►
Description
This is the first meeting of the 2021-2022 Interim. Please see the agenda for details.
For agenda and additional meeting information: https://www.leg.state.nv.us/App/Calendar/A/
Videos of archived meetings are made available as a courtesy of the Nevada Legislature.
The videos are part of an ongoing effort to keep the public informed of and involved in the legislative process.
All videos are intended for personal use and are not intended for use in commercial ventures or political campaigns.
Closed Captioning is Auto-Generated and is not an official representation of what is being spoken.
A
All
right
members
will
we
please
go
ahead
and
turn
on
your
cameras,
and
you
will
get
this
meeting
started.
A
Welcome
welcome
to
the
first
meeting
of
the
interim
standing
excuse
me
joint
interim
standing
committee
on
health
and
human
services
members
before
we
begin.
I
just
want
to
make
sure
members
and
folks
participating
on
the
zoo.
Have
your
microphones
muted,
unless
you
are
speaking
please
this
minimizes
background
noise,
but
if
we
can
keep
our
cameras
on
that
will
help
us
maintain
forum
throughout
the
meeting.
Mr
ashton,
will
you
please
call
the
role.
C
A
Thank
you.
It
looks
like
assemblywoman
tied
it
here.
Titus
is
having
some
microphone
difficulties.
Maybe
broadcast
can
help
her
out.
A
I
just
wanted
to
take
a
moment
to
welcome
everybody
to
our
newly
established
interim
joint
standing
committee
on
health
and
human
services.
I'm
very
excited
for
the
opportunity
to
be
chairing
this
committee,
I'm
grateful
for
vice
chair
dunya
and
his
participation
in
helping
set
up
these
meetings
and
coordinate.
I
also
want
to
just
briefly
thank
staff
so
much
for
helping
ensure
that
we
have
all
the
folks
on
this
meeting
today
that
are
here
to
present
to
us
and
also
extended.
A
Thank
you
to
all
the
folks
who
are
watching
and
are
participating
today
in
their
various
roles.
A
couple
of
housekeeping
announcements.
Before
we
begin
agenda
items
may
be
taken
in
or
in
a
different
order
than
listed
two
or
more
agenda
items
may
be
combined
for
consideration.
A
An
item
may
be
removed
from
this
agenda
or
discussed
in
or
discussion
of
an
item
on
this
agenda
may
be
delayed
at
any
time.
The
committee
meeting
material
can
be
found
on
the
nevada
legislatures
website.
Sorry
I
have
a
hair
hanging
out
with
my
eyelashes.
A
A
Spiritual
meeting
format
is
important
to
keeping
everyone
safe
during
the
kobe
19
pandemic.
Members
of
the
public
may
provide
comment
in
four
different
ways
which
are
listed
on
the
agenda.
You
can
call
in
the
call
in
number
is
listed
on
our
meeting
page
and
on
the
agenda.
You
can
email
comments
to
hhs
interim
lcb.state.nb.us.
A
A
Please
also
pay
attention
and
mute
your
microphone
as
you
as
you
can,
while
not
speaking
just
helps
us
keep
down
those
unintended
noises
with
that.
I
would
like
to
move
on
to
brief
introductions
of
our
members
and
staff
members.
If
you'd
like
to
introduce
yourself,
please
include
the
district
you
represent
and
your
interest
in
this
interim
committee
as
well
as
your
goals
for
this
committee
during
the
interim.
A
I
do
ask
that
we
keep
these
relatively
brief,
because
we
do
have
a
dense
agenda
today,
so
I
will
go
ahead
and
ask
senator
donate
by
share
donate
to.
Please
start
us
off.
D
Thank
you
so
much
chair,
peters
and
good
morning
to
the
committee
members
senator
donate
representing
senate
district
10,
which
is
in
central
las
vegas
and
covers
the
las
vegas
strip.
My
interest
here
today
is:
I
have
a
background
in
public
health
graduated
from
unlv,
with
my
bachelor's
in
public
health
and
currently
work
as
a
health
administrator,
so
looking
forward
to
working
alongside
all
of
you
to
address
the
cover
19
pandemic
and
what
the
blueprint
of
public
health
looks
like
in
our
state
beyond
this.
Thank
you.
A
I'm
going
to
move
on
up
through
the
senators
and
then
we'll
move
through
the
assembly
members
senator
harris.
Could
you
please
introduce
yourself
and
then
we'll
go
on
to
some
neurons.
D
E
I'm
joe
hardy
family
physician
work
at
toro
university
medical
school,
grateful
to
be
on
this
committee
and
look
forward
to
helping
everybody,
have
good
health
and
positive
outlooks
for
the
future
appreciate
it.
Thank
you.
F
F
D
I'm
david
orentlicher,
I'm
a
physician
and
lawyer
and
I
teach
at
unlv
schools
of
law
and
medicine
in
las
vegas
health
care
reform
is
a
big
interest
of
mine.
I
teach
and
write
about
it,
so
I'm
interested
looking
forward
to
working
with
this
committee
on
that.
My
district
is
assembly,
district
20
on
the
southeast
side
of
las
vegas
and
some
of
northwest
henderson.
A
J
Yes,
we
do
sorry
for
the
trials
and
tribulations
of
rural
nevada's
and
access
to
wi-fi,
I'm
happy
to
be
on
the
committee
excited
to
serve
with
all
of
you
who
are
as
equally
passionate
about
health
care.
As
I
am,
I
represent
district
38,
which
is
a
rural
district,
almost
lying
county,
all
of
churchill
county,
I'm
a
family
practice
doctor
also
remain
the
county
health
officer
for
lyon
county.
J
So,
as
you
can
all
imagine,
it's
been
a
very
dramatic
couple
of
years,
for
I
think
all
of
us
in
the
state
of
nevada,
but
especially
those
in
healthcare,
and
so
I'm
looking
forward
to
to
work
in
a
bipartisan
way
to
help
solve
also
something.
J
A
Thank
you,
assemblywoman
assemblyman
hathan.
I
think
you
are
laughed
up.
D
Assemblyman
hafen
from
a
dis
assembly
district
36.,
I'm
going
to
echo
what
my
colleagues
have
stated
and
and
just
add
that
I'm
hoping
that
we're
able
to
use
this
interim
committee
to
help
address
some
of
the
shortages
in
the
medical
field,
both
through
the
was
being
called
the
great
resignation
across
the
country,
as
well
as
some
of
the
issues
through
rural
nevada
and
getting
access
to
medical
staff
and
doctors
and
a
little
bit
of
my
background
is.
I
currently
sit
on
the
desert
view
hospital
board
in
relation
to
healthcare.
A
Thank
you.
This
hair
on
my
eyelashes
is
starting
to
drive
me
crazy.
I
might
have
to
step
away
for
a
second.
I
am
assemblywoman
peters.
I'm
excited
to
be
chairing
this
interim
committee.
I
vice
chair
of
the
assembly
session
committee
on
health
and
human
services
and
was
really
grateful
for
the
opportunity
to
dive
into
the
issues
that
are
relevant
to
healthcare
in
the
state
of
nevada
and
beyond.
A
I'm
really
excited
for
the
agendas
that
we
have
planned
out
for
this
session
and
I'm
really
looking
forward
to
the
very
discussion
that
I
I
believe
we
will
be
able
to
have
during
this
interim.
We
do
have
a
relatively
brief
interim,
I
think
only
eight
meetings
and
we
are
trying
to
get
through
quite
a
bit
of
material
and
information.
A
So
I
I
think-
and
I
encourage
my
colleagues
to
reach
out
and
continue
working
on
other
issues
and
keep
doing
deeper
dives
into
issues
as
they
come
up
and
your
interest
is
piqued.
We
have
so
many
stakeholders
in
the
state
who
are
interested
in
health
care
and
there's
a
lot
to
take
on.
A
My
background
is
in
environmental
engineering,
but
I
have
a
educational
history
in
environmental
toxicology
and
a
familial
history
and
working
in
healthcare,
both
my
mother,
my
grandfather,
my
stepfather
and
my
grandmother
have
been
in
the
healthcare
industry,
so
I
grew
up
exposed
to
the
health
care,
particularly
mental
health
care
needs
of
nevada.
A
For
most
of
my
life,
I
also
grew
up
both
in
reno
and
in
wyoming
county.
So
the
perspective
of
our
rural
communities
is
really
important
to
me
that
we
consider
and
ensure
we're,
including
those
folks
in
our
discussions.
You
know
our
healthcare
deserts
are
dire
across
the
state,
but
it
is
particularly
highlighted
in
our
rural
communities.
A
A
A
B
Oh,
thank
you
so
much
jr
peters
good
morning,
I'm
patrick
ashton
and
I
work
as
a
senior
policy
analyst
with
the
research
division
of
the
legislative
council
bureau.
This
is
my
third
legislative
interim.
I
assisted
the
legislative
committee
on
healthcare
and
the
committee
to
study
the
costs
of
prescription
drugs
during
the
past
interim
last
session.
I
also
served
as
the
comedy
policy
analyst
for
the
assembly,
health
and
human
services.
B
Just
some
background
about
myself
myself.
I
hold
two
master's
degrees
from
unr,
one
in
political
science,
with
a
major
in
public
policy,
the
other
one
in
social
work
and
I'm
also
a
licensed
social
worker
and
work
for
the
aging
and
disability
services,
division
at
dhhs
and
the
university
center
for
autism
and
neurodevelopment
at
unr.
B
K
K
K
I
have
a
phd
in
public
health
with
an
emphasis
in
health
behavior
from
uc
san
diego,
where
I
also
completed
a
transdisciplinary
training,
pre-doctoral
fellowship
that
added
biological
and
biomedical
background
to
the
degree
in
a
master's
in
exercise
physiology
and
then,
after
moving
up
here
from
san
diego,
I
worked
with
nevada's
division
of
public
and
behavioral
health
for
almost
five
years
before
joining
lcb
and
just
like
patrick
I'm
very
excited
and
honored
to
be
serving
the
committee,
this
interim
and
and
really
looking
forward
to
working
with
you
all.
So.
A
Thank
you
both
next
I'd,
like
mr
casara,
to
introduce
himself.
D
Chairpeers
members
of
the
interim
committee,
my
name
is
john
cucera,
with
the
fiscal
analysis
division
of
the
legislative
council
bureau,
I'm
primary
staff
for
our
interim
finance
committee,
but
I
am
secondary
staff
for
this
joint
interim
standing
committee
on
health
and
human
services
and
I'm
happy
to
address
any
general
budget
or
fiscal
related
questions
or
concerns
as
they
may
arise,
within
the
fiscal
division.
We
generally
segregate
responsibilities
by
executive
budget
and
within
the
fiscal
division.
There
are
several
analysts
that
share
responsibility
for
the
department
of
health
and
human
services,
giving
given
its
size
and
scope.
D
D
D
A
Thank
you,
I'm
always
so
impressed
with
the
resumes
of
our
staff.
Lcd
really
is
one
of
the
most
wonderful
groups
of
staff
to
work
with,
and
I
want
to
encourage
all
the
members
of
this
committee
to
please
utilize
our
staff.
If
you
have
questions
or
comments,
if
you
have
issue
areas
that
you
would
like
to
explore
within
the
health
field,
our
ltd
staff
is
just
fantastic.
A
Additionally,
in
this
committee
we
receive
assistance
from
our
two
research
policy,
analysts,
julianne
king
and
crystal
rowe.
You
will
likely
receive
emails
from
all
of
these
staff
members
at
some
point
in
time,
so
I
would
also
recommend
favoriting
their
email
addresses
so
that
you
can
make
sure
you're
getting
those
emails.
A
So
thank
you
lcp
just
one
more
time
for
all
that
you
do.
We
really
appreciate
you
and
look
forward
to
moving
forward
in
this
committee
with
your
help.
A
Next
on
the
agenda's
public
comment,
I
would
like
to
go
ahead
and
start
our
public
comment
for
the
beginning
of
this
movie.
A
No,
I
failed
to
give
a
little
background
on
our
public
comment
process
this
morning,
so
while
we're
waiting
for
people
to
queue
up,
I
would
just
like
to
say
to
reiterate
that
we
are
limiting
public
comment
to
two
minutes
per
speaker.
Staff
will
be
timing.
Each
speaker
during
public
comment
to
ensure
everybody
has
a
fair
opportunity
to
speak.
We
also
ask
that
you
do
not
repeat
what
a
previous
commenter
has
stated
if
you
do
feel
inclined
to
ditto.
That
is
great
and
fine,
and
we
will
take
that
into
consideration
as
well.
A
An
additional
opportunity
to
make
public
comment
will
be
available
at
the
end
of
the
meeting.
Our
broadcasting
production
staff
will
interact
with
those
making
public
comment
and
providing
testimony
to
facilitate
participation
in
the
meeting
so
bps.
If
we
can,
please
add
the
first
callers
to
public
comment.
C
Thank
you.
My
name
is
leanne
mcallister
l-e-a-n-n-m-c-a,
l,
l.
I
s
t
e
r.
I
am
the
executive
director
of
the
nevada
chapter
of
the
american
academy
of
pediatrics.
Thank
you
for
prioritizing
discussing
the
covet
19
pandemic.
At
today's
meeting.
The
nevada
aap
strongly
advocates
that
we
should
prioritize
having
students
physically
present
in
school.
This
must
happen
with
careful
measures
to
keep
students
and
staff
safe.
C
C
C
D
D
I
want
to
share
with
this
committee
a
brief
update
on
how
our
three
hospitals
are
doing
as
it's
no
secret.
That
kovich
is
surging
again
in
nevada
right
now,
while
omicron
variant
cases
cause
less
admissions.
We
currently
are
seeing
the
most
number
of
cases
at
our
hospitals
and
a
high
volume
of
non-covered
care.
At
the
same
time,
unfortunately,
80
to
85
percent
of
those
we're
seeing
admitted
are
unvaccinated.
D
We
continue
to
experience
staffing
shortages,
just
as
the
national
crisis
has
shown
across
the
country,
but
this
particular
hits
us
particularly
hard
in
nevada.
Our
infection
rates
are
high,
and
these
shafting
shortages
together
create
the
perfect
storm
of
full
emergency
departments.
We
wanted
to
make
sure
the
committee
also
understood
the
impact
that
these
staffing
shortages
have
on
our
partners
in
the
post-acute
care
space
like
nursing,
home
facilities
and
home
health,
where
patients
can't
know
where
to
go
when
they
leave
the
hospital.
D
Currently
we
have
over
100
patients
alone
in
our
three
hospitals
who
are
waiting
for
such
placements.
Many
of
the
issues
this
interim
committee
will
look
at
today
and
over
the
course
of
the
next
year
will
have
a
significant
impact
on
our
ability
to
provide
life-saving
services
to
nevada
patients
in
particular.
Sunrise
hospital
is
the
number
one
provider
of
medicaid
services
state
caring
for
nevada's,
most
vulnerable
population,
and
they
take
this
responsibility
very
seriously.
D
As
you
consider
issues
related
to
medicaid
and
the
pandemic,
we
ask
you
keep
in
mind
the
impact
your
decisions
will
have
on
our
ability
to
provide
these
services.
We
look
forward
to
working
with
you
on
these
important
issues
and
please
consider
us
our
resource.
And
lastly,
I
think
we
have
optim
reason
to
be
optimistic
as
we
anticipate
a
sharp
decline
in
the
omicron
search,
but
wanted
to
remind
the
public.
D
A
Thank
you
for
that
update
next
caller.
Please.
D
Good
morning,
chair
peters
and
vice
chair
donate
honorable
members
of
the
interim
health
and
human
services
committee.
For
the
record,
my
name
is
eddie
ablester,
I'm
representing
the
nevada
dental
association.
This
morning,
I
want
to
speak
to
you
regarding
regulation
r035-2,
which
is
proposed
by
the
board
of
dental
examiners
with
the
current
pandemic
and
the
significant
need
for
our
many
qualified
healthcare
providers
in
the
community.
D
This
morning
the
nevada
dental
association
has
submitted
a
letter
outlining
their
concerns
and
we
have
attached
language
that
was
previously
worked
on
in
march
of
2021
when
we
sat
down
with
the
nevada,
dental
hygienist
association,
the
oral
health,
the
oral
health
committee
and
in
the
division
of
public
and
behavioral
health,
as
well
as
the
immune,
immunization
division
and
sort
of
created
a
document.
As
you
will
see,
with
changes
that
were
all
mutually
agreed
upon.
D
We
ask
that
the
interim
health
and
human
service
committee
sends
recommendations
back
to
our
board
of
dental
examiners
to
collaborate
with
these
stakeholders
on
these
changes
before
sending
it
to
ledge
commission
for
adoption,
I
have
reached
out,
and
I'm
continually
working
with
the
board's
lobbyist,
to
fix
some
of
the
redundancies,
contradictions
and
confusion
in
the
current
language.
D
C
Nevada
and
I'm
calling
to
kind
of
point
out
the
other
day,
senator
johnson
had
a
meeting
with
the
senate,
and
it's
been
confirmed
that
early
treatment
of
coven
19
with
iber
medicine,
hydroxycornoquin
and
other
protocols
used
by
the
frontline
doctors
has
saved
thousands
of
lives,
hundreds
of
thousands
of
lives.
C
C
C
This
pandemic
has
been
handled
terribly
from
the
beginning,
and
the
use
of
remdi
severe
in
the
hospital
is
killing
people.
You
guys
need
to
get
your
ducks
in
in
order
and
start
prescribing
early
treatment
to
everyone
in
the
state.
A
C
I'm
calling
about
the
coveted
19
anything
that's
on
this
agenda
that
has
to
do
with
covenant,
19
or
sorrow
kobe
2..
The
science
is
clear:
the
virus
is
spreading.
Despite
the
scam
mask
that
you
have
all
forced
onto
the
public,
it
is
all
theater
and
you
are
demanding
it
of
people
when
the
science
has
already
told
you
through
the
years
prior
that
these
viruses
pass
through
these
masks.
C
Not
only
do
they
pass
through
the
mask,
it's
even
been
verified
by
the
front
line,
doctors
and
many
other
doctors
and
independent
doctors
right
now,
as
well
as
I
would
just
like
to
say,
the
the
vaccine,
on
the
other
hand,
that
we
will
discuss
now,
why
are
the
vac
still
getting
covered?
Breakthrough?
Cases
is
a
way
of
telling
you
your
genocidal
backs
is
not
working.
If
you
need
three,
four,
five,
six
boosters,
it's
telling
you
it's
not
working.
C
C
Let
me
ask
you
a
question:
where
is
community
the
so-called
fda
approved
vaccine
being
used
in
the
united
states
of
america?
Please
inform
your
public,
let
us
know
where
is
it
at
because
everything
else
is
still
under
e-ua
and
you
guys
are
force
vaccing,
the
entire
country,
against
what
you
should
be
doing,
and
you
know
it.
C
A
Thank
you
and
thank
you
to
folks
who
called
in
I
know
that
it
takes
bravery
to
make
those
calls
and
to
offer
those
pieces
of
our
either
opinion
or
or
advice.
I
do
feel
like
it's
important
for
us
to
to
talk
about
the
importance
of
science
and
research
and
hhs
in
particular.
A
Those
are
the
governing
bodies
of
why
we
make
public
health
decisions,
so
peer
reviewed
articles
are
the
best
place
to
find
information,
and
if
you
need
help
finding
information,
you
can
reach
out
to
our
research
analysts,
to
our
legislators
and
to
our
department
of
health
and
human
services
to
ensure
that
their
decisions
are
made.
Based
on
that
peer-reviewed
information.
A
We'll
go
ahead
and
close
the
public
comment
period.
We
will
have
another
public
comment
period
at
the
end
of
this
meeting,
if
people
so
desire
to
call
in
at
that
time.
Next
we
will
move
on
to
agenda
item
three,
which
is
the
consideration
of
regulations
proposed
or
adopted
by
certain
licensing
boards
pursuant
to
nrs439b.225.
A
Eric
robbins,
please
go
ahead
and
begin
with.
D
Hi
eric
robbins
from
lcb
legal.
So,
as
the
chairwoman
stated,
the
joint
interim
standing
committee
on
health
and
human
services
is
required
by
nrs
439b
0.225
to
consider
regulations
from
certain
licensing
boards
and
state
agencies
that
license
healthcare
providers
and
healthcare
facilities
that
pertain
to
the
requirements
for
the
issuance
or
renewal
the
license
certificate
or
similar
credential
from
by
those
boards
and
agencies,
and
the
committee
doesn't
take
formal
action
on
those
regulations
but
those.
D
D
D
So
with
that,
I
will
ask
if
any
of
the
members
of
the
committee
have
any
questions
concerning
the
regulations
and
if
so,
then
we
can
get
the
person
from
the
representative
from
the
agency
up
to
respond
to
the
question.
J
Thank
you.
I
have
some
questions
regarding
the
board
of
pharmacy
regulation
r08520
and
I
have
a
question
regarding
the
dental
board
regulation
and
I'd
appreciate.
If,
if
I
had
an
opportunity
to
ask,
those
representing
those,
two
groups
would
be
available.
A
So
folks,
from
the
board
of
pharmacy
regulations,
we
can
start
there.
A
E
Are
we
going
to
go
through
the
regulations
one
at
a
time,
or
are
we
going
to
have
the
board
of
pharmacy
come
up
and
talk
about
all
three
or
four
of
their
regulations?
A
All
right
coming
back
to
it,
we
have
quite
the
staffed
agenda
today
and
those
regulations.
I
were
sent
out
to
everybody
before
the
meeting
started.
So
if
we
have
specific
comments
on
those
regulations
at
this
time,
we
can
ask
the
the
folks
who
are
here
representing
those
boards
to
speak
to
those
questions
based
on
on
those
regulations.
A
A
Moved
on
in
the
legislative
commission
and
adopted
so
does
anybody
else
have
other
questions
that
we
can
queue
up
for
our
boards
before
we
ask
them
to
to
come
up
assembling
then
orrin
liquor?
Can
you
let
me
know
who
it
is
that
you
would
like
up
to
your.
E
E
Then
the
next
one
was
the
interns.
Then
the
next
one
was
the
ethics,
and
then
I
didn't
have
any
challenges
or
questions
with
drug
alcohol,
but
did
with
the
board
of
occupational
therapy
and
the
chiropractic
board
and
the
dental
examiners
and
the
board
of
pharmacy
with
their
one.
Two,
three
or
four
different
regulations
proposed.
E
Oh,
this
is
what
I
got
and
then
it
doesn't
match
with
the
item
numbers
so,
while
you're
listening
to
other
people
I'll
try
to
make
that
correlation
with
what
they
are.
F
O
A
Great,
I
think,
that's
a
great
place
to
start.
Let's
go
ahead
and
start
with
the
board
of
pharmacy
questions
and
I've
had
assemblywoman
titus
queued
up
as
a
for
a
question
and
is
there
anybody
else
that
I
missed
legislators
who
have
questions
on
these?
Okay?
Yes,
we'll
go
ahead
and
start
there.
Thank
you,
mr
west.
O
Thank
you,
madam
chair,
and
thanks
for
everybody's
service
on
the
committee.
I'll
just
do
a
brief
summary
and
then
I
can
answer
any
questions
so
I'll
start
with
dr
titus.
This
question
r085.20.
O
This
is
a
regulation
that
the
board
is
proposing
it's
currently
through
public
hearing,
and
it
is
related
to
recovery,
room
centers.
So
as
the
hot
as
we've
seen,
the
hospitals
become
decentralized
a
little
bit.
We
begin
to
see
surgery
centers
that
that
got
licensed
with
the
health
department
and
now
we've
seen
recovery
room
centers.
So
these
are
just
like
the
recovery
room
center.
O
That's
at
a
hospital,
but
there's
they're
outside
the
hospital
they're
licensed
by
the
health
department
and,
as
you
gave
us
permission,
the
legislature
gave
us
permission
in
the
2019
session.
If
the
health
and
human
services
adopts
a
new
license
type
and
they
need
a
license
from
us
in
order
to
manage
the
drugs
with
the
dea
and
with
the
manufacturers
and
all
those
other
things,
we
can
propose
new
license
type.
So
this
is
it
we
work
closely
with
the
industry.
O
J
Thank
you,
a
chairwoman
for
allowing
me
to
ask
a
question,
sir.
I
really
didn't
need
all
of
that,
because
I
could
read
the
regs
also,
and
I
understand
the
concept
all
I
wanted
to
do
was
ask
a
brief
question,
and
that
is
tell
me
the
purpose
and
what
they
do
in
the
lining
of
the
euthanasia
technician.
O
So
I'm
sorry
about
that.
Madam,
the
euthanasia
technician
that
is,
along
with
that
part
of
the
regulation
is
a
license
type
that
the
state's
had
for
many
years
for
licensed
people
with
the
veterinary
board
that
can
possess
certain
controlled
substances
in
order
to
euthanize
an
animal
and
so
we're
just
tidying
it
up.
Their
old
license
allowed
them
more
access
to
the
to
the
drugs
that
they
needed
to
euthanize.
O
The
animal
now
we're
just
saying
these
are
the
animals,
so
it
already
was
a
licensed
type,
just
pairing
their
spectrum
back
a
little
bit
to
make
sure
that
they
didn't
have
other
drugs
that
they
didn't
need.
J
Excellent,
thank
you
that
wasn't
a
term
I
I
assumed
it
was
for
the
veterinary
board,
but
I
wanted
to
confirm
that
with
previous
discussions
that
we've
had
regarding
end
of
life
for
humans,
so
I
want
to
make
sure
we're
still
within
the
role
of
just
a
veterinarian
board.
Thank
you.
That's
all
I
have
for
the
pharmacy
board.
E
O
Yeah,
thank
you
senator
hardy,
just
for
the
record
dave
wiest
executive
director
of
the
board
of
pharmacy.
This
is
lc
by
lcb
file.
R013.21.
O
These
these
items
would
so
what
we're
talking
about
here
is
a
automated
machine
that
you've
seen
before
I'm
sure
that
can
be
placed
at
certain
locations
that
can
actually
end
up
dispensing
the
medication
we
see
them
in
emergency
rooms
and
other
things
around
the
state
we're
expanding,
where
those
can
be
and
writing
some
more
rules
for
him,
as
senator
hardy
pointed
out.
O
So
as
it
relates
to
the
senate
bill
last
session
regarding
to
languages,
they
would
have
to
comply
with
that
serve,
so
the
machine
will
have
to
be
able
to
communicate
to
the
patient
figure
out
what
language
it
needs
to
be
on
there
and
that
would
have
to
be.
The
language
would
have
to
be
on
the
bottle.
O
Yes,
okay,
the
machines
are
are
commercially
available,
as
I
said,
were
like
many
states,
expanding
the
use
of
them
they're
at
least
allowing
the
rules
to
expand
the
use
of
them
so
that
they
could
be
placed
at
more
places
where
people
don't
have
access
the
language.
I've
not
seen
it
with
the
machine,
but
that's
obviously
this
is
a.
This
is
just
for
this.
O
It
has
not
gone
to
public
hearing
yet
so
this
is
not
the
final
language
that
we
will
probably
see
when
we
get
to
the
legislative
commission,
but
the
language
itself
has
been
done
in
oregon
a
little
bit
in
california,
and
I
think
we're
the
third
state
to
do
it.
We're
progressing
on
that
language
and
you'll
see
that
at
legislative
commission
at
some
time.
E
So
I
looked
at
one
of
those
automatic
places
that
measure
the
weight
that
goes
into
a
90-day
prescription
as
before.
It's
sent
out
and
I'm
wondering
if
the
weight
of
that
is
going
to
be
taken
into
account
of
the
translation
of
languages,
maybe
more
printed
than
something
else,
and
so
would
a
different
language
change
the
weight
and
are
they
going
to
actually
have
to
figure
out
how
to
do
the
weight
without
the
language
and
then
put
the
language
on,
which
is
a
double
step
in
trying
to
put
language
on
or
they
I.
