fifth
of
our
high
schoolers
are
getting
the
recommended
amount
of
moderate
physical
activity
every
day,
so
20
and
only
about
a
third
did
not
have
any
soda
for
the
seven
days
prior
to
them.
Taking
this
survey
so
a
lot
of
room
for
improvement
in
regard
to
healthy
behaviors.
O
In
regard
to
multi-sector
community
prevention
programs
that
I
was
alluding
to
in
the
healthy
community
study
and
getting
back
to
that
last
slide
in
regard
to
healthy
behaviors,
the
main
health,
let's
go.
5210
program
is
a
wonderful
program
in
the
state
of
maine
that
can
help
a
community.
A
state
move,
the
needle
in
regard
to
improving
these
behaviors
and
I've
been
using
the
5210
messaging
for
the
last
at
least
seven
years
of
my
practice.
O
Knowing
that
it's
easy
to
remember,
it's
very
translatable
to
different
languages,
different
cultures,
ethnicities,
educational
levels,
it
makes
sense
it's
simple
and
each
of
these
numbers
are
associated
with
a
behavior
that
we
know
can
help
reduce
chronic
diseases
and
improve
weight
status.
So
five
or
more
fruits
and
vegetables
each
day,
two
hours
or
less
of
screen
time.
A
recreational
screen
time,
one
hour
or
more
of
moderate
physical
activity
and
zero
sugary
drinks.
O
And
this
is
the
the
puzzle
cartoon
that
they
like
to
use
to
show
that
this
again
requires
all
facets
of
the
community
working
together
to
make
a
difference.
So,
ideally,
you
want
to
improve
environments
and
policies
to
make
families
and
children
have
the
easy
choice,
be
the
healthy
choice
and
that's
what
this
let's
go.
Program
does
as
well
as
other
other
programs
that
are
like
this.
O
And
I
should
mention:
other
states
are
using
this
program
other
than
maine,
for
instance
iowa
hawaii
and
municipalities
such
as
pittsburgh,
charlotte
north
carolina.
O
Behaviors,
this
became
a
statewide
program
in
maine
in
2006
and
as
of
last
year,
they
had
1630
sites
across
the
board.
Here
you
can
see.
Schools
day
cares
after
school
programs,
cafeterias,
health
care
practices,
including
practices,
family
practices
that
take
care
of
adults
and
even
workplaces,
which
is
not
included
on
this
graphic.
So
a
lot
of
a
lot
of
sites
in
their
state
working
together
to
make
a
difference
in
the
health
of
the
population.
O
O
After
the
success
that
I
was
realizing
with
individual
patients,
we
were
fortunate
to
be
awarded
with
the
wellness
frontier
award
in
2018
from
the
health.
O
O
And
then
part
of
the
washoe
county
community
health
improvement
plan
was
to
increase
fruit
and
vegetable
consumption
and
physical
activity,
and
this
model
was
rolled
out
as
a
community
model
with
the
county
working
in
conjunction
with
washington,
county
health
district
in
2018.
O
We
actually
made
a
lot
of
progress
and
it
was
very
exciting.
We
actually
got
into
five
elementary
schools
in
washoe
county
school
district
right
before
the
pandemic,
and
then,
unfortunately,
things
came
to
a
halt
after
the
pandemic
started.
But
I'm
very
happy
to
hear
over
the
last
couple
weeks,
I've
been
informed
at
the
same
schools
and
in
the
health
district
or
the
school
district
in
general
is
has
a
renewed
interest,
and
I
think.
O
I
get
more
enthusiasm
than
before
to
participate
with
5210
program,
so
I'm
looking
forward
to
see
how
this
rolls
out
and
I've
found
out
that
the
washer
county
health
district
through
a
state
grant
has
some
funding
to
help
bolster
this
program.
So
I'm
looking
forward
to
continued
growth
in
washoe
county.
O
There's
a
lot
of
community-based
prevention
models
such
as
the
let's
go
program
to
build
upon.
I
think
the
experience
that
that
I've
had
here
in
reno
and
and
developing
helping
and
develop
the
5210
healthy
washoe
program
gives
us
some
good
footing,
potentially
and
hopefully
roll
out
into
the
state
to
really
improve
statewide
wellness.
O
There's
also
a
lot
of
good
policy
recommendations
that
I've
already
touched
upon.
I
urge
you
to
go
to
the
state
for
childhoodobesity.org
to
look
more
of
this
detail.
It
is
important
for
communities
to
set
reasonable
expectations.
We
can
see
from
that
that
first
graphic
that
I
showed
you.
It
took
us
40
to
50
years
to
get
to
where
we
are
so
it's
gonna.
You
know
change
is
not
going
to
happen
overnight.
We're
looking
at
cultural
change,
lifestyle
change
for
a
population,
so
we
have
to
be
smart
with
how
we
set
our
expectations.
O
So
we
don't
get
disappointed
because
this
is
going
to
you
know
this
is
going
to
take
years
of
commitment
to
make
a
difference
and
to
do
this,
it's
going
to
take
funding
personnel
and
a
lot
of
effort.
O
O
O
So
that's
all
I
have
to
say
in
regard
to
wellness
promotion
and
childhood
obesity.
I
again
I
appreciate
for
you
here
today.
If
you
have
any
questions,
I'm
more
than
happy
to
take
those
this
is
me
feel
free
to
reach
out
via
email
or
my
cell
phone.
I'm
for
this
topic,
I'm
always
available.
Thank
you.
A
Thank
you
so
much,
dr
shane.
We
appreciate
that
presentation.
Do
we
have
any
questions
from
any
of
the
committee
members?
Let's
go
to
assemblywoman
titus.
J
Thank
you,
dr
shane,
for
that
presentation.
I
graduated
from
medical
school
over
40
years
ago
now,
and
the
one
true
fact
that
that
we
are
still
following
that
I
learned
in
med
school
back
then
was
to
way
to
avoid
obesity.
Is
diet
and
exercise
we're
still
talking
about
this
many
years
later
on
what
to
do
about
it,
but
it's
the
same
mantra,
diet
and
exercise,
prevents
obesity
at
all
ages
and
and
or
at
least
helps
limit
the
obesity.
J
So
it's
it's
concerning
to
me
that
we're
still
here
that
we
still
have
these
issues
that
we
continue
to
talk
about.
What
I
didn't
hear
in
your
presentation
was
some
collaboration
with
some
community
partners,
and
some
of
that
we
were
talking
about
government
things,
but,
but
I
didn't
hear
mention-
maybe
you
know
boys
and
girls
clubs.
I
didn't
hear
mention
getting
into
some
of
the
preschools
some
of
these
programs
and
is
the
american
academy
of
pediatrics
engaged
in
any
of
those
and
actually
actively
pursuing
some
of
those
partnerships.
O
Yeah
we
here
locally
in
with
my
my
experience
here
with
the
healthy
living
program
that
I
helped
create
and
also
healthy,
wash
show.
We
did
have.
We've
had
some
involvement
with
the
boys
and
girls
clubs
also
with
the
daycare
program
associated
with
the
boys
and
girls
club
here
in
reno
head
start,
the
head
start,
the
csa
head
start
program.
O
So
there's
you
know,
unfortunately,
it
takes
takes
dedicated
personnel.
A
lot
of
this
work-
that's
been
done
so
far
has
been
with
volunteer
effort,
including
myself,
and
really
to
make
a
difference
to
get
into
all
these
programs.
Like
I,
I
showed
you
in
the
state
of
maine.
You
need
a
dedicated
workforce.
You
need
dedicated
personnel
to
creating.
You
know
face-to-face
relationships
and
training.
These
programs,
to
you
know,
walk
the
talk.
J
Yeah,
thank
you.
