Public Health, Welfare, and Labor Committee - House and Senate

The. Health committee meetings pre glad it doesn't but it's everyone we I know we have a good long agenda so we'll try to move through its systematically happy to have representative josh miller coater in this meeting with me do you have any comments nope ready to all okay with that we will go ahead and get started one thing before we do start I want to remind everybody next week december the eleventh we are going to have christmas in the capital it's at ten thirty please come and participate that's where we have brain gifts for all the care kids that are in foster care and the custody at dcfs. And as well as in dy as custody so we will have some use with us from our juvenile detention centers and I will be sending out through both the senate and the house kind of a list of suggestions that you won't want to purchase one of the things that we're gonna focus on for DYS is trying to build their libraries and michael crump has put together kind of a list of authors of a recommendations of books and so we're going to try to build out those libraries at the j DC centers for those kids but we will also have kind of suggestions of different things that you could bring to donate and if you'll just bring them unrapped that would be great and if you need assistance I can help you and I can shop for you to if you would like that so again christmas in the capital is december the eleventh at ten thirty and the old supreme court rame and we just invite anybody in everybody to come and bring gifts for our kids that are in foster care and incarcerate in custody. Okay with that we will move to I need a motion to consider the. Approve the minutes for november one number two motion second all those in favor of say I and opposed I have it in those minutes are approved. Next time we have mr cook mr kickons to come up we will have a presentation. By him. And our annual reports for the all timers and dementia advisory councils twenty twenty three annual report so with that if you'll state your name for the record you are recognized to proceed. Thank you madame chaira david cook the director of public policy for the alzheimer's association committee I appreciate the opportunity to present to you the in your report from the also limited advisory council when the council was approved by the legislature we put in there dismandating reporting so that you would have a status of the implementation of the alzheimer's dementia state plan which was established in october twenty twenty two to provide a little bit of context I wanted to just go through some of the unique um things about all timers and dementia again as you might know all summers is not a normal part of aging a presence unique challenges that only for the individuals who are living with the disease but especially for their caregivers so what makes the all time as unique in terms of prevention of those the research is still evolving evidence is is strong that there are them some steps that we can take to reduce our risk by making key lifestyle changes including participating regular activity maintaining good health what we do know is what's good for the heart is also good for the brain so risk reduction is going to be an essential part of the public health response over the next few years and i'll talk about that a little bit more details we go on and diagnosis there's really not a single test that they can can determine if someone has also in treatment says you know there is no cure for all simers but there are treatments that may change disease progression we are hopeful there is a treatment out on the market now but the name of the can be that I shall promise and then we know there will be as many as two treatments another treatment that we expect to receive fda approval on some time in january maybe february and that will be to to treatments out on the market but what's important to know about these treatments is that they're only viable for individuals with mile kind of impairment or in the early stages of all simers and so early detection and diagnosis is. Critical to give people access to treatments that can give them more time for their families and so one of the priorities of uh association is is again as we find ourselves in the air treatments making sure that treatments become available and it's essential that we continue to create equal access for patience regardless of their payer type and so we continue to monitor the public payers but also private payers and and monitor their coverage determinations as more treatments come online. Nearly eighty percent of our patience indicate that they they also live with other chronic conditions such as diabetes and maybe cardiovascular issues will be city at others most of those are over the age of sixty five although there are those who are under the age of sixty five who are diagnosed with younger ones that and also what's unique about also since there's not a a dedicated funding stream from the federal government like we see an other chronic diseases in two two thousand and seventeen congress enacted the bald acts which stands for building our largest dimension infrastructure act arkansas was awarded core capacity funding under the bold act in twenty twenty one or twenty two sorry about that until that was came into the state for us to again do some things around her infrastructure just insured that we have a a strong public health response to all timers in other forms of dimension. Um you can guys see on the screen here the impact that also is having across the state of arkansas prevalence continues to climb we know here in arkansas over fifty eight thousand our kansas over the age of sixty five are currently living with all simers by twenty twenty five we expect that number two uh increase by sixteen percent or nearly sixteen percent over sixty seven thousand what's important to know about these statistics in these prevalence numbers as it only captures individuals over the age of sixty five living with all summers and there are multiple other forms of dementia such as the mention would louis bodies fascinated to mention parkinson's form it also doesn't cover those who are living with younger onset alzheimer's most of those cases go on diagnosed and they're very difficult for us to together to give you a firm number of how many individuals of course living with younger onset here in the state. All similar death continues a desk continue to increase all signs of the six leading cause of death here in arkansas our forecast numbers stop