E
E
O
Excellent
question:
so
the
way
technology
is
already
used
in
the
pharmaceutical
industry,
not
necessarily
on
these
machines,
but
there
might
be
some
that
are
that
do
I'll
cover
that
the
weight
is
measuring
the
the
vial
and
then
the
tablet
to
make
sure
accuracy,
and
we
see
that
in
some
pharmacies
that
are
traditional
pharmacies
right
now.
These
automated
dispensing
systems
that
we're
talking
about
here
are
generally
pre-loaded
bottles
that
just
have
the
pills
in
them
or
the
eye
drops
in
them,
and
then
the
machine
actually
puts
the
label
on
them.
O
So
I
haven't
seen
ones
that
use
the
weight
exclusively
to
determine,
because
the
pharmacist
prior
to
them,
going
into
the
machine
is,
is
counting
out
the
pills
and
putting
them
in
the
bottle.
30
pills
like
doing
a
pre-pack
which
you're
very
familiar
with
pre-packed,
and
then
it
just
goes
in
there.
So
I
have.
I
will
have
to
watch
that
for
the
weight.
If
I
I
don't
think,
there's
not
loose
pills
that
are
just
being
put
into
a
bottle
by
most
of
the
machines
they're
pre-packed
forms.
O
E
I
appreciate
that
and
madam
chair,
let
me
ask
it
this
way.
What
davois
has
said
is
this
is
going
to
go
to
a
public
hearing,
as
opposed
to
this
hearing.
Is
that
the
case
with
all
of
these
proposed
regulations
is
these
are
for
us
to
say
something
before
they
actually
have?
The
public
hearing?
Is
that
correct.
O
Dave
reads
for
the
record
so
for
mine:
I
have
two
that
are
still
going
to
public
hearing
and
I
have
two
that
have
gone.
I
pointed
that
out,
so
the
the
one
with
the
use
nation
tech
has
gone
and
then
the
two,
the
one
I'm
talking
about
here
and
also
the
one
I
apologize,
the
euthanasia
tech-
is
the
one
going
the
public
hearing
march
at
the
march
board
meeting,
and
this
is
going
to
public
hearing.
O
The
other
two
are
going,
we'll
go
to
legecom
so
and
we
always
appreciate
your
feedback
and,
more
importantly,
direction.
So
it's
never
too
late
to
give
us
some
advice
on
how
to
how
you
want
things
done.
E
A
I'm
going
to
ask
that
eric
robbins
our
staff
answered
that
question
and
give
us
a
brief
description
of
how
like
the
status
of
these
and
where
they'll
be
going.
I
also
will
ask
that
staff
follow
up
with
us
on
these
regulations
to
give
us
a
status
where
they
are
and
where
they
will
be
for
the
next
public
comment
or
decision.
D
Eric
robbins
lcb
legal
for
the
record.
I
can't
comment
on
the
the
regulations
that
are
still
in
the
proposed
stage,
but
I
don't
know
whether
the
agency
has
had
a
public
hearing
on
those
or
or
not.
Yet
I
think,
as
mr
wiest
was
saying,
some
of
them
they
have
and
some
of
them
they
have
not.
D
If
the
regulation
says
that
it
on
the
top
of
the
regulation
that
it's
been
adopted,
then
the
agency
has
heard
the
regulation
had
all
their
public
hearings
and
adopted
the
regulation.
But
the
regulation
has
not
gone
before
the
legislative
commission
yet
so
that
that's
the
stage
that
would
be
in
if
the
regulation
is
approved,
then
the
regulation
has
been
both
adopted
by
the
agency
and
gone
before
the
legislative
commission
and
is
effective
now.
D
So
the
if
the
committee
had
concerns
with
that,
the
members
of
the
committee
could
recommend
changes
that
the
regula
that
the
agency
adopted
another
regulation,
changing
the
regulation
or
propose
legislation
at
the
end
of
the
interim
to
address
their
concerns.
E
That
that's
helpful.
I
appreciate
it.
A
Senator
I'm
gonna
ask
that
the
that
our
staff
follow
up
with
us
on
these
regulations,
with
the
status
of
where
they
are
so
that
we
have
an
idea
of
the
process
that
they're
all
in
and
they
can
work
with
the
different
boards
on
that
piece
so
that
you
will
know
and
and
be
able
to
participate
in
those
areas.
If
you
would
like
to,
I
would
like
to
move
on
to
the
next
set
of
regulations
up
for
question.
That
would
be
the
board
of
dental
examiners.
D
Good
morning,
everyone,
this
is
phil
sue
on
behalf
of
the
board.
J
Thanks
so
thank
you,
madam
chairwoman,
may
I
go
ahead.
J
J
I
might
add
at
the
last
session
ab269
and
that,
as
the
representative
from
the
dental
association
pointed
out,
was
worked
on
by
multiple
groups,
including
the
dental
hygienist,
the
dentist
and
those
associated
to
come
up
with
a
better
rendition
of
that
bill
and
the
amendment
version.
But
I'm
wondering
how
why
the
original
bill
was
put
in,
but
not
the
amended
version
that
all
had
agreed
on
and
I'm
wondering
if
you
had
reached
out
to
the
folks
that
are
being
affected
by
this
before
this
current
regulation
was
presented.
J
D
Again
for
the
record
on
bill
sue,
general
counsel
and
interim
executive
director
of
the
state
board,
dental
examiners-
and
I
thank
the
committee
and
interpreters
for
the
opportunity
to
speak
with
the
committee.
As
to
your
particular
question,
I
I
my
understanding
my
understanding
of
the
history
of
this
particular
regulation.
It
was
first
proposed
as
an
emergency
regulation
back
in
december
of
20
2019
or
2019
no
2020,
28
2020.
I
apologize
so
it
was
before
the
legislative
session.
I
think
we
were
I
I.
D
Of
why
the
the
assembly,
the
amendments
from
the
assembly
bill
269
language,
were
not
incorporated
into
this
into
the
regulations
that
the
board
had
proposed.
It
wasn't
something
that
was
shared
during
the
december
2020
workshop,
and
I
for
history
say
just
just
so.
The
committee
is
aware.
I
worked
closely
in
first
of
all,
I
want
to
thank
dr
capraro.
D
She
was
a
state
little
help
officer
at
the
time,
and
she
and
I
worked
closely
to
try
to
craft
regulations,
to
permit
dental
regulation
licensees
to
administer
vaccinations
in
light
of
the
situation
that
the
state
was
in,
and
so
I
just
I
guess.
In
short,
I
don't
know
why
the
amended
language
from
ab269
was
not
incorporated
into
the
bill
into
our
regulations.
It
wasn't
something
that
was
brought
up
previously
in
the
workshop
or
in
any
any
form,
either
finalized
or
otherwise.
J
J
2020.,
okay
and
then
second,
so
dr
capraro
was
involved
in
the
current
regulations
that
you're
presenting.
D
Yes,
let
me
clarify
I
apologize
january
7th
of
2021
and
previous
to
that
I
was.
I
had
certain
discussions
and
and
email
exchanges
with
dr
perella
franklin,
the
language
that
we
used
was
in
large
part
borrowed
from
similar
language
that
the
board
of
pharmacy
had
proposed
for
their
pharmacy
technicians
to
administer
vaccinations.
J
Okay,
so
I
appreciate
that-
and
I
just
want
to
make
sure
that
all
folks
are
or
that,
especially
those
that
are
affected.
I
I'm
in
favor
of
the
what
dentists
are
what
you're
trying
to
do,
allowing
the
dentist
to
it
properly
trained
and
to
administer
these
vaccines.
I
think
it's
appropriate.
However,
I
just
want
to
make
sure
again
that
regulations
aren't
being
passed
without
proper
input
from
those
that
are
being
affected.
So
thank
you,
madam
chairwoman,
for
the
questions.
A
Thank
you
and
I
think
that
there
may
be
a
timeline
discrepancy
because
of
when
we
were
working
on
those
bills
during
session
in
2021,
which
would
have
been
around
probably
the
march
period
time
period.
So
that
would
have
been
after
that
public
input
session
happened
in
january
of
2021.
If
those
dates
are
correct,
so
there
may
be
some
additional
work
to
be
done
on
those
senator
hardy.
I
signed
your
hand
up
for
the
dental
examiners.
E
We
used
we
came
to
this
before
with
the
board
of
pharmacy
and
we
put
in
statute
that
a
student,
a
pharmacy
student
was
allowed
to
give
immunizations
and
it
probably
would
behoove
us
to
recognize
that.
If
we're
having
dentists
do
vaccinations,
we
probably
ought
to
allow
dental
students
to
do
immunizations
because
they
have
to
be
taught
what
they're
doing
and
where
they're
doing
it.
So
I
think
it'd
be
wise
to
recognize
that
if
dentists
are
going
to
do
it,
we
probably
ought
to
train
the
dental
students
and
allow
that
to
happen
as
well.
A
Are
there
other
questions
for
the
board
of
dental
examiners,
seeing
none?
I
would
ask
that
we
would
move
on
to
the
next
board
the
chiropractic
physicians.
It
looks
like
have
the
next
question,
which
I
believe
comes
from:
assembly
name
orienter.
If
you
would.
D
And
boy,
so
there
are
a
couple
things
I'll
start
with
the
first
question
and
it
refers
to
oh
so
it
says
the
board
will
not
issue
a
license
or
by
endorsement
if
they
look
at
the
report
from
the
fbi
for
the
applicant's
criminal
record
and
the
person's
been
convicted
of
a
crime
described
in
this
other
section,
and
the
board
has
not
previously
taken
disciplinary
action.
A
D
M
A
D
To
the
in
the
specific
statute,
however,
in.
M
D
M
Them
in
the
past,
that's
how
we've
addressed
those
things,
depending
on
their
status,
with
their
licensing
with
the
state
that
they've
been
disciplined
in.
D
M
You're,
right
and
since.
D
The
reference
to
the
nrs
it
says
convicted
of
a
crime
described
in
such
section
3
of
nrs
634.140.
D
So
I
looked
at
that
subsection
and
it
has
a
few
parts
to
it
and,
and
the
last
part
I
think
it
was
the
crime
of
moral
turpitude,
and
I
didn't
see
a
definition
of
that.
But
I
know
that
often
it
it's
an
art
use,
it
has
an
art,
long
history
and
it's
sometimes
it
has
an
archaic
definition
and
I
wasn't
sure
if
the
term
there
might
sweep
too
broadly,
as
sometimes
that
term
does
do.
Do
we
know
what
that
how
that
is
interpreted
for
this
regulation.
M
A
Sorry,
I
can't
answer
that.
No
thank
you.
Thank
you
for
the
questions
assemblyman
as
well,
and
I
think
you
can
ask
for
follow-up
from
our
staff
eric
robbins,
if
you're
interested
in
pursuing
that
that
piece
for
all
boards,
the
we
have
one
more
request
for
questions
from
the
board
of
occupation
therapy.
I
would
say
this
question
be
brief
and
looks
like
that
came
from
senator
harvey
if
you'd
like
to
go
ahead.
A
Want
it
so
we
had
a
dense
additional
agenda,
so
I'm
hoping
that
we
can
move
through
these
quickly.
So
if
your
question
can
be
brief,
I
would
appreciate
it
and
we
could
get
miss
stanberg
back
for
senator
harvey's
brief
question.
E
A
E
I
was
smiling
when
assemblyman
warren
lecker
talked
about
moral
and
turpitude,
because
that
has
come
up
with
other
boards
as
well,
and
we
we
tried
to
figure
that
out.
So
I
think
it's
a
work
in
progress
well
all
of
the
boards,
if
they
still
have
that
in
there.
E
But
then
I
looked
at
one
man's
crime
in
one
man's
state
is
different
than
our
state
and
in
this
period
of
time
where
we
are
decriminalizing
things,
we
probably
are
going
to
put
some
people
out
of
competition
for
jobs
and
moving
to
nevada,
because
they
have
been
accused
of
smoking,
a
joint
someplace
elsewhere,
and
now
they
have
a
crime
and
they've
been
convicted
and
they've
been,
but
yet
they've
been
freed
and
yet
they've
been
expunged
and
etc,
etc,
but
nevertheless
there's
no
leeway
or
give.
It
seems
like
that.
E
A
I
cannot
remember
who
asked
for
the
board
of
occupation
therapy.
So
please
remind
me
if
that
was
you
and
you
had
a
question
for
them.
Is
that
some
of
their
hearty
or
something
sorry
I'll
be
right?
There
sorry
assembly,
woman,
titus.
E
I
I
brought
it
up.
It
was
about
the
telehealth
for
occupational
therapists
and
I
think
I've
been
okay
with
what
we
were
saying
and
I'll
just
take
a
further
look
at
it
in
another
venue.
Thank
you.
A
Thank
you.
I
appreciate
that
again,
I'm
going
to
have
staff
follow
up
with
us
on
the
status
of
these
threats
and
where
you
can
find
the
next
opportunity
for
comment
or
decision
on
these.
With
that,
my
house
staff
is
there
anything
else
that
we
need
to
do
under
this
particular
item.
E
I
did
have
other
questions
on
and
I'm
not
sure
which
one
it
was,
but
the
division
of
public
health
and
behavioral
health
on
the
top
of
my
number
three
that
wasn't
actually
in
order
when
we
start
taking
the
timeline
and
the
grandfather
clauses
that
don't
exist.
Are
we
going
to
have
enough?
E
A
One
of
those
two
concerns:
are
there
folks
from
those
different
entities
interested
in
responding?
I
see
paul
schubert
with
dpph
available
for
that
first
comment
and
if
I
I'm
going
to
ask
that
we
make
the
response
as
brief
as
possible
so
that
we
can
move
on
to
our
our
other
agenda
items.
Please.
E
D
Chair
peters,
it's
paul
schubert
with
the
division
of
public
and
behavioral
health
and
it
with
regards
to
our
056-20
and
the
requirements
that
we're
implementing
in
those
regulations
for
additional
training.
What
I
would
say
is
that.
D
For
the
number
of
hours
of
training
within
the
current
regulations,
these
are
just
modifying
the
subjects
that
that
will
be
necessary
and
in
order
to
implement
actually
the
the
senate
bill
from
the
2019
session
senate
bill
362..
D
So
I
I
hope
that
addresses
the
question.
If
not,
I
can.
A
Thank
you
for
the
response.
I
have
jennifer
pierce
on
as
well,
which
she
is
ready
to
respond
to.
Yes,
the
speech
language,
pathology,
audiology
and
hearing
aid,
dispensary
board
regulation.
Thank
you
good
morning,
chair
peters
and
members
of
the
committee.
For
the
record.
My
name
is
jennifer
pierce,
I'm
the
executive
director
of
the
speech.
A
G
A
G
Wanted
to
clarify
your
comment,
our
regulation
actually
changes.
A
Our
annual
requirement
to
10
hours
annually
from
the
currently
required
15
just
to
align
with
the
national
practice
standards
and
only
one
of
those
10
hours
annually,
was,
was
being
drafted
to
be
required
in
ethics.
We
did
hold
our
first
public
workshop
last
night
and
the
board
voted
to
amend
that
language
slightly,
so
we'll
still
be
drafting
the
language
to
require
10
hours
annually,
and
then
at
least
one
of
those
10
hours
would
be
either
in
ethics.
A
Thank
you
always
really
interesting
to
get
these
regulations,
and
I
appreciate
the
committee's
interest
in
these
and
we're
going
to
move
on
to
our
next
agenda
item.
I
I
do
want
to
thank
all
of
the
board
and
representatives
who
were
in
attendance
today
to
respond
to
those
questions.
Thank
you
so
much
for
your
time
and
for
your
attention
to
these
details.
A
Okay,
our
next
agenda
item
agenda
item
four,
is
a
brief
review
of
the
committee's
duties
and
responsibilities.
This
again
is
our
first
committee
hearing
of
this
newly
established
committee,
so
I'm
going
to
go
ahead
and
let
policy
staff,
patrick
ashton,
take
the
lead
on
this
one.
Thank
you.
B
Future
peters
for
the
record,
patrick
ashton,
committee
policy,
analyst
with
the
legislative
council
borough
just
a
short
disclaimer
as
legislative
staff.
I
cannot
advocate
or
oppose
any
of
the
proposals
that
come
before
you
I'm
here
to
assist
the
chair
and
the
members
with
any
questions
concerning
policies
that
may
arise.
B
My
colleague
christie
robusto
and
I
are
available
to
assist
the
committee
and
its
members
on
any
issues
related
to
health
and
human
services.
In
addition,
the
research
division
is
available
to
provide
information
and
assistance
on
a
confidential
basis
to
individual
members
of
the
legislature
on
any
topic.
So
please
feel
free
to
reach
out
to
me
or
my
colleagues.
At
any
time.
B
I
will
now
review
with
you
the
responsibilities
and
duties
of
the
joint
interim
standing
committee
on
health
and
human
services
in
short
hhs.
For
that
purpose,
please
find
an
electronic
copy
of
the
comedy
brief
on
the
comedy's
meeting
page
I'd
like
to
take
just
a
few
minutes
to
cover
some
highlights
on
page
one
of
the
comedy
brief.
You
find
a
list
of
the
legislators
and
alternates
appointed
to
the
hhs
committee,
followed
by
a
section
on
responsibilities
of
the
committee.
B
Pursuant
to
assembly
bill
443
this
bill
passed
during
the
2021
legislative
session
and
significantly
changed
the
interim
structure
of
the
legislative
interim
ab443
repealed.
The
legislative
committee
on
health
care,
its
primary
responsibilities
and
duties
were
transferred
to
the
new
hhs
committee,
including
reviewing
and
evaluating
the
effectiveness
of
brokerage
to
prevent
illnesses,
analyzing
the
overall
system
of
medical
care
in
nevada
and
coordinating
service
provision
to
avoid
duplication
of
efforts.
B
B
B
Sincerely,
since
the
responsibilities
of
the
legislative
committee
on
healthcare
were
transferred
to
this
committee,
it
must
conduct
the
study.
Now
you
will
hear
more
details
about
the
study
requirements
during
agenda
item
7
today,
generally
for
the
next
8
months.
You
can
expect
presentations
about
many
health
and
human
services
issues,
with
a
focus
on
public
health
and
the
covered
19
pandemic.
B
Next,
on
page
3,
you
will
find
an
overview
of
relevant
audits
and
reports
regarding
health
and
human
services
issues
in
nevada.
The
comedy
brief
contains
hyperlinks
to
the
audits
and
reports.
If
you
like,
to
dig
deeper
in
certain
issues
on
the
bottom
of
page
3
is
the
list
of
committee
meeting
dates
for
the
2021-2022
intern,
starting
today
we
will
meet
every
month
on
the
third
thursday
of
the
month,
with
the
exception
of
the
march
meet.
B
A
Thank
you
so
much,
and
thank
you
so
much
for
putting
together
that
committee
brief.
It
is
very
helpful
to
have
that
all
in
one
spot
where
everyone
can
see
our
expectations
and
resources
for
the
committee.
Are
there
any
questions
from
committee
members
on
the
duties
and
the
committee
brief
presented
briefly
there's
seeing
none
I'm
going
to
move
on
to
the
next
agenda
item.
This
is
one
we've
all
been
waiting
for:
a
presentation
on
the
state
of
the
coronavirus
disease
of
2019,
known
as
covid19
pandemic
in
nevada.
A
We
have
a
couple
of
folks
from
the
division
of
public
and
behavioral
health
under
the
department
of
health
and
human
services,
including
melissa,
pete
block
the
state
epidemiologist
julia
keith,
the
deputy
administrator
and
kira
morgan.
The
chief
bio
station
looks
like
they
have
all
loaded
up,
I'm
going
to
go
ahead
and
welcome
you
to
the
committee.
Thank
you.
So
much
for
being
here,
please
go
ahead
with
your
presentation.
M
Hi,
so
I'm
kyra
morgan,
I'm
the
chief
biostatistician
for
the
department
of
health
and
human
services,
and
I
am
going
to
kick
off
our
presentation
today
by
giving
just
a
brief
status
update
on
some
of
our
statewide
coping
19
metrics.
So
if
we
could
jump
right
in
to
the
slide,
thank
you.
You'll
notice,
on
the
next
couple
of
slides.
M
M
So
this
slide
here
is
looking
at
daily
new
cases
which
are
coming
in
currently
right
about
double
the
magnitude
of
what
we
saw
last
winter,
we're
looking
specifically
since
december
20th
in
this
update,
because
that
is
when
we
started
to
see
increases
in
our
statewide
metrics
in
nevada.
A
lot
of
states
in
the
country
started
this
winter
surge
ahead
of
us,
and
so
we
were
a
little
bit
delayed.
So
all
the
updates
that
I'm
going
to
talk
about
are
really
related
to
the
last
month
of
data.
M
So
we
like
to
track
our
cases
using
a
14-day
average
that
takes
out
some
of
the
seasonality
and
weekly
reporting,
and
things
like
that.
The
14
day
average
did
increase
almost
six-fold
from
an
average
of
625
cases
being
diagnosed
every
day
as
of
december
20th
to
4248
cases
being
diagnosed
every
day.
Currently,
I
would
just
highlight,
on
the
right
hand,
side
of
this
graph
that
we
are
starting
to
see
just
very,
very
early
indications
of
some
stabilization.
M
The
growth
rate
of
the
cases
is
slowing
down,
and
so
I
am
hopeful
that
we
are
going
to
see
the
other
side
of
this
sooner
than
later.
Next
slide,
please
here
we're
looking
at
statewide
hospitalizations,
which
are
also
increasing
in
all
of
our
regions.
Currently,
that
increase
has
been
in
the
magnitude
of
165.
M
Since
december
20th,
we
did
see
the
steepest
growth
occurring
immediately
after
the
christmas
and
new
year's
eve
holidays,
and
I
did
also
want
to
reference
that
southern
nevada
hospitalizations
are
obviously
driving
a
huge
proportion
of
this.
I
believe
most
recent
numbers-
southern
nevada
accounted
for
88
of
our
statewide
covered
19
hospitalizations
and
then
just
sorry
to
compare
that
to
last
winter.
We
are
just
right
under
where
we
had
seen
our
highest
number
of
hospital
hospitalizations
statewide
we
reached
just
over
2000
in
december
of
2020..
M
However,
in
clark
county
this
year
we
are
currently
recording
record
hospitalizations
for
coca-19
next
slide.
This
is
our
critical
care,
hospitalizations
intensive
care
unit
and
ventilator
use.
We've
seen
increases
here
too,
but
not
you
know
comparable
to
the
magnitude.
We
do
know
that
this
particular
variant
is
less
severe,
and
so
we
are
seeing
increases
to
critical
care,
but
they're
not
directly
comparable
to
the
increase
in
cases
that
we're
seeing
our
icu
utilization
increased
about
94
from
165
individuals,
hospitalized
in
nevada,
to
317
as
of
day
before
yesterday,
and
then
for
ventilator
use.
M
We
currently
have
167
individuals
on
a
ventilator
which
is
a
65
increase
since
december
20th.
All
of
these
metrics
are
heavily
concentrated
in
southern
nevada
as
well.
96
of
those
ventilators
are
in
clark,
county
and
90
of
icd
utilization
is
in
part
next
thing.
M
This
graph
here
is
looking
at
mortality,
which
has
not
increased
significantly
since
this
surge
december
20th
started
we're
averaging
seven
over
19
deaths
per
day.
We
did
go
down
to
about
five,
so
we're
seeing
just
very,
very
moderate,
increases
to
this
measure
and
we're
not
quite
sure.
Frankly,
if
we'll
see
that
you
know
our
mortality
numbers
precipitate
into
a
significant
surge.
M
Some
of
the
states
that
are
further
ahead
of
us
are
showing
increases
to
cover
19
deaths,
but
some
countries
who
are
much
further
ahead
of
us
are
not
having
that
effect.
There's
a
couple
reasons
that
our
death
numbers
could
be
delayed.
It
is
a
lagged
indicator,
meaning
that
we
expect
some
amount
of
time
to
pass
between
when
cases
increase
when
mortalities
increase.
Essentially,
you
know
individuals
have
to
get
sick
enough
to
require
hospitalization,
and
then
you
know
for
the
case
to
actually
result
in
death.
There's
also
a
slight
reporting
delay
which
could
add
to
that.
M
But
I
do
you
know,
want
to
anchor
to
vaccinations
not
only
preventing
infection,
but
also
reducing
the
severity
of
symptoms
in
our
breakthrough
cases
and
then
again.
Preliminary
data
around
the
omicron
variant
suggests
that
it
presents
with
less
severe
illness
next
slide
here,
we're
looking
at
new
case
demographics.
I
think
it's
important
to
understand
who's
being
diagnosed
with
kevin
19
again,
specifically
since
december
20th,
the
age
group
of
20
to
49
year
olds
account
for
71
percent
of
new
cases,
so
we
are
seeing
a
healthier
age
range
of
individuals
being
diagnosed.
M
37
percent
of
the
cases
diagnosed
were
non-hispanic
whites.
An
additional
34
were
hispanic
or
latino,
so
those
two
groups
account
for
71
percent
of
the
cases
as
well.
However,
I
did
include
a
graphic
here
that
looks
at
rates
per
capita,
so
these
are
rates
for
100,
000
individuals
by
race,
ethnicity
and
just
to
kind
of
track
with
that.
For
you
quickly
the
first
half
of
that
trend,
you'll
notice,
the
blue
line
is
really
kind
of
taking
the
lead
and
making
up
a
higher
proportion
of
cases
per
capita.
M
That's
our
hispanic
latino
population
and
then,
as
of
about
february
march
of
2021,
we've
seen
that
shift
to
our
black
non-hispanic
population.
So,
even
though
they're
making
up
a
smaller
just
share
volume
of
cases,
they
are
disproportionately
affected
on
a
per
capita
basis
with
covenant
infection.
Currently
next
slide
here
touching
on
vaccinations
again
nevada
has
approximately
52
of
our
population
completely
vaccinated.
M
Sometimes
we
look
at
that
as
a
percentage
of
individuals,
five
and
older,
because
those
are
the
people
that
are
eligible.
It
increases
a
little
bit
when
we
consider
that
age
group
to
55
and
then
62
percent
of
nevadans
have
at
least
initiated
vaccination,
meaning
they
have
some
level
of
protection,
although
obviously
not
as
strong.
M
I
do
think
that,
because
the
surge
we're
experiencing
right
now,
just
is
so
large
in
magnitude
that
we'll
probably
want
to
refresh
this
study
at
the
end
of
january,
and
so
I
anticipate
that
our
our
level
of
natural
immunity
in
the
community
is
going
to
go
up
pretty
significantly
just
based
on
the
number
of
people
currently
being
diagnosed
with
building
so
that'll
be
an
interesting
update
next
slide,
and
then
this
is
my
last
slide
before
I
hand
it
over
to
melissa.
M
I
just
wanted
to
touch
a
little
bit
on
expectations
on
the
trajectory
of
cases.
We
know
that
what
we're
seeing
is
double
the
magnitude
of
what
we
saw
in
our
our
last
winter
surge,
but
we
do
expect
it
to
last
for
a
shorter
time
frame
nationally.
Some
public
health
agencies
are
predicting
trends
will
decline
in
early
february.
M
The
cdc
is,
I
think,
they're
a
little
more
cautious
to
not
put
out
a
false
positive
expectation
and
then
not
make
that
so
they're
predicting
coins
aren't
going
to
start
coming
down
nationally
until
april
dobson
analytics
we're
predicting
that
nevada
is
actually
very
close
to
what
what
I'm
going
to
call
our
peak.
Even
though
I
don't
love
that
term.
I
think
that
we
will
probably
start
seeing
declining
trends
by
the
end
of
february.
M
I
think
it's
a
little
bit
too
early
to
say
with
full
confidence
that
we're
there
right
now,
but
we
do
have
just
early
indications
that
we
are
kind
of
hitting
that
level
of
stabilization
in
nevada.
So
I'm
still
pretty
comfortable
saying
that
we're
going
to
start
coming
down
by
the
end
of
february
and
then
due
to
the
lower
severity
of
omicron
compared
to
delta
hospitalization
rates
are
lower
than
what
we
saw
in
previous
surges.