Do
you
have
any
outcome
data
on
the
the
main
experience
that
from
the
19
I
mean
2020
to
2021?
Is
there
any
outcome,
data
on
on
that
engagement
and
has
it
affected
childhood
obesity.
O
Well,
they
they
do
have
a
very
a
robust
data
collection
system
that
I'd
be
more
than
happy
to
send
you
it's
pretty
it's
a
it's
a
large
document.
They
do
every
year,
they
they
send
out
questionnaires
and
they
and
they
do
other
measurements,
including
bmi
measurements.
O
We're
looking
at
bmi
data
collected
by
the
state
similar
to
our
our
mechanism,
they,
as
far
as
bmi
effect
on
bmi
that's
been
kind
of
plus
or
minus
up
until
the
pandemic.
They
had
shown
some
stabilization
and
a
number
of
age
groups.
They
definitely
have
shown
that
since
they've
instituted
this
program
that
they've
positively
impacted
behaviors,
so
those
five
two
and
oh
behaviors
have
definitely
improved
throughout
the
state
in
various
various
settings
that
have
that
implementation
has
occurred
so
in
schools,
daycares
and
other
settings.
O
I
think
you
know,
as
I
alluded
to
as
far
as
far
as
setting
expectations
go,
I
think
we
and
I
think
myself,
including
other
experts
in
the
field
we,
you
know
our
primary
focus,
is
lifestyle
and
behavioral
change,
because
we
know
that
in
itself
can
make
a
difference
in
chronic
disease
risk,
regardless
of
weight
change.
O
O
J
I
certainly
would
appreciate
that
I'm
sure
other
members
would-
and
I
just
want
to
thank
you
for
your
dedication
and
and
recognizing
that
being
fit,
isn't
necessarily
a
bmi.
It's
an
overall
mental
health
and
a
whole
bunch
of
things
into
that.
So
again,
thank
you
for
your
dedication.
Thank
you,
mr
chair.
O
You're
welcome
I
I.
I
could
also
add
that
you
know
that
once
the
healthy
community
study,
I
showed
that
included,
maine
and
and
the
one
part
of
the
country
that
had
the
biggest
difference
in
bmi
improvement
was
in
the
northeast
and
they've.
Had
the
most
community-based
programs
implemented
over
the
last
10
to
15
years
compared
to
other
parts
of
the
country,
so,
indirectly
that
that
gives
us
a
hint
that
this
kind
of
programming
is
is
making
a
difference.
A
Thank
you
so
much.
You
tell
me
a
woman,
quick
question
for
you,
dr
shane.
Given
your
experience
and
your
advocacy
efforts
throughout
the
state,
have
there
been
any
conversations
that
you're
familiar
with
with
reforming
the
school
lunch
programs
that
we
have
in
schools?
A
Cinnamon
rolls
wasn't
really
healthy,
wasn't
really
culturally
diverse
of
what
they
were
feeding
us,
and
so
I
mean
we
had
farms,
small
farms,
maybe
three
plots
in
their
elementary
schools,
but
we
didn't
do
a
good
job
at
educating
all
throughout
k-12
in
terms
of
what
healthy
eating
looks
like
and
especially
during
college.
O
Well,
that's
yeah,
that's
a
great
question
because,
unfortunately,
there's
still
a
lot,
a
lot
of
pizza,
pizza,
hamburgers
and
other
foods
that
we
associate
with
healthy
nutrition
being
served
at
schools.
Believe
it
or
not.
You
know,
since
the
2010
you
know
federal
lunch
program.
Overhaul
studies
have
shown
that
kids
who
participate
in
the
school
lunch
programs
actually
do
have
better
weight
status
than
those
and
kids
who
do
not
participate.
O
O
I
know
in
washoe
county
I
was
just
on
a
stakeholders
group
for
the
student
wellness
for
washoe
county
school
district
and
we've
just
kind
of
resurrected
this.
O
This
group,
in
april
after
over
two
years
of
hiatus
and
the
current
director
of
school
nutrition,
is
very
enthusiastic
with
the
5210
programming
and
I
had
mentioned
there
were
five
publix
five
elementary
schools
that
are
participating
in
implementing
and
piloting
this
program
and
currently
they're.
Looking
at
modifying
their
school
lunchrooms
utilizing
the
smarter
lunchroom
scorecard,
which
came
out
of
value
or
cornell
university
several
years
ago,
so
there's
there
is
work
here
at
least
locally.
O
Hopefully
this
can
become
a
statewide
movement,
but
the
short
of
it
is
we're
working
on
this.
But
it's
a
you
know:
it's
a
slow
process.
A
Great,
thank
you,
yeah.
I
would
encourage
any
of
the
members
that
you
are
familiar
with
in
the
community
to
perhaps
bring
policy
recommendations
on
this
issue.
I
distinctly
remember
that
all
we
had
the
free
and
reduced
lunch.
I
went
to
a
title
one
school
in
las
vegas.
B
Thank
you
so
much
for
sure.
I
have
three
kids
in
the
school
system,
and
I
this
year
we
experienced
like
the
punishment
through
loss
of
your
recess
privileges
right
as
a
product
of
behavioral
challenges
in
the
classroom.
This
is
one
of
the
children
to
me.
I
was
if
this
is
kind
of
backwards.
We,
you
know
when
my
kids
acting
out.
B
The
best
thing
to
do
is
throw
them
outside
run
some
energy
out,
and
then
you
know,
re
re
engage
with
the
behavioral
issue
after
that,
but
there
doesn't
seem
to
be
a
standard
of
that
in
our
school
system
right.
So
how
do
we
integrate
and
ensure
our
kiddos
are
getting
these?
These
outdoor
exercises
the
school
lunch
that
senator
donate
was
talking
about
and
nutrition
issues
and
ensuring
we're
integrating
that
with,
like
overall
behavioral
health
and
overall
understanding
of
like
what?
B
What
is
what
is
the
best
thing
for
and
ourselves,
and
this
kind
of
goes
back
to.
I
think
what
dr
woodard
was
talking
about
earlier,
with
understanding
like
health
literacy
promotion
right
like
that
that,
when
you're
having
a
hard
day,
maybe
sitting
in
the
corner,
while
your
friends
go
out
to
play,
is
not
the
best
way
of
dealing
with
that,
if
you're
having
a
hard
day,
maybe
going
outside
practicing,
some
behavioral
changes
is
the
best
thing
for
you.
B
So
I
just
I'm
curious
if
there's
any
policy
discussion
going
around
between
your
office
or
and
the
agencies
that
you
work
with,
and
the
school
districts
on
these
issues,
similar
to
what
senator
jonathan
was
asking
about,
that
could
be
a
follow-up,
but
my
my
my
real
question
has
to
do
with
really
this.
B
This
challenge
we
have
on
seeing
obesity
through
the
lens
of
like
your
physical,
the
physical
skate
right
that
has
a
lot
to
do
with
the
and
you
had
a
beautiful
side
up
that
showed
all
the
dynamic
issues
around
what
causes
obesity
and
what
causes
health
challenges
related
to
obesity.
B
So
my
question
is
in
the
world
of
of
science
around
obesity.
What
are
we
doing
to
address
these
dynamic
narratives?
What
are
we
doing
to
reduce
this
victim
mentality
that
a
person
is
obese
because
they
have?
They
have
behavioral
problems
right
that
need
to
be
addressed.
What
are
we
doing
to
scope
out
what
our
epigenetic
issues
that
maybe
we
as
a
as
a
society,
need
to
change
our
behavior
to
help
support
communities
who
have
a
propensity
for
obesity
because
of
the
treatment,
the
historic
treatment?
What
are
we
doing
around
that
space?
O
Well,
yeah,
those
are,
you
know.