at two thousand nineteen and there's a reason for that because during the public health emergency during the pandemic there are multiple debts and we didn't want to include those desk because it could skew uh the number of people actually die from all similars during that period but we've seen a two hundred fifty percent increase in alzheimer's deaths here in arkansas from two thousand and two thousand nineteen and again the succeeding cost of death also wanted to pay consideration to the impact on care givers are when someone receives an alzheimer's diagnosis typically care giving duties fall to the family and the friends here in arkansas that represents a hundred and fifty four thousand care givers who went way twenty two provided and estimated two hundred and sixty eight million hours of unpaid care and the value of the care that they provide is over four point four billion dollars and cost savings to the state so here givers play an essential role in the health care space providing care for individuals of all similar dimension civil glass we're seeing more and more people choosing to age in place it's important to ensure that our family care givers are supported. The. Subject of kind of decline is is often one of the earliest signs of the mention and an offers population estimates memory and thinking changes that are associated with an increase risk and in the absence of more widespread diagnosis this measure offers a broader picture of what cognitive impairment could possibly look like across the states uhm even among those who have not yet been diagnosed so when twenty twenty analysis through the birth we found out that shocking fifty four percent of those who reported self reported experiencing memory problems have not talked to their physician about this eleven and a half percent of those age forty five and over reported that they are experiencing some confusion or memory loss and of that population sixty percent say it's created functional difficulties but what shocking and alarming for us is that they do not console a physician they haven't had those conversations and what we do know from our research and from surveys is that uh conditions are not initiating those conversations and patients are not as well and so more education in the public health space around the importance of our detection and diagnoses certainly essential going back to the again the importance of access to treatme. You look at the caregiver data you know on a recent survey we found that care can we do this of often fall to women and she can see over sixty percent of the caregivers are women but we also learn a third of all care givers are under the age of fifty and what we're seeing in this demographic is an emergence of what we call sandwich care givers and those are caregivers who have children at home they're providing care for the trying to to navigate family life but also have an age parents who is experiencing memory lost or perhaps living with dimension and so they're they're providing care for kids and and aging parents more than half have been providing care for at least four years and then forty one percent over forty percent have a household income of fifty thousand dollars or less. On the national scale of course carrying for someone living with all simers can take a very physical and emotional social and financial toll on families the total lifetime cost of caring for someone would dementia seventy percent of that is born by families either throughout a parking spencer's or long term care expenses or from the value of just unpaid care approximately two thirds as I mentioned our women. And compare with care givers of people without the mention twice as many givers of those with the mentioned indicate substantial motional financial and physical difficulties especially as the disease progresses the need for more direct intervention is needed and so that can cause again emotional in physical strange and what we particularly are are a concerned about is again as you invest in that care for someone else often our caregivers neglect their own personal care which leads to increase emotional and physical health concerns as well. So what i'd like to do now was switch gears a little bit in just talk specifically about the alzheimer's intervention state plan and the status of important implementation and provide you with the annual report. As you can see the members of our advisory council is codashchaired by a senator clinton pinzo who was recently appointed to take the place of senator hill who's duties in the senate have taken away from the council but continues to support the work and represent of july maybe who is served as our co chair you can see on the screen the state agency partners and the other partners that we have around the table who have worked on again developing the state plan and continue to work on ensuring its implementation. As a state plan was established we we leaned heavy on the healthy brain initiative roadmap from the cdc uh the hbi road map includes recommendations and strategies uh for states to to use to prioritize their response to all simers and other forms of dimension and so looking at the each bear roadmap we focused on four priority areas again public awareness and education the importance of educating providers about all the detection diagnosis but also consumers and of course the importance of risk reduction and making sure that people knew what support services were available. I'm accessing quality of cares another area that we looked at just in cancer enhancing quality care and also ensuring that there is access to care regardless of your zip code family caregiver support was an issue that the council brought out the stand on its own recognizing the importance of supporting our family care givers and increasing support services they navigate the challenges of dimension. And then finally dimensive training and work force development we we looked at the dimension training standards across care settings and put forth recommendations to increase those dimension training standards and so I want to kind of go through what we've achieved the twenty twenty three with the support of the legislature. One of the first bills that so I was unacted during the twenty twenty three session was just an update to the the membership of the alzheimer's mentioned advisory council we had under representation from home care providers so we added the arkansas home base services association and we strengthen the representative we had a representation we had from assisted living