M
Again,
if
you
consider
those
as
with
respect
to
new
cases,
but
overall
volume
is
probably
likely
to
surpass
what
we
observed.
M
Last
year
again
last
year
we
reached
just
over
2000
hospitalizations
statewide
right
now,
we're
sitting
just
over
1800,
so
it's
possible
that
we
just
kind
of
hover
really,
similarly
to
where
we
were
last
year,
but
we
could
supersede
those
numbers
and
then
hospitalizations
will
likely
peak
up
to
two
weeks
after
new
cases,
just
because
again
allowing
time
for
those
individuals
to
reach
a
level
of
severity
where
they
might
need
hospitalization,
and
with
that,
I
think
it
will
turn
it
over
to
melissa
piccola.
Our
state
epidemiologist.
H
Good
morning,
melissa,
peak
bullock
for
the
record
ms
kyra
has
just
illustrated
in
our
data.
Nevada
is
currently
facing
the
effects
of
the
omicron
variant,
as
is
the
nation.
I
wanted
to
highlight
some
characteristics
of
omicron.
It
is
highly
transmissible,
more
transmissible
than
the
other
variants
that
have
circulated
previously.
H
It
has
the
ability
to
evade
immune
responses,
and
it
has
a
shortened
incubation
period
which
also
takes
into
account
the
speed
in
which
transmission
is
occurring.
It
has
reduced
susceptibility
to
certain
therapeutics
and,
as
kyra
has
stated,
the
severity
of
illness
is
not
completely
understood,
but
data
is
suggesting
an
overall
milder
illness
than
previously
circulating
variants.
H
Next
slide:
okay,
omicron
and
special
populations
in
our
k-12
schools.
The
characteristics
we
just
described
of
omicron
are
causing
rapid
transmission
within
the
school
setting.
This
is
resulting
in
a
higher
number
of
school
associated
cases
than
what
we
have
seen
previously,
even
in
the
first
half
of
the
school
year
and
last
school
year.
This
is
also
affecting
the
ability
for
our
schools
to
remain
open
to
in-person
instruction
because
of
instances
where
a
large
proportion
of
staff
are
unable
to
report
to
work.
H
H
Given
the
increase
of
transmissibility
and
the
limited
ability
to
apply
social,
distancing
and
cohorting
within
correctional
facilities,
and
you
couple
this
with
the
vulnerability
of
the
inmate
population,
there
is
potential
for
significant
negative
impacts.
In
addition,
staffing
challenges
that
already
exist
are
being
magnified.
L
Again,
julia
peek
for
the
record,
I
serve
as
one
of
the
deputy
administrators
here
at
the
division.
I
have
been
working
for
with
the
testing
issues
since
the
beginning
of
the
pandemic,
with
our
with
our
team
testing.
L
This
is
typically
a
lab-based
pcr,
where
you
get
your
collection
and
then
it's
sent
out
to
a
lab
to
be
processed
privately
or
in
some
cases.
You
could
get
a
rapid
test
and
then
get
the
results
that
same
day,
this
is
a
free
resource.
Often
that's
provided
to
the
community.
We've
gotten
a
good
amount
of
support,
just
through
direct
funding
and
also
from
our
federal
partners
again
coming
in
and
standing
up
these
sites
on
our
behalf.
L
These
certainly
do
have
potential
issues
with
appointments
and
folks
showing
up
for
appointments.
But
if,
if
we
don't
have
an
appointment
system,
then
it
does
cause
potentially
weights
to
get
that
testing
and
could
have
traffic
issues
and
other
issues
in
that
regard.
But
it
is
meant
to
allow
people
to
have
a
single
or
multiple
sites
in
their
community
to
know
that
they
can
go
and
get
tested
for
free
at
those
sites.
So
we
continue
to
stand
those
up.
L
We
have
both
privately
funded
community-based
testing
through
state
and
local
dollars,
but
then
also
we
have
some
sites
in
las
vegas
that
are
supported
through
another
project
that
our
federal
partners
supply
for
surge
testing.
Probably
one
of
the
biggest
new
discussions
is
at
home
testing.
This
really
wasn't
used
in
nevada
early
on,
I
would
say,
but
now
is
such
a
convenient
way
to
test
your
family
and
it
does
have
nuances,
and
it's
a
matter
of
educating
folks
what
those
are.
L
There
are
a
few
things
that
I'd
like
to
highlight
just
for
nevadans,
as
they
figure
out
how
they
would
like
to
get
their
at-home
test
kits.
As
you're
aware,
the
federal
government
has
really
two
projects
related
to
this.
L
The
first
one
started
just
a
couple
days
ago,
where
you
can
request,
based
on
your
address,
four
kits
be
sent
to
you.
I
did
it
myself
relatively
easy
and
I'll
just
note
that
we
are
aware
of
some
challenges
related
to
the
program
and
we've
shared
that
with
our
federal
partners,
some
challenges
specifically
in
our
rural
communities
or
for
those
individuals
that
lives
in
apartment
complexes.
L
So
we
share
that
with
the
feds
and
they're
working
through
that,
but
again
not
the
only
program,
that's
available
to
you
another
one
is
related
to
ensuring
that
private
insurance
covers
covid
19
at
home
test
kits
through
a
pharmacy
and
you're
allowed
up
to
eight
kits
per
month,
depending
on
how
many
people
you
have
on
your
plan.
L
So
that
again
is
a
supply
challenge
for
our
pharmacies,
but
certainly
something
that
could
make
testing
availability
much
more
privatized
in
the
future
and
probably
the
project
that
I'm
most
excited
about
is
the
at-home
test
kit
program
that
we're
doing
here
in
nevada.
L
The
next
thing
is
targeted
testing
we've
presented
to
many
of
you
in
front
of
the
interim
finance
committee.
Just
talking
about
the
federal
grants.
We
have
some,
I
would
just
like
to
target
focus
on
congregate
settings.
They
focus
on
schools.
We
had
a
large
epidemiology
and
laboratory
capacity.
Grant.
That's
really
focused
entirely
on
our
school-based
setting
to
keep
kids
in
school.
We've
also
had
funding
for
general
community-based
testing,
as
well
as
test
testing
in
our
skilled
nursing
facilities
and
other
health
care
facilities
that
are
potentially
a
high
risk.
L
The
last
thing
is
private
testing,
and
this
is
really
hopefully
the
future
of
testing
and,
as
we
enter
an
endemic
stage,
just
being
able
to
test
privately
through
your
insurance
or
again,
if
you
choose
to
do
the
at-home
test,
kits
that
you
could
get
that
through
your
insurance
I'll
just
say
early
on
some
private
companies
in
nevada,
for
example.
Example,
some
of
our
large
gaming
institutions
set
up
testing
for
their
employees
and
we
really
learned
a
lot
about
what
they
did.
L
We
also
for
state
of
nevada
employees
and
I
believe,
legislative
council
bureau
employees
had
a
similar
policy
where
we
set
up
vaccine
or
testing
programs,
and
so
folks
would
get
weekly
testing
if
they
weren't
vaccinated,
and
so
that
was
something
that
the
state
of
nevada
is
an
employer
set
up,
and
then
we
provided
testing
to
meet
that
demand.
That's
going
to
be
moving
for
us
to
our
nevada,
public
employees,
benefits
program
and
they're.
L
Looking
to
launch
that
testing
soon,
there's
also
a
great
deal
of
testing,
I
would
say
around
travel,
and
so
that
should
really
be
something
that
folks
are
able
to
access
privately,
as
opposed
to
using
a
community-based
testing,
location
or
other
testing
modalities
that
are
targeted
really
for
people
who
are
symptomatic
or
part
of
the
targeted
testing
high-risk
groups.
L
A
Thank
you
so
much
for
the
presentation,
and
I
also
want
to
extend
our
gratitude
to
your
office
for
all
of
the
work
that
you've
been
doing
during
the
pandemic,
but
particularly
during
this
spike.
That
has
impacted
so
many
of
us.
I
don't
know
anybody
at
this
place,
who
has
not
come
across,
or
at
least
had
one
family
member
come
across
this
particular
variant
despite
their
vaccination.
A
Although
the
symptoms
do
seem
to
be
much
much
less
on
my
vaccinated
friends,
which
is
you
know,
we
can
attribute
to
those
vaccines
working
well,
I
did
want
to
just
pitch
out
here
for
those
who
are
watching
that
those
coved
tests,
those
at-home
tests,
you
can
order
online
they're
super
easy
to
get.
I
ordered
them
for
my
family,
although
we
have
five
of
us.
So
that's
one
of
the
things.
That's
not
super
functional
about
them.
A
We
could
only
get
four
of
my
house,
but
I
was
able
to
scrounge
up
an
extra
one
from
another
family
that
had
ordered
them.
That
was
not
taking
or
wouldn't
need
all
four
themselves,
but
that
could
be
found
at
covidtests.gov
and
I
also
found
it
at
the
usgs
website.
I
don't
remember
what
that
one
is
off
the
top
of
my
head.
Let's
see.
A
I
also
wanted
to
just
put
out
there
that
our
school
cases
are
impacting
so
so
many
of
us
you're
not
alone
out
there.
If
you
are
stressed
out
about
kids
being
home
again,
we
have
one
who's
been
at
home,
almost
exclusively
since
a
week
before
christmas,
because
she
caught
a
cold
and
couldn't
go
into
school
for
that
week,
and
then
we
had
break,
and
now
we
are
in
exclusion
because
of
so
many
cases
in
her
school.
So
we
we
really
feel
for
you
and
for
our
community
members
who
are
impacted
by
this.
A
Just
remember,
you're,
not
alone.
If
you
need
resources
and
help
please
reach
out,
we
as
your
legislators
are
able
to
help
you
find
resources
if
you
need
them,
but
you're,
just
you're,
not
alone
out
there.
We
have
some
questions
lined
up.
Just
so
folks
know
the
lineup
I
have.
I
have
assemblywoman
titus,
assemblyman
haven,
assemblyman,
orton,
liquor
and
vice
chair
donate
in
the
queue
for
questions,
I'm
going
to
go
ahead
and
start
with
assemblywoman
titus.
J
Thank
you.
Thank
you,
madam
chairwoman,
for
the
ability
to
ask
questions
and
again
I
I
too
wanna
thank
the
presenters,
all
those
involved
with
this
covid
crisis
that
we
now
all
agree
it's
endemic
as
opposed
to
a
pandemic.
So
it's
not
gonna
go
to
go
away
going
to
have
to
live
with
this
and
for
those
who
don't
already
know.
J
My
family
was
touched
by
this
crisis,
more
than
me
just
being
the
county
health
officer
here,
but
my
brother-in-law,
who
was
just
56
years
old,
died
december
28th
for
covid,
no
more
big
conditions,
and
I've
said
this
before
he
was
not
vaccinated
but
did
not
seek
care
either
until
it
was
too
late.
So
I
don't
know
a
family
that
hasn't
been
touched
in
this
state.
Having
said
that,
however,
I
have
some
some
questions
regarding
the
testing,
and
one
of
my
concerns
is,
as
was
mentioned
in
the
presentation.
J
The
omicron
variant
does
move
very
quickly
just
for
an
example.
The
incubation
period
for
omron
is
just
three
days,
whereas
the
initial
covid
that
we
first
identified
was
five
to
six
days
and
then
the
next
strain
was
four
days
and
then
the
delta
var
and
the
alpha
variant
was
about
four
days.
Also
so
now
we're
down
to
three
days
in
transmission,
so
it
does
spread
like
wildfire.
The
question
I
have
is
regarding
the
different
variants.
J
We
know
that
the
omicron
does
not
seem
to
be
as
although
it's
more
infectious
it
doesn't
seem
to
be.
The
symptoms
are
not
serious
as
much
and
we
see
that
the
death
rate
is
staying
pretty
much
plateaued.
Are
we
doing
the
subtesting?
J
These
rapid
tests
do
not
identify
whether
you
have
the
delta
variant
or
whether
you
have
omicron,
or
what
do
you
have,
and
so
who
is
doing
that
test?
Are
we
still
trying
to
do
subsets?
So
we
know
if
delta's,
even
out
there
anymore.
I
know
they
do
on
a
national
level.
These
variants,
because
these
are
just
for
the
variants
that
we've
heard
about.
There
are
many
other
variants
that
we
are
watching.
So
tell
me
what
the
state
is
doing
to
identify
the
different
variants.
L
Yeah
happy
to
do
that:
julia
peek
for
the
record
and
I'll
turn
it
over
to
melissa.
If
she
has
anything
to
add
on
that
as
well,
we
certainly
are
continuing
to
do
review
of
what
variants
we
find
in
the
community.
We
do
it
through
a
number
of
different
processes.
L
One
of
the
most
interesting
thing
that's
occurred
as
a
result
of
covitt
is
using
wastewater
surveillance
as
a
mechanism
to
understand
what
variant
is
circular
circulating
in
our
community.
So
we
have
several
sites
actually
in
nevada
who
are
doing
that
review
and
providing
that
information
up
to
us.
We
also
still
do
have
a
great
deal
of
testing
at
our
public
health
laboratories,
both
the
nevada
state,
public
health
laboratory
and
the
southern
nevada
public
health
laboratory.
L
I'll
just
note
that
the
nevada
state
public
health
laboratory
just
launched
a
new
website
that
really
shows
you
what
they're
finding
in
their
specimens
also
for
some
of
these
other
testing
modalities.
For
example,
the
one
that
we
use
for
schools
most
often
is
through
a
partnership
with
perkin
elmer
and
keller
labs.
L
They
do
about
10
percent
of
the
variant
testing
on
those
samples,
so
we
do
still
have
a
great
deal
of
testing
and
review
related
to
understanding
what's
circulating
and
that
that
does
have
an
impact
on
therapeutics
as
well
and
what
will
work
and
won't
work
and
that's
very
important
for
certain
cases.
So
the
group
is
aware
of
these
at-home
test
kits,
it's
really
something
you
do
privately
within
your
own
home
and
that's
not
reported
to
public
health.
So
that's
not
information.
L
For
example,
you
don't
bring
your
at-home
test
kit
in
and
we
somehow
are
able
to
to
detect
what
kind
of
variant
you
have.
You
would
need
to
go
for
additional
testing
and
then
a
specimen
like
the
pcr
would
be
sent
to
again
the
state
public
health
up
to
do
that
testing.
L
H
Add
yeah,
I
would
just
add
that
the
lineage
and
variance
surveillance
efforts
that
go
on
are
really
just
surveillance
to,
let
us
know
what's
circulating
in
our
community,
in
what
proportion
not
every
laboratory-based
molecular
test
goes
on
to
have
sequencing
performed
julia
referenced.
The
website
that
nevada
state
public
health
lab
has
launched.
It
really
is
amazing.
H
If
you
haven't
taken
a
look,
but
it
does
explain
their
process,
they
do
have
capacity
to
perform
about
200
sequencing
a
day
and
then
they're
tracking
the
variants
through
real
time
in
their
website
and
right
now,
they're
showing
about
98
as
omicron
in
nevada,
great.
A
J
Thank
you,
so
the
nevada
hospital
association
released
their
report
yesterday,
regarding
you,
know
the
staffing
issues
and
I
know
we're
going
to
talk
about
that,
probably
on
another
agenda
item,
but
they
also
made
mention
that
43
of
the
hospitalized
patients
are
not
vaccinated,
and
so
the
reason
for
the
question
on
the
omicron
and
the
variance
is
that
that,
as
we
move
through
this
process,
hopefully
we
don't
see
a
continuing
increase
in
this
percent,
not
of
unvaccinated.
I
mean
not
again.
43
of
the
people.
J
Hospitalized
have
been
vaccinated
so
to
say
that
it's
just
related
to
the
non-vaccinated.
It's
just
not
accurate
again,
we'll
see,
we'd
be
curious
to
see
if
that
number
starts
creeping
up
as
more.
You
know,
resistance,
or
some
of
these
things
are
not
effective
against
this.
These
viruses
or
these
mutations
of
these
viruses.
J
My
my
question
is:
are
we
looking
at-
and
I
also
read
a
study
just
yesterday
from
israel
that
getting
an
another
dose
of
the
vaccine
say
even
of
course
those
didn't
seem
to
help
at
all,
with
the
omicron
variant
or
any
of
these
variants.
So
are
we
looking
anything
in
the
the
pipeline
to
perhaps
increase
the
resistance
or
to
to
help
with
some
of
that?
J
Some
of
these
preventive
measures
there's
a
state
reaching
out
for
any
of
these
antivirals
that
we're
taking
I'm
concerned
because,
as
julia
knows,
I'm
concerned
that
we
put
19.6
million
dollars
into
from
the
american
rescue
plan
act
at
ifc
to
the
monoclonal
antibody
treatment,
but
now
we're
finding
out
that
omicron's,
probably
not
sensitive
to
monoclonal
antibody
treatment.
That's
currently
out
there.
So
are
we
doing
anything
else
that
to
kind
of
pre
preemptively
anticipate
that
we'll
have
less
sensitivity
with
our
vaccines.
L
Yeah
julia
peak
for
the
record
I'll
go
ahead
and
start,
and
I
don't
know
if,
because
if
you
have
anything
to
add
once
I'm
done
one
of
the
things
dr
titus,
that
I
just
say
is
that
the
nevada
hospital
association
we
of
course
review
that
data
really
closely
as
well,
and
one
of
our
follow-up
questions
was
how
many
vaccines
have
these
folks
had.
Is
it
one?
Is
it
two?
Is
it
boosted?
What's
that
look
like
and
they
don't
collect
that
level
of
detail?
L
So,
even
though
we
say
43
are
vaccinated,
that
could
be
a
single
dose
or
an
incomplete
dose.
So,
as
melissa
noted
earlier,
the
full
the
full
set
of
vaccinations
that
are
available
to
you,
based
on
based
on
your
age
and
and
risks
and
other
things,
we
encourage
folks
to
get
that
vaccination
again.
It
does
reduce
the
severity
okay
related
to.
I
would
say,
then
what
the
pharmaceutical
companies
are
doing.
L
There's
been
some
that
have
been
looking
at
specifically
boosters
or
vaccinations
just
for
omicron,
but,
as
you
know,
the
the
variance
changed
so
quickly.
I'm
also
looking
at
the
number
of
boosters
and
all
those
things.
L
So
so
our
teams
watch
that
as
well,
cdc
and
acip
also
watch
those
and
provide
recommendations
for
us,
but
I
do
we'll
cover
it
a
little
bit
in
our
next
presentation
as
well,
but
we
really
in
public
health,
look
at
this
full
spectrum
of
services
that
we
can
be
providing
from
again
vaccination
for
primary
prevention
to
secondary
prevention,
disease
investigation
and
then
the
therapeutics
as
you've
mentioned,
is
a
core
part
of
the
response
that
we
have
to
consider
and
again.
Thank
you
on
record
for
isc
approving
that
funding
press
for
therapeutics.
L
We
did
ask
for
it
broadly,
not
just
for
monoclonal
antibodies,
because
we
don't
know
what
will
happen
first
of
all,
with
the
variance,
but
also
what
our
pharmaceutical
partners
are
coming
up
with
in
real
time,
and
so
there
appears
to
be
now
one
monoclonal
antibody
treatment,
that's
effective
against
omicron,
but
the
supply
is
very
low
and
so
nevada
gets
an
allocation
and
we're
trying
to
figure
out
how
to
best
use
our
funding
to
direct
those
most
at
risk
for
severe
disease
to
get
that
specific
treatment.
L
But
that
said
we're
also
looking
in
that,
in
combination
with
the
oral
antivirals
that
you
mentioned,
we
are
getting
those
at
an
allocation
again,
our
federal
partners
are
supplying
that
to
our
board
of
pharmacy,
and
then
we
look
at
cases
ability
to
actually
distribute
and
use
within
your
community,
and
so
we've
been
distributing
to
our
skilled
nursing
facilities,
for
example,
hospitals,
we're
going
to
be
looking
at
looking
at
distributing
through
some
of
our
public
health
programs
like
the
southern
nevada
health
district
as
part
of
their
pharmacy
program,
so
we're
looking
at
how
to
get
those
out
again.
L
It's
a
supply
issue
in
this
case
and
supply
will
just
go
up.
The
other
thing
that
we're
seeing
is
that
again,
pharmaceutical
companies
are
coming
out
with
new
possible
treatments
regularly
and
so
we're
watching
that
closely.
Potentially,
you
know
an
iv
antiviral
coming
out,
so
as
those
become
available,
we
want
to
make
sure
that
we
use
that
19
million
dollars
to
set
those
resources
up
in
the
community,
so
we
can
quickly
triage
people
to
whatever
of
that.
Menu
is
most
appropriate
for
them,
based
on
their
risk
and
accessibility
and
other
things.
L
We
are
certainly
happy
to
provide
updates
on
how
how
we're
distributing
that
money,
as
you
are
well
do,
and
to
assist
you
in
helping
navigate
for
your
residents,
how
they
access
that
service,
because
timely
treatment,
especially
for
the
oral
antivirals,
is
very
very
imperative.
As
we
look
at
actually
the
efficacy
of
those
therapeutics.
L
Julia
peak
for
the
record-
and
I
certainly
have
dave,
I
think,
stayed
on
as
well.
If
there
are
these
questions,
so
the
federal
government
does
control
what
supply
we
have.
We
certainly
are
vocal
about
trying
to
get
more
of
that
allocation,
but
they
do
control
where
that
goes
into
which
state
once
it
comes
to
us,
we're
providing
that
as
we
can
to
those
who
request
it.
L
The
real
issue
has
come
with
just
the
supply
constraints
as
far
as
a
physician
prescribing
it
that's
certainly
allowable,
and
we
have
provided
the
pharmacies
that
are
going
to
carry
it,
and
I
don't
know
if
you'd
like
dave
to
speak
to
that
or
I
could
follow
up
with
a
list
of
those
different
entities
that
have
it
in
stock.
J
It's
a
concern,
obviously
in
my
field,
but
I
think
for
the
public
in
general
that
they
may
not
have
access
without
government
permission.
So
I
think
a
follow-up
to
the
committee
would
be
helpful
and
thank
you
for
your
time
and
again
thank
all
of
you
on
that
have
presented
today
for
for
all
the
efforts
you're
doing
these.
I
know
these
are
tough
questions
tough
times.
So
thank.
M
And
chair
is
clara
morgan.
Is
it
okay?
If
I
step
in
and
just
elaborate
a
little
bit
related
to
the
43
percent
of
hospitalizations
that
are
vaccinated,
I
did
just
want
to
reference.
Dr
titus.
I
know
you're
probably
well
versed
in
this,
but
in
case
maybe
some
people
are
still
listening
to
public
comments
or
others
might
benefit.
I
did
want
to
just
elaborate
on
julia's
sentiment
around,
not
understanding
if
those
individuals
have
received
their
booster.
There
is
preliminary
data
coming
primarily
out
of
the
uk.
M
There
was
an
article
that
was
recently
published
in
the
lancet
that
indicated
that
vaccination
without
a
booster
25
weeks
after
your
second
dose,
can
reduce
efficacy
down
to
about
10
protection,
and
so
it
is
really
important
right
now
to
differentiate.
I
know
the
cdc
has
not
changed
their
definition
for
fully
vaccinated,
but
it
is
really
important
to
understand
the
difference
that
a
booster
shot
can
have
on
that
vaccination
series.
So
I
just
wanted
to
use
that
as
an
opportunity
to
really
emphasize
that,
for
maybe
other
people
who
might
be
listening.
A
Thank
you
so
much
for
the
responses
to
those
questions
and
assemblywoman
titus
is
correct.
We
would
love
to
hear
more
from
you
about
how
this
is
rolling
out
and
what
the
limitations
are.
A
D
But
thank
you,
madam
chair,
and
I'll
try
to
keep
this
brief
and
just
echo
my
colleagues
praise
to
all
of
you
and
thank
you
for
what
you've
been
doing
and
and
echo
that
we,
you
know,
we've
all
been
touched
by
this
with
family
and
friends,
and
my
question
was
in
in
regards
to
the
prison
population,
and
I
know
you
gave
the
data
of
tracking
that,
but
do
we
have
any
any
information
or
any?
You
can
follow
up
later,
if
possible,
on
the
vaccines?
D
P
Carissa
loper
for
the
record.
I
can't
speak
to
if
we
are,
if
they're
vaccinating
inmates
upon
admission,
but
we
do
work
with
the
nevada
department
of
corrections
to
ensure
that
they
have
vaccines
in
stock
at
their
facilities
and
that
their
pharmacist
and
medical
staff
can
can
administer
those
to
the
inmates
upon
their
request.
D
And
if
you
could
just
ask
them
if
they
are
doing
that
and
then
follow
up
and
then
also
you
know
it's
slightly
off
topic,
but
I'd
be
curious
to
know
if
they're
also
doing
that
with
hepatitis
and
and
other
vaccines,
if
you
could
just
ask
departmental
corrections
and
provide
that
information.
I
greatly
appreciate
that.
Thank
you
so
much
and
thank
you,
madam
chair.
A
Thank
you.
I
think
we
can
also
have
staff
potentially
reach
out
to
department
of
corrections
on
that
issue
as
well.
The
next
I
have
so
I
actually
want
to
go
back.
We
have
a
zoom
chat,
but
I
don't
believe
it
is
a
part
of
the
record
and
kevin
dip
with
washoe
county
made
made
a
comment
on
on
this
chat
that
I'd
like
for
him
to
make
on
the
record
on
the
zoom
video.
If
he's
available.
Mr
dick,
are
you
available
to
talk
a
little
bit
about
that
covered?
Q
Yes,
thank
you,
chair
peters.
My
my
comment
was
that
the
the
hospital
association
went
there
indicating
that
they
have
43
percent
of
the
coven
19
cases
being
vaccinated
that
are
hospitalized.
What
we're
finding
in
nevada
and
nationally
are.
There
are
a
number
of
people
that
are
showing
up
at
the
hospitals,
for
other
medical
needs
that
they
have
and
then
the
the
hospitals
are
testing
them
and
finding
they
have
covet
19..
Q
Q
This
doesn't
reduce
greatly
the
burden
on
the
hospital
because
they
still
have
to
treat
that
patient
as
one
that's
in
it
has
an
infectious
disease
and
put
them
in
their
infectious
disease
war
to
try
to
prevent
the
transmission.
But
I
think
that
if
you
just
look
at
that
statistic
and
the
of
43
vaccinated,
I
don't
think
it
reflects
the
the
rate
of
severe
cases
that
are
vaccinated,
that
are
the
vast
majority
or
of
the
severe
cases
are
unvaccinated.
Q
A
E
Sure
so
we
we
know
that
there
are
some
that
are
asymptomatic,
so
when
they
come
to
the
hospital
and
they
get
a
I'll
call,
it
just
a
screening
test
and
they're
positive.
There
is
a
obviously
percentage
of
people
who
are
asymptomatic
in
the
community
and
even
though
they
haven't
been
tested,
even
though
they
don't
know
that
they
have
it
they're,
still
capable
of
passing
it
down
to
somebody
else.
E
So
do
we
have
that
kind
of
statistic
about
the
percentage
of
asymptomatic,
covid
people,
not
patients,
but
people
right
now,
and
you
know
the
theory
is
the
more
we
test,
the
more
we
find
the
more
we
find.
We
may
find
more
people
that
didn't
know
they
were
positive,
but
they're
certainly
able
to
pass
that
on
to
somebody
else.
Hence
the
challenge
with
testing
giving
us
sometimes
a
false
sense
of
security.
Q
Yeah,
thank
you
senator
hardy,
and
really
that's
the
this
million-dollar
question.
We
really
don't
know
how
many
people
have
cobit
19,
because
we
do
have
asymptomatic
cases
and
with
the
the
the
percentage
of
people
that
we
have
now
that
are
getting
vaccinated
and
the
protections
that
the
vaccine
does
afford.
Q
Many
vaccinated
people
may
end
up
having
an
asymptomatic
case
because
of
that
protection,
but
they're
not
seeking
testing,
because
they
don't
have
any
symptoms
and
right
now
we
have
an
extremely
high
demand
for
testing
and
that's
driven,
I
think,
primarily
by
people
that
are
symptomatic
now
with
the
omicron
or
they
have.