Obviously,
you've
highlighted
how
complicated
this
this
issue
is.
I
mean
first
off,
you
know,
training
healthcare
providers
about
this
disease
and
the
factors
that
surround
it
and
also
how
to
address
patients
not
intimidate,
or
you
know,
blame
patients
for
their
their
health
problems,
particularly
if
they
have
obesity.
O
I
think
that's
the
first,
the
first
step,
and
I
I
actually
I
failed
to
mention
that
it
was
a
big
omission,
but
I'm
sorry,
but
I
failed.
The
mission
mentioned
that
we're
currently
I'm
currently
working
with.
O
But
overall
I
think
you
know
and
ultimately
that
the
goal
is
to
hopefully
have
you
know
a
statewide
program
such
such
as
we've
tried
to
develop
here
in
washoe
county.
They
hit
all
those
pieces
of
the
puzzle,
all
the
different
sectors
of
of
a
community,
to
look
at
wellness,
promotion
and
obesity
prevention.
O
In
the
same
way
until
and
and
that's
you
know,
it's
going
to
take
it's
going
to
take
some
work,
as
I
alluded
to
with
that
one
study,
you
know
it
can
be
done,
but
it
these
the
communities
that
have
done
the
best
like
maine.
O
You
know
that
you
have
to
get
the
whole
community
behind
it.
You
have
to
get
buy-in
and
it
you
know,
take
some
dedicated
professionals
to
and
a
long
view.
You
know
you
have
to
look
at
the
a
long
picture.
You
just
can't
look
at
a
quarter
or
a
year.
B
I
I
appreciate
the
comments
that
that
it
is
really
an
issue
area
where
we,
I
think,
societally
and
culturally,
have
to
address
our
own
biases
that
are
heavily
steeped
in
body
image
and
looking
at
other
factors
that
add
into
lifestyle
and
and
and
much
farther
than
choice
right
and
it's
not
just
choice,
and
we
there
are
people
I
can
think
of
across
the
spectrum,
including
you
know,
our
teachers
are
integrated
in
this
as
they
address
our
kiddos
at
school
and
when
they're,
seeing
our
children's
lunches
either
through
the
schooling
program
are
packed.
B
We
have
professional
trainers
and
gyms
who
are
part
of
this.
We
we
have
a
whole
community
based
around.
How
do
we
address
our
bodies
and
our
physical
well-being,
but
it's
so
much
more
dynamic
than
that,
and
I,
I
think,
one
of
the
pieces,
I'm
really
looking
forward
to
having
a
better
social
conversation
around.
Is
the
component
of
genetics
really
that
not
everybody's
built
the
same
and
our
bodies
don't
function
all
the
same,
and
we
don't
understand
a
lot
of
that.
B
Yet
it's
not
in
the
common
like
intellect
of
our
community.
So
how
do
we?
How
do
we
better
develop
that,
and
where
do
we
start?
Is
it
through
a
health
education
program
in
our
school
district?
Is
it
through
the
counties
taking
on
public
advisory
efforts
to
ensure
people
are
hearing
these
these
language,
this
new
language,
and
talking
about
about
our
health
and
well-being
and
physical
being
in
a
different
way
like?
Where
do
we?
B
Where
do
we
put
these
these
funds
to
ensure
that
our
community
is
elevating
out
of
the
space
of
really
body
negativity
and
into
a
space
of
well-being?
B
I
can
even
think
of,
like
our
business
partners,
insurance
has
stepped
up
and
started
providing
coverage
for
for
gym,
gym
memberships,
and
things
like
that,
but
even
like
I
just
recently
got
hit
with
a
a
new
app
to
to
track
my
my
emotional
well-being
and
encourage
more
physical
integration
into
emotional
well-being.
B
So
there
are
a
lot
of
players
who
are
in
this
space
but
as
a
community
as
a
whole,
like
I
really
look
forward
to
to
folks,
like
you
advising
us
on
where's
the
best
place
to
put
these
funds,
how
do
we
ensure
that
we're
using
the
right
language?
How
do
we
make
sure
that
we're
really
diving
into
what
the
real
problems
are,
and
not
just
blankets,
stating
that
bmi
and
bmi
is
the
standard
for
obesity
and
and
and.
A
O
Yeah
and
actually
I
I'm
actually,
I've
become
not
only
as
a
colleague
but
I've
become
a
friend
with
the
the
woman
who
developed
and
directs
the
program
in
maine
and
over
recent
years,
they've
really
tried
to
get
away
from.
O
Saying
that
their
program
is
an
obesity
prevention
program,
I
mean,
obviously,
we
would
love
to
improve
weight
status
in
individuals,
but
really
their
their
number.
One
goal
is
to
improve
lifestyle
and
behavior,
and
I
know
obesity,
medicine
specialists
such
as
myself,
you
know
across
the
board,
really
focus
on
habits
and
lifestyle.
O
And
in
order
to-
and
I
guess
in
order
to
not
only
as
a
health
care
professional,
promoting
this,
this
kind
of
messaging-
you
know
in
a
community
program-
this
would
be
done
through
implementation,
with
perhaps
a
coordinator
that
would
go
into
an
elementary
school
who
was
interested
in
in
creating
a
healthy
environment
for
their
their
children
and
through
that
process.
O
You
know,
you
know
that
that
implementation
process
would
impart
the
importance
of
behavior
change,
lifestyle
change
and
not,
and-
and
you
know,
the
weight
status
is
a
nice
secondary
benefit.
But
it's
not
you
know
a
primary
focus.
A
A
Good
anyone
from
las
vegas
with
any
other
further
questions
at
this
time.
A
Great.
Thank
you
so
much
akin
dr
shane,
for
presenting
at
this
time,
yeah.
A
We
will
take
a
short
recess
so
that
we
can
go
ahead
and
break
and
we'll
turn
back
with
a
presentation
from
dr
packam
on
the
healthcare
workforce,
supply
and
demand
in
nevada,
so
we'll
do
the
break
between
with
the
return
at
12
45.
A
All
right
welcome
back
to
our
meeting
the
end
of
recess.
Let's
go
ahead
and
proceed
with
our
next
presentation
items.
It
looks
like
members
are
getting
back
from
their
lunch,
so
we
will
start
with
the
presentation
on
our
health
workforce
supply
and
demand
in
nevada
the
implications
for
chronic
disease
prevention
and
treatment
we
have
to.
We
have
dr
john
packham,
who
is
the
co-director
of
the
nevada
health,
workforce,
research
center
and
policy
director
at
the
nevada,
public
health
association.
So
please
proceed
when
you're
ready,
sir.
A
F
All
right,
thank
you
for
the
opportunity
to
speak
today
on
health
workforce
issues
and
try
to
tie
them
to
a
lot
of
what
you've
already
heard
about
chronic
disease
prevention
and
treatment.
The
information
that
I'm
going
to
be
sharing
with
you
today
is
my
slide
information.
I'm
going
to
be
sharing
with
you
this
afternoon.
F
We
think
about
prevention
and
workforce
development
in
building
on
some
of
the
previous
presentations.
I'd
like
to
argue
that
there
is
a
role,
a
unique
set
of
workforce
development
issues
for
each
of
those
three
buckets
of
primary
secondary
and
tertiary
prevention.
F
I'm
gonna
devote
most
of
my
attention,
however,
to
secondary
and
tertiary
prevention,
but
building
on
a
great
presentation
before
me
by
dr
shane
would
just
argue
that
that,
when
we
think
about
primary
prevention,
there's
of
course
a
role
for
a
core.
What
I'd
call
core
traditional
public
health
professions,
education
and
training,
which
are
sorely
underfunded
in
the
state
of
nevada,
long
history
of
that.