communities by adding a rather and of course we have the architect healthcare association who also represents assisted living communities on the council. What are the other pieces of infrastructure that we put force that we are perhaps most excited about is the establishment of a dimension services coordinator within the department of human services to give you an update we do know that position is posted and the agency is actively working to fill that but that establishes a dedicated position within the hs to kinda look at or are respond to our our services the aging services that we have available how do we strengthen those support services for individuals who are navigating the challenges of dimension so I have in that position we joined other states across the country who have similar positions and have seen a a cost savings in terms of making sure that there's a coordinated state government response to all sorters and other forms of dimension. Again continued the support of family caregivers through a partnership with the department of human services into two years ago we established an also dimension of a respect grant program and and it's pilot year it's established to provide care givers with a five hundred dollars grants to secure services for respite the eligibility of that you just have to be a career with someone with a confirm diagnosis of dimension and you must hire someone living outside of the home to provide that career caregivers are eligible for two grants and a calendar year but have to wait six months in between award periods one thing that's not captured on the screen but i'm going to detail in a few slides is that we also establish the twenty five percent rural threshold just insuring that those ones did not stay on the metros but they got out to the rural areas where we saw that there was AAA dear a dire need for for respite services so we want to ensure that those funding scott got to the communities as well so that funding levels at two hundred thousand dhs included another two hundred thousand that is funded by a federal block grant through DHS but that provides two hundred thousand or funding for this also much dimension respond grant program. And then I can solve made history became one of the first states to have established dimension training standards for home care providers fresh home care providers act seventy requires two hours a dimensional training for those who provide home care at two o two requires a minimum of two hours of dimension training for law enforcement and other first responders are console becomes one of only twelve states in the country to have this statutory requirement i'm just to insure that our first responders are equipped with the tools they need to again mitigate situations with individual dimensions. Are we also working are you going to hear a little bit more about that later today in the agenda but at three thirty five required four hours of dimension training for all direct care providers inside assisted living communities and two hours of annual continuing ad for direct your staff that again resident assisted living facilities we did not have a dimension trained training statute for a left but this act also prompted the agency to update the rules that govern assisted living communities and that work is nearing its completion as well. What I want to do is going to look forward to what we are seeing at some of the priorities recommendations we have for twenty twenty four you know we we look at this diagram your projected prevalences you can see over the next thirty years expected to to skyrocket and continue to increase what's important to note is that these prevalence studies were based on current in an older or I guess current recent older americans a group that's a live through a time with lower rates of obesity and I beares a lower prevalence of other risk factors that again increase your risk of developing dementia and so the big question for public health is what is this look like if you base this models on the current public health situations that we see her in arkansas we see a lot of public health concerns that of course increase our risk of developing the mention high rates of obesity hypertension stroke and diabetes all those increase our risk so there's reason to believe given the public health factors that we see across the state that are numbers are extremely conservative was we think about prevalence that that you know that sixty seven thousand number could be much higher than that so that certainly something that we are our watching this past year for the first time ever through the also mars associations are national research conference we received access to nationwide estimates on county level prevalence of people will also dimension which gave us a more granular look at what was happening across the states and across the country and even inside arkansas at the counting level what we see with prevalence this research was compiled from a rush university medical center in chicago and so what I did was pull out the counties here and arkansas that of course had the highest privilege numbers you look at the chicago and philips counties and the delta that have increased risk. The prevalence and then newton marion and and carol course the lowest numbers of a prevalence. And they fail billy this county why data is extremely important it allows us to make a form public health strategy to develop a public health strategy to drive risk reduction which again is an essential part of the public health response uh going forward also early detection and diagnosis do community level education for the counties that we see had the highest prevalence and improve access to diagnostics to education improve excess education carrots port services not having to create new strategies or new infrastructure but working within our existing infrastructure so how do we utilize the area agencies on aging the minority health commission and some of our existing infrastructure to increase access to education support services uh diagnostics how do we ensure that our clinicians are prioritizing or detection and diagnoses and also ensure that our consumers in our candidates are equipped with the tools they need to self abicate as they begin to experience memory concerns and memory loss they can advocate for themselves to their commission and early detection and diagnosis becomes an essential part again of the public health response I can't say that enough today I guess i'm keep repeating that. The. So that the immediate needs that we we see that