Q
I
mean
without
the
big
increase
we've
seen
in
omicron
or
they've,
been
a
close
contact
of
a
case
and
so
we're
finding
here
in
washoe,
county
30,
35
percent
or
so
of
of
cases
over
the
last
seven
days
are
positive
for
covet
19.,
so
that
that
tells
us
there's
just
a
lot
of
it
out
there
in
the
community
and
we
don't.
We
don't
have
a
way
of
ascertaining
how
much
is
really
out
there
because
of
those
asymptomatic
cases.
Q
That's
why
it's
so
important
that
people
practice
precautions,
the
masking
wearing
a
n95,
if
you
can
at
kn
95,
are
more
effective
than
the
cloth
masks
that
both
most
of
us
have
been
using
up
up
until
now,
with
omicron
social
distancing,
you
know
trying
to
stay
in
your
home
while
you
can,
while
this
tremendous
wave
is
passing
over
us
and
avoiding
interactions
with
other
people,
that
you
don't
don't
need
to
be
engaged
with
those
those
are
the
things
we
need
to
do
to
try
to
suppress
the
spread
of
the
omicron
variant
right
now,.
A
Yes,
go
ahead
and
I'm
gonna
ask
that
that
dpv8
please
consider
responding
as
well.
Let
me
know
if
you'd
like
to
respond.
E
So
you
know
I,
I
read
a
lot
obviously
about
this
and
we
talk
about
hand
washing
and
I'm
I'm
not
sure.
I've
read
a
article
about
hand
washing
and
how
important
it
is,
and
I'm
wondering
if
one
of
our
major
efforts
to
hand
wash
may
not
be
as
effective
as
we
think
it
is,
and
sterilizing
doorknobs,
etc,
etc.
And
you
know
I'm
not
going
to
pick
on
anybody,
but
it's
not
impossible
to
not
touch
your
mask
at
some
point
when
you're
wearing
it
when
you're
out
and
around
and
with
people.
E
Q
Well,
thank
you
for
the
question
senator
hardy
and
I
apologize.
I
don't
think
I
identified
myself
for
the
record.
I'm
kevin
dick
district
health
officer
for
the
washoe
county
health
district
and
appreciate
you
bringing
up
hand
washing.
I
should
have
mentioned
that
and
the
reason
I
should
have
is
overall
for
infectious
diseases.
It's
it's
very
important
that
we
do
hand
washing
to
prevent
us
getting
sick
from
all
kinds
of
different
diseases.
Q
With
touching
our
our
face,
our
mouth
food
that
we're
eating
those
kinds
of
things.
I
have
not
seen
a
study
recently
with
omicron
or
or
covet
19
in
regards
to
hand
washing
and
early
in
the
in
the
pandemic,
we
were
heavily
emphasizing
hand,
washing
cleaning,
high
touch
surfaces,
etc.
Q
I
believe
that
that's
still
important
that
we
that
we
need
to
be
promoting.
However,
I
think
our
understanding
of
covet
19
has
evolved
and
we
excuse
me.
We
are
more
aware
that
it
is
incredibly
transmissible
through
airborne
transmission
and
that's
why
ventilation,
masks,
distancing
number
of
number
of
people
within
a
space
are
all
important
to
try
to
control
the
spread
through
that
airborne
transmission.
A
I
was
talking
to
myself.
I
was
asking
if
miss
pete
bullock
had
any
response,
as
they
say,
epidemiologists
to
the
handwashing
comment.
I
know
with
three
kids,
it's
incredibly
important
for
us
still,
despite
despite
what
it
may
impact
for
for
covid.
We
are
still
catching
polls
from
from
just
general
touch
services
that
the
kids
are
exposed
to.
But
if
you
miss
people,
if
you
would
like
to
respond,
please
go
ahead.
H
Yes,
absolutely
melissa
peak
bullock
for
the
record
and
I
I
absolutely
agree
with
the
responses
made
by
kevin
dick.
Previously,
we
don't
have
recent
studies
out
on
handwashing
with
omicron
and
covid19,
but
again
it's
extremely
important
to
reduce
the
spread
of
infectious
disease
across
the
board,
especially
when
you
look
at
settings,
as
you
have
just
mentioned,
chair
in
daycares
preschools,
the
school
setting.
There's
a
lot
of
high
touch
surface
areas.
A
lot
of
you
know
touching
the
mouth,
the
nose
touching
other
objects,
touching
your
friends
that
sort
of
thing.
H
It's
also
extremely
important
when
you
look
at
food
safety,
so
even
in
your
own
home,
so
washing
your
hands,
you
know
after
you
cough
sneeze,
use
the
bathroom
before
you're
preparing
food
for
other
people,
because
that
is
also
a
great
vehicle
for
the
spread
of
disease
as
well.
So
I
just
want
to
reiterate
that
hand
washing
is
a
great
prevention
tool
to
be
implemented
to
help
with
all
infectious
diseases.
A
Thank
you
so
much.
I
mean
myself
this
time,
mr
of
sorry,
except
excuse
me
assemblyman
or
liquor.
I
have
you
next
on
the
list.
If
you
would
like
to
go
ahead
with
your
comments
or
questions.
D
Chair,
I
have
a
question
about
the
statistic
on
completed
vaccination,
as
kyrah
mentioned,
that
there
are
different
definitions
out
there,
what
it
means
to
be
completely
or
fully
vaccinated.
So
I'm
just
curious,
which
definition
you're
using
if
somebody's
had
two
modern
or
pfizer
shots
is
eligible
for
a
booster
hasn't
had
a
booster.
Yet
do
you
still
count
them
as
completed?
M
Yeah,
this
is
kyrah
morgan
for
the
record
carissa.
You
probably
have
more
details
than
I
do
so
simon.
If
I'm,
if
I
get
this
wrong
when
we're
talking
about
fully
vaccinated,
currently
we're
not
including
booster
or
follow-up
doses,
I
think
that
that
is
because
our
national
leaders
haven't
changed
that
definition,
so
we're
still
anchoring
to
what
the
cdc
is
using.
We
do
on
our
dashboard,
have
a
separate
measure
which
indicates
follow-up
doses.
M
So
that's
not
just
your
booster
for
your
average
healthy
adult
who's.
You
know
25
weeks
out,
but
it's
also
individuals
who
are
immune,
compromised
or
eligible
for
another
dose
as
part
of
their
vaccination
series,
and
so
that
is
listed
currently
for
nevada
as
609
000,
boosters
or
follow-up
doses
have
been
administered.
A
So
I
have
one
more
person
on
my
q
for
for
comment
and
then
we're
going
to
move
on
to
the
next
agenda.
Daniante,
please
go
ahead.
D
Thank
you
so
much
chair,
peters
and,
of
course,
thank
you
to
the
dhhs
staff
for
your
presentation.
Your
work
is
definitely
noticed
and
we
greatly
appreciate
you.
I
just
have
two
quick
questions.
The
first
one
lies
with
the
recent
announcement
by
the
federal
government
with
them
with
the
shipment
of
free
95
mask.
Can
you
detail
the
state's
strategy
on
how
we're
going
to
implement
that
change
and
that
shipment,
how
we're
going
to
distribute
it
throughout
the
state
and
then
my
second
question
is
more
about
vaccine
uptake.
D
Can
you
talk
about
some
of
the
groups
that
we're
seeing
that
might
share
vaccine
hesitancy
and
how
we're
closing
the
gaps
for
folks
that
either
face
language
bearers
or
other
types
of
barriers
and,
of
course,
who
are
actually
hesitant
like
what
are
we
doing
in
terms
of
that
work?
Thank
you.
So
much.
L
Perfect,
thank
you.
Julia
peak
for
the
record
I'll
go
ahead
and
start
out
with
ppe.
Specifically
the
n95
mask,
so
we're
still
figuring
out
locally.
How
we're
going
to
implement
that.
But
I'll
just
say.
One
of
the
things
that
I
think
nevada
did
exceptionally
well
is
to
double
our
stockpile
of
ppe
prior
to
this
surge.
So
we
do
have
that
that
stockpiled
we're
looking
to
fill
a
number
of
requests
from
our
schools
because
they
want
to
upgrade
again
to
make
sure
they
do
have
the
n95
or
the
km95.
L
So
we're
working
through
that
request,
at
least
in
that
high
risk
setting.
Our
healthcare
providers
have
always
been
able
to
ask
for
that
supply
so
again,
just
touching
base
with
them.
Making
sure
that
in
those
settings
where
there
is
potential
high
risk
spread
that
they
do
have
even
our
state
supply.
But
but
again,
if
the
federal
partners
are
sending
additional
supplies,
we
will
certainly
use
that
as
well
and
then
to
make
sure
that
that
there
is
availability
of
supply
for
kn-95s
or
or
n95s
for
our
general
public.
L
So
we
could
look
at
a
very
similar
methodology
to
how
we're
doing
the
at-home
test
kit
distribution
again
over
90
community
partners
statewide,
and
so
we
can
certainly
provide
updates,
as
we
delineate
how
that's
going
to
go.
But
we
do
have
a
really
healthy
supply
of
ppe
in
our
state.
Luckily,
because
of
prior
planning
I'll
go
ahead
and
turn
over
the
vaccine.
Efforts
to
chris
eloper
to
handle.
P
Thanks
julia
chris
loper
for
the
record.
Thank
you
for
the
question
senator.
So
we
are
working
with
immunized
nevada
make
the
road
nevada
a
number
of
other
groups
through
immunized
nevada,
who
is
working
with
those
local
partners
on
the
ground
to
reach
hispanic
populations,
african-american
populations
and
younger
adults,
so
18
say
to
29.
That's
where
we're
seeing
less
uptake
of
the
vaccine
so
translates
to
more
hesitancy,
though
we
don't
always
know
specific
reasons.
Why?
A
Thank
you
so
much.
I'm
gonna
go
ahead
and
move
us
on
to
the
next
agenda
item
wall,
so
we
can
keep
things
moving
forward,
but
in
the
same
vine
we're
going
to
be
talking
about
an
overview
of
public
health.
Lessons
learned
from
the
covenant
19
pandemic
and
the
path
forward
really
looking
forward
to
what
we're
looking
at
moving
forward
and
how
to
reduce
the
potential
future
pandemic
impacts
to
our
communities.
H
Good
morning,
melissa
peeple
at
state
epidemiologists
in
the
division
of
public
and
behavioral
health
for
the
record.
Once
again,
I
am
joined
today
by
julia
peak
deputy
administrator
within
the
division.
Chris
loper
health
bureau
chief
in
the
division
and
megan
come
lastly
associate
director
of
the
center
of
public
health
excellence,
larson's
institute
for
unr.
H
So
what
is
public
health,
and
why
did
we
not
hear
about
it
until
proven
19,
while
the
terminology
may
be
new
to
many?
The
concepts
and
applications
are
far
from
novel
public
health
is
a
broad
term,
but
it
encompasses
targeted
focuses
such
as
prevention
of
disease
and
death.
This
can
be
related
to
infectious
disease,
injury
and
chronic
disease.
Another
major
focus
is
on
targeted
intervention
or
prevention
measures
for
certain
populations.
H
This
is
largely
tied
to
available
funding
sources,
which
is
illustrated
through
our
maternal
and
child
health
program.
Another
term
that
was
not
widely
known
before
the
pandemic
was
epidemiology.
While
there
are
many
subsets
of
epidemiology
infectious
disease,
epidemiology
has
been
a
foundation
throughout
the
pandemic
response.
H
Infectious
disease
epidemiology
is
a
practical,
science-based
practice
that
is
concerned
with
minimizing
the
impact
of
infectious
agents
on
the
health
of
the
public.
This
is
a
population-based
science
that
studies
patterns
of
disease
incidents
and
uses
the
disease-specific
data
to
identify
interventions
in
order
to
minimize
the
risk
of
transmission
and
severe
outcomes.
H
Take
into
account
many
factors,
such
as
the
mode
of
transmission,
the
incubation
period,
the
window
of
transmissibility,
also
known
as
the
infectious
period
seasonality
and
the
stability
of
the
infectious
agents.
Common
terms
used
in
epidemiology
are
also
vital
components
and
those
include
biostatistics
case
investigation,
contact,
tracing
disease
transmission,
the
epidemic
curve,
vaccination
and
treatment.
H
Gonna
provide
just
a
brief
history
of
public
health.
During
the
past
150
years,
two
factors
have
shaped
the
modern
public
health
system.
H
More
effective
interventions
against
health
threats
were
developed
and
public
organizations
were
formed
to
employ
newly
discovered
interventions,
as
scientific
knowledge
grew
public
authorities
expanded
to
take
on
new
tests.
This
included
sanitations
immunization
regulation,
health,
education
and
personal
health
care.
H
Before
the
18th
century,
epidemics
such
as
the
plague,
cholera
and
smallpox
were
often
thought
of
as
signs
of
poor,
moral
or
spiritual
conditions,
and
few
public
health
efforts
had
occurred.
However,
in
the
late
17th
century,
public
health
authorities
adopted
and
enforced
isolation
and
quarantine
measures
as
a
result
of
the
plague.
H
In
the
18th
century,
isolation
of
the
ill
and
quarantine
of
the
exposed
became
common
measures
to
contain
infectious
diseases,
especially
considering
smallpox
the
19th
century.
This
marked
a
great
advance
in
public
health.
The
great
sanitary
awakening.
This
was
the
identification
of
filth
as
both
a
cause
of
disease
and
a
vehicle
of
transmission.
H
H
The
discovery
of
bacteriologic
agents
such
as
anthrax,
tuberculosis,
diphtheria,
typhoid
and
yellow
fever.
This
led
to
advances
in
immunizations
and
water
purification
efforts
to
control
the
spread
of
disease.
The
germ
theory
of
disease
provided
a
sound
scientific
basis
for
public
health.
The
means
of
controlling
infectious
disease
changed
dramatically.
H
H
The
scientific
advances
that
were
made
led
to
the
development
of
state
and
local
health
departments
and
laboratories,
which
provided
the
opportunity
to
continue
scientific
growth.
A
major
focus
was
improving
sanitation
through
treatment
and
control
of
bacteria
and
water
in
1891.
The
presence
of
fecal
bacteria
in
water
was
first
identified
as
the
cause
of
typhoid
fever
and
resulted
in
the
first
sewage
treatment
techniques.
H
Much
of
the
history
I
have
just
discussed
was
focused
on
public
health
issues
related
to
infectious
disease,
because
at
that
time
people
were
dying
at
young
ages
related
to
uncontrolled
transmission
of
diseases
because
of
the
advances
made
over
time
and
public
health
people
are
now
able
to
live
longer
and
live
long
enough
to
face
the
consequences
of
chronic
disease.
Public
health
has
expanded
greatly
throughout
the
course
of
history
and
now
encompasses
prevention,
efforts
related
to
infectious
disease,
chronic
disease
and
injury
prevention.
H
H
Examples
of
this
are
vaccinations
to
prevent
the
spread
of
disease
education
on
the
risks
of
tobacco
and
alcohol.
Public
health
was
a
major
voice
to
promote
smoke-free
indoor,
air
laws
and
seat
belt
safety
laws.
Public
health
set
help
to
set
food
and
safety,
water
standards,
develop
food,
school
nutrition
programs
and
we
track
and
respond
to
disease
outbreaks.
H
L
It
over
to
julia
peak
julia
peak
for
the
record.
One
of
the
questions
that
we
get
most
often
in
public
health
is
what
is
the
difference
between
public
health
and
health
care
or
clinical
services,
and
it
does
cause
confusion
to
to
see
what
we
focus
on
in
public
health
is,
as
melissa
had
noted.
It
really
is
our
eyes
are
on
community
health
population,
health
and
how
we
can
impact
change
over
time,
ideally
through
prevention
and
risk
production.
L
A
focus
for
us
is
really
meeting
people
where
they
are
at
on
the
spectrum
of
prevention.
We
also
have
a
larger
scope,
as
was
presented
earlier,
clean
air,
safe
food
reduction
of
disease
and
infection.
Ultimately,
so
everyone
has
the
ability
to
live
the
longest
and
healthiest
life
possible.
A
lot
of
our
work
is
looking
at
disparities
and
risks
in
certain
groups,
both
geographically
and
demographically.
L
They
say
that
your
zip
code
could
have
more
impact
on
your
health
status
and
ability
again
to
live
a
long
and
healthy
life,
as
opposed
to
your
genetic
code.
So
geography
is
a
huge
thing
that
we
look
at.
We
also
have
an
example
on
here
for
clinical
services,
and
this
is
much
more
what
people
are
aware
of.
It
is
you
going
to
your
doctor
or
dentist
and
looking
at
plans
and
interventions
for
individual
health,
it's
an
individual
assessment
of
risk
and
strategies
to
address
the
health
status
of
that
individual.
L
To
give
you
an
example,
just
looking
at
asthma,
if
you
go
to
your
doctor
and
you
have
issues
with
breathing
you're
gonna,
just
look
at
symptoms,
you're,
going
to
do
tests
and
and
you're
going
to
get
some
sort
of
medication
potentially
prescribed
if
you
do
have
an
asthma
attack,
so
that
your
individual
health
is
sustained.
L
When
we
look
at
asthma
from
a
population
health
perspective,
we
say,
one
of
the
studies
we
looked
at
was
actually
asthma
admissions
to
hospitals,
and
is
there
a
geographic
or
demographic
issue,
that's
potentially
causing
this
and
where
and
how
can
public
health
intervene?
That's
just
one
example,
but
it
is
looking
at
the
same
condition
just
through
a
different
lens
xyz.
L
This
is
one
of
the
best
things
that
I've
seen
that
that
helps
you
understand.
Where,
in
public
health,
we
can
make
an
intervention
that
affects
the
most
people,
but
also
different
strategies?
I'm
just
again
for
this
presentation
we're
going
to
look
at
covid,
and
I
just
want
to
give
a
couple
of
examples.
So
the
individual
again
has
so
much
power
in
how
kovid
is
transmitted
and
prevented
with
the
individual.
We've
done
a
lot
with
information
sharing
direct
outreach
individ
to
individuals
through
our
community-based
organizations
through
media
and
other
outreach
opportunities.
L
Looking
at
the
specific
risk
for
that
individual
and
addressing
any
questions
they
have
potentially
related
to
vaccination
or
during
the
conversations
for
isolation
and
quarantine,
if
they're
a
case
or
a
contact,
we
talk
to
them
about
what
their
potential
risks
are.
We
make
a
change
individually
every
time
we
do
that.
L
When
we
look
at
policy
some
of
the
things
that
we've
done
are
emergency
regulations
or
temporary
regulations
looking
at
mandates
for
vaccinations.
That
is
where
you
can
come
in
and
make
the
most
change
in
the
shortest
period
of
time,
as
was
mentioned
earlier,
some
of
our
seatbelt
laws,
smoking
laws
and
other
things
are
really
good.
Examples
of
how
public
health
policy
has
has
truly
impacted
people's
ability
in
our
communities
to
live
long
and
healthy
lives.
L
This
next
slide
is
really
pivotal
and
not
pivotal.
I'm
not
going
to
spend
a
huge
amount
of
time
on
it,
but
it's
it's
great
to
understand
the
scope
of
public
health
and
our
partners
have
developed
this
10
essential
public
health
services.
It's
something
we
look
at
to
ensure
that
our
health
department
is
operating
from
a
place
of
equity,
but
also
that
we're
meeting
every
single
place
on
this
essential
public
health
services
and
that
we're
providing
the
best
opportunity
for
our
residents
through
our
services.
L
Many
of
these
programs
have
been
highlighted
during
the
pandemic,
so
the
public-
and
you
all
have
seen
how
we've
addressed
very
specific
things,
but
there's
certainly
the
opportunity
to
assess
and
plan
that
kind
of
portion
of
the
circle
to
make
sure
that
for
the
next
pandemic
or
the
next
health
issue
that
we're
prepared
and
miss
kamlasi
is
going
to
talk
later
on
about
some
very
strategic
things,
we're
doing
to
make
sure
that
we
are
providing
the
best
public
health
services
in
nevada
and
that
we
continue
to
have
a
quality
improvement
process.
L
I
already
mentioned
this
a
little
bit,
but
we
really
have
a
structural
foundation
in
levels
of
prevention.
Meeting
people
where
they're
at
as
I
mentioned
earlier,
primary
prevention
is
focused
on
ensuring
that
there's
the
littlest
risk
possible,
hopefully
to
eliminate
the
spread
of
a
disease
or
a
condition
or
to
reduce
the
risk,
and
that's
been
a
huge
part
of
our
covid
response.
You
saw
this
in
our
state
home
orders
initially
and
then
you've
also
seen
this
with
vaccination
efforts
to
ensure
that
people
reduce
their
risk
of
contracting
the
disease.
L
This
is
also
really
true
for
chronic
disease
as
well.
If
we
can
get
screening
programs
for
cancer
to
help,
people
who
might
otherwise
not
have
been
able
to
identify
that
they
had
cancer,
identify
it
early
and
then
hopefully
refer
for
treatment.
Tertiary
prevention
occurs
when
the
person
already
has
severe
illness
and
it's
ensuring
that
we
have
therapeutics
in
place
and
they
have
access
to.
L
Those
services
talked
about
it
a
little
bit
earlier
in
our
presentation,
but
for
covid
it's
making
sure
that
we
have
as
much
supply
in
nevada
as
we
are
allowed
continuing
to
advocate
for
more,
but
then
ensuring
that
it's
accessible
to
whomever
is
is
most
at
risk
for
disease,
severe
disease
or
death.
L
I'm
gonna
transition
to
talk
about
some
of
our
core
public
health
programs,
I'm
going
to
use
the
lens
of
covet
19,
but
I'm
also
going
to
highlight
some
of
the
other
things
that
these
teams
have
done.
This
is
not
an
exhaustive
list.
Public
health
is
a
huge
agency,
and
so
I'm
just
going
to
highlight
a
few.
The
first
I
would
say,
as
it
related
to
the
covid
19
response,
was
our
planning
and
preparedness
programs.
They
focus
on
emergency
response
and
logistics.
They
have
also
done
planning
exercises
locally
well
prior
to
the
pandemic.
L
Looking
at
pandemic
flu
planning
and
how
we
would
intervene
also
have
taken
great
effort,
as
it
relates
to
environmental
issues
and
how
we
can
help
people
navigate
services
if
there's
a
wildfire
or
a
flood
or
whatever.
That
might
look
like.
Also,
they
have
a
regular
eye
on
healthcare
capacity,
getting
information
on
er
bed
status
and
helping
us
understand
what
that
looks
like
prior
to
covet
and
with
coved.
L
They
also
have
worked
hard
on
crisis
standard
standards
of
care
that
have
again
looked
at
healthcare
capacity.
Healthcare
access
they've
been
a
pivotal
liaison
between
our
public
health
programs
and
emergency
management,
I'll
just
say
without
them
being
there
as
the
liaison,
it
would
have
been
a
much
rockier
implementation,
because
our
emergency
management
national
guard
have
been
the
right
hand
of
the
public
health
response,
so
just
want
to
acknowledge
the
team
for
doing
that,
also
the
resource
management
and
logistics.
L
As
I
said,
we
have
doubled
the
stockpile
of
ppe
in
our
state,
that's
a
logistics
challenge
and
also
ensuring
that
it
gets
to
the
folks
who
need
it.
This
has
been
necessary
as
well
for
testing
and
other
resources
that
we've
had
to
distribute
out
to
the
community,
and
I
do
just
want
to
highlight
here
also
our
community
health
nurses.
L
They
were
providing
emergency
planning
and
services
well
prior
to
covid,
and
they
also
now
were
continuing
to
provide
vaccinations,
std,
testing,
family
planning
and
did
so
during
the
pandemic
as
well,
for
their
residents
talked
a
lot
about
epidemio
and
laboratory
capacity.
I'll
just
say
that
there's
great
opportunity
here
to
improve
testing
in
the
short
term,
and
I
talked
about
that,
but
also
laboratory
services.
L
The
most
ready
one
will
be
in
churchill
county
so
that
they
can
service
on
behalf
of
the
state,
public
health
lab
a
number
of
our
rural
communities,
also
disease
investigation
and
what
I'll
say
for
disease
investigation.
In
addition
to
what
we've
provided
is
we
had
such
a
small
workforce
to
do
all
diseases
prior
to
covid?
We
still
have
a
very
small
work
workforce
for
epidemiology,
even
with
the
covid
funding,
and
it
has
to
do
with
pipeline
efforts
and
finding
and
retaining
people
who
have
skills
in
epidemiology.
L
Again.
Some
of
the
efforts
we're
going
to
talk
about
for
opportunities,
we'll
highlight
highlight
this
with
covid.
We
had
to
quickly
redirect
our
disease
investigators,
who
were
potentially
investigating
syphilis,
which
nevada
has
the
highest
rates
of
syphilis
in
the
nation,
but
the
fire
for
lack
of
a
better
word
was
povid,
and
so
we've
had
to
redirect
those
resources.
L
We
were
having
to
prior
to
covered
look
at
which
stds,
for
example,
we
would
investigate
nationally
there's
the
highest
rates
of
chlamydia
that
have
been
seen
in
so
long
and
stacer
and
counties
are
not
able
to
investigate
chlamydia,
though
undiagnosed.
Chlamydia
can
cause
infertility
so
again
such
an
important
public
health
project,
but
we
just
can't
staff
it
with
the
categorical
funding
that
we
have
from
our
federal
partners.
L
L
But
by
the
time
we
actually
got
funding
for
workforce
and
I.t
investments
and
other
things
we
were
well
into
the
pandemic,
and
so
we
were
forcing
our
epidemiologists
to
not
only
recruit
and
train
and
supervise
these
staff,
but
they
had
to
respond
directly
themselves
to
cases
that
were
coming
in
through
the
floodgates
so
that
that
delay
in
ensuring
that
we
had
the
funding
to
quickly
stand
up.
Services
was
really
really
challenging
environmental
health.
We
did
talk
about
this
a
little
bit
early
on.
They
are
such
a
strong
part
of
our
public
health
response.
L
They
helped
us
early
with
povid
to
look
at
infection
control
and
cleaning
even
sending
them
into
skilled
nursing
facilities.
Initially,
to
figure
out
where
risk
could
potentially
be
in
the
facilities
that
we
could
limit,
spread.
They've
also
done
a
great
deal
of
work
to
look
at
events.
Nevada
just
relies
so
heavily
on
special
events
and
and
having
visitors
and
ensuring
that
our
restaurants
and
our
events
are
as
safe
as
possible,
has
really
been
on
the
backs
of
our
environmental
health
professionals.
L
We
also
have
done
a
lot
with
climate
change
and
air
quality
and
temperature
issues
with
kovid
we
had
to
and
the
wildfires.
For
example,
we
had
to
close
schools
just
because
the
circulation
that
was
necessary
to
prevent
the
spread
of
cobit
within
the
classroom
it
needed
to
occur
with
the
ventilation
and
we
just
couldn't
with
the
air
quality
outside
and
that's
something
with
climate
change
that
we'll
just
be
having
to
deal
with
much
more
also
with
covid,
when
the
temperatures
were
hot,
outside
people
would
congregate
indoors
and
we'd
see
transmission
indoors
again.
L
The
last
thing
not
specifically
related
to
provide,
but
a
lot
of
work
is
done
on
looking
at.
Do
people
have
access
to
safe
and
close
outdoor
recreation?
Can
we
change
the
landscape
of
our
communities
to
ensure
that
there's
walking
paths
and
safe
parks
and
other
things
in
our
communities?
So
we
encourage
people
to
go
outdoor
and
recreate
and
increase
their
overall
health
and
wellness?
L
I'm
just
going
to
give
one
example
of
this
unless
it's
certainly
better
to
talk
to
this
than
me.
But
I
just
want
to
explain
how
we
were
doing
this
well
prior
to
covid
and
give
you
an
example
of
how,
in
epidemiology,
we
can
track
a
source
with
our
environmental
health
partners
and
really
put
an
end
to
it.