F
But
I
would
also
argue
and-
and
dr
shane
is
a
great
example
of
the
importance
of
building
public
health
competencies
into
a
wider
range
of
clinical
and
non-clinical
occupations.
Both
unr
and
unlv
offer
a
dual
degree:
programs
for
students
in
medicine
and
nursing
that
tied
them
to
mph
degrees
and
other
public
health
training.
F
When
we
look
specifically
at
chronic
disease
and
associated
workforce
challenges,
just
highlight
a
couple
of
elements
that
you
see
in
the
literature
addressed
by
researchers
and
policy
analysts,
and
I
would
just
start
out
that
a
lot
of
the
training
and
delivery
systems
that
characterize
health
care
in
nevada
in
the
u.s
are
still
rooted
in
that
standard
15-minute
office
debt
model
of
episodic
illness.
F
Likewise,
as
you
heard
in
the
discussion
on
a
community
health
workers,
we
still
have
un
uneven
reimbursement
models
when
it
comes
to
care
coordination,
patient
navigation
and
so
forth.
I'm
hoping
that
one
of
the
legacies
of
the
cobot
19
pand
epidemic
will
be
a
reimbursement
and
policy
that
reflects
what
we've
gained
from
expansion
and
reimbursement
of
telehealth
in
nevada.
As
I
will
argue,
these
are
all
compounded
by
persistent
workforce
shortages,
particularly
in
primary
care,
particularly
when
we
look
at
the
pretty
severe
maldistribution
of
physicians
and
other
providers
by
specialty
and
geography
in
our
state.
F
I'd
highlight
just
one
example
of
the
importance
of
stretching
the
workforce,
but
also
attending
to
what
would
be
needed
as
we
move
to
more
coordinated
team-based
care,
this
highlighting
cancer
care.
This
is
a
great
report.
It's
a
little
bit
dated,
and
I
think
if
this
were
updated
or
refreshed,
you'd
see
additional
roles
for
community
health
workers
and
those
assisting
with
patient
navigation.
F
When
it
comes
to
this
type
of
chronic
disease
care
and
treatment,
I
would
argue
it's
kind
of
the
glass
half
empty
the
glass
half
full
approach,
though,
and
thinking
about
those
challenges
or
what
we
know
works,
and
these
involve
both
policy
measures
at
the
state
and
federal
level,
as
well
as
actions
undertaken
by
industry
and
employers
of
individuals
engaged
in
chronic
disease
prevention
and
treatment.
F
We
also
need
to
address
the
associated
training
mismatch
and
again,
I
think
we're
seeing
that
in
all
of
our
health
professions
school
through
interdisciplinary
training,
as
well
as
training
in
outpatient
and
primary
care
settings
and
again
a
lot
of
those
measures.
Don't
necessarily
require
us
to
produce
more
health
professionals
in
some
instances
they
do
call
on
us
to
think
about
how
we
stretch
and
make
the
work
of
those
individuals
more
efficient.
F
Finally,
as
I
kind
of
put
my
public
health
hat
on
a
lot
of
these
workforce,
challenges
can
be
addressed
by
greater
attention
to
some
of
the
upstream
prevention
and
population
focused
strategies
that
were
discussed
in
the
the
foregoing,
presentations
that
have
nothing
to
do
with
workforce,
but
everything
to
do
with
primary
prevention.
F
Whoops
went
a
little
fast
there,
just
a
quick
note
on
the
way
workforce
challenges
in
our
state
are
compounded
by
forces
that
aggregate
or
aggravate
rather
or
worsen,
demand
for
health
care
and
health
services
in
our
state.
F
F
Economic
growth,
additional
population,
health
needs
and
health
system
issues
are
additional
drivers,
ramping
up
demand
as
the
pandemic,
hopefully
winds
down,
but
I
would
argue
that
those
demographic
factors
are
at
the
top
of
my
list.
I
think
we'll
also
as
a
state
need
to
pay
attention
to
what
the
demand
for
healthcare
looks
like
post-pandemic.
F
One
of
the
wild
cards,
though
again,
will
be
some
of
those
temporary
measures
that
we
saw
during
the
public
health
emergency
relating
to
insurance
coverage,
telehealth
provisions
and
so
forth.
So
there
are
there.
There
are
some
wild
cards,
regardless
of
what
packham
says.
I
would
argue
that
industry
is
signaling
through
facility.
Construction,
inpatient
and
outpatient,
both
north
and
south
is
anticipated,
steady,
increasing
demand
for
services.
F
When
I
turn
attention
to
supply,
I
just
want
to
note
or
recognize
a
couple
of
trends
on
that
top
of
the
list
would
be
again
persistent
workforce
shortages
I'll
provide
a
couple
of
illustrations
of
how
enduring
those
are
and
their
impact
on
chronic
disease
prevention.
I'd
also
argue
that
we
have
kind
of
a
good
news,
bad
news
story
in
many
professions,
in
both
medicine
and
nursing.
F
For
example,
we've
seen
a
nice
steady
growth
in
the
number
of
licensed
professionals,
but
in
some
cases
and
in
some
regions
of
the
state,
we're
treading
water,
and
what
I
mean
by
that
is
that
when
you
adjust
that
growth
in
licensees
with
population
growth,
particularly
in
southern
nevada,
we're
almost
treading
water
unlike
medicine
and
nursing,
that
is
still
still
seeing
a
a
growth
in
per
capita
health
professionals
in
our
state
and
in
behavioral
health.
F
I've
also
alluded
to
a
related
trend,
as
our
state
continues
to
age
that,
as
the
average
age
continues
to
rise,
we
also
have
an
aging
health
workforce,
they're,
not
separated
from
the
populations
they
serve
and
are
again
an
important
supply
characteristic
also
highlight
the
geographic
male
distribution
of
health
professionals
and
all
things
being
equal.
We
see
those
shortages
being
much
more
severe
in
rural
areas
of
the
state
as
compared
to
urban.
F
In
addition
to
be
a
reno
city
councilman,
he
is
overseas,
the
community
health
alliance
and
fqhc
up
here
in
north
and
he's
making
a
really
a
great
case
for
attending
to
improving
the
diversity
of
our
health
workforce
so
that
we
can
address
issues
of
trust.
I,
the
previous
presentations
on
immunization
and
variation
by
race
and
ethnicity,
are
a
reminder
that
you
build
trust
in
the
health
workforce
when
that
workforce
reflects
the
communities
that
they
serve,
and
that
includes
people
of
color
needing
providers
of
color
to
oversimplify
matters
there.
F
When
we
look
at
workforce
shortages,
this
is
a
map
that
sadly
hasn't
changed
much
in
presentations.
I've
made
over
the
last
couple
of
years,
upwards
of
two-thirds
of
our
state's
population
reside
in
a
federally
designated
primary
care,
health,
professional
shortage
area.
It's
actually
a
very
similar
story
with
respect
to
dental
health
and,
as
you
saw
earlier
in
dr
woodard's
presentation,
even
worse
when
it
comes
to
mental
health,
professional
shortage
areas.
But
I
will.
F
Just
kind
of
rounding
out
that
discussion
is
this
is
relatively
recent
data
from
the
county,
health
rankings
and
road
maps
data
release,
and
this
just
underscores
the
huge
differences
between
urban
and
rural
areas
of
the
state.
The
urban
figures
are
in
dark
blue.
The
rural
areas
of
the
state
are
in
the
light
blue
and
we
have
some
counties:
lyon,
county
and
pershing
county,
for
example,
upwards
of
six
thousand
residents
for
every
primary
care
doc.