we need to address coming forwards we can look at the fiscal session again increased public health messaging about the importance of risk reduction of some of the warning signs that may not be a common sign of normal aging early detection diagnosis especially now that we have treatments who that are viable for people on the early stage again early detection diagnosis is essential and then ensure that our state health improvement plans in our state aging plans are inclusive of priorities that again and so the buyers risk reduction or detection and diagnosis on the policy asked that we are put forward is is we're hopeful for some state funding that would actually find a public awareness campaign specific to or detection diagnosis that would educate not only clinicians but consumers about the importance of or detection some of the warning signs and when it's time to again consult a physician about memory loss that begin to experience as you age and so that's why the asked that we we are making of legislature going forward. Are also we will continue to monitor public and pipe private payers to ensure that there is coverage for fda approved treatments for all simers just improve access to coverage and control of screening diagnostics and care planning services and there also ensure there's coordination of these services and resources which is something that could be captured by the dimension of services coordinator. More specifically just to can I look at some of the specific proper policy asked that we are working on in twenty twenty four again increase access to kind of assessments and care playing services for the medicaid population and so one of those ask is to ask the medicaid agency to establish a reimbursement rate for a planning code that already exists from CMS and this plenty code reimburses providers for a concert screenings but also care planning services and as medicated establishes this reimbursement rate it's important to know that this would only be for individuals who are not dual eligible so if they are covered by medicare you know that that that benefit is picked up by medicare but it's for those who are under the age of sixty five covered by medicaid so they could have access to cognitive screening and and of in the secure planning service and getting public awareness education behind that is making sure providers know about this and consumers know that they can access the benefit. Um can I look at the family care give her some area talked about over a hundred and fifty four thousand or kansas provider and pay care to people with all simers are other forms of dementia and I i've already mentioned that in twenty twenty two they provide two hundred and sixty eight million hours of unpaid care to you know a value over four point four billion dollars we talked about the caregiver demographics but as you're in on the impact that care givers you're giving has on the work force over fifty percent seven percent said they had the leave take leave may be retired early to ride here for a patient eight percent turned down a promotion eighteen percent had to go from full time to part time work so care giving has just a significant impact on our work force 16 percent how to take a leap of absence seven percent may have lost job benefits as well so ensuring that we are providing support for family caregivers is essential to stabilize the work force as we're going to see his prevalence increases the more impact we see on family careers as well. So II mentioned the dimension here give arrest with grant program the current funding level is two hundred thousand again that's funded by a federal block grants in here one it served four hundred families I mentioned that the twenty five percent threshold to hit royal communities was so that twenty five percent the three year one we actually hit thirty two percent through our partners but those funds expired in march of twenty twenty three and when you compare that year over a year to what we are seeing already here in twenty twenty three twenty twenty four as of december first two hundred sixty six families have already been served so over half of the funds are already gone are real threshold as holding a thirty eight percent which is encouraging but there's only sixty eight sixty seven thousand dollars roughly left of the two hundred thousand and so we have shown over the last two years that the need is great we're also again prioritizing royal communities making sure that money gets out to the road communities to the families that desperately need it we are asking that the state match the federal block grants and increase the funding level from two hundred thousand to four hundred thousand so we continue to strengthen this program and then sure people have access to the response services they desperate. Public awareness and condition education again early detection diagnosis risk reduction is an essential part of the public health response to all simers and the mentioner and one way we can kind of advance that eh is again funding funding for public health interventions to educate providers and consumers on the importance of brain health early detection and diagnosis and risk mitigation and why this is so critical is that there's still such a stigma attached to all sermers and dimension and if we can normalize the conversation around brain health in the way that we've done it in the public health space round middle health that will be huge for our population but it also encourage people to again have these conversations along with their families with the providers as well especially now that we have again treatments available for individuals in the early stages of mci. I mentioned just touch back on it established medicaid coverage for the cpt code that exists from cms and then increased funding forward to insurer care of a respect program which is again at two hundred thousand we are asking for four hundred thousand to again increase the impact of that program over the last two years it's it's had huge successes and we've identified the needs and there's also some conversations happening on how we can expand those resources and get them out to even more families as well so we've tried to do more with less we're just asking for your support to continue to support the family suggestions. Well that i'm happy to take any questions that you might have and I can I went through some of that pretty quick but i'm happy yet to answer any questions. Do we have any questions. Senator chest failed your recognizer thank you so much and thank you for