L
So
within
washoe
county
we
have
an
e
coli
0157
h7
bacterial
infection,
and
we
started
seeing
a
number
of
cases
come
in
in
washoe
county,
and
this
is
really
important
to
address
quickly,
because
this
bacteria
can
produce
a
toxin
that
can
affect
kidneys
and
cause
kidney
failure.
So
the
teams
in
environmental
health
and
epidemiology
focused
a
good
amount
of
attention
on
it.
Initially
they
were
able
to
do
the
investigations
of
the
cases
coming
in.
L
So
again,
when
that's
reported
to
public
health,
the
epidemiology
teams
follow
up
with
the
individual
and
figure
out
what
their
potential
exposure
was
and
then
based
on
similarities.
Between
those
cases,
we
can
figure
out
where
the
common
source
occurred
and
so
based
on
the
investigation
that
this
team
did.
It
was
linked
to
one
source
and
then
environmental
health
specialists
were
able
to
go
in
and
look
at
food
samples
sent
to
our
public
health
laboratory
again
a
great
resource
to
us
in
our
public
health
response.
L
Ultimately,
we
were
able
to
identify
the
source
of
infection
and
completely
stop
further
transmission,
and
then
we
worked
with
the
facility
to
make
sure
that
their
safety
standards
were
in
place
to
prevent
this
from
happening.
Also
note
just
because
we've
talked
about
it
in
covid,
when
community
transmission
is
so
incredibly
high.
It's
really
really
difficult
for
us
to
say
that
this
was
the
single
source
of
exposure.
L
Both
just
quantity
and
an
individual
could
have
multiple
locations
where
they
could
have
potentially
been
exposed.
So
I
know
that's
been
a
challenge
for
us
to
do,
but
also
a
challenge
for
the
public
as
they
try
to
assess
locations
of
higher
risk
or
lesser
risk.
That's
been
quite
a
challenge
with
covid
joseph,
I
think
two
slides
okay.
I
just
wanted
to
talk
a
little
bit
about
analytics
because
you
hear
us
talk
about
data,
a
ton
as
it
related
to
covid,
but
I
just
want
to
say
we
look
at
data
for
everything.
L
It's
been
inherent
in
the
pandemic
response
to
make
sure
that
we
are
able
to
provide
data
quickly
and
that's
not
only
to
be
transparent,
but
to
address
any
specific
issues.
That's
been
one
of
the
most
difficult
parts
of
the
public
health
response,
because
public
health
data
is
often
not
timely,
not
overnight
or
within
a
couple
days.
We
take
a
year
to
make
sure
our
hiv
data
is
correct.
L
We
use
data
beyond
kovid
to
look
at
morbidity
and
mortality,
as
I
said,
both
demographically
and
geographically,
to
figure
out
what
is
the
specific
issue
causing
a
specific
outcome?
Sometimes
it
is
risks
of
an
individual,
sometimes
it's
access
to
health
services,
and
so
we
have
to
look
at
all
of
those
things.
The
data
also
helps
us
benchmark
where
we're
at
for
a
certain
issue,
and
so
we
can
make
measurable
improvement
in
those
areas.
L
Nevada
is
so
dependent
on
categorical
funding,
as
I've
already
mentioned,
that
it
also
helps
show
us
where
there
might
be
diseases
or
conditions
that
need
additional
attention
and
therefore
funding
healthcare
licensure
for
the
next
slide
joseph
this.
I
cannot
not
even
begin
to
explain
the
the
burden
that
this
group
has
taken
on
related
to
infection
control
and
then
specifically
laboratory
licensing.
L
This
slide
provides
a
summary
of
all
the
different
types
of
licensing
and
quality
assurance
that
we
provide
at
the
different
types
of
facilities.
I
do
just
want
to
highlight
what
our
child
care
facilities
have
done.
As
melissa
noted,
there's
just
been
such
a
challenge
just
with
children
in
general,
with
spread
and
making
sure
that
we
provide
infection
control
in
those
settings.
But
I
do
want
to
call
out
medical
laboratory
licensing.
L
This
small,
but
mighty
team
has
been
able
to
bring
on
so
many
labs
and
also
sites
that
do
specimen
collection
and
send
out
for
results.
The
workload
has
increased
exponentially
and
they've
also
been
following
up
on
complaints
that
we
get
from
the
public
related
to
those
specimen
collection
sites
or
laboratory
quality
or
other
things,
and
it's
just
been
such
an
under
resource,
but
a
pivotal
part
of
the
response.
L
P
Good
morning,
committee
members
crystal
overhealth
bureau,
chief
for
the
record,
as
you
have
heard,
vaccines
and
immunization
as
a
standard.
Preventive
practice
are
considered
one
of
the
top
public
health
achievements
of
the
past
century
and
are
credited
with
helping
to
lengthen
life
expectancy
in
the
united
states
and
globally.
Vaccines
help
prevent
some
of
the
deadliest
infectious
diseases
that
still
exist.
Today.
P
We
hear
a
lot
about
the
covid
vaccine,
but
the
divisions
immunization
program
has
always
been
working
to
ensure
nevada's
population
can
access
all
recommended
vaccines,
immunization
program
staff,
work
with
federal
and
local
partners
and
nevada's
vaccine
providers
to
order,
distribute
and
track
publicly
supplied
vaccines
and
ensure
all
vaccines
administered
in
the
state
are
recorded
in
our
nevada
web
ic
immunization
information
system.
We
work
with
a
variety
of
community
partners
to
use
local
data
and
information
down
to
the
zip
code
level
to
improve
activities
and
ensure
vaccines
are
being
distributed
equitably.
P
The
immunization
program
also
works
closely
with
our
colleagues
in
the
epidemiology
office
to
track
and
respond
to
vaccine
preventable
disease
outbreaks
in
the
state.
One
example
of
this
in
action
happened
back
in
2017
when
we
experienced
a
pertussis
or
whooping
cough
outbreak
in
rural
nevada,
which
spread
into
the
school
system
following
standard
disease,
investigation
activities,
exposed
contacts
were
identified
and
provided
with
treatment
to
help
prevent
them
from
developing
whooping
cough.
P
Additionally,
the
immunization
program
was
brought
in
to
work
with
our
local
partners
and
in
the
community
to
ensure
they
had
enough
vaccine
to
do
targeted,
pertussis
clinics,
and
we
helped
provide
education,
information
to
local
providers,
partners
and
the
public
about
pertussis
disease
and
the
vaccine.
Ultimately,
the
outbreak
was
quelled
due
to
these
combined
actions
next
slide.
P
To
that
end,
the
division's,
chronic
disease
prevention
and
health
promotion
program
has
always
worked
on
tracking
understanding
and
preventing
chronic
disease
in
nevada,
tobacco,
cessation
and
control
is
something
most
of
us
have
heard
about
and
are
familiar
with,
indoor
clean
air
acts
and
such
but
less
publicized
programs
that
are
no
less
important
include
diabetes
prevention,
programming,
like
the
diabetes
self-management,
education
program
and
the
national
diabetes
prevention
program.
We
also
run
heart
disease
prevention
programs
like
the
self-monitoring
blood
pressure
program
working
with
local
health
providers,
and
we
run
a
strong
stroke
prevention
program.
P
In
the
context
of
the
cova
19
pandemic,
we
began
to
see
early
on
that
individuals
with
co-morbidities
like
obesity,
diabetes,
heart
disease
or
who
already
had
compromised.
Lung
health
were
and
remain
more
likely
to
be
infected,
exposed
and
much
more
likely
to
end
up
with
symptomatic
disease
that
results
in
the
person
being
hospitalized
for
dying.
P
This
further
drives
home
the
importance
of
continuing
and
increasing
efforts
to
help
prevent
chronic
disease.
We
also
saw
covid
impacting
some
communities
and
groups
more
than
others,
resulting
in
both
health
and
economic
crises
for
the
people
who
could
least
afford
either
across
public
health.
We
have
renewed
and
invigorated
our
efforts
to
use
local
data
and
work
with
diverse
community
partners
to
ensure
program
resources
are
distributed
equitably.
P
Next
slide,
please:
the
division
works
with
many
partners
and
at
many
levels
to
ensure
access
to
healthy
food
for
nevadans
food
access,
and
nutrition
is
a
concern
for
public
health
because
of
how
closely
what
a
person
eats
is
tied
to
their
health
status,
as
the
previous
slide
made
clear,
not
to
mention
the
safe
food
practices.
Julia
talked
about
with
environmental
health,
obesity,
heart
disease
and
diabetes
are
all
related
to
a
person's
eating
habits
and
patterns
which
are
a
direct
result
of
the
food
they
can
access
and
their
knowledge
of
nutrition.
P
P
And
finally,
we
worked
with
multiple
state
and
local
agencies
and
partners
to
help
food
banks
navigate
the
pandemic
and
best
serve
nevada's,
most
vulnerable
and
food.
Secure
individuals,
including
working
with
the
aging
and
disability
services
division
to
serve
older
nevadans.
That's
just
a
taste
of
what
we've
done
during
the
pandemic
and
before
to
work
with
all
of
our
partners
and
agencies
across
the
state
to
protect
food
security,
combat
food
insecurity
and
ensure
that
populations
can
access
safe
and
healthy
foods.
Next
slide,
I
will
wrap
up
my
short
section
by
touching
on
maternal
and
infant
health.
P
Recently,
in
action,
the
mch
and
immunization
staff
partnered
to
provide
an
educational
webinar
to
parents
wanting
to
know
more
about
the
kovid
19
vaccine
for
children,
ages,
5
to
11
years.
They
have
also
been
working
closely.
Those
teams
to
ensure
children
and
youth
with
special
health
care
needs
are
able
to
learn
about
and
access
the
covet
19
vaccines
from
their
trusted
providers.
P
Despite
the
challenges
we
have
all
faced,
enrolled,
nevada
families
were
successfully
served
and
creative
program
ideas
were
implemented,
like
virtual
group
parties
and
eventual
outdoor
group
events
to
keep
the
families
connected
and
to
provide
social
interaction
for
the
children
home
visitors
ensured
that
families
were
quickly
connected
to
any
resource
they
needed,
especially
during
the
shutdown
periods.
When
many
people
lost
their
job
and
suddenly
needed
housing
or
food
assistance
or
help
navigating
unemployment
insurance.
Our
home
visitors
were
integral
to
helping
people
get
information
and
access
resources
that
they
needed.
P
R
Thanks
carissa
and
good
morning,
chair
peters
and
members
of
the
committee,
it's
good
to
see
you
all
again.
My
name
is
megan
kamlotsi,
I'm
the
associate
director
of
the
center
for
public
health
excellence
within
the
larsen
institute
at
the
university
of
nevada
reno,
and
just
want
to
provide
a
brief
recap
before
we
jump
into
the
opportunities.
So
what
you've
heard
this
morning
so
far
is
a
brief
history
of
how
governmental
efforts
to
keep
the
public
healthy
came
to
be
and
how,
through
scientific
advances
and
constant
evolution,
they've
come
pretty
far.
R
I
think
one
of
the
toughest
things
to
really
wrap
your
head
around
when
thinking
about
public
health
is
that
it
involves
so
many
things,
and
there
are
things
that
we
don't
necessarily
associate
with
the
term
health.
But
hopefully,
this
presentation
has
helped
clarify
the
difference
between
the
individual
healthcare
we
seek
at
the
doctor's
office
or
in
a
hospital
and
how
public
health
professionals
work
to
keep
entire
communities
healthy.
The
other
critical
thing
to
reiterate
is
that
when
public
health
activities
are
working,
we
don't
necessarily
know
or
hear
about
them.
R
R
Public
health
prior
to
the
kobut
pandemic
over
19
pandemic,
or
we
may
never
have
even
heard
the
term
it's
something
that
happens
in
the
background
and
it's
generally
invisible,
but
it
has
a
real
impact
on
our
daily
lives,
whether
we
realize
it
or
not.
R
However,
in
your
role
as
state
policy
makers,
it's
critical
that
you
understand
what
public
health
agencies
and
practitioners
do
both
in
your
communities
and
across
the
state.
The
health
of
your
constituents
depends
on
having
strong
public
health
systems,
public
health
systems
that
keep
our
communities
safe
and
healthy
during
normal
times
and
that
are
well
equipped
and
have
the
resources
to
respond
to
crises
or
emergencies
when
they
happen.
R
So
on
that
note,
we'll
turn
to
current
achievable
opportunities
to
improve
public
health
in
nevada.
My
team,
at
the
center
for
public
health
excellence,
is
working
closely
with
the
division
of
public
behavioral
health
on
a
number
of
these
initiatives,
and
I'm
excited
to
discuss
a
few
of
them
with
you
today.
So
I
think
it
sounds
like
you're
going
to
do
a
deep
dive
into
all
things:
public
health,
as
you
get
into
the
sb
209
study.
So
today
I
just
want
to
provide
a
high
level
overview
of
a
few
opportunities.
R
Each
of
these
opportunities
has
a
legislative
policy
or
funding
component
and
I'm
sure
you'll
hear
more
about
them
as
the
interim
progresses,
but
we
are
also
happy
to
answer
questions
or
have
additional
conversations
go
into
more
detail
on
these
offline.
So
next
slide
joseph
please
so
by
way
of
background
in
nevada,
responsibilities
for
public
health
activities
are
split
between
state
and
local
governments.
R
In
addition,
statute
establishes
a
district
health
department
in
counties
with
a
population
of
700,
000
or,
more
so
currently,
clark
county,
which
is
served
by
southern
nevada.
Health
district
nrs
also
authorizes
the
establishment
of
a
health
district
in
smaller
counties,
and
these
health
districts
may
be
formed
by
two
or
more
adjacent
counties,
two
or
more
cities
or
towns
within
any
county
or
a
combination
of
county
and
cities
or
towns
within
it,
and
so
washoe
county
health
district
is
created
using
this
model.
R
In
addition,
statute
requires
all
counties
to
have
a
board
of
health
and
authorizes
cities
to
establish
a
board
of
health
as
well,
and
so
carson
city,
health
and
human
services
falls
into
this
category,
and
so,
if
this
all
seems
confusing
or
complicated,
that's
because
it
is
outside
of
clark
and
washoe
counties.
Depending
on
where
you
live.
Certain
public
health
services
may
be
provided
by
the
county.
They
may
be
provided
by
the
city,
and
so
others
may
be
provided
by
the
state
through
dpvh.
R
The
the
result
of
this
whole
system
is
that,
especially
in
rural
and
frontier
areas,
it
can
be
hard
for
residents
to
navigate
services.
It's
hard
to
or
more
complicated
to
ensure
equity
and
the
system
just
doesn't
function
as
smoothly
as
it
could,
and
these
challenges,
I
would
say,
were
highlighted
during
the
coconut
team
pandemic.
R
Washoe
clark
and
carson
were
able
to
stand
up
their
responses
pretty
quickly
because
of
existing
infrastructure
and,
like
julia
mentioned,
those
relationships
with
emergency
managers,
but
it
was
a
lot
harder
to
do
in
rural
areas
where
county
board
of
health
county
boards
of
health
may
or
may
not
have
existed,
and
if
they
did,
they
may
not
have
known
that
state
epidemiology
work
was
functioning
in
the
background
again.
This
is
public
health
happens
in
the
background,
and
so
even
those
in
positions
of
authority
may
not
know
that
it's
happening.
R
So
the
opportunity
here
is
for
rural
and
frontier
counties
to
pursue
local
administration
of
public
health
services,
and
this
would
provide
rural
governments
more
autonomy
and
independence
over
public
health
services
and
really
streamline
systems
and
processes.
It's
also
an
opportunity
to
review
statutory
language
and
consider
providing
additional
opportunities
or
flexibility
in
creating
health
districts
for
formalizing
these,
like
potentially
regional
partnerships
or
health
districts
in
rural
areas.
We
probably
don't
have
the
capacity
or
resources
to
stand
up
a
health
district
in
every
rural
county,
but
could
foresee
really
regional
health
districts
being
created
to
serve.
R
It
may
involve
a
state
or
local
public
health
agency,
and
the
academic
institution
may
be
a
school
of
public
health,
school
of
medicine
or
nursing,
an
entire
university
or
a
community
college.
It
usually
takes
the
form
of
a
letter
of
agreement,
a
memorandum
of
understanding
or
a
contract
that
identifies
the
goals,
objectives,
kind
of
mission
of
the
partnership,
as
well
as
governs
activities
and
responsibilities
of
each
partner
and
outlines
the
parameters
for
sharing
resources.
R
So
why
are
we
working
to
establish
academic
health
departments?
This
is
really
a
way
to
institutionalize
partnerships
and
allow
collaboration
to
continue
regardless
of
changes
in
leadership,
styles
and
priorities.
It
helps
narrow
the
gap
between
a
public
health,
academia
and
public
health
practice
by
bringing
academics
and
practitioners
together.
There's
this
mutual
beneficial
and
like
reinforcement,
loops
in
having
that
communication,
it's
really
focused
on
making
the
most
of
limited
public
health
resources
and
ultimately
improving
the
health
of
the
community
next
slide.
R
So
the
next
way
we'll
talk
about
improving
the
health
of
nevadans,
is
by
pursuing
public
health
agency
accreditation
through
the
public
health
accreditation
board,
which
is
a
national
non-profit
organization.
That's
dedicated
to
advancing
continuous
quality
improvement
among
public
health
departments.
R
The
accreditation
process
involves
a
framework
for
systematically
assessing
community
needs
and
services.
So
that's
this
one
piece
that
julia
mentioned
when
we
talked
about
the
public
health,
the
ten
essential
public
health
services
and
so
evaluating
what
communities
need
and
then
ensuring
that
the
services
that
we
provide
from
public
health
agencies
meet
the
needs
so
really
developing
that
plan
and
then
ensuring
continuous
quality
improvement.
R
So
it's
not
a
one
time
we
apply
for
accreditation
and
we're
done,
but
it's
really
a
framework
to
change
culture
and
thinking
and
practices
to
create
a
cyclical
process
that
ensures
that
as
needs
change,
the
services
change
and
respond
to
those
changes
at
a
high
level
accreditation
demonstrates
demonstrates
public
health
agencies
capacity
to
deliver
the
10,
essential
public
health
services.
R
R
So
if
it
is
a
fairly
complex
or
comprehensive
process,
why
are
we
pursuing
it?
We
are
pursuing
it
because
during
the
accreditation
process,
public
health
agencies
are
working
toward
being
responsive
to
change
and
focusing
on
common
goals
of
depart
the
department
or
the
agency
and
the
communities
they
serve.
They're
establishing
a
system
of
shared
decision
making
that
involves
agency
leadership,
staff,
community
partners
and
customers.
It's
a
very
community
focused
and
engaged
process
where
we're
ensuring
we're
hearing
we're
asking
the
community.
R
So
we've
talked
about
improving
public
health
in
nevada
by
pursuing
local
administration.
Academic
health
departments
and
accreditation
and
as
julia
has
mentioned,
ongoing
non-categorical
funding
is
critical
to
each
of
these
efforts,
as
well
as
other
public
health
activities,
and
there
are
numerous
opportunities
to
invest
in
the
state's
public
health
infrastructure.
R
R
R
Current
efforts
to
pursue
accreditation
for
division
of
public
and
behavioral
health
are
funded
through
federal
funds
as
well,
and
those
expire
in
june.
2023
and
ongoing
funding
will
be
necessary
to
be
necessary
to
continue
the
accreditation
process
and
really
that
focus
on
continuous
quality
improvement.
R
R
Dpdh
has
also
developed
mobile
services
to
help
improve
public
health
responses
in
certain
areas
of
the
state,
and
these
services
currently
rely
on
federal
funding
as
well,
and
once
the
spending
expires
again,
the
services
will
not
necessarily
be
able
to
continue
without
additional
resources
and
then
finally,
the
coven
19
pandemic
has
highlighted
the
need
to
expand
epidemiology
and
laboratory
services
and
oversight
statewide,
especially
in
certain
certain
counties,
and
so
we'll
need
funding
to
support
these
services
as
well.
R
I
think
probably
most
of
you
are
aware
that
historically,
public
health
has
influxes
of
funding
following
crises
or
emergencies,
but
as
soon
as
the
emergency
resolves
or
gets
a
bit,
better,
funding
tends
to
dry
up
and
public
health
is
left
to
do
all
of
the
things
you
heard
about
today.
Providing
these
core
public
health
services
that
keep
us
all
healthy,
typically
on
a
shoestring
budget,
especially
in
nevada,
but
every
as
we've
seen
during
the
pandemic.
R
It's
going
to
be
important
to
consider
investing
in
public
health
infrastructure,
and
I
know
that's
going
to
be
the
topic
of
the
sb
209
study
and
so
you'll
delve,
much
more
deeply
into
it.
At
this
point,
I
think
we're
happy
to
answer
any
questions
about
these
opportunities
or
any
of
the
information
we
presented
today.
A
Thank
you
all
so
much
for
all
that
information
and
some
good
insight
into
a
future
action
we
can
take.
I
have
a
couple
questions
that
have
come
up.
I'm
going
to
go
ahead
and
ask
assemblywoman
titus
to
kick
us
off.
J
J
It's
always
a
difficult
task
to
be
in
public
health
when,
at
the
same
time,
you
want
to
make
sure
that
individuals
have
a
right
to
that
self-determination
on
their
health,
and
it's
a
sometimes
that
fine
line
that
you
have
to
intersect.
To
do
that.
So
thank
you
for
for
all
that
you
do.
But
again
we
can't.
J
We
can't
forget
that
right
to
self-determination,
I've
been
wondering
about
the
the
percent
nevada
notoriously
has
been
low
on
vaccination
rates,
and
the
vice
chair
asked
about
what
we're
doing
to
god
and
get
the
covet
vaccine
out
there.
J
But
I'd
like
to
ask
you
about
the
percent
of
overall
vaccination
rates
that
nevada
was
before
this
crisis
and
where
we
are
now,
because
I'm
very
concerned
that
our
vaccination
rate
was,
I
think,
if
I'm
not
correct,
we're
about
50th
in
the
nation
on
all
the
other
vaccines
and
I'm
wondering
where
we
are
with
the
cova
vaccine
and
making
sure
we
haven't
lost
sight
of
the
importance
of
tetanus
shots
and
other
immunizations
shingles
and
pneumonia
and
flu
and
all
of
those.
J
L
I
think
julia
peek
for
the
record
and
then
I'll
turn
it
over
to
chris
oliver
as
well.
I
just
want
to
reiterate
in
public
health,
the
risk
reduction
model
and
self-determination
for
folks
to
assess
their
risk
and
make
decisions.
Many
public
health
programs
outside
of
covid.
We
look
at
that
and
we
provide
opportunities
for
intervention
that
may
not
be
popular
among
everybody.
Programs
that
we've
stood
up
in
the
past
include
needle
exchange
programs
that
again
appear
to
some
to
be
encouraging
drug
use.
L
But
for
us
it's
an
infection
control
measure,
that's
pivotal
for
the
people
in
the
community
that
need
it.
Also
comprehensive
sex
education
programs
again
could
be
a
very
unpopular
topic,
but
it's
something
to
provide
education
and
then
again
allow
individuals
to
make
assessments
about
their
own
risk.
So
risk
reduction
is
a
core
part
of
a
public
health
response
and
just
allowing
people
to
to
meet
people
where
they're
at
as
I've
said
multiple
times
in
this
presentation.
As
far
as
the
immunization
rates,
I'm
happy
to
turn
it
over
to
krista.
P
Julia,
thank
you,
dr
titus,
for
the
questions.
So
we
have
notoriously
struggled
in
nevada
with
vaccination
rates.
However,
we
aren't
the
lowest.
We
are
lowest
for
the
flu
as
we've
seen,
but
for
our
childhood
vaccination
rates.
If
you're
looking
at
the
series
of
vaccinations
that
children
are
recommended
to
receive
by
the
time
they're
two
years
old,
we
we
were
on
middle
of
the
pack,
probably
about
36
on
the
last.
Look
that
I
I
looked
at.
P
So
that's
looking
at
that
poor
series,
dr
titus
dtap,
measles,
mumps,
rubella,
chickenpox
hepatitis,
a
and
b
for
children
for
adult
rates
with
pneumococcal
shingles
and
others.
We
also
struggle
to
get
those
rates
higher,
but
that's
across
the
board
across
the
nation.
So,
even
if
you
were
to
look
at
the
rankings,
we
may
rank
low,
but
the
highest
ranked
in
state
is
looking
at
60
coverage
right.
P
So
we
do
track
all
of
that
and
we
work
with
our
local
health
authorities
and
all
of
our
partners
to
continue
to
enroll
more
providers
into
our
public
public
programs
like
vaccines
for
children
or
the
317
adult
program.
J
Thank
you
for
that,
because
I'd
like
to
see
us
continue
to
try
to
push
that
needle,
so
that
those
who
want
the
vaccine
any
vaccine
have
access
to,
and
I
think
a
lot
of
it
and
you'll
hear
me
bring
this
up
time
to
time
again.
Is
access
access
to
care,
rel,
information,
trusting
and,
for
you
know,
trust
the
information
they
have.
J
That
public
trust
issue
is
is
huge
and
so
just
making
sure
that
anyone
who
wants
the
vaccine
has
access
to
it,
and
especially
in
the
not
just
rural
areas,
but
especially
in
some
urban
areas
where
they
don't
have
access
to
care.
Nor
do
they
trust
what
they're
hearing
or
they
don't
hear
anything.
So
I
think
it's
important.
Thank
you
for
that.
I
didn't
hear
anybody
under
the
public
health
discussion.
L
L
There
are
so
many
things
we
need
to
do
prior
to
talking
to
you
about
your
diabetes
and
so
you're,
not
even
ready
to
talk
about
diabetes
unless
you
have
safe
again,
a
safe
neighborhood,
secure
housing,
access
to
food,
access
to
water,
etc,
and
so
we
are
part
of
those
groups
that
look
at
that,
though
we
don't,
we
don't
have
housing
supports
necessarily
in
public
health.
L
P
I
I
would
add
that
for
homeless,
we
definitely
look
at
homelessness
as
a
sorry,
dr
titus,
we
do.
We
look
at
homelessness
as
a
targeted
group
right.
So
if
we're
looking
at
immunizations
or
diabetes
prevention
work,
we
consider
people
who
are
homeless
as
a
target
group
and
how
do
we
best
reach
them
with
our
resources
and
services.
J
Little
district
ourselves
amongst
four
counties,
including
carson
douglas,
I
believe,
story
and
and
lyon,
and
one
of
when
these
folks
call
me
I
I
actually
refer
them
to
the
covet
hotline
and
this
week
again
I
decided
to
call
the
covet
hotline
because
I'm
referring
patients
to
the
covet
hotlines
or
potential
folks
to
the
covet
hotline,
and
I
and
I
got
an
answer
machine
that
said:
hey
we
were
we're
closed.
You
have
to
call
during
business
hours.
J
A
suicide
hotline
say:
hey
call
back
on
monday,
sorry
we're
not
here
and
I'm
wondering
if
we
don't
have
we.
We
have
all
these
folks
that
we're
doing
exposure
contact
tracing
those
kind
of
things
we
don't
have
people
to
monitor
the
covet
hotline,
because
folks
are
scared.
Folks
are
don't
know
what
to
do.
They
don't
know
where
to
turn
and
I'm
wondering
about
the
covet
hotline
and
should
just
be
called
covert
information
as
opposed
to
a
hotline,
or
are
we
looking
at
stepping
that
up
and
actually
giving
people
true
information?
J
Having
that
one
handoff,
where
somebody
answers
the
phone
to
say:
hey,
because
we're
doing
these
home
tests?
If
we're
sending
out
500
000
home
tests
and
people
have
now
tested,
they
won't
know
what
to
do,
and
I'm
worried
that
we're
going
to
overrun
even
worse,
limited
ability
that
we
have
now
with
staffing
at
our
hospitals
that
are
already
incredibly
busy
full
to
for
staffing
issues
and
critical
situations.