F
I
would
also
note
that
most
of
those
bars
there
are
higher
than
the
u.s
average
of
1310
residents
per
primary
care,
physician,
so
interesting,
geographic
variation
in
shortages,
in
this
case
primary
care,
physicians
per
capita
but
levels
almost
uniformly
lower
than
national
rates
kind.
Of
closing
out
the
discussion,
then
of
shortages
and
so
forth,
dr
woodard
presented
a
little
information
earlier
on
what
it
would
take
if
we
had
a
population
to
provider
rates
similar
to
the
national
average
information
we
shared
with
attendees
at
a
nursing
summit
last
week.
F
This
is
a
staggering
number
just
to
be
average.
Our
state
would
need
4
300
additional
registered
nurses
today
to
be
average.
I
want
us
to
aspire
to
be
more
than
average,
but
that's
what
it
would
take
there
and
you
see.
Other
important
categories
include
including
primary
care,
physicians
and
other
members
of
that
chronic
disease
management
team.
I'd
like
to
then
shift
and
kind
of
close
and
round
out
my
discussion
by
talking
about
ways.
F
We
address
these
shortages
and
again
I
I
take
a
positive
view
of
this,
because
most
of
the
measures
that
I'm
going
to
discuss
in
the
remainder
of
my
presentation
are
are
policy
strategies
that
state
and
federal
governments
can
take
to
address
these
shortages.
As
I
mentioned
earlier,
there's
no
substitute
for
growing
our
own
and
that
simply
means
increasing
the
number
and
diversity
of
healthcare
education,
graduates
spanning
from
medicine
and
nursing
to
allied
health,
the
oral
health
and
behavioral
health
and
so
forth.
F
I'd
also
like
to
to
argue
that
when
you
couple
grow
your
own
strategies
with
what
we
know
works
to
keep
those
individuals
in
the
state-
that's
a
just,
I
think-
needs
to
be
at
the
core
of
what
we
do
as
a
state
to
address
some
of
those
shortages
that
I
alluded
to
earlier.
F
This
figure
highlights
that,
beginning
with
the
the
first
wave
of
gme
grants,
then
governor
sandoval
legislation
on
at
that
time
it
was
10
million
over
the
miami
for
gme
grants.
What
we
saw
is
a
real
nice,
steady
growth
in
the
number
of
both
residents
and
fellows.
F
The
residents
was
much
more
impressive,
but
this
is
a
great
development
because,
in
addition
to
increasing
the
supply
of
gme
graduates
or
those
completing
their
gme
training
in
nevada,
we
do
a
pretty
good
job
of
keeping
those
we
keep
anywhere
between
50
to
60
percent
of
those
completing
their
gme
training
in
nevada.
So
as
that
pie
expands,
so
does
the
slice
who
ultimately
remain
in
the
state
to
practice.
I
would
add
again
with
your
grow
your
own
strategies,
measures
that
we've
undertaken
to
keep
our
own
full
disclosure.
F
My
office,
oversees
the
nevada
health
service
corps
program,
but
this
small
but
mighty
program
that
the
legislature
has
supported,
is
just
a
great
model
of
a
program
that
matches
individuals
that
need
loan
repayment.
I
know
very
few
physicians
or
nurses
that
don't
need
some
form
of
loan
repayment
or
assistance
with
that,
but
this
matches
those
seeking
that
with
those
in
return
or
exchange
practicing
in
a
medically
underserved
area.
F
The
individuals
in
this
picture
is
a
pa
and
a
nurse
practitioner
that
work
in
the
clinic
in
lovelock,
nevada,
pershing,
general
hospital
and
a
really
good
example
of
how
we
address,
at
least
in
rural
areas,
both
primary
care
and
behavioral
health
care
capacity
going
from
zero
to
one
nurse
practitioner
providing
behavioral
health
services
is
huge
in
rural
areas.
F
I
know
the
behavioral
health
issues
in
clark,
county
and
urban
areas
of
the
state
are
staggering,
but
this
is
a
great
way
to
think
about
how
we
address
those
workforce
shortages
in
rural
areas
of
the
state.
In
this
slide,
I've
listed
a
long
list
of
ways
that
we
stretch
the
existing
workforce
and
I
think
the
most
appropriate
one
for
our
discussion
of
chronic
disease
prevention
is
expanding,
team-based
models
of
care
that
needs
to
be
coupled
with
interprofessional
and
team-based
education
of
those
individuals
we're
slowly
moving
in
that
direction.
F
I
think
it
also
means
thinking
about
ways
that
non-physician
clinicians
can
practice
at
the
top
of
their
scope.
We
saw
a
number
of
states
look
at
ways,
for
example,
that
physician
assistants
could
practice
at
the
top
of
their
scope,
maybe
expand
their
scope.
That's
a
a
trickier
conversation
but
again
in
each
one
of
these
are
ways
to
extend
or
stretch
or
make
more
efficient
use
of
existing
health
workers.
F
A
great
little
example
of
what
we
accomplished
as
a
state
when
we
extended
this
expanded
the
scope
of
practice
for
advanced
practice,
nurses
and
expanded
programs,
training,
physician
assistants,
I've
double
checked
these
numbers
and
what
we've
seen
in
less
than
a
decade
is
a
pretty
spectacular
growth
in
them.
Both
the
number
of
licensed
individuals
who
are
advanced
practice.
Nurses
in
our
state
we're
a
net
importer
now
of
those
individuals,
but
we've
also
seen
really
impressive
growth
in
the
per
capita
number
of
apr
ends
in
our
state.
F
This
is
a
trend
you
will
not
see
in
any
other
profession,
and
that
is
a
mere
tripling
of
the
per
capita
number
of
advanced
practice
nurses.
Owing
to
that
change
in
full
practice
authority
coming
out
of
the
2013
legislative
session,
I'll
close
out
my
list
here
by
just
talking
about
some
measures
that
our
state
can
take
or
revisit
when
it
comes
to
benefiting
from
individuals
interested
in
relocating
in
nevada
to
practice.
F
Some
of
these
are
completely
unsustainable.
Traveling
nurses,
for
example.
There
were
hospitals
in
clark,
county,
paying
200
dollars
an
hour
for
traveling
nurses
and
fifty
dollars
an
hour
for
nursing
assistants.
F
F
This
sadly,
and
unfortunately,
was
a
bill
that
didn't
get
a
committee
hearing
in
the
2021s
session.
I
would
argue
quite
strongly
that
it's
one
that
the
the
legislature
needs
to
revisit.
The
licensure
compact
is
not
going
to
be
the
be-all
and
end-all
when
it
comes
to
addressing
shortages,
but
it
will
be
an
important
part,
at
least
in
the
case
of
nursing,
for
our
state.
F
If
we're
going
to
have
a
comprehensive
approach
to
addressing
shortages,
I
recently
read
in
a
board
of
medical
examiner's,
most
recent
annual
report
that
our
state
in
2021
great
issued
licenses
to
1158
physicians
in
the
last
calendar
year.
454
of
those
individuals
or
39
percent
of
those
new
licensees
were
a
product
of
our
state's
participate
participation
in
the
interstate
medical
licensure
compact.
So
again
it
needs
to
be
a
part
of
the
conversation
of
how
we
as
a
state,
address
those
issues.
A
Thank
you
so
much
dr
packham.
Any
questions
from
let's
go
with
that's
only
women
titus
and
then
we'll
go
to
something
one
gorilla
in
vegas.
So
that's
something
winters
so.
J
Thank
you,
dr
pack,
and
moyes
good
to
hear
from
you
and-
and
you
are
the
you
are
the
data
person
and
I
agree
with
that.
The
nursing
compact
legislation,
as
you
know,
assembly
men,
p.k
o'neil,
and
I
co-sponsored
that
bill
and
we're
looking
forward
at
bringing
that
back.