this in lighting report. Um personal contact with with the ravages of about signers I truly appreciate they were doing more to raise the awareness i'm concerned about the drugs and the the sad effects could you speak to those possible side effects from the drugs that are supposed to be a market at this point and the fact that insurance coverage in arkansas is not available for them. Or am I mistaken. So in terms of the side effects with any drug there is going to be a possible side effects as a patient abc organization we're going to continue to advocate for for access to these drugs and some of especially with the can be some of the side effects that we have monitored and sold from from from the clinical data is you know exposure to possible brain bleeds but a lot of those cases happen with individuals and other forms who have also have other common ideas so that's something that we continue to market from the research perspective in terms of your question around pair coverage it's diverse we do know that possible shields may the coverage determination not to cover it are console across the shirt internet arm has made that cover determination with the other payers who have come around the table because it's on the formulary medicaid will cover it the ba health system is providing coverage forward as well united health is another company that is covering the drug and so II think as you know as more drugs come on the market we're going to see payers come around so it's something that we continue to monitor I think one thing that we are concerned about is that on the state health employee benefits program is not current currently provide coverage for that so that's an issue that we want to to work on as well I appreciate that thank you so much mister chairman thanks for all you do thank you this is so needed because it has such a devastating effect not only only individual when they lose themselves because it is losing yourself not being able to cope having been one who has been fully able to do so so we have got to continue to work I want to thank you and thank the chair persons of the all similar mention a subcommittees that are doing great work as well thank you so much and thank you mister chair. Thank you sandra chest of all I would just say from the perspective of the also association and the all summers dimension by zero council we have been encouraged in optimistic by the increased support that we've seen from the arkansas legislature to respond to this this need that we're seeing across the state. The questions from committee. Which cook up a personally or thank you and and the council are last my mother to alzheimer's little over a year ago. And we dealt with that's very very tough so present what you're doing in. I'm sorry you've had that personal experience I lost a grandmother my dad's currently living with it so but thank you I represent miller for all your work appreciated. Right community now we will move on to the review of the tobacco seller commission report mister mac gilmore. Or his designate. Yeah. We all please identify yourself for the rear. The. Hello everybody my name's emily lane i'm the project director for the tobacco settlement commission evaluations on a house date uca. And i'm going to give you a very brief overview in the handed over to miss may franklin with the tobacco settlement medicaid expansion to talk about the program that she overseas. So we're here today to review the quarterly report for january to march of twenty twenty three and in the document if you flip to page four you'll see a two page in program that gives you just a quick heater highlights of different accomplishments and progress that have been made over the quarter. I'm not going to recurrently take those numbers for the for you you can see them for yourself. There is also some testimonials from people who have received. Uh. Programming educational programming or exercise programming or they've been a part of some type of tobacco settlement from the program and you can see how real arkansas are being affected by these programs the bulk of the document is individual sections where you can see a lot more detail about what each other programs goals are and how they're progressing towards their annual goals. And the back of the document on page fifty four I believe you'll see a summary table so it's page sixty two is right towards the end. This shows you the overall progress across all programs for this particular quarter ninety five percent of the stated goals were in progress on track to me annual goal so that is good. I'm going to give you just a really quick overview so this quarter compared to the same quarter and twenty twenty two we see a lot of. I improve menson increases in these numbers because for windless covered restrictions so a lot more community outreach community education happening in this particular quarter we saw about thirty thousand more arkansans educated over this quarter fifteen thousand or so more kids educated on a number of different health topics and also there's a lot of programming that focuses on getting kids engaged in hands on things to try to promote them to enter the health field later on so that's really important work that it is just ongoing i'm not going to take too much more cos I want to leave plenty of time for miss franklin but I do want to mention since mister cook was up here and give a really compelling presentation on and I also must there was a grant to give in to you ms centers on aging during this quarter that's highlighted in this report from a usda it's about a three hundred and fifty thousand dollars grant for a virtual reality based dimension education and of course the centers on aging have been doing dimension education for require some time now and and so this is a nice boost to their efforts and so I wanted to throw that in there given that mister **** presentation so if there are any questions for me let's leave them until after miss franklin gives her presentation and then i'll filled any questions you may have thank you. The. Good afternoon i'm mary franklin director of the division of county operations with the department of human services and here today to represent the tobacco settlement medicaid expansion programs which is one of the programs that is funded by the state's tobacco settlement dollars. In the tobacco settlement medicaid expansion and and just a note this this is not the same program as the are home program is funny through the adult expension. But this tobacco settlement medicaid expansion program covers