F
F
Hotline
really
appreciate
your
feedback
on
that,
and
definitely
we
can
look
at
that
and
you
know
as
people
we
had
a
lot
of
people
working
in
the
hotline
at
one
point
and
we've
had
individuals
that
have
left
and
because
things
were
slowing
down,
we
did
not
step
back
up
again
but
really
appreciate
your
feedback
again,
and
we
can
certainly
look
at
that.
L
This
is
julia
peak
for
the
record.
I
know.
Nikki
speaks
on
behalf
of
the
quad
county
phone
number,
which
is
what
dr
titus
is
referring
to.
L
I'll,
also
say
that
we
have
stood
up
resource
navigation
services
through
nevada
21,
which
has
way
more
services
than
just
covid,
but
we
did
utilize
that,
because
it's
a
known
number
and
resource,
we
also
have
the
vaccine
scheduling,
call
center
and
they
are
open
seven
days
a
week
because
again
people
work
at
different
schedules
and
have
the
availability
availability
to
talk
to
somebody
at
at
off
hours
and
on
the
weekends.
Absolutely
as
as
for
the
home
kits,
we
don't
disagree
with
you.
L
We
have
a
meeting
actually
scheduled
for
1
pm
with
a
call
center
to
talk
through
what
that
might
look
like.
Several
states
are
standing
up,
similar
resources
to
help
people
navigate
regardless
of
the
type
of
test
they
got.
What's
it
mean,
and
what
do
I
do
now,
and,
and
should
I
get
therapeutics
again-
can't
give
clinical
information
but
can
certainly
take
them
through
screening
criteria,
criteria
and
offer
resource?
So
that's
absolutely
something
we're
looking
at
and
having
conversations
today.
J
Thank
you
for
all
of
that
nikki.
Thank
you
for
the
clarification.
It
was
the
quad
county
hotline
that
I
called
I
thought.
Hey
I've
been
referring
people
to
this
quad
county
hotline.
I
ought
to
call
that
hotline
and
see
what
kind
of
information
they're
getting
so
as
you
can
imagine,
I
was
a
little
bit
dismayed
when
I
got
a
an
answer
machine,
but
I
appreciate
the
clarification.
J
Hopefully
you
may
consider
staffing
that
again
with
this
current
surge
and
these
home
tests
and
I'm
sure
julia
in
your
meeting,
you
guys
will
be
discussing
some
concerns
about
what
to
do
with
that
information.
Where
do
we
have
people
turn
and
and
how
do
we
direct
them,
so
they
don't
flood
our
emergency
room
system
even
more
than
it
already
is
and
again.
Thank
you
all.
Thank
you,
madam
chair,
for
the.
F
Please,
dr
texas,
if
you're,
when
you're
instructing
your
patients,
you
know
we
that
hotline
can
be
very
busy,
so
if
they
do
get
even
an
answering
machine
during
working
hours
make
sure
they
leave
a
message.
I
know
that
our
team
works
very
hard
to
return
any
messages.
A
Thank
you
so
much
for
the
information
on
that
and
those
hotlines
can
be
very
helpful,
as
we
know
with
telemedicine
right
for
access.
So
I'm
grateful
for
for
that
information
and
update.
I,
I
have
sent
senator
mcdonald
on
the
my
list
for
questions,
but
I
kind
of
want
to
piggyback
on
what
we
were
just
talking
about
with
information
in
excess,
with
a
question
that
I
had.
If
you
don't
mind,
so
I
will
ask
about
really
interest
in
this
academic
public
health
department
idea.
I'm
sending
something
like
that
up.
A
I
think
one
of
the
divisions
I
see
across
agencies
is
with
getting
this
newest
science
and
information
into
practice
at
the
agency
level,
and
so
I
guess
my
question,
for
you
is
right
now.
What
is
public
health's
role
in
addressing
misinformation
and
then
how
would
the
adoption
of
an
act
of
health
or
the
standing
up
of
an
academic
public
health
department
help
with
that
that
combating
misinformation
piece,
in
addition
to
all
of
the
other
things
that
they
would
do,
but
I'm
more
interested
in
that
misinformation?
L
Yeah,
julia
peake
for
the
record
I'll
go
ahead
and
start
and
then-
and
as
you
mentioned,
we
do
have
several
of
our
local
health
department.
Slot
and
again.
Dr
titus
is
a
county
health
officer
and
doing
a
a
yeoman's
amount
of
work
in
lyon
county
as
well.
So
we
can
all
speak
to
how
we're
working
on
this
we're
doing
so
much
public
messaging
and
outreach,
and
we
have
regular
calls
with
the
media
to
try
to
talk
through
that.
L
We've
also
utilized
our
medical
advisory
team,
an
objective
third
party
group
to
look
at
the
science
and
make
recommendations
to
us
in
the
governor's
office
so
that
we
do
have
that
group
of
extreme
extremely
high
level
doctors
who
serve
in
the
community
and
public
health
experts.
L
Some
of
the
challenges
with
misinformation
as
well
is
that
trusted
friend
or
family
member
or
community
partner
to
deliver
that
information,
as
opposed
to
one
of
us,
delivering
that
information
and
and
that's
an
opportunity
for
what
you're
going
to
be
looking
at
in
the
interim
study
related
to
a
public
health
service
corps.
Potentially-
and
perhaps
we
call
it
a
community
health
worker
program,
but
getting
people
who
actually
live
in
the
community
to
share
accurate
and
appropriate
information
to
the
community,
that
could
be
folks
with
no
degree.
L
One
of
the
things
we
did
early
on,
I
believe
with
cares.
Relief
funds
was
work
with
the
minority,
health
and
equity
coalition,
who
put
together
a
great
a
great
resource
for
us
with
with
focus
groups
of
specific
communities,
so
that,
as
we
looked
at
how
we're
going
to
roll
out
testing
and
vaccination
information,
they
had
already
done
the
legwork
and-
and
I
don't
know
if
you're
aware,
but
they
function
under
unlv
and
they
they
stood
that
up
with
having
their
faculty.
L
Do
the
needs,
assessments
and
then
the
evaluation
and
providing
that
information
to
us.
So
they've
been
a
pivotal
part
of
that.
The
other
thing
I'll
just
say
that
the
university
of
nevada
reno
has
done.
Is
they
set
up
through
the
judy
larson
institute
of
training
for
staff,
as
well
so
before
they
even
hit
the
health
department
for
epi
and
disease
investigation
that
they
have
basic
level
knowledge
of
the
information
to
provide?
Because
that
could
be
the
single
voice
that
an
individual
in
our
community
talks
to
to
get
accurate
information?
L
And
we
need
to
assure
that
whoever
that
person
is
the
touch
point
to
the
community
member.
They
have
the
correct
information
or
they
know
who
to
call
to
get
that
information.
So
very
long
answer
to
talk
about
misinformation,
but
our
local
health
departments
are
doing
this
as
well,
so
certainly
put
it
up
to
them
to
respond.
A
I
realize
it's
a
really
complex
piece
of
the
puzzle
to
get
our
our
hands
around
right.
Misinformation
comes
from
all
kinds
of
sources
and
it's
difficult
to
identify
and
control
those
or
come
back
as
best
we
can.
I
do
see
miss
aker
and
mr
dick
on
for
the
local
health
districts.
I'm
sure
we
have
one
from
clark
county
as
well.
I
just
don't
see
them
popping
up,
so
I'm
going
to
go
ahead
and
start
with
miss
baker.
F
So,
yes,
when
you
know
undressing
misinformation,
where
you
know
we
look
at
what
individuals
are
saying
within
our
area,
what
we're
hearing
what's
being
posted
on
our
social
media
and
try
and
get
that
messaging
out
of
the
accurate
information
we
talk
with
a
number
of
individuals
personally,
as
they're
coming
to
our
events-
and
it
is
a
big
piece
of
our
response-
is
making
sure
that
we
get
that
information
accurately
out
there.
F
We
also
use
our
board
of
health
and
our
board
of
supervisors
to
as
we
report
on
the
response
to
address
any
misinformation
and
make
sure
that
the
our
board
has
the
information
to
talk
with
their
constituents.
Q
Yes,
thank
you
kevin
dick
washoe,
county
health,
district
and
yeah.
I
think
that
there's
misinformation
and
then
there's
disinformation
and
we
have
people
that
are
actively
promoting
information
that
is
incorrect
in
our
communities
and
and
I
consider
that
to
be
disinformation,
not
just
people
that
are
missing
informed
and
we
can't
really
counter
that
on
a
point
by
point
basis,
because
when
you
get
to
conspiracy,
theory
type
approaches
to
this,
there
are
an
infinite
number
of
arguments
and
things
that
people
can
make
up
that.
Q
We
just
can't
take
the
time
to
rebut
every
single
one.
Our
efforts
are
focused
on
providing
scientific
information
and
trying
to
help
people
in
our
community
that
are
trying
to
understand
and
make
up
their
minds
about
things
so
that
they
have
that
that
correct
information,
one
of
the
things
that
we're
doing
is
at
our
board
of
health
meetings.
Q
We
have
many
people
that
show
up
to
make
public
comment,
as
we
heard
some
of
earlier
in
this
meeting,
where
they're
using
public
comment
as
a
platform
for
misinforming
our
compu
our
communities
and
in
fact
we
had
youtube,
take
down
one
of
our
deborah
health
meetings
because
of
all
the
misinformation
that
was
part
of
the
public
comment
at
the
beginning
of
the
meeting.
Q
So
we
have
now
after
the
public
comments,
we
have
added
to
our
agenda
an
update
on
covet
19
so
that
we
can
provide
correct
information
to
people
that
are
viewing
that
meeting
and
so
that
they
get
that
and
not
just
the
misinformation
that's
being
put
out
there,
and
I
agree
very
much
with
what
julia
peake
said
about
those
conversations
that
occur
between
family
members.
Q
Those
are
the
types
of
interactions
that
are
going
to
help
with
people
that
are
vaccine,
hesitant
to
influence
their
their
decision
making
and
as
as
nikki
aker
mentioned,
we
also
have
people
available
when
we're
doing
our
vaccination
clinics
to
help
talk,
talk
with
people
about
the
vaccine,
the
safety
and
how
that
was
developed.
Q
I
would
also
like
just
to
add
briefly
in
response
to
assemblywoman
titus's
question
about
homelessness.
Q
I
think
that
there's
a
a
definition
that
I'd
like
to
share
with
the
interim
committee
that
I
think
will
be
helpful
for
for
understanding,
public
health,
and
that
is
that
public
health
is
creating
the
conditions
in
which
people
can
live,
healthy
lives
and
that's
different
than
health
care,
where
primarily,
that
is
providing
medical
treatment
to
individuals.
Q
I
very
much
appreciate
all
the
vaccinations
that
are
administered
by
our
in
our
medical
community,
that
is
public
health,
but
but
public
health
is
really
based
on
creating
those
conditions
where
people
can
live
healthy
lives
and
all
of
the
the
things
that
were
presented
in
formally
in
the
presentation
are
aspects
of
that.
Q
But
miss
p
gave
a
lot
of
examples
as
well
in
her
response
of
other
things
that
we
do
working
with
partners
in
our
community
to
try
to
establish
those
conditions
for
people
to
live,
healthy
lives
and
what
we
saw
with
the
impacts
of
coping
19
in
our
communities.
Was
we
had
large
segments
of
our
population
that
weren't
living
in
conditions
that
were
allowing
them
to
live
healthy
lives
and
the
impact
of
copit19
just
exasperated
those
conditions
that
they
were
already
in?
Q
And
so
it's
really
important
that
we
we
back
up
a
little
bit
and
we
not
just
focus
on
so
much
the
statutorily
mandated
responsibilities
of
public
health
around
the
prevention
of
of
disease
and
really
understand
what
the
breadth
of
public
health
is
that
we
need
to
be
doing
in
the
state.
Q
With
that,
I
will
wrap
up
and
I'd
like
to
point
out.
We
have
michael
johnson
on
the
on
the
meeting
who
is
representing
the
southern
nevada
health
district.
A
D
Yes,
thank
you,
chair
peters,
dr
michael
johnson,
director
of
community
health,
southern
nevada,
health
district.
I
would
echo
what
kevin
and
nikki
said
we
work
very
closely
with
our
board
of
health
and
a
variety
of
other
boards
that
we
work
with
the
snhd
and
provide
we
have
a
section
on
each
agenda
for
those
meetings
about
covet,
updates
and
reinforcing
the
scientific,
credible
information
around
covid.
D
We
also
routinely
address
this
on
our
our
website
and
our
director
of
communications.
Here,
we've
done
a
variety
of
media
events
that
present
the
accurate
information
and
dispel
the
myths
around
the
misinformation,
also
within
our
clinical
services.
Any
touch
point
we
have
with
patients
or
folks
in
our
community
that
access
our
services.
We
reinforce
the
accurate
messages
and
answer
any
questions
that
that
folks
may
have
also
routinely
through
media
interviews
that
myself
and
many
others
do
here
at
the
health
district
we
routinely
reinforce
the
you
know
the
accurate
messages
and
address
misinformation.
D
So
we
we
hit
it
from
a
variety
of
fronts
since
it
it
is
a
real
problem.
I
mean
at
many
of
our
testing
locations,
including
this
morning
we
have
annie,
baxter,
show
up
who
are
saying
vaccines,
don't
work
and
a
variety
of
other
things
routinely.
So
we
we
we
do
our
best
to
address
those
with
with
the
folks
that
we
serve
thanks.
A
Thank
you
so
much
I'm
going
to
go
ahead
and
ask
senator
donati
for
his
question
now.
D
Thank
you
so
much
chair
peters.
This
question
probably
is
more
guided
towards
the
dhhs
staff.
Can
you
talk
about?
I
don't
know
if
we've
we've
mentioned
it
today,
but
I
would
love
to
hear
your
feedback
on
under
the
context
of
kova
19.
What
has
been
the
coordination
challenges
and
opportunities
between
the
state,
hhs
team
and
tribes
or
indigenous
communities?
If
you
could
touch
on
that,
that
would
be
greatly
appreciated.
L
For
the
record,
I
just
want
to
highlight
that
dem
and
our
php
programs
actually
had
a
very
good
relationship
with
our
tribal
communities
prior
to
covid.
So
that
was
extremely
helpful,
but
there
are
major
coordination
challenges
to
make
sure
that
we
are
supporting
each
tribe
in
the
way
in
which
they
want
to
be
supported,
and
so
that
has
included
providing
epi
support
when
they
ask
for
it
also
providing
test
kits.
There
have
been
challenges,
though,
with
the
relationship
with
our
federal
partners,
the
specific
tribe
and
the
state.
L
We
had
an
instance
where
federal
partners
came
out
to
do
a
visit
with
one
of
the
tribes
and
neither
the
state
nor
the
tribe
thought
they
requested
that
support,
and
so
we
kind
of
scrambled
to
figure
out
how
best
to
use
the
resource
provided
by
the
federal
partner,
and
so
there's
great
work
to
be
done
with
our
tribes.
The
other
thing
is
turnover,
relationships
are
established
and
then
I've
seen
it
through
the
cove
endemic
with
the
tribes,
but
really
with
public
health
professionals
in
general.
L
When
those
relationships
with
those
folks
end
then
trying
to
find
a
new
contact
within
each
tribe
and
and
making
sure
that
the
tribe
knows
which
person
within
the
health
department
to
reach
out
to
that
that
liaison
work
is
there
because
again
they
operate
really
independently
and
when
they
need
support,
they
need
to
know
how
they
ask
for
that
and
in
which
way.
L
We
had
regular
calls
with
our
tribal
partners
included
throughout
the
pandemic,
and
that
was
a
great
opportunity
just
to
provide
information
on
resources
and
how
to
request
the
tribes
had
opportunities
to
speak.
We
provided
updates
each
local
health
department
and
emergency
manager
provided
updates
so
that
just
the
the
communication,
which
is
always
how
we
fail
or
succeed
that
regular
communication
was
a
way
just
to
say
what
happened
this
week.
L
And
what
do
you
need
and
what's
it
look
like,
and
so
we
had
that
I
would
say
for
at
least
a
year
as
we
were
really
standing
up
the
response.
It's
dwindled
but
really
based
on
just
the
need,
and
is
it
a
good
use
of
their
time
to
meet
with
us,
but
great
amount
of
work
can
still
be
done
there.
One
of
the
things
that
we've
established
in
dhhs-
and
I
don't
know
if
sister
agencies
have
as
well-
is
that
we
have
tribal
liaisons
at
each
one
of
our
agencies.
L
We
also
have
a
tribal
liaison
at
dhhs,
so
at
the
very
least
the
tribe
knows
to
reach
out
to
that
person
and
that
person
can
help
navigate
services,
so
so
we're
doing
our
best.
But
there
is
a
great
deal
of
turnover
again
often
within
the
tribe,
that
we
just
need
to
make
sure
that
we're
communicating
with
them
regularly.
F
Yeah,
so
we
have
had
very
minimal.
F
Contact
with
the
tribes
in
carson
and
douglas,
but
absolutely
you
know
if
there
were
questions
in
that
we're
able
to
answer
them.
The
tribes
have
not
reached
out
to
us
for
any
testing
kits
any
ppe
and
we
do
have
a
healthcare
coalition
that
we
have
encouraged
the
tribe
to
be
a
part
of.
But
you
know,
as
julia
brought
up
it's
that
the
turnover
that
we
see
in
the
tribes
on
the
local
level
within
our
local
emergency
management
committee.
F
There
is
a
liaison
that
person
again
it
was
turnover
they
were
very
consistent
in
attending
and
then
they
were
getting
a
new
one
and
is
attending
more
regularly.
But
again
it's
it's
been
difficult
to
have
that
relationship.
F
We're
not
done
trying,
because
you
know
we
really
value
that
partnership
with
the
tribes.
So
so
that's
where
we're
at.
Q
Sure
kevin
dick
washoe
county
health
district.
Thank
you,
chair
peters.
We
do
work
with
our
our
tribes,
both
the
pyramid,
lake
reservation
and
the
reno
sparks
indian
colony.
However,
you
know
administratively
they're
they're
kind
of
siloed
within
the
the
way
our
indian
health
services
operates
and
and
the
just
kind
of
the
the
structure,
but
we
do
work
with
them.
They
we
do
have
I
joke.
Q
We
have
an
international
agreement
with
the
reno
sparks
indian
colony
on
our
emergency
preparedness
activities
and
and
they're
conducting
pods
along
with
us.
When
we
have
emergencies,
we
train
as
well
with
the
reno,
I'm
sorry
the
pyramid
lake
reservation
as
a
region.
In
fact
their
tribal
representatives
were
with
us
when
we
went
back
to
national
training
at
emmitsburg
on
the
response,
and
then
we
coordinate
in
various
ways
with
between
our
clinics
and
even
our
air
quality
monitoring
operations
with
them.
Q
D
Sure
yeah
I
mean
we've
had
a
similar
experience.
We
routinely
reach
out
and
disseminate
information
to
the
tribes
and
in
contiguous
surrounding
counties,
although,
as
kevin
mentioned,
the
sort
of
siloed
structure
of
tribal
nations
sometimes
makes
it
difficult
and
challenging
to
work
with
we'd
like
to
do
more
with
the
tribes.
But
but
our
experience
thus
far
has
been
pretty
minimal.
A
Thank
you.
Thank
you
for
the
responses
and
thank
you
for
the
question.
Senator
van
gaante
do
not
see
you
on
this,
so
I'm
assuming
there's
no
follow-up
on
that.
We
have
one
more
item
I'd
like
to
get
to
before
we
move
to
a
brief
lunch
break,
I'm
going
to
ask
staff
to
go
ahead
with
our
next
item
number
seven
overview
of
the
interim
study
on
the
coping
19
health
crisis
pursuant
to
senate
bill
209,
our
senior
policy
analyst
chrissy
robusto
will
present
this
topic
for
us.
K
Hi
thanks
chair
peters,
for
the
record
christy
robusto
research
division,
the
legislative
council
bureau
as
nonpartisan
staff
as
you're
aware-
I'm
not
allowed-
I'm
not
here
to
advocate
for
issues
I'm
here
to
assist
members
with
policy
issues
brought
forward
to
this
committee
and
just
to
reiterate,
please
always
feel
free
to
reach
out
to
me
or
my
colleagues.
At
any
time
for
any
questions
you
may
have.
I
will
now
review
the
covid19
interim
study
summary
with
you.
K
Since
the
responsibilities
of
the
lchc
were
transferred
to
this
committee
for
assembly
bill
443.
The
committee
must
conduct
the
study
and
make
recommendations.
There
are
six
key
areas
that
the
study
must
address
and
those
are
outlined
for
you.
The
first
being
examine
the
public
health
infrastructure
in
nevada,
which
has
been
talked
about
throughout
some
of
the
presentations
today.
K
The
committee
needs
to
report
the
results
of
the
study
and
any
recommendations
concerning
the
response
and
future
public
health
crises
to
both
the
governor
and
the
lcb
for
transmittal
to
the
2023
legislative
session,
and
it's
also
important
to
note
that
the
bill
did
not
contain
any
additional
bdrs
related
to
the
study.
Therefore,
should
the
committee
choose
to
recommend
any
study
related
to
bdrs,
they
would
have
to
come
from
the
10
general
bdrs
allocated
to
the
committee
and
with
that,
sir
peters
and
that
concludes
my
presentation-
we're
happy
to
take
any
questions.
K
A
You
for
that
and
as
earlier
discussed
in
the
committee
brief
by
mr
ashton
as
part
of
this
committee
duties,
we
are
required
to
complete
an
interim
study
on
the
covid19
health
crisis
pursuant
to
senate
bill
209.,
as
just
described
by
mr
booster.
Are
there
any
questions
from
the
committee?
See
I've
lost
a
few
folks?
A
It's
probably
about
that
time.
I
don't
see
any
questions
about
this
particular
piece
I
wanted
to.
Let
members
know
that
I
decided
on
assigning
this
interim
study
to
vice
chair
dunya,
who
was
also
the
sponsor
of
this
bill
during
the
2021
session.
People
take
charge
of
it
and
complete
the
study
requirements
with
the
assistance
of
staff
throughout
the
next
month.
The
next
months,
every
other
committee
meeting
senator
donante,
will
report
back
to
the
committee
on
the
progress
of
the
study
and
you
will
have
the
opportunity
to
provide
feedback
and
ask
questions.
A
J
Assembly,
woman
matt,
thank
you,
madam
chairwoman,
and
thank
you
for
vice
chair
to
be
willing
to
serve
that
place.
Thank
you
for
your
bill.
J
A
That
is
our
hope.
Actually,
my
hope
for
the
entire
committee
is
that
we
hear
recommendations
throughout
the
period
of
our
meetings
for
potential
bdrs,
so
we
can
individually
be
considering
those
for
personal
bdrs
as
well
as
consider
them
as
a
committee
and
continue
to
have
those
discussions
and
bet
vet
those
bills
as
or
build
ideas
as
they
come
up.
So
I
appreciate
that
comments.
Assemblywoman
titus
there
any
other
questions
before
we
briefly
break
for
a
quick
lunch.
A
I
apologize.
You
know
15
minute.
Lunch
is
not
a
lot
of
time
to
get
some
sustenance,
but
I
I
did
try
and
warn
folks
to
be
prepared.
So
at
this
point
I'm
going
to
take
a
quick
lunch
break
about
15
minutes.
It
is
12
40
right
now.
So
let's
look
at
getting
back
here
at
12
55.
A
If
we
can,
if
we
can,
we
still
have
quite
a
bit
to
get
through,
so
I
would
would
like
like
us
to
get
started
as
soon
as
we
possibly
can.
Thank
you
all
and
we'll
see
you
shortly.
A
Welcome
back
officially
back
to
order,
thank
you
so
much
for
accommodating
that
brief
break.
I
hope
everybody
got
some
kind
of
sustenance
in
a
potty
break
before
we
jump
into
this
next
section.
I'm
really
excited
about
this
particular
piece.
As
most
folks
know,
on
the
line.
Medicaid
is
one
of
our
largest
budget
items.
A
A
So
I'm
going
to
go
ahead
and
open
up
our
agenda
item
eight,
which
is
the
overview
of
a
medicaid
program
in
nevada.
We
have
administrator
suzanne
biermann
here
with
her
deputy
administrator
and
with
her
deputy
administrators
with
most
of
them.
I
think,
if
not
all
I'm
going
to
go
ahead
and
let
you
start
and
then
following
your
presentation,
we
will
take
a
few
questions
from
our
committee.
N
Great
thank
you
for
the
opportunity
cheer
peter's
happy
to
be
here
today
to
talk
a
little
about
medicaid
with
you
all.
Do
you
want
to
mention
you're
you're
correct?
We
do
have
all
of
the
medicaid
deputy
administrators
here
to
help
with
questions
and
answers
as
needed,
but
I
also
wanted
to
welcome
robert
thompson
he's
the
deputy
administrator
for
the
division
of
welfare
and
supportive
services
and
they
manage
medicaid
eligibility,
so
we
handle
the
program
and
the
service
side
and
they
do
eligibility.
N
D
N
Okay,
let
me
see
if
I
can
get
that
pulled
up.
I
apologize.
A
N
He
did
just
get
an
update,
it's
going
to
be
deputy
administrator,
phil
berell,
and
I
just
got
a
note
that
he's
pulling
up
the
slides
right
now.
So
I
think
we
should
be
good,
but
if
not
and
broadcast
could
help.
That
would
be
great.
D
E
A
N
Great,
thank
you
so
much
and
apologies
for
that
slight
delay
and
technical
difficulty.
So
here
we
have
the
overview
of
our
presentation.
As
I
mentioned
before,
I'm
thrilled
to
have
deputy
administrator
robert
thompson
joining
us
and
if
you
could
advance
to
the
next
slide,
please
we
have
kind
of
an
overview
of
a
slide.
We
use
pretty
often
when
we
do
these
presentations
kind
of
some
of
our
fast
facts.
We
call
them
about
medicaid
and
nevada.
N
We'll
talk
more
about
this,
we
have
several
slides
dedicated
to
this,
but
have
seen
a
significant
growth
in
the
program
over
the
course
of
covet
and
the
public
health
emergency.
So,
as
you
can
see
here,
we've
had
over
200
000
additional
individuals
added
to
the
program
during
the
time
of
the
public
health
emergency.
That's
about
a
33
percent
growth
in
the
program
we
can
talk
about.
N
Some
of
the
the
reasons
why
and
as
I
mentioned,
we
have
a
couple
of
additional
slides
that
dig
into
that
in
a
little
bit
more
detail,
there's
high
level
information
on
the
expenditures,
as
you
mentioned.
Certainly
one
of
the
state's
large
budget
items
don't
want
to
reflect
that
here.
N
Additionally,
we
play
a
big
part
in
maternal
and
child
health
and
are
always
looking
for
opportunities
to
work
with
our
partners
at
public
and
behavioral
health,
and
do
you
just
want
to
flag
that
we
pay
for
60
percent
of
the
birds
in
nevada
and
are
really
interested
in
working
to
improve
maternal
and
child
health
outcomes?
We
didn't
include
a
lot
of
information
on
that
today,
as
we've
heard
that
there
will
be
additional
interim
health
meetings
that
really
do
a
deeper
dive
on
that,
but
did
wanna
flag.
N
But
here
I'm
going
to
flag
that
about
75
76
of
our
enrollees
do
receive
care
from
the
now
four
managed
care
organizations,
and
I
know
that
there's
an
also
an
opportunity
this
afternoon
to
hear
from
them
directly
just
some
high-level
demographic
information
about
the
program
about
42
percent
of
the
program.
Enrollees
are
children
about
10
percent
are
duly
eligible.
Do
you
want
to
flag
that
that
particular
dual
eligible
population
and
the
elderly
and
disabled?
N
Well,
they
do
make
up
a
smaller
percentage
of
our
overall
enrollees.
They
do
account
for
a
large
percent
of
our
programmatic
expenditures,
so
that
and
then
flagging
that
medicaid
pays
for
some
benefits
that
commercial
health
insurance
doesn't
like
long-term
care.
You
can
see
here
that
medicaid
paid
for
about
62
of
nursing
facility
bed
days
next
slide.