If
nobody
else
does,
hopefully,
the
state
will
get
on
board
with
that
one,
because
we
think
that's
huge.
J
I
have
some
questions
regarding
other
areas
that
you
might
see
where
we
can
expand
access
access
to
care
and
have
have
providers
on
the
nursing
compact
that
you
mentioned
that
I
I
feel
we
need
to
get
to
move
forward
on
you.
You
showed
us
the
one
on
physicians
that
expanded
but
there's
other
health
care
professionals.
J
F
Well,
yeah,
I
would,
I
would
just
mention
real
quickly
that
of
the
eight
existing
interstate
licensure
compacts.
We,
for
example,
only
participate
in
two.
We,
as
I
mentioned,
participate
in
the
interstate
medical
licensure
compact,
as
well
as
the
psychology
inner
jurisdictional
compact
say
that
five
times
real
fast,
but
we
don't
participate
as
I've
noted
in
the
nursing,
physical
therapy,
ems
there's
even
an
advanced
practice
registered
nurse
compact
and
then
finally,
an
occupational
therapy.
So
there's
other
avenues
there
and
again.
J
So
do
you
and
thank
you
for
that?
Do
you
keep
track
on
the
time
across
those
professions
of
from
application
to
actually
time
of
licensure,
so
they
can
actually
practice.
J
For
example,
I
was
on
the
state
board
of
medical
examiners
years
ago,
and
you
know
it
would
take
months
sometimes
longer
to
when
somebody
applies
for
a
medical
license
to
get
that
license.
Does
your
department
keep
track
on
what
those
numbers
look
like
across
those
different
professions
and
how
long
it
takes
to
get
people
their
license.
F
I
don't,
but
I
would
recommend
that
you
speak
to
representatives
of
those
boards
who
should
have
that
information,
I'm
not
trying
to
dodge
it,
but
between
anecdote
and
what
you
hear
from
various
stakeholders.
You
hear
all
sorts
of
different.
You
hear
those
individual
experiences
of
it
taking
six
months
and
one
profession
and
two
weeks
and
another,
but
that
again
reducing
that
that
time
lag
is,
is
one
more
strategy
that
we
need
to
pay
attention
to
right
at.
J
I
just
you
know,
as
you
mentioned,
my
dental
hygienist
took
over
six
months
six
to
nine
months.
I
think,
to
get
her
license
and
and
when
she
had
trained
and
was
educated
in
california
and
passed
all
the
necessary
tests,
but
it
took
that
long
to
get
her
license.
J
I
was
just
wondering
if
anybody's
holding
those
professional
licensure
boards
accountable
on
the
timing
in
any
one
spot,
or
do
we
have
to
reach
out
to
each
individual
board
to
find
that
out,
and
that
might
be
something
our
staff
can
do-
is
find
out
really
how
long
it
takes
from
each
of
those
boards.
That
would
be
helpful.
Thank
you.
F
Yeah,
I
completely
agree
with
you
and
I
and,
and
I
wouldn't
say
we
should
do
that
for
the
purposes
of
shaming
one
board
or
another,
but
if
one
board
takes
three
weeks
and
another
board
takes
three
months,
that
the
three-month
board
stands
to
learn
something
from
what
others
are
doing
more
quickly.
At
the
end
of
the
day,
we
want
to
safeguard
the
public's
health
through
this
process
and
the
roles
important
roles
boards
play,
but
again,
if
we
can
attenuate
or
decrease
that
that
timeline,
that's
one
more
tool
in
our
tool,
chest.
J
F
Yeah-
and
I
I
I
think
I
will
just
agree
with
you-
that
that
would
be
a
good
approach
and
one
of
the
I
haven't
seen
the
the
latest
data
on
this,
but
a
year
or
so
ago,
when
we
were
up
to
our
eyeballs
in
the
pandemic.
F
Both
the
medical
board
and
the
nursing
board
presented
data
on
those
individuals
who
received
a
temporary
licensure
through
that
governor's
directive
11
during
the
public
health
emergency
and
one
of
the
I
thought
fascinating
undiscussed
parts
of
that
experience
was
how
miniscule
the
number
of
complaints
or
patient
safety
issues
that
were
associated
with
those
individuals
and
they
all
they
all
didn't
move
to
nevada
to
practice,
but
quite
a
few
of
them
did
through
telehealth
as
we're
learning,
and
I
think
that
that
type
of
information
on
the
experience
of
our
state,
with
which
my
recollection
this
was
like
a
two-page
application
for
that
temporary
license
needs
to
be
examined,
because
it
may
be
the
case
that
we
we
can
do
that
just
so
that
an
individual
can
begin
practicing
without
you
know
going
through
all
of
the
hoops
that's
required
in
a
the
complete
application
process.
A
Thank
you
so
much
assemblywoman
gorilla.
E
Thank
you
very
much
vice
chair
and
I
had
two
quick
questions.
The
first
you
had
in
your
slide
presentation
a
list
of
the
number
of
deficits
for
the
different
professions,
with
nurses
being
over
four
thousand.
I
apologize.
I
can't
get
it
up
on
my
screen
to
say
which
slide
that
was,
but
you
by
chance
have
a
breakdown
of
what
those
deficits
are
per
county,
especially
in
the
rurals.
F
I
I
do
not
have
that,
but
you
don't
have
it
for
every
county
rep.
I
do
have
a
report
that
I
will
share
with
patrick
and
get
to
everybody
in
the
committee
where
we
look
at
probably
75
occupations
in
the
state.
F
I
do
have
data
for
clark,
washoe
and
then
kind
of
the
balance
of
the
state
as
well
as
the
state
metric,
but
I
I
think
that
would
be
of
importance,
given
the
fact
that
90
percent
of
the
state
resides
in
those
two
counties,
but
I
will
make
sure
that
you
get
that
information.
E
Thank
you.
I'd,
definitely
interested
in
seeing
how
that
might
look
and
then
the
other
question
when
you're
talking
about
the
grow
our
own.
I
hear
a
lot
of
conversations
about
that.
It
seems
like
we're
talking
about
perhaps
taking
a
student.
That's
just
graduated
high
school
and
getting
them
into
that
pipeline.
But
have
there
been
conversations
about
taking
current
people
in
professions
and
growing
them
within
that
pipeline?
So
taking
a
like
a
cna
and
bringing
them
to
the
rn
level
or
taking
a
social
worker
and
making
them
an
lsw?
F
There
are
some
great
conversations
and
I
would
are
even
argued,
some
great
work
in
our
state
in
that
area
and
one
I
would
highlight
that
young
woman
I
showed
in
my
picture
of
him
she's
a
national
nevada
health
service
corps,
individual.
She
started
out
in
that
hospital
in
lovelock,
as
a
nursing
assistant
then
went
to
reno
to
get
her
a
bachelor's
degree
in
nursing
and
then
a
a
master's
degree
at
nursing
in
that
pipeline
the
whole
time
wanting
to
return
to
lovelock
to
practice
and
her
getting
that
degree.
F
You
know
homegrown
student,
getting
your
degree
and
training
in
nevada
and
then
the
use
of
the
national
nevada
health
service
corps
to
kind
of
seal
the
deal
so
that
she
could
go
back
practice
in
her
community
and
paid
down
her
student
loans
and
debt.
It's
just
a
great
example
of
addressing
issues
all
along
that
pipeline
that
you
mentioned.
I
would
also
add
that
there's
a
lot
of
interest
right
now
in
people
who
are
in
the
process
of
shifting
and
changing
careers.
F
There
was
a
lot
of
concern
during
the
pandemic
that
physicians,
nurses
and
other
health
professionals
were
leaving
the
profession.
I
think
those
were
exaggerated.
They
were
certainly
changing
jobs,
but
not
the
profession.