four different populations with the goal of increasing the help them well being of our handsets by expanding healthcare coverage to targeted populations the first population is for is a pregnant woman's benefit when this tobacco settlement medicate expansion program was created DHS took steps to increase the income limit for a pregnant women coverage when arkansas are kensings applied for pregnancy related services and that so the tobacco settlement program covers pregnant women between thirty three and two hundred and fourteen percent of the federal poverty level. In addition to their at first this was a limited benefit program covering only pregnancy related services but in january of this year january twenty twenty three that actually was expanded to fall state plan services for pregnant women and this this is all pregnant women not just the pregnant women above a hundred and thirty three percent federal poverty level are second population is work in the tobacco settlement medicate expansion program is an increase it expanded impatient in outpatient hospital reimbursements and benefits to a dots between nineteen and sixty four years of age and part of the implementation of that at the time dhs covered medicaid covered twenty hospitalization days in a year and that was increased in the tobacco settlement medicare and expension a current matches with federal dollars to cover the state share of expenses for hospitalization beyond day twenty. The third population in this tobacco settlement medicaid expansion expanded nine institutional coverage and benefits to seniors aged sixty five in above and to implement that. Dhs created a medicaid category it's called the are seniors program and it covers arkansas seniors adam below eighty percent of the federal poverty level. And it also provides four state planned services available to those individuals. Yeah. And the fourth population this population was added through a change in legislation and actually began a effective july first of twenty seventeen and that was to use these to back some tobacco settlement it's fines to find five hundred editional slights for the community and employment supports waiver that is administered by the division of developmental disability services at d h and so some of these tobacco funds are now used to phone five hundred individuals who receive services through the swaver. And with that i'm happy to take any questions thank you. All right thank you so much are there any questions for the committee. See nine OK thank you so much for your presentation and at without objection this autumn stands reviewed thank you. Are you moving on to item e. Thank you for being here. Thank you madam chair chuck thompson attorney arkansas department. Jamie turper in the period for administrator. Craxmatt attorney for department health thank you. This is exhibit e members in your packet. Good afternoon members thank you madam chair thank you mister croche we have before you the rules pertain the architecture description drug monitoring program that's exhibit e these rules updates are almost exclusively related to act sixty seven of twenty twenty three these aren't accordance with the acts of the general assembly and there are some minor some minor formatting and then some typos that we included armed to be corrected while we were doing a review of the rules to come into compliance with the act there's also addition of some language that's more reflective of act on twenty fifteen i'm sorry at twelve twelve oh eight of twenty fifteen that was we are always enforcing the law the language wasn't as explicit in accordance with that act so we want to make sure we reflected the language exactly as the act read that about it i'll be happy to take any questions. Okay can you just give us like a brief little review of what that act specifically did other than I mean I have a seat in your description is there anything one thing that I thank you madame chair for that question yeah I think that the biggest thing is act sixty seven twenty twenty three would you have we the act added obyn to the arkansas opinion recovery partnership of the pdmp advisory council that's an important that's important for policy and and and advisory purposes act sixty seven twenty twenty three r so added language regarding medical examiner access and that's to to to be more clear on on the ability of the medical examiner before it was more of an administrative um red tape barrier than medical examiner could request access and have to send a letter to us and now it's just it it streamlines it instead of wasting paper and and in time now the medical examiner could just go ahead and look at it directly instead of having it sent a paper request to us okay and then previously we were the I see also that uh datas would be able to be released for mortality reviews the correct mancher that's the two thousand are the appropriate debt mortality reviews that we have under the the department of health including the information reviews okay I think there get changes any questions for members of the committee if night see nine without objection this rule will stand reviewed. It will move on to your next rule thank you members thank you manager. You may proceed thank you madame chair would you have individual coming up to join us from staff and if they come to pass this over to correct smith he's going to introduce this rule. Good. Jaguard smith branch chief with the arkansas department of help thank you thank you madame chair and mister cochair and members before you have the proposed new rules pertaining to youth injury mitigation and information courses for athletic personnel and coaches these rules are to implement act six forty two of twenty twenty three also known as the coach safely act. Just a brief over you the act is designed to inact a requirement for coaches in personnel of high risk youth activities to take certain courses eighty eight is tasked with approving the courses that they are returned that they may take to fulfil this requirement those courses are designed to follow emergency preparedness concussions and heat and weather related injuries physical conditioning and hard effects and ever now at normalities. Uhm and without happy to take any questions to who pays for the training would they have to do pay then out of pocket like if they are a coach with au basketball or. More you know soccer sociation arkansas state documentation or whatever this would apply to them correct correct and that would go through either the coach or the association okay so add the