Please,
okay,
there
are
two
sides,
as
I
foreshadowed
we'll
be
spending
a
little
bit
more
time.
Talking
about
our
caseload
increase,
and
here
you
can
see
over
the
last
year.
N
So
not
a
lot
of
pre-covered
numbers
on
this
particular
slide.
But
you
can
see
the
steady
incline,
even
over
the
the
last
year
up
from
765
000
enrollees
up
about
100
000
from
that
to
close
to
860
as
of
860
000.
As
of
november.
N
On
the
next
slide,
you
can
see
the
the
historical
trends
with
the
november
2019
data
included,
and
I
will
say,
pre-covered
and
that
whole
you
know
pre-february
2020
number
back
years
before
that
was
pretty
consistent,
our
enrollment
at
around
645
000.
So
this
just
kind
of
gives
you
a
a
little
bit
of
a
more
zoomed
out
insight
into
how
our
enrollment
has
changed
over
time.
So
from
that
pretty
consistent
around
645
to
the
the
steady
increases
that
we've
seen
during
the
time
of
the
public
health
emergency.
N
So
something
that
we've
talked
about
a
lot
is
how
the
public
health
emergency
has
impacted.
The
medicaid
program
definitely
provided
opportunities
to
ensure
that
nevadans
have
and
remain
insured
during
the
public
health
emergency.
There
are
something
that
we'll
talk
about
later
in
the
presentation
as
well.
One
of
the
hallmarks
of
the
medicaid
program
is
that
it's
a
federal
state
partnership,
so
the
family's
first
coronavirus
response
act,
which
was
passed
by
congress
in
2020,
did
a
couple
things
to
help.
N
States
address
the
public
health
emergency
and
one
of
those
was
providing
some
additional
federal
funding,
but
there
were
also
coverage,
continuity
or
maintenance
of
effort
requirements
attached
to
that
additional
federal
financing,
which
has
really
restricted
the
way
that
people
leave
the
program
during
the
the
time
period
of
the
public
health
emergency.
N
And
we
can
talk
about
that
in
in
greater
detail
and
again
one
of
those
issues
that
I'm
very
glad
that
we
have
are
counterparts
from
division
of
welfare
and
supportive
services
to
do
eligibility
determinations
joining
us
today
to
discuss
in
further
detail
next
slide,
please.
N
So
this
is
just
a
high
level
overview
of
some
racial
and
ethnic
demographics.
That
kind
of
show
you
that
medicaid
serves
diverse
populations,
and
I
always
just
like
to
focus
on
the
fact
that
medicaid
to
me
is
a
health
equity
program
and
the
decisions
that
we
make
in
the
in
the
program.
Do
you
have
implications
for
the
the
diverse
populations
that
we
serve
so
I'll
now
turn
this
over
to
my
colleague
from
the
division
of
welfare
and
supportive
services,
deputy
administrator
robert
thompson,
for
an
overview
of
medicaid
eligibility?
Thank
you.
D
Thank
you
suzanne
for
the
record
robert
thompson,
deputy
administrator
for
the
division
of
welfare
and
supportive
services,
so
the
division
of
welfare
and
supportive
services
is
the
entry
point
for
snap
tanf,
energy
assistance,
child
care,
child
support
and
medicaid.
D
The
welfare
division
is
an
integrated
agency
and
by
being
integrated,
we
do
allow
our
customers
to
apply
for
snap,
tanf
and
medicaid
on
the
same
application
being
processed
by
the
same
caseworker.
Not
all
states
offer
that
some
states
still
require
their
customers
to
apply
for
snap
at
one
agency
and
medicaid
at
another
agency.
D
Next
slide,
please
so
the
division
of
welfare
and
supportive
services
has
more
than
one
way
to
apply.
We
still
offer
in
person
service.
We
have
our
offices
throughout
nevada
and
in
our
rural
many
rural
cities,
so
we
can
offer
face-to-face,
but
through
the
pandemic
we
have
really
worked
hard
to
shift
our
customers
away
from
face-to-face
service
and
coming
into
our
lobbies
and
to
plot
apply
via
access.
Nevada
access.
Nevada
is
our
tool
to
apply
through
our
website.
D
We
also
allow
our
customers
to
apply
over
the
phone
they
can
apply
for
medicaid
over
the
phone
without
completing
an
application.
Nevada
does
allow
for
verbal
attestation
of
signatures
or
medicaid
that
is
not
allowable
for
snap
or
tanf
at
this
time.
But
right
now
we
can
let
our
customers
apply
for
medicaid.
Verbally,
we
have
over
100
on-site
community
partners
through
non-traditional
doors.
We
are
in
community
centers
detention
centers.
We
have
our
workers
going
to
the
homeless
shelters
approximately
100
throughout
the
state,
where
we
actually
go
out
into
the
community
and
connect
with
those
customers.
D
They
cannot
reach
us.
We
also
accept
referrals
through
the
health
exchange
and
our
hospitals
can
sign
up
for
presumptive
eligibility,
which
means
we
allow
the
hospitals
to
determine
eligibility.
That's
for
two
months,
a
person
coming
into
a
hospital.
If
the
hospitals
are
certified,
they
can
do
their
own
eligibility
apply
and
then
we
must
re-process
the
application
within
60
days
and
next
slide.
Please,
and
I
will
turn
it
back
over
to
suzanne.
N
N
Again,
I
know
we're
going
to
talk
much
more
about
managed
care,
but
to
just
want
to
highlight
here
that
managed
care
is
a
service
delivery
model
that
we
use
in
the
urban
county,
so
clark
and
washoe,
and
for
all
of
our
populations,
a
handful
of
exceptions,
the
most
significant
being
that
the
age,
blind
and
disabled
population
is
not
served
by
managed
care.
N
So
just
wanted
to
provide
those
caveats
here,
as
we
talk
about
enrollment
into
to
manage
care
plans
and
note
that
for
about
25
of
our
population,
this
really
doesn't
apply
because
they're
in
the
state's
fee
for
service
program.
N
N
So,
just
kind
of
wanted
to
provide
a
really
high
level
overview
of
how
this
works
for
remember
from
a
member's
perspective,
as
I
mentioned
previously
for
our
enrollees,
who
aren't
in
managed
care,
they
receive
services
from
fee
for
service,
as
I
mentioned,
that's
primarily
in
the
rural
areas,
and
we
work
with
a
vendor
to
pay
providers
directly
for
the
care
that
is
provided
under
the
state's
fee
for
service
benefit.
N
So
this
kind
of
goes
back
to
the
whole
federal
state
partnership
that
that's
the
hallmark
of
the
medicaid
program,
where
that
the
state
can
make
certain
programmatic
decisions,
as
long
as
the
overarching
federal
framework
and
rules
are
being
followed.
So
here
I
know
a
lot
of
the
optional
services
that
are
listed
here.
N
Don't
really
feel
optional
if
you're
in
need
of
those-
and
I
know
during
special
session
a
lot
of
us
had
some
some
really
difficult
conversations
around
optional
services
and
how
they
really
are
very
needed
and
make
a
huge
impact
on
the
health
and
lives
of
the
nevadans
we
serve
so
just
wanted
to
flag
that
there
there
is
that
distinction
in
the
federal
framework-
and
this
is
also
not
an
exhaustive
list
of
either
all
of
the
mandatory
or
optional
services,
but
just
want
to
provide
some
high
level
information
on
the
services
or
benefits
that
the
medicaid
program
provides
next
slide.
N
N
Okay,
I
think
we
talked
about
this
one,
so
I
won't
spend
a
lot
of
time
here,
but
just
a
graphic
depiction
again.
That
shows
the
two
service
delivery
models
that
we
use
here
in
nevada,
with
the
vast
majority
of
the
population
being
served
by
the
managed
care
organizations
which
again
you'll
hear
much
more
about
in
the
next
presentation
and
then
the
fee
for
service
program
which
again
serves
the
age
blind
and
disabled
and
members
in
the
rural
and
frontier
communities.
N
Okay,
so
a
little
bit
more
information
on
fee-for-service
since
we're
not
having
a
stand-alone
presentation
on
this
one,
but
just
wanted
to
note
a
couple
of
details
about
the
program.
Individuals
may
receive
all
medically
necessary
services
from
any
provider
enrolled
in
medicaid
primary
care.
Physician
referrals
are
not
required
for
specialist
care
under
the
fee
for
service
program.
N
N
Okay,
this
is
just
more
information
on
the
state
federal
partnership
that
that
is,
you
know,
a
really
significant
part
of
how
the
medicaid
program
works
is
that
it's
jointly
funded
and
overseen
by
the
federal
and
state
governments.
So
here
you
can
just
kind
of
see
that
feds
and
state
together
together,
pay
for
the
funding
that
goes
to
providers,
of
course
in
managed
care
organizations.
N
It
comes
through
us
to
manage
care
organizations
to
the
providers,
but
I
just
wanted
to
flag
here
that
the
federal
government
pays
a
guaranteed
percentage
of
all
of
the
costs,
and
the
federal
share
is
something
that
we
refer
to
as
fmap,
and
that
acronym
is
the
federal
medical
assistance
percentage.
So
we
include
an
acronym
slide,
but
that
is
one
that
we
use
pretty
often
and
again
just
refers
to
the
amount
of
the
programmatic
expenses
that
are
covered
by
the
federal
government.
N
Next
slide,
please,
okay,
so
this
has
a
lot
more
granular
information
when
we're
at
the
budget
committees.
We
usually
spend
a
lot
of
time
talking
about
this.
I
won't
go
into
it
in
great
detail
here,
but
do
you
just
want
to
outline
a
couple
of
things
about
the
financing
of
the
medicaid
program?
Again,
the
the
federal
medical
assistance
percentage
of
the
fmap
is
the
share
of
the
cost
of
the
programs
paid
for
by
the
federal
government.
N
As
you
can
see,
this
varies
by
eligibility
category
and,
as
I
mentioned
before,
there
are
certain
enhancements
that
the
state
is
currently
receiving.
You
can
see
on
this
chart,
there's
one
that
says
with
ffcra.
So
that's
the
family's
first
coronavirus
response
act,
which
I
mentioned,
which
has
provided
an
enhancement
of
6.2
percent,
additional
funding
for
the
time
of
the
public
health
emergency
and
again,
there's
always
a
nuance
in
medicaid.
N
So
that
applies
to
eligibility
groups
with
the
exception
of
the
newly
eligible
adults
or
the
medicaid
expansion
population,
which
already
was
receiving
a
higher
federal
share
of
funding
as
compared
to
the
pre-expansion
eligibility
category.
So
you
can
see
that
90
here
is
the
federal
matching
for
that
newly
eligible
adult
or
medicaid
expansion
population
and
then
a
lot
more
granular
information
on
the
fmap
enhancements
and
how
those
vary
by
eligibility
category.
N
N
Of
course,
medicaid
only
pays
for
people
enrolled
and
eligible
for
the
program
only
for
services
that
going
back
to
that
slide
of
the
required
and
optional
services
are
services
that
are
covered
in
nevada
and
those
are
all
outlined
in
our
contract
with
the
federal
government,
which
is
called
the
state
plan.
So
a
lot
of
times
you
hear
us
talk
about
state
plan,
amendments
or
spas,
and
those
are
really
just
amendments
to
the
state's
contract
with
cms.
N
Next,
the
provider
has
to
be
enrolled
in
medicaid
and,
lastly,
the
services
that
are
reimbursed
have
to
be
medically
necessary,
so
just
kind
of
them
four
pillars
that
are
sometimes
helpful
to
think
through.
So
just
wanted
to
highlight
that
next
slide.
Please.
N
Okay,
here
it's
been
a
busy
year
years,
so
I
wanted
to
highlight
some
of
the
the
work
around
coped
and
additional
things
that
we've
been
working
on
since
this
committee
or
the
interim
health
committee
previously
had
has
met
so,
as
I
mentioned
previously,
have
really
been
working
to
ensure
that
we
are
evolving
along
with
changing
federal
rules.
N
You
saw
all
of
our
caseload
slides
that
represent
that
33
increase
in
our
program
also
implemented
some
program
flexibilities
that
were
needed
during
the
time
of
coba
to
make
sure
that
we
could
provide
needed
services
and
quickly
respond,
also
again
evolving,
with
additional
federal
options
and
working
in
that
overarching
federal
framework
as
additional
options
for
covet
testing
treatment.
N
Vaccination
became
available
for
even
previously
uninsured
groups.
This-
the
state
medicaid
agency
here
dhcfp
work
to
implement
all
of
those,
so
just
want
to
flag
that
also
working
closely
with
the
division
of
welfare
and
supportive
services
to
implement
legislation
from
the
last
session
and
in
particular,
some
eligibility
and
coverage
expansion
options.
I
know
we're
going
to
talk
more
about
all
things.
Maternal
and
child
health
related
at
a
later
meeting,
so
won't
go
into
great
detail
about
this,
but
working
with
our
partners
at
welfare
and
supportive
services
to
implement
presumptive
eligibility,
rob
deputy
administrator
thompson.
N
I
briefly
touched
on
hospital
presumptive
eligibility,
but
we're
working
to
expand
the
settings
in
which
presumptive
eligibility
can
be
determined
for
pregnant
women.
That
again
was
coming
out
of
last
session
and
some
expansions
related
to
coverage
for
for
lawfully
residing
pregnant
women,
who
haven't
been
here
for
five
years,
who
just
wanted
to
highlight
those
expanded
coverage
opportunities?
N
Also,
we
have
worked
to
implement
additional
provider
types
and
services
to
support
maternal
and
child
health,
doulas
community
health
workers.
We
have
pending
amendments
to
the
state
plan
to
allow
us
to
reimburse
those
providers
for
services
and
have
created
provider
types
that
will
enable
that
reimbursement
for
those
critical
services
and
are
working
on
provider.
Education
related
to
those
new
opportunities.
N
Next
slide,
please:
okay
on
the
next
slide
I'll
pause
for
a
second
to
give
the
presentation
time
to
catch
up,
but
we
outlined
some
challenges
and
opportunities,
and
these
closely
aligned
with
things
that
we
have
highlighted
as
strategic
priorities
for
a
number
of
years
and
are
continuing
to
work
on.
So
one
of
those
is
promoting
continuity
of
coverage
and
care
coordination.
N
I
think
you
heard
us
talk
pre-coveted
pandemic,
a
lot
about
the
remaining
uninsured
in
nevada,
and
certainly
the
public
health
emergency
has
has
changed
all
of
that
and
data's
in
flux,
and
we
can
talk
more
about
the
process
of
what
is
called
in
technical
medicaid
parlance,
the
unwinding
of
the
public
health
emergency,
which
is
basically
the
process
of
going
back
to
doing
those
renewals
and
redeterminations
on
the
normal
process
that
existed
before
before
the
public
health
emergency.
N
So
really
working
hard
with
division
of
welfare
and
supportiveness
is
to
prioritize
continuity
of
care,
as
we
work
through
that
process
always
interested
in
things
that
we
can
do
to
enhance
and
strengthen
primary
care
opportunities
but
flag
that
we've
been
working
closely
with
public
and
behavioral
health
to
hopefully
transition
the
office
of
primary
care
over
to
the
division
of
healthcare,
financing
and
policy
to
work
on
some
of
those
programs
that
allow
opportunities
to
enhance
the
workforce,
a
lot
of
programs
with
ursa
j1
visas
and
and
other
opportunities
to
to
grow
our
workforce
addressing
children's
behavioral
health
needs.
N
I
I
know
there's
mention
of
this
in
the
public
and
behavioral
health
presentations
this
morning,
but
just
really
aware
of
those
increased
needs
for
behavioral
health
generally
and
children's
behavioral
health,
specifically
always
working
on
initiatives
and
opportunities
to
advance
affordability
and
value-based
purchasing
initiatives.
N
We
have
another
presentation
related
to
that
this
afternoon,
so
just
want
to
be
cognizant
of
the
fact
that
we
know
that
medicaid
is
a
large
part
of
the
state's
budget
and
want
to
be
good
stewards
of
taxpayer
dollars
and
smart
purchasers
of
care.
So
always
looking
for
opportunities
before
a
crisis,
you
need
to
be
a
little
bit
more
proactive
in
how
we
can
increase
the
value
of
services.
N
We
provide,
as
I
mentioned
a
little
bit
before,
are
aware
of
the
workforce
challenges
that
face
the
state
and
working
with
partners
to
to
help
address
those
assume
that
the
continuous
coverage
requirement
is
the
technical
requirement
that
has
led
to
kind
of
the
pausing
of
redeterminations
during
the
public
health
emergency.
So,
as
I
mentioned
before,
planning
for
the
unwinding
of
of
those
requirements
when
the
public
health
emergency
ends
and
promoting
coverage
and
trying
to
reduce
churn
throughout
that
process.
N
Another
thing
I
know
we've
talked
a
lot
about
kobed
and
I
appreciate
the
state
biostatistician
presenting
before
me
this
morning
on
the
vaccination
rates
for
nevadans
and
did
just
want
to
flag
that
in
nevada
and
every
state,
the
medicaid
population
significantly
lags
the
overall
state
average
for
vaccination,
coveted
vaccination
uptake
and
that's
something
that
we've
been
working
really
closely
with
our
managed
care
organizations
to
to
try
to
address,
but
is
certainly
a
challenge
for
us.
N
So
I
know
that
was
a
lot,
but
just
wanted
to
give
you
all
a
high
level
overview
of
the
program,
some
of
the
things
that
we've
been
working
on
and
some
of
our
ongoing
challenges
and
opportunities,
and
also
wanted
to
provide
the
opportunity
for
deputy
administrator
thompson
to
add
anything
here,
related
to
challenges
and
opportunities
from
the
dwis
perspective,
sorry,
division
of
welfare
and
supportive
services.
A
Thank
you
and
thank
you,
deputy
administrator
thompson
as
well
for
your
time
today.
Are
there
any
questions
from
my
committee
members?
I
have
a
few
sorry
I'm
having
to
expand
my
screen
a
little
bit
to
see
no
assembly.
Woman
titus
has
questions,
and
then
I
have
a
symptom
of
haven
as
well.
Assemblywoman,
I
believe,
is
having
her
video
off.
So
I
think
we
still
have
her
audi
video
so
go.
A
J
J
I
have
a
ton
of
questions
but
I'll
try
to
keep
it
the
policy
because
you
know
I
ask
a
lot
of
these
questions
at
ifc
on
the
monies
committee,
but
at
the
ifc
committee
I
asked
a
policy
question
and
you
were
going
to
get
back
to
me
regarding
the
medicaid
spending
trends
by
provider
type,
and
I
still
don't
have
that,
and
I
really
think
that
you
mentioned:
we've
had
a
33
increase
in
medicaid
enrollment,
but
you
didn't
say
anything
about
what
percent
increase
we
did
on
providers.
J
You
mentioned
different
provider
types,
but
not
how
they're
being
utilized
and
along
with
that
same
question
of
that
860
000,
medicaid
enrollees,
that
doesn't
necessarily
mean
they
had
access
to
care
and
I'm.
I
asked
this
question
a
lot.
I've
never
gotten
an
answer.
I
would
love
an
answer
now
you
keep
saying.
Well,
it
takes
time,
there's
a
delay
in
the
provider's
billing.
J
I
still
need
to
know
did
are
those
folks
accessing
care
and
what
the
provider
spending
trends
are.
N
So
I'm
happy
to
follow
up
or
I'm
not
sure
if
mr
cassara
is
still
on
and
can
speak
to
that,
but
happy
to
make
sure
that
we
get
that
to
you
happy
to
walk
through
it.
It's
quite
a
long
report,
but
we
we
do
have
and
did
provide
that
information
to
legislative
staff.
J
Great
thank
you
for
that.
Hopefully,
I'm
still,
if
I
turn
my
video
on,
you
still
get
that,
but
I'd
love
to
see
that
looking
forward
to
that
did
you
also
include
the
percentage
of
increase
in
providers
that
have
agreed
to
see
medicaid
patients
because
one
of
the
things
I've
pointed
out
time
and
time
again,
I
would
see
whoever
walks
through
my
door,
but
the
reality
is.
I
couldn't
get
them
referred
to
anybody
how
we
improve
that.
N
N
We
do
have
reports
that
we
do
on
a
regular
basis
around
access
to
care,
there's
actually
a
federal
regulation
that
applies
to
the
fee
for
service
program
called
the
access
to
monitoring
review
plan,
and
we
just
updated
that
when
we
went
through
the
ab3
process,
which
was
the
the
budget
reductions,
you
know
the
six
percent
rate
reductions
that
we
work
to
implement
and
then,
due
to
some
additional
funding
that
was
identified
during
session,
didn't
end
up
implementing
that
which
I
think
we're
all
really
grateful
and
didn't.
N
You
know
grateful
that
that
didn't
come
to
fruition,
but
we
did
a
lot
of
work
with
our
federal
partners
to
actually
get
approval
and
effectuate
those
rate
reductions.
We
were
still
in
the
process
of
it
during
legislative
session,
but
we
have
updated
those
access
to
monitoring
ruby
plans
and
on
the
fee
for
service
side.
That's
really
the
the
best
report
that
we
have
about
the
overall
access
to
care
and
again
it
is
updated
on
a
regular
basis.
So
we
can
also
provide
that
information.
I
mean.
N
Unfortunately,
I
don't
have
a
data
system
that
says
x,
y
and
z
providers
across
the
state.
Are
you
know,
accepting
new
medicaid
enrollees
on
a
daily
basis?
That
would
be
wonderful.
I
I
don't
know
how
to
get
there
but
open
to
all
ideas
on
that
and
happy
to
provide
that
access
to
monitoring
review
plan.
I
would
also
note
on
the
managed
care
side
which
serves
you
know
about
75
percent
of
the
state's
population.
N
There
are
different
federal
requirements
around
network
adequacy,
so
that's
something
that
we're
constantly
monitoring
and
working
with
the
plans
on
to
ensure
that
they
are
meeting
those
it's
kind
of
the
managed
care
version
of
the
access
standards.
So
they
may
also
have
additional
information
to
provide
during
their
presentation
on
that
today,
but
did
want
to
flag
those
two
ways.
We
can
provide
additional
information
on
provider
enrollment
and
the
number
of
new
providers
that
we
have
seen
over
time.
J
Great,
thank
you,
and
also
one
of
the
things
we're
looking
at
in
behavioral.
Health
is
the
concept
of
computer
programs
of
open
bed
so
that
we
know
if
there's
a
bed
available,
especially
in
the
mental
health
aspect
of
it,
and
is
there
any
thought
of
medicaid
looking
at
using
such
a
program
so
that,
as
a
provider
we
can
know,
maybe
what
medicaid
providers
are
out,
there
would
receive
a
patient,
and
maybe
that
could
be
a
thought
that
moving
forward
we
could
solve
some
of
this
referral
problems.
J
N
J
That
is
there
any
of
that
residual.
Then
sitting
in
the
budget.
That's
not
used,
because
now
we've
taken
that
money
from
the
federal
government
do
we
have
an
excess
there.
That
has
not
been
allocated
to
fade
to
your
increased
rates
or
reimbursing
providers
or
some
incentive
to
see
medicaid
patient
yeah.
N
So
I
will
see
if
our
fiscal
deputy
wants
to
chime
in
on
this
question,
but
I
do
believe
you
know
there's
still
a
lot
of
uncertainty
around
how
long
the
public
health
emergency
is
going
to
last
there's
going
to
be
a
period
of
time
when
we
are
working
to
reinstitute,
renewals
and
redeterminations.
But
that's
and
perhaps
deputy
administrator
thompson
could
provide
more
information
on
this,
but
that's
not
an
overnight
process.
So
it's
not
like
a
flip
the
switch
and
the
230
000.
N
You
know
individuals
have
been
redetermined
at
once,
so
that
will
be
a
gradual
process
and
there's
still
uncertainty
at
the
federal
level
around
the
enhanced
fmap.
Currently
under
current
law,
which
is
the
family's
first
corona
virus
response
act
that
fmap
will
end
at
the
last
day
of
the
quarter
in
which
the
public
health
emergency
ends
and
we'll
still
be
working
on
renewals
and
redeterminations
during
that
time
period.
N
So
there
will
be
a
time
period
where
we
still
have
enhanced
caseload
and
are
no
longer
receiving
the
enhanced
stuff
map,
so
we're
trying
to
to
budget
with
a
lot
of
uncertainties
right
now.
So
that
would
be
my
high
level
answer
and
I
would
pause
to
see
if
our
finance
team
has
anything
they
would
like
to
add,
but
hopefully
that
that's
helpful.
J
It
doesn't
and
and
this
finance
team,
because
this
is
getting
lengthy,
they
can
respond
and
I'd
like
I'd
like
to
see
all
the
the
information
that
you
say,
you've
provided
it'd
be
great
to
send
it
out
again
to
because
we
do
have
new
members
on
this
committee
and
perhaps
didn't
see
that
so
I
haven't
seen
it
I'd
love
it
final
question,
one
of
the
many
times
we've
spoken
there's
been
questions
regarding
removing
folks
from
the
roles
and,
as
folks
have
gotten
employed
and
there's
other
options
for
them
out
there
and,
as
we
know,
without
without
being
employed.
J
When
this
initial
happened,
we
had
a
lot
of
people
move,
leave
our
state
to
move
in
with
other
family
members
etc.
And
it's
been
a
concern
about
removing
folks
from
the
rules.
Where
are
we
in
that
process?.
N
Yo
I'll
start
and
then
invite
deputy
administrator
thompson
to
add
or
clean
up
any
of
this.
I
don't
get
wrong
right,
but
there
are
instances
in
which
the
division
of
welfare
and
supportive
services
can
close
eligibility
even
right
now
during
the
continuous
coverage
requirements
that
we've
been
talking
about,
and
those
are
things
like
if
someone
dies
or
moves
out
of
state
or
asks
for
their
case
to
be
closed
again.
N
D
So
robert
thompson
for
the
record
suzanne,
you
are
correct.
The
only
other
exceptions
we
make
are
cases
that
were
approved
in
error
or
a
customer
refusing
to
comply
with
our
investigation
and
recovery
if
we
suspect
fraud
and
they
will
not
cooperate
with
us
but
other
than
those
you
are
accurate.
J
A
Thank
you
no
problem.
We
understand
technical
difficulties
in
this
day
and
time
I
just
dropped
off
twice
during
the
presentation
because
of
my
own
technical
difficulties.
So
thank
you
for
your
questions.
I
have
an
assemblyman
next
and
then
some
here
hardy
on
the
list,
after
that
we
do
have
another
couple
of
things
to
get
through
today.
A
So
let's
keep
these
as
specific
as
possible
to
what
the
presentation
was
on
today
and
if
you
have
additional
questions
that
we
can
move
into
other
or
either
offline
or
other
topic
areas,
we
can
do
that
in
future
topic
items
so
go
ahead.
Assembly
manhattan.
D
Thank
you,
man,
I'm
sure,
and-
and
I
just
want
to
to
thank
everyone
on
on
this.
I
I
look
at
the
medicaid
information
that
you
just
presented
and
looks
like
you
guys
have
done
an
absolute
excellent
job
at
getting
people
enrolled.
D
You
know
adding
200
000
people
to
the
roles
with
33
that
that's
just
absolutely
amazing.
I
know
during
regular
session
we
were
trying
to
figure
out
how
to
get
people
enrolled
and
it
looks
like
you
guys
have
done
it,
and
so
congratulations
on
the
great
work
and
and
I'd
just
like
to.
I
know
that
you
one
of
the
challenges
for
you
was
the
primary
care
chair,
peters
and
I
actually
spoke
yesterday
about
the
the
workforce
issues.
D
We
feel
you
there
and
we
we
we're
hoping
that
something
during
the
center,
and
we
can.
We
try
to
address
that
and
bring
something
forward
to
help
that
process,
because
it's
not
just
in
medicaid
it's
across
the
whole
spectrum
of
health
care
right
now,
and
so
I
I
feel
your
pain
there,
and
hopefully
we
can.
We
can
do
something
to
help.