I
I
think
we
saw
more
interest,
though,
in
individuals
entertaining
careers
in
health
care,
as
well
as
public
health,
enrollments
and
applications
to
most
health
professions.
Schools,
including
public
health,
are
up
right
now
and,
and
those
are
good
developments
that
we
we
need
to
support
with
dollars
in
expanded
capacity.
E
A
B
Thank
you
so
much
vice
chair
and
thank
you
for
the
presentation
and
john
really
interesting
to
follow.
Some
of
the
data
work
that
you
guys
in
your
office
has
been
doing.
We've
been
talking
a
lot
about
the
bottlenecks
in
the
pipeline
right
and
where
those
bottlenecks
are
occurring
and
at
that
nursing
conference.
The
other
day
we
heard
from
a
few
folks
that
some
of
that
bottleneck
is
occurring
within
our
educational
institutions,
and
we
see
this
really
across
the
board,
even
in
our
our
primary
education
system.
B
When
we're
looking
for
people
who
specialize
in
a
field
that
pays
really
well,
it's
hard
to
bring
them
into
academia,
it's
hard
to
bring
them
in
to
become
teachers,
and
so
I'm
wondering
if
you
have
thoughts
on
what
we
can
do
policy
wise
around
those
bottlenecks,
specifically
within
the
education
systems,
or
if
you
can
point
us
in
the
direction
where
someone
has
fleshed
out
some
of
the
issues
in
those
areas
and
and
what
some
of
the
solutions
might
be.
F
There
was
data
presented
at
our
summit
last
week
that
indicated
a
associate
degree
trained,
rn
graduating
in
nevada
will
make
more
than
orvis
or
unlv
paid
their
assistant
associate
level
faculties.
We
absolutely
have
to
address
that
now.
That
may
be
a
conversation
that
needs
to
take
place
more
within
the
system
of
higher
education
than
the
legislature,
but
one
would
hope
that
there
would
be
a
broad
agreement
that
you're
never
going
to
expand
capacity.
B
I
think
that's
an
important
point
to
to
this
conversation,
just
how
many
players
are
out
there
in
the
pipeline.
We
have
the
educational
institutions
and
she
we
can't
tell
you
what
to
do,
but
we
can
help
establish
the
social
license
in
the
state
of
nevada,
for
what
it
is
our
that
our
expectations
are.
We
can
help
establish
what
what
what
our
growth
metrics
should
look
like
and
tie
those
into
other
metrics
that
are
established
by
institute
that
we
don't
control.
B
So
I
think
there
are
some
options
in
there,
but
I'm
really
interested
in
kind
of
trying
to
flush
those
out
and
see
how
we
can
establish
a
you
know
a
way
to
decompress
those
those
pipeline
compressions
yeah.
F
And
and
to
the
extent
that
they're
able
and
and
can
do
it,
I
I'd
like
to
plan
on
putting
together
my
office
and
put
together
a
white
paper
on
the
nursing
shortage
over
the
next
month,
and
one
thing
I'd
like
to
get
data
on
from
the
nursing,
deans
and
directors
is
the
number
of
qualified
applicants
that
they
turn
away
every
year,
because
what
happens
is
those
individuals
that
are
on
that
waiting
list
that
are
turned
away
due
to
capacity
constraints
in
our
nursing
programs?
F
A
they
either
attend
a
private
college
here
in
college
or
university
for
nursing
school
with
tuition
that
is
substantially
higher
than
our
public
programs
or
worse.
They
leave
the
state
and
never
come
back,
and
so
we
compound
our
problem
anytime,
that
we're
turning
away
qualified
applicants
and
I
think,
we're
turning
away
quite
a
few
still
due
to
those
capacity
constraints.
B
B
There
was
no
way
you
could
get
into
those
programs,
and
I
think
that
those
standards
have
shifted
that
we're
looking
towards
towards
some
other
metrics,
but
I'm
not
sure
that
that
message
is
getting
out
in
in
the
potential
pipeline
for
our
high
school
graduates
and
people
who
are
looking
to
attend
universities
in
the
state.
F
Well,
and
that's
a
that's,
a
good
reason
why,
in
that
pipeline,
work,
whether
we're
talking
with
middle
schoolers
or
high
schools,
the
emphasis
that
we
need
to
place
on
stem
education
so
that
an
8th
or
9th
grader
who
thinks
they
might
go
into
medicine,
for
example,
but
by
high
school
realizes,
they're
interested
in
nursing.
If
you've
got
that
stem
background,
you
have
a
leg
up
on
others,
pursuing
those
degree,
programs
and
health.
A
A
Don't
see
this
don't
see
any
so,
let's
go
ahead
and
move
on
to
our
final
presentation,
which
is
policy
considerations
on
chronic
diseases
and
prevention.
We
have
chris
seiverson.
Excuse
me
for
the
mispronunciation,
the
chair
of
the
nevada
advisory
council
on
the
state
program
for
wellness
and
the
prevention
of
chronic
disease.
Please
begin
when
you're
ready.
N
You
thank
you,
as
this
is
the
first
time
that
I
have
been
that
I
will
be
presenting
to
this
group.
I
wanted
to
just
take
a
quick
second
and
introduce
myself
and
my
slides
are
not
moving.
N
I
am
the
ceo
of
the
nevada
business
group
on
health
and
nevada
health
partners,
which
is
a
non-profit
nevada
corporation,
which
represents
employers
primarily
in
northern
nevada.
I'm
also
the
chair
of
the
nevada
advisory
council
on
the
state
program
for
wellness
and
prevention
of
chronic
disease.
The
board
chair
of
the
national
alliance
of
healthcare
purchasing
coalition
board
vice
chair
of
nevada,
co-imagine
health
and
I
have
been
around
benefits
and
health
related
human
resources
for
over
40
years
in
northern
nevada.
N
N
You
hear
a
lot
now
on
the
concept
of
well-being,
which
I
think
encompasses
not
only
wellness
in
the
traditional
terms
of
physical
health
but
wellness
and
has
several
dimensions,
including
employee,
emotional
well-being,
coping
physical
well-being,
and
I
know
that
we've
heard
a
lot
today
on
mental
health,
and
I
I
have
to
say
I
am
fully
in
support
of
advancing
mental
health
in
the
state
of
nevada
and
to
speak
to
dr
packham's
presentation.
N
Certainly,
the
need
for
more
providers
in
the
state
is
is
nowhere
as
deep
as
it
is
in
mental
health
as
well
in
talking
about
total
person,
health
we're
talking
about
individual
family,
community
and
population,
as
well
as
biological,
behavioral,
social
and
environmental,
and
why
is
this
important?
This
is
important
because
chronic
diseases
such
as
diabetes,
cardiovascular
disease,
obesity,
joint
disease
can
also
occur
with
chronic
pain,
depression
and
opioid
misuse.
N
All
of
these
conditions
are
exacerbated
by
chronic
stress,
if
proven
has
taught
us
anything.
It
is
that
stress
and
mental
health
really
has
a
large
impact
on
our
physical
well-being,
definitely
with
a
long-term
risk
of
covet
understanding
conditions
in
which
a
person
lives
addressing
behaviors
at
an
early
stage
such
as
dr
shane
talked
about
in
obesity
and
managing
stress
not
only
can
prevent
multiple
diseases,
but
can
restore
health
and
stop
the
progression
of
a
disease
across
a
person's
life
span
just
another
quick.
N
What
are
we
asking
and
again,
since
this
is
my
first
time
addressing
this
committee,
I
was
not
quite
sure
what
you
were
looking
for,
but
just
we'll
talk
abroad
brush
in
policy
areas
we're
looking
for
committed,
sustained
current
funding
within
our
own
state
oftentimes.