coat with the association would have to pay for the training courses the smith. Okay do we know if these training and courses exist for all these different types of sports that are listed here yes ma'am and uh at his already posted on their website a list of approved courses back when ax were to win into effect we went ahead and posted it approved list of courses and that's on our website available for the public to go and check in and make sure that what courses are available to them okay and what is the penalty of a coach does not. Take am one of these courses. Eighty h responsibilities for proving the courses we don't regulate whether or not they have taken him that responsibility lies with the eat association. And so it's on the association's responsibility to make sure that their coaches are taking that in checking that off okay but their act itself didn't provide for any type of penalty. Are there any further questions. All right thank you seen nan this item will stand reviewed this rule reviews. Moving are now to adam g. Thank you department of health. Well hope to see you guys at the christmas in the capital as well. The. Yeah. Yeah. Okay sorry go ahead and state your names for the record and come on up and will get started with item g and you're gonna be at the table it looks like for the rest of the of the meeting so back all up back a line however you want to say it. We'll start with item g yeah we only have a few rules today this is mitrous chief of staff dhs i'm elizabeth pittman director for division of medical services thank you jane at me and deputy secretary of programs and medicaid director right let's role this is our revisits over the third party liability rule we brought it to you I believe two months ago and then cms requested that we out of page to our state plan amendment and this is an attestation that we do follow the third party liability rules which means that we seek other payment first or we at pay and then go look for a third party sources of funding such as additional insurance or other liabilities and it is not a change to our program so there's no financial impact it's simply an attestation with cms that were following their rules and see a mister proved it on november sixth then happy to take any questions okay are there any questions seen now that the item stands reviewed moving to the next item h. This. I'm item each is the rules pertaining to the the life choices lifeline this was an act that was passed during the last session i'm sorry don't have the act number with me seven o three thank you jean agree and this rule brings us into compliance with the requirement to pass a role for that accident it's the first step under that act so we ask for approval. To meet that requirement. Okay no did you want to add more to adam h. M I just wanted to add that we were working through this process this is new. Umm to us as a help line in additional sources and as we develop some maternal health and approach for the state that we partner with others that I think this will evolve. So yeah I think I think so too and I am just so for the members that are here present you know we're really doing kind of deep diverse and to some of the all the different types of things that are happening around this issue particularly this issue but i'll medicaid issues I suppose but but I know that senator was here earlier I don't see him in the room now there is okay so but yeah this is just one area that we might want to look at seeing how we can explore expanding this type of idea as that correct. It is under the under maternal health and infant mortality we are trying to look at all you know levers in outreach clinical and reporting and we're working with our different partners advertising in other state agencies to develop an approach where had a most recent meeting with ums to discuss some ideas we we have scheduled and meeting with eighty eight I think is still in the ram and then there's some other non profits that are very interested so I think there's a lot to do in the space and I think it will take all of us working together with the different levels to improve the maternal health yeah II agree and so just again thanking as senator dots and I think this is a great act great legislation and nothing there's room to kind of expand and grow it into you know other. I don't know possibilities for us and thank you for that are there any questions on item h. Say nine this item stands reviewed moving on to the next I this is the rule for electronic visit verification for home health providers and we came to you probably two and a half three years ago for our personal care even roll and this is the second half of that fees too that adds the home health providers to the electronic visit verification it's a mandate from cms. And happy to take any questions we received no comments on this role okay representative miller you recognize for question thank you manager did you say this is a the electronic deal is a verification from cmass yes there is a mandate from CMS i'm yes sir it is a main day from cms that we verify visits that occur in the home through an electronic means so we use an application on the phone that verifies the start and in time the location the caregiver providing the service there's actually six data points that remandated to car right so the so the the the care you were would be required to have their location services on yes on their phone and even if if it doesn't work at the time the way their app works right now is they are going ahead and log that on to the app itself and then when they're reconnected to an internet connection or their cell phone data plan it'll download that information into the system. So so there's not a a reason for their to be a concern you know some people don't necessarily want to have their location services on. You know and at all times they would only have to turn it on. When they were logging in is that correct or they could only turn it on when they were logging in at the home yesterday as long as that gps court networks when they were at the home longing in and out of the visit that would be sufficient and I think it makes sense I just also have heard concerns about. You'll hey we don't necessarily wanna. I understand that and yes or I think but that is all we need is for that starting and time of the visit to be locked thank you very much alright thank you let's see. Senator boyd thank you matter just curious is this like a government developed app or is this like a private company developed apt is their competition in