D
The
question
that
I
have
was,
with
this
increased
growth
in
the
medicaid
coverage.
Do
we
still
have
an
idea
of
you
know
how
many
people
are
a
percentage
of
the
population?
That's
still
uninsured,
that
qualifies
for
medicaid.
N
So
I
think
thank
you
for
the
question
assemblyman.
I
think
it
is
a
great
question.
It's
something
that
I
wonder
about
a
lot
and
my
sense
of
it
is
that
we're
going
to
have
to
wait
until
after
the
public
health
emergency
and
see
what
it
looks
like
once
we're
done
with
redeterminations
to
really
have
a
sense
of
what
the
new
normal
is
to
compare
to
both
during
the
time
of
the
public
health,
emergency
and
pre-public
health
emergency.
N
To
really,
you
know,
compare
those
remaining
uninsured
numbers
pre-covered
right
now
and
then
what
we're
looking
like
once
we're
done
with
the
unwinding
of
the
public
health
emergency.
So
that's
the
the
best
answer
I
know
to
give,
but
I
really
think
it's
a
great
and
fascinating
question
and
you
know
wonder
a
lot
about
how
much
of
that
growth
has
come
from
the
remaining
uninsured.
N
And
you
know,
we've
talked
a
lot
about
that
report
from
2019
from
the
gwen
center,
which
was
the
last
real,
comprehensive
reporter
data
point
that
I
have
that
looked
at
this
question
in
great
detail,
but
really
to
look
at
it
and
see
what
that
looks
like
when
we're
done
with
unwinding
and
the
federal
government
and
our
partners
there
centers
for
medicare
medicaid
services
are
really
interested
in
this
question
as
well
and
trying
to
promote
continuous
coverage
to
the
to
the
extent
possible
I
mean-
certainly
I
think
everyone
knows
and
realizes
that
there
will
be
people
that
are
no
longer
eligible
because
of
income
and
those
are
appropriate
disenrollments.
N
I
think
there's
there's
widespread
agreement
on
that
point,
but
really
asking
for
a
lot
of
data
to
track
this
issue
so
from
states
and
our
our
colleagues
at
division
of
welfare
and
supportive
services.
I
know
that
they're
going
to
be
requesting
regular
reporting
on
this.
So
I
I
think
it's
a
great
question
that
I
don't
know
how
we
ever
say.
You
know
this
200
000
was
that
200
000,
but
I
think
you
know
just
thinking
through
it.
There's
got
to
be
overlap.
N
There,
but
I
don't
unfortunately,
have
any
report
to
point
to
and
I
think
it
would
be
pretty
difficult,
if
not
impossible,
to
do
while
we're
still
in
such
a
volatile
state
with
you
know
so
much
flux
and
all
of
our
our
numbers
that
will
occur
once
we
start
redeterminations.
D
Completely
understand
when
those
numbers
do
become
available,
I'd
love
to
see
them
because
again,
I
think
you
guys
have
done
an
absolutely
amazing
job
at
trying
to
capture
as
many
folks
as
possible,
and-
and
so
I
just
didn't
the
other
question-
I
won't
have
an
answer
for
me
today,
but
the
you
know
the
remaining
population
percentage
that
you
guys
are
targeting
to
to
try
to
get
enrolled.
N
Well,
thank
you
for
your
interest
and
we
would
be
happy
to
come
back
and
provide
regular
updates
on
these
questions
because
they
are
really
important
to
us,
and
you
know
that
goal
of
promoting
coverage
so
happy
to
provide
ongoing
updates
on
on
those
questions.
A
E
Thank
you,
madam
chair.
I
appreciate
the
presentation,
simple,
direct
and
actually
optimistic
for
helping
people
through
their
difficult
times
and,
quite
frankly,
even
though
we
have
heard
over
and
over
how
medicaid
doesn't
pay
all
the
costs
that
hospitals
have
or
not
for
medicaid
and
being
able
to
cover
so
many
lives,
hospitals
probably
be
in
a
worse
position,
which
means
the
loss
of
the
economic
benefit.
Now
I
don't
know
if
we've
been
able
to
figure
out
the
loss
of
the
private
benefit,
the
economic
benefit
in
this
covid
era,
our
ameri
emergency
pandemic.
E
We
know
that
we've
probably
had
a
loss
of
income
for
the
private
sector
does.
Has
there
been
thought
of
how
this
portends
to
the
actuarial
approach,
to
what
happens
with
what
we're
discussing
with
a
single
source
or
a
look
at?
Has
there
been
a
juxtaposition
actuarial
study
to
say,
what's
going
to
happen?
If
we
go
to
a
single
source
like
we
virtually
have
a
partial
single
source
to
look
at
modeling
right
now
with
medicaid?
N
Thank
you
for
the
question
senator
hardy.
I
think
it's
a
really
interesting
question
and
I'll
take
a
shot
at
it,
and
hopefully
my
responses
do
a
good
job
of
at
least
addressing
part
of
your
your
questions.
So
one
thing
the
medicaid
managed
care
rates.
Do
you
have
actuarial
requirements
and
they
have
to
be
actuarially
sound,
so
we
do
work
with
a
contracted
team
of
actuaries.
That's
really
specific
and
highly
technical
skills.
So
we
have
to
certify
that
our
rates
are
actually
sound
for
medicaid
managed
care
to
the
federal
government.
N
So
we
do
work
on
that
piece.
I
think
your
broader
question
might
have
had
to
do
with
coordination
between
medicaid
and
the
other
payers
and
the
public
option.
Does
that
sound
right
then
that
we'll
be
talking
about
later
today
in
the
presentation
on
senate
bill
420,
that's
what
I
was
imagining.
You
are
alluding.
N
Okay,
great,
so
there
is
an
actuarial
study,
and
this
is
a
part
of
the
presentation
that
I'll
present
on
sb420
that
it
requires
sb
420
requires
the
department
of
health
and
human
services
to
apply
for
and
submit,
what's
called
a
1332
waiver
and
I'll
explain
that
in
my
next
presentation
to
the
federal
government
and
as
one
of
the
requirements
of
the
1332
waiver,
there
are
requirements
for
actuarial
analyses
and
studies
that
accompany
any
1332
waiver.
N
So
and-
and
there
are
provisions
in
sb
420,
that
promote
alignment
and
coordination
between
medicaid
managed
care
and
the
public
option
to
be
developed.
We're
working
on
that.
That's
a
lot
of
my
presentation
on
sb
422.
N
It's
a
process
and
that
plan
is
set
to
become
effective
or
operational
on
january,
1st
of
2026
so
still
very
early
in
the
implementation
phases
of
all
of
that
work.
But
there
certainly
is
thought
to
how
medicaid
can
best
align
with
those
with
that
those
new
public
option,
opportunities
that
are
being
developed
and
both
medicaid
managed
care
rates
and
1332
waivers
do
require
some
actuarial
analyses.
E
I
guess
that's
part
of
it:
how
much
did
we
lose
in
the
private
industry
with
covid
as
it
were,
and
depending
on
medicaid?
What
was
the
overall
hit
to
private
industry,
private
hospitals,
private
care
providers
dependent
now
on
medicaid,
but
not
being
able
to
get
as
well
remunerated
as
they
were
with
private
industry
insurance
type
plans.
A
If
not
senator
hardy,
that
is
a
piece
of
this
interim
puzzle
that
I
would
love
to
continue
to
explore
with
our
private
stakeholders
to
talk
about
what
some
of
these
losses
have
looked
like
and
what
the
future
of
private
industry
looks
like
as
we
unwind
the
from
the
public
emergency
and
as
more
people
move
off
of,
hopefully
medicaid
and
onto
those
private
insurance,
or
as
we
establish
this,
the
state
option
the
public
option
and
people
have
that
option
as
well.
So
suzanne,
if
you
have
some
I'm
sorry,
I
missed
you.
A
If
you
have
something
that
you'd
like
to
add,
that's
fine,
if
not,
we
can
move
on
to
the
next
topic.
N
Thank
you,
chair
peters,
it's
a
really
interesting
question,
but
I
don't
have
a
number
or
a
hard
answer
for
that.
So,
but
I
do
think
it's
an
interesting
question
and
you
know
happy
to
continue
to
provide
medicaid
related
information
as
you
all
work
work
through
some
of
these
really
global
health
systems,
questions
that
you're
addressing
in
the
interim
soon.
Thank
you.
J
Chair
peter
may
ask
one
more
question
before
we
leave
this
topic.
Yes,
we.
J
Yeah,
real
quick
and
you
won't
be
able
to
answer
this,
but
when
you
give
us
all
this
information
afterwards,
would
you
please
include
I'm
curious
and
how
much
we
are
actually
spending
per
medicaid
recipient?
Now,
we've
we've
bumped
up
the
enrollees.
We
have
a
significant
amount
and
I
think
a
simple
number
would
be
what
what
did
we
spend
this
year
actually
spend
per
medicated
patient,
not
how
many
we
have
enrolled
versus
what
we
spent
per
medicaid
patient
in
the
say
the
last
couple
years,
if
you
could
add
that
data
to
it
that'd
be
great.
A
A
Under
this
agenda
item
we
will
hear
a
total
of
five
presentations.
The
first
presentation
is
from
miss
rubilid.
I
apologize
if
I
said
that
incorrectly
I
tried
to
get
some
coaching
from
my
staff
with
nevada
medicaid,
followed
by
a
presentation
from
each
of
the
four
mcos
in
nevada.
A
You
will
hear
all
the
presentations
and
then
I
will
open
it
up
for
some
questions,
but
only
after
those
presentations,
so
we
can
make
sure
everyone
gets
their
adequate
amount
of
time
and
during
this
piece
please
either
take
notes.
Send
me
a
quick
message:
if
you're
interested
in
asking
a
question
or
raise
your
hand
and
hear
it
always
work,
miss
rubelin,
please
go
ahead.
G
Thank
you
good
afternoon,
chair
peters
and
members
of
the
committee.
I
am
sandy
rublet,
I'm
a
deputy
administrator
for
the
division
of
health
care
financing
and
policy.
I
have
oversight
responsibility
for
the
managed
care
and
quality
assurance
department.
I
also
have
with
me
teresa
carsten
she's,
a
chief
with
the
division
and
she
oversees
the
managed
care
and
quality
unit.
In
case
we
have
any
detailed
questions
that
I
can't
address
next
slide.
G
G
Mandatory
enrollment
is
in
urban
clark
and
washoe
counties.
Disenrollment
may
occur
for
individuals
in
unique
situations
and
tribal
members
have
the
option
to
opt
out,
managed
care
organizations
help
members
navigate
the
health
care
system.
They
must
maintain
an
adequate
network
of
healthcare
providers
and
they
have
the
flexibility
to
offer
additional
value-added
services.
So
examples
of
value-added
services
would
be
supportive,
housing,
costco,
memberships,
free
cell
phones,
things
of
that
nature
next
slide,
and
so
here
are
our
current
four
managed
care
organizations.
G
We
have
anthem,
health
plan
of
nevada,
silver
summit
health
plan
and,
as
of
january
1,
we
have
malena
healthcare
and
they
will
also
be
presenting
to
you
after
this
presentation.
G
G
Okay,
so
we
did
reprocure
the
managed
care
contracts,
and
so
we
just
finished
that
the
new
contract
started
january
1..
Our
approach
to
that
procurement
was
that
we
contracted
with
mercer
government
health
services
consulting
to
assist
us.
G
We
also
did
conduct
eight
community
listening
sessions
and
some
key
decisions
that
were
key
facts
that
we
put
into
the
decision
to
award
up
to
four
contracts
were
the
ability
to
expand
and
have
additional
choice
for
members,
a
minimum
number
of
covered
lives,
threshold
for
a
new
vendor
to
sustainably
operate,
and
then
the
administrative
burden
on
providers
and
state
staff
for
oversight
next
slide.
G
We
did
undergo
an
external
quality
review
readiness
review,
which
is
required
by
cms
before
allowing
molina
to
go
live
and
we
do
have
a
command
center
still
ongoing
to
triage
transfer
of
care
issues.
You
know
the
best
laid
plans
always
have
potential
issues,
and
so
we
do
meet
twice
a
day
at
the
beginning
of
the
day
and
end
of
the
day.
To
make
sure
we
can
timely
address
any
problems
with
transition
of
care,
and
so
the
contract
did
require
an
equal
distribution
of
members
among
the
plans.
G
So
all
four
plans
we
distributed
25
percent
per
plan
in
order
to
reduce
resi
recipient
disruption
and
create
market
stability.
We
also
offered
all
members
whether
they
were
redistributed
to
another
plan
or
not
the
ability
to
switch
plans.
We
did
make
exceptions
for
members
that
were
considered
high
risk,
and
so
examples
of
that
were
members
that
were
currently
receiving
dialysis
or
chemotherapy
members
receiving
high-risk
case
management,
which
would
include
high-risk,
pregnant
members
and
members
receiving
value-added
benefit
of
housing.
Services
are
on
a
waiting
list
to
receive
housing
services,
and
then
we
did.
G
Okay,
so
contract
improvements.
So
these
are
some
of
the
things
that
are
different
from
the
former
contracts
that
we
are
implementing
with
the
new
contracts.
So
there
are
changes
to
maternal
and
child
health.
Criminal
justice
involved,
behavioral
health
systems,
both
adult
and
children,
health,
equity,
and
then
there
is
a
new
community
reinvestment
requirement.
G
Okay,
so
in
the
area
of
maternal
and
child
health,
we
do
have
performance-based
auto
assignment
algorithms,
which
are
focused
on
outcomes
starting
in
2023,
and
so
what
that
means
is
if
a
member
doesn't
choose
and
falls
into
the
auto
assignment,
it
will
be
weighted
on
based
on
contractor
performance
and
the
maternal
child
health
outcomes,
with
the
preference
given
to
the
higher
performing
contractors
we
did,
we
do
have
obstetrics
centers
freestanding
birthing,
centers
added
as
an
essential
community
provider.
G
G
Excuse
me
so
for
the
criminal
and
just
criminal
justice
involvement,
we
have
a
corrections
liaison
to
facilitate
medicaid
enrollment
and
transitions
from
prison,
as
as
the
data
is
available,
we
do
have
some
timing
issues
with
the
data
getting
it
as
currently
as
we
could.
So
we
have
the
we
do
have
to
identify
a
housing
lead
to
assist
individuals
exiting
the
criminal
justice
system.
We
also
ensure
care
coordination
and
case
management.
Connections
are
available
for
health
care
services
and
community
resources
next
slide,
so
the
behavioral
health
system
enhancements
so
residential
treatment.
G
G
We
have
directed
payments
established
to
ensure
that
payment
methods
are
maintained
for
certain
providers,
university,
medical
center
unit,
university
of
nevada,
reno
and
certified
community
behavioral
health
centers.
It's
a
long
sentence
there
crisis
stabilization,
centers
are
designated
as
essential.
Community
providers
and
public
mobile
crisis
teams
are
also
designated
as
essential
community
providers.
G
Okay,
so
children's
behavioral
health
system
has
been
broadened
state
and
county
children's
programs
added
as
essential
community
providers.
Access
to
treatment
providers
and
services
for
12
months
is
required
for
children
leaving
custody,
regardless,
if
in
network
of
the
plan
that
they
are
entered
into.
G
G
We
require
a
public
population
health
strategy
which
addresses
health
equity,
and
we
require
participation
in
in
a
statewide
project
to
reduce
african
american
morbidity,
morbidity
and
mortality
next
slide,
so
community
or
investment.
We're
really
excited
about.
This
is
a
new
requirement
for
our
contracts.
We
require
the
plans
to
reinvest
three
percent
back
into
the
communities
to
support
population
health
strategies
and
so
part
of
that
implementation
is
that
we
require
their
plans.
They
are
due
to
the
state.
G
So
we're
hopeful
that
future
data
collection
will
allow
medicaid
to
strengthen
time
and
distance
network
adequacy
standards
in
the
future,
and
then
we
are
also
participating
in
the
988
implementation,
in
coordination
with
the
division
of
public
and
behavioral
health
for
emergent
crisis.
Behavioral
health
needs.
A
Thank
you,
miss
rubella.
We
really
appreciate
that
information.
I
know
there
are
a
couple
questions
that
have
already
come
up
about
the
nco
in
your
on
your
particular
area,
but
we
will
wait
until
after
mcs
have
the
opportunity
to
present
to
ask
this
question.
So
hang
tight
folks,
all
right
now.
Our
first
managed
care
organization
presenting
today
will
be
from
anthem,
nevada,
medicaid,
blue
cross,
blue
shield.
We
have
lisa
bogart
and
lisa
thompson
here
to
present
on
behalf
of
anthem.
I
Thank
you
good
afternoon
for
the
record.
This
is
lisa
bogard
health
plan,
president
for
anthem,
nevada,
presenting
with
me
today,
is
dr
lisa
thompson,
she's,
one
of
our
esteemed
anthem,
medical
directors.
Thank
you,
chair
peters,
for
the
opportunity
to
present
to
the
committee
today
next
slide.
Please.
I
One
in
eight
americans
actually
hold
a
blue
cross
and
blue
shield
member
card.
That's
over
117
million
people,
and
that
includes
about
10.4
million
people
in
25
states
who
are
anthem,
medicaid
members,
anthem's,
87
years
of
experience
across
the
country,
extensive
visibility,
robust
membership,
deep
community
support,
as
well
as
a
broad
range
of
services,
not
only
makes
it
a
recognized
brand,
but
also
one
of
the
most
trusted
brands
in
providing
medical
coverage
for
all
stages
of
life
and
and
various
life
needs
next
slide.
Please.
I
So
I'm
incredibly
proud
that
we've
been
able
to
bring
anthem's
history
experience
and
resources
to
the
great
state
of
nevada.
In
fact,
anthem
has
been
serving
nevada
for
more
than
50
years
and
we
have
been
a
trusted
partner
with
our
state
for
over
12
years
we
have
more
than
427
nevadans
that
receive
services
that
includes
our
commercial
government,
sponsored
specialty
health
plans.
I
So
that's
one
in
every
five
nevadans
at
anthem.
We
we
know
nevada.
We
have
been
in
nevada
for
so
long
and
serving
so
many
nevadans
that
we've
become
experts
at
really
evolving
programs,
services,
value-added
benefits
and
offerings
to
effectively
really
align
with
our
state
priorities
and
to
address
a
broad
range
of
nevada
life
needs.
I
We
also
have
more
than
1
300
nevadans
that
are
employed
by
anthem
and
that's
inclusive
of
our
call
center
here
locally
in
las
vegas,
and
we
were
also
the
first
nevada
health
plan
to
be
accredited
by
ncqa
and
to
be
awarded
the
multicultural
health
care
distinction
by
ncqa,
which
certainly
vouches
for
our
experience.
In
serving
diverse
populations,
we
offer
service
plans
for
many
life
needs
that
includes
medicaid
medicare,
employer-sponsored
insurances,
federal,
employee
coverage,
specialty
vision
and
dental
and,
of
course,
the
aca
exchange
plans.
I
So,
basically,
if
nevada
has
a
need,
we
work
for
a
solution,
which
is
why
we
really
enjoyed
such
a
collaborative
relationship
with
our
state
partner
over
the
years
and
and
why
we
look
forward
to
doing
a
lot
more
in
our
aligned
mission.
C
Thank
you
lisa
good
afternoon,
everyone
for
the
record.
I
am
dr
lisa
thompson.
As
lisa
pointed
out,
we
serve
all
nevadans
and
we
meet
them
wherever
they
are
in
their
healthcare
journey.
Anthem's
vision
is
to
improve
the
health
of
humanity.
How
do
we
do
that
through
our
population
health
strategy?
I
know
population
health
is
a
buzz
phrase.
That's
been
thrown
around
a
lot
lately,
but
for
us
at
anthem,
it's
not
just
a
trendy
term.
It's
what
we
do.
C
The
needs
of
nevadans
have
changed
over
time
and
our
population
health
strategy
has
evolved
to
meet
those
needs.
This
is
an
area
where
our
innovation
really
shines.
We've
progressed
from
doing
retrospective
reviews
of
population
data
to
a
fast-forward
transformation
of
best-in-class
data
analytics
that
allows
us
to
proactively
identify
individuals
and
communities
who
experience
barriers
and
disparities
which
prevent
them
from
achieving
optimal
health,
we're
guided
by
a
person-centered
focus
and
our
priorities
are
aligned
with
those
of
the
state,
especially
when
it
comes
to
addressing
quality
measures
and
impacting
disparities
in
maternal
and
child
health.
C
C
C
C
So
we
used
our
population
health
model
and,
together
with
our
health
equity
task
force,
we
rolled
up
our
sleeves
and
we
went
to
work.
We
partnered
with
the
nevada
health
centers
to
bring
their
mammogram
into
an
underserved
community
through
collaboration
with
many
of
our
community
partners.
We
were
able
to
provide
more
than
30
mammograms
in
one
day,
distribute
250
food
boxes,
provide
flu
shots
and
covet
vaccine
and
most
of
all
engage
people
in
what
was
a
super
fun
event.
C
C
We
partnered
with
the
reno
doula
project
and
launched
the
first
pilot
program
for
nevada
medicaid
members
in
january
of
2021.
By
the
time
the
nevada
assembly
bill
256
passed,
calling
for
medicaid
coverage
of
doula
services.
Anthem
was
already
set
to
expand
its
program
to
date.
100
of
the
births
in
this
program
have
been
healthy
next
slide.
Please.
C
Anthem's
covet
19
response
highlights
our
innovation,
agility
and
commitment
to
achieving
health
equity.
Since
the
beginning
of
the
pandemic,
we
have
not
taken
a
back
seat
or
a
one-size-fits-all
approach.
We
have
consistently
taken
the
initiative
to
find
out
what
the
community
needs
and
what
we
can
do
to
help.
This
also
means
we
haven't
just
focused
on
anthem
members:
we've
stepped
up
to
the
plate
to
provide
care
to
anyone
who
needs
it.
C
We've
been
engaged
in
a
multi-pronged
strategy
to
support
nevadans
throughout
the
pandemic,
including
digital
marketing
and
social
media
campaigns,
to
educate
communities,
connect
people
to
resources
and
improve
access
to
care.
Our
team
has
worked
tirelessly
to
get
over
120
000
covet
vaccinations,
administered
and
135
000
covet
tests
done
by
hosting
more
than
1500
events
since
2020.,
it
is
mind-blowing
to
realize
this
included,
855
events
in
clark,
county
and
285
events
in
washoe
and
2021
alone,
and
we're
not
stopping
and
we're
not
slowing
down
back
to
you,
lisa.
I
Thanks
dr
thompson,
for
the
record,
this
is
lisa
bogart,
so,
in
addition
to
the
programs
that
that
dr
thompson
just
shared
I'd
like
to
share
another
way,
that
anthem
is
supporting
nevada
and
that's
it
really,
particularly
some
of
the
most
vulnerable
nevadas
and
that's
through
our
housing
support.
Anthem
firmly
believes
that
housing
is
health.
I
Anthem
was
here
when
the
aca
expansion
entered
managed
care
with
many
homeless
members
going
straight
to
the
er
for
their
medical
care.
We
quickly
created
a
mobile
crisis
assessment
team
that
not
only
assessed
the
members
but
additionally
ensured
that
they
had
an
appropriate
level
of
care
to
actually
be
discharged
to
and
that
that
discharge
plan
included
access
to
ensure
that
they
were
assessed
for
additional
needs
and
that
included
housing.
I
So
we
also
created
the
anthem,
pathway,
pathway
forward
program
that
offers
medical
housing
and
social
determinants
of
health
support
to
parolees
transitioning
back
into
the
community.
I'm
incredibly
proud
of
this
program
since
2018
our
program
has
achieved
a
very
low
five
percent
recidivism
rate,
so
this
strategy,
really
that
has
gone
into
our
housing
response.
It's
hard
to
describe
it
to
you
in
in
10
minutes.
I
I
So
one
of
the
things
that
we
have
have
learned
over
time
is
that
one
size
certainly
does
not
fit
all
when
it
comes
to
addressing
housing
and
that's
why
we
really
have
to
take
these
situations
and
listen
and
assess
the
situations
and
come
up
with
those
solutions
that
are
based
specifically
on
those
members
unique
needs.
So
one
example
that
I'd
like
to
share
with
you,
and
that
is
a
50
54
year
old
anthem,
medicaid
member
who
was
homeless
for
16
years
since
2019
that
member
had
353
er
visits
and
44
inpatient
visits.
I
Several
of
the
admissions
were
due
to
psychosis
and
actually
suicide
ideations.
So
one
of
our
amazing
absolutely
amazing,
behavioral
health
case
managers
was
able
to
connect
and
get
close
to
this
member
and
really
earn
his
trust.
So
she
found
out
that
really
he
he
didn't
intend
to
hurt
himself,
but
he
really
was
just
looking
for
a
housing.
You
know
stability,
a
place
to
rest
his
head
to
get
some
sleep
and
to
get
out
of
the
you
know,
sometimes
harsh
nevada
weather.
I
He
was
also
not
hearing
adhering
to
his
medication
treatment,
and
so
he
did
have
opportunity
for
other
housing,
but
was
evicted
for
not
complying
with
housing
rules
or
his
psychosis
didn't
really
suit
him
to
be
in
the
room,
sharing
a
room
with
other
men,
so
our
behavioral
health
health
care
manager.
She
was
able
to
connect
with
him
and
even
though
he
had
been
offered
injectable
medication
previously
because
of
the
trust
that
they
had
built
together,
he
agreed
to
take
the
injections
and
actually,
after
he
began
them,
he
said:
okay,
it's
not
so
bad.
I
I
So
the
best
part
about
this
is
that
not
only
the
member
was
able
to
reunite
with
his
family
and
and
begin
building
those
relationships,
but
he
has
not
had
another
er
visit
or
hospital
admission
since
being
placed
in
housing.
So
this
is
just
one
example,
but
anthem
has
recorded.
You
know
approximately
a
2
million
reduction
in
medical
costs
and
er
costs
amongst
members
and
that's
within
the
90
days,
then
90
days
of
being
placed
in
housing.
A
I
Okay,
we'll
do
so
one
of
my
favorite
things
is
that
member
story-
and
we
have
so
many
to
share,
but
really
when
I
think
of
the
success.
It
really
is
the
passion
of
our
members
or
our
associates.
They
are
member
focused.
They
are
collaborative,
they're,
agile
and
results
orientated,
and
that's
really
what
it
takes
to
work
at
anthem,
blue
cross
and
blue
shield.
We're
fortunate
to
have
a
great
parent
company,
we're
well
resourced
and
backed
by
our
corporate
parent
company
as
one
of
the
world's
leaders
in
managed
care.
I
So
we
design
programs
and
support
with
local
needs
and
priorities
in
mind,
and
we
certainly
contribute
thousands
of
volunteer
hours
to
the
community
and
invest
millions
of
dollars
each
year
to
support
our
members
in
in
our
communities.
I
We
provide
and
support
our
members
and
communities
in
ways
that
we
would
support
our
own
families
and
neighbors.
That's
because
that's
who
we
are
supporting
our
families
and
neighbors
in
nevada,
and
we
only
want
what
is
truly
best
for
our
own,
so
we're
proud
of
what
we've
accomplished
so
far
and
really
look
forward
to
continuing
our
work
in
alignment
with
this
committee,
our
state
partners
and
nevadans.
A
Thank
you
so
much
for
being
here,
both
mrs
bogart
and
dr
thompson.
We
really
appreciate
you
taking
the
opportunity
to
let
us
know
how
things
are
going
and
programs
that
you
guys
have
been
building
in
the
state
of
nevada.
There's
some
really
impressive
statistics:
okay,
next
we're
going
to
move
on,
and
I
don't
know
if
folks
can
tell
from
our
agenda.
But
we
put,
we
put
the
mcos
on
our
list
in
alphabetical
order
with
no
preference.
A
So
next
would
be
health
plans
of
nevada,
medicaid,
united
healthcare
services,
and
we
have
kelly
simonson
he's
the
president
of
that
that
nco
here
for
the
presentation,
ms
simonson,
please
go
ahead.