We
are
relying
on
subgrants
or
grants
from
the
cdc
which
do
not
allow
a
lot
of
flexibility
in
state
programming,
we're
looking
for
support
on
programming
on
two
different
levels.
N
N
The
second
area
I
wanted
to
talk
about
was
chronic
disease
prevention
and
management,
specifically
obesity,
tobacco
use
and
diabetes,
and
one
thing
that
we
have
heard
today.
All
of
these.
N
Right
all
obesity
affects
diabetes,
which
affects
mental
health
and
there's
so
many
areas
where
we
cross
over
and
have
common
themes
and
common
needs.
Obesity
in
nevada
is
growing.
I'm
not
going
to
spend
a
lot
of
time
on
this.
I
think
you
heard
from
dr
shane
a
lot
about
obesity
and
lily
hauser
as
well
policy
considerations
and
mental
health
and
obesity.
N
Looking
at
this
as
a
stand-alone
disease
requiring
health
plans,
providers
and
vendors
to
collaborate
and
cover
evidence-based
lifestyle
programs
such
as
the
cdc
diabetes
prevention
program
and
the
diabetes
self-management
education
program
as
well
again
committed
sustained
funding
within
our
own
state
to
support
community
health
workers,
which
we've
heard
about
earlier
internet
and
electronic
programs,
which
is
sort
of
an
advancement,
if
you
will
from
telehealth
a
lot
of
programs
now
are
app-based
programs,
the
covering
of
registered
dietitians
and
obesity
management
specialists
within
the
state,
again
programming
for
residents,
employees
and
public
and
private
employers
as
well
in
tobacco
use.
N
I
know
that
we,
this
group,
is
probably
very
versed
in
the
impact
of
tobacco
in
our
state.
We'd
like
to
look
at
increasing
enforcement
of
retailers
to
comply
with
sorry
require
mandatory
retail
and
merchant
training
and
increasing
fines
to
those
revoking
licensure
for
those
who
continually
have
repeated
non-compliance.
N
Offenses
utilize
current
funding
and
available
to
allocate
available
and
allocate
funding
to
local
communities
close
the
loopholes
and
include
minimum
distance
requirements
and
support
community-based
education,
and
then
I
wanted
to
talk
about
diabetes,
and
this
is
a
program
that
our
organization
has
taken
on
for
several
reasons.
First
and
foremost,
we
found
that
when
we
looked
at
chronic
disease
states
within
our
employer
population,
we
found
that
most
often
diabetes
is
not
a
primary
diagnosis,
but
it
is
a
comorbidity
and
many
other
diagnosis,
whether
it
be
heart,
disease,
kidney
disease
and
other
illnesses.
N
We
found
that
diabetes
was
often
a
comorbidity
diabetes
is
the
seventh
leading
cause
of
death
in
2019?
N
Over
34.1
million
adults
were
estimated
to
have
diabetes,
which
26.8
million
were
diet
were
diagnosed
and
7.3
million
were
undiagnosed,
and
one
of
the
things
that
we
deal
with
in
my
industry
is
the
costs
associated
with
diabetes
and
a
direct
medical
and
lost
productivity
attributed
to
those
diagnosis
diagnosed
with
diabetes
was
327
billion
dollars
in
2017,
which
extrapolate
those
in
today's
dollars
is
just
really
incredible.
N
The
prevalence
diabetes
is
higher
in
men
compared
to
women,
american
indian,
alaskan
native
black
and
hispanics
adults,
as
compared
to
white
and
asian
adults,
25
years
and
older,
with
less
than
high
school
education
and
adults
25
years
and
older
with
a
household
income.
So
we're
definitely
talking
about
a
prevalence
in
the
nevada,
underserved
populations.
N
Policy
considerations
in
regards
to
diabetes
management
would
be
to
develop
in-state
funding
mechanisms
for
diabetes
prevention
program
and
diabetes
self-management
program.
We
are
relying
on
cd
cdc
funds
currently
that
may
disappear
in
2023
and
cover
dpp
and
dsmes
for
state
employees
under
current
benefit
plans,
as
well
as
medicaid
dpp
programming,
is
currently
covered
under
the
medicare
program.
N
What
we've
been
able
to
do
is
we
have
six
of
our
employers
who
were
able
to
pilot
the
dpp
and
dsmes
programs.
We
did
achieve
over
a
five
percent
weight
loss
for
those
and
encouraged.
We
are
encouraging
our
employers
to
cover
dpp
and
dsmes
as
a
paid
benefit
program,
and
we
have
employers
who
are
planning
on
piloting
this
program
as
well.
We'd
like
to
offer
to
pilot
this
program
through
the
state
employees
program
date
have
program
and
work
with
them
as
well.
N
Lastly,
I
I
would
be
remiss
if
I
didn't
take
this
opportunity
to
just
talk
about
other
overarching
politics
policy
considerations
in
health
care,
and
I
would
be
more
than
happy
to
talk
about
any
of
these
more
at
length
at
a
later
date.
One
is
to
expand
step
therapy
and
prior
authorization.
Language
outside
of
the
cancer
care
that
we
do
currently
within
the
state
continue
to
monitor
and
potentially
cap
the
cost
of
drugs
to
ensure
drugs
to
employers,
plans
and
consumers.
N
I
do
a
lot
of
work
nationally
on
high-cost
claims
and
high-cost
drug
claims,
the
drugs
that
we
traditionally
think
of
are
cancer
drugs,
but
I
will
say
that
ms
drugs,
multiple
sclerosis,
drugs,
have
really
overtaken
just
about
those
cancer
drugs
in
regards
to
cost
and
usage
and
then
those
orphan
drugs
that
cover
very
rare
but
just
incredibly
high
cost
drugs
working
with
high
cost
claims
with
the
removal
of
the
claims
cap
by
the
aca,
the
burden
of
states,
employers
and
individuals
has
skyrocketed.
N
And
is
very,
very
detrimental
to
those
employers
who
are
self-insured,
such
as
the
state
of
nevada
and
the
employers,
primarily
that
we
that
I
represent
support
the
coverage
of
biomarker
testing
and
the
use
of
precision
medicine
again
oftentimes.
This
is
in
the
drug
area.
I
I
joke
that
in
prescription
medicine,
we
have
often
used
a
shotgun
approach.
N
If
you
will
where
we
will
try
multiple
drugs,
one
after
the
other
to
find
a
drug
that
worked
with
many
biomarker
testing
protocols
that
have
been
established
recently,
you
can
find
the
drug
that
works
the
first
time,
which
would
create
not
only
a
much
better
patient
experience,
but
a
much
better
treatment.
Alternative
I'd
like
to
continue
to
monitor
the
use
of
copay,
accumulator
programs
and
the
impact
on
end
user
and
overall
use
of
rebate
programs
and
also
the
advancement
of
health
health
equity.
N
A
Thank
you
so
much
ms
everson.
Let's
go
to
questions
from
committee
members.
Anyone
doesn't
look
like
we
have
here
in
carson
city.
Anyone
from
las
vegas
looks
like
assemblywoman
gorilla.
Is
that
you.
A
Sorry
all
good
any
questions
from
committee
members
either
virtually
or
in
las
vegas.
I
don't
think
I
see
any
so.
Thank
you
so
much
miss
everson
for
your
presentation,
greatly
appreciated.
A
Let's
go
ahead
and
move
on
to
our
next
agenda
item
agenda:
item
9
presentation
on
the
work
of
the
committee
to
conduct
an
interim
study
concerning
the
costs
of
prescription
drugs.
For
this
presentation
we
have
our
committee
policy
analyst
patrick
ashton,
who
will
go
ahead
and
present
on
this
subject
area
so
patrick
whenever
you're
ready.