the marketplace i'm just trying to understand yes sir so it is a good a company developed app there are different models that you can use we'd do it's called a mixed model so we actually contract with a vendor to provide the app that's doing personal care right now they develop that any provider in the space can use that app at no charge they can also hire their own vendor and then not vintage and integrate with our app and a lot of personal here providers have done that because each pass has their own electronic visit verification vendor and so when they use a third party that third party can do it across all of those different even fee finders. So there's some kind of sharing but there's also the room for competition to make it better yes sir okay thank you. Well and and if some locations we were just discussing don't have cell service at their location how how does that work yes so when you do the app comes on and you log into the app it records your location at that time records all the information it needs and then when you get back to a location where you have wifi or cell service it downloads that way okay gotcha alright thank you any other questions members of the committee seem nine this item stands reviewed. Okay next item this is the last item you have to listen to me for and this is another act that was passed in this past legislative session and for a long acting reversable contraceptive reimbursement prior prior to this implementation we covered that as part of the global payment or hospital per dm this allows it to be paid for on top of that so that hospitals and providers don't have to reschedule the a woman to come back after the delivery to have the large concerted and they can do it at the time of delivery and so this allows for better family planning and birth spacing. Yep. Representative pocking ten year question thank you thank you chairwoman do we have a total car savings associate I can't seem to buy my paper is out i'm just curious we get it cause I know dear in session when you pass that we couldn't get the total number of cost savings for the state by passing their cell and I bass around and never got an answer from DHS i'm kind of hope and I can get one today we don't have savings because we would have to know how many births we prevented you know and had costs me saved we do have and the cost of actually implementing and we get a ninety ten match from the federal government on this because it's a family planning service so it's only two hundred and eighty thousand dollars per year of seat general revenue catch a boy we have no idea of how many births will see lesser because of this it's very hard to predict that number but we do anticipate some savings thank you. Alright seeing no other questions add this item stands reviewed think thank you everyone and have your holidays to. Okay next. And i'm k. Okay if you'll state your name or go ahead item k. Then you are. Go ahead and start on palestine for the record palestine department of human services director of office of subsidies abuse and mental health services so the rule that we have today for behavioral health is our outpatient counseling services manual and we made two changes one change was to the manual and that was lifting the requirements for the primary care physician referral prior to the tenth session being delivered and so we've worked with the providers and are the primary care positions primarily pediatricians on this war and what we found was most individuals who are receiving counseling services don't even get to that ten session most people get services that are less than seven sessions and so and there was a lot of work being done administrative work being done to connect those without even the the need for that final authorization going through so what we did was lifted that we've had some conversations with primary care physicians particularly pediatricians are primary care positions providing services to children and their concern around their communication that comes when they don't get communication from a provider this providing counseling services to children without this referral and so we're looking at other mechanisms for them to be triggered that information coming over to them knowing that they have a patient that's getting counseling services I think we've resolved that and can continue working with primary care physicians and be heral health providers to make sure that they get that information so that was the other the one change the other change was to rates and so a year ago we changed counseling rates and we looked at the rate methodology for that in changing those cancelling rates and we increased the council rate for individual counseling. A and family councilling. And we started out by looking at a state comparison looking at other states to see if we were in line with other states and and we were pretty much in line and what we determined that we would do is go to a percentage of medicare and so we raise those counselling rates to eighty percent of the medicare rate at that time we also looked at a service that was well well above a hundred percent of the medicare rate and that was for group counseling so we did a temporary role change using a disaster of spar state plan a minute and when ahead and raised those counselling rates we denied do a corresponding decrease to the group therapy rate we have now come in and we're making those raise cancelling rates permanent and then we're also decreasing the group therapy rates so we've got um some financial impact on that to make sure that we're in line and so our financial impact on the toll essentially costs for year to implement this role is a little over a million dollars so one million ten thousand eight hundred and eighty eight dollars for the current this call year and that was this last year and then now that's this year and then for the next fiscal year what will have a full fiscal year or step the school year it'll be two million twenty one thousand and seven hundred and seventy seven dollars so that's our fiscal impact also noting that you know concerns from providers and what we got during public comment and I think the main concern for providers was the obviously the decrease to the group counseling rate and sell in in having that come in alignment with with the medicare and percent the medicare rate and I think the the main group of providers that we've been talking to the main concerns are around a group of seriously million ill adults. And as is you all may or may not know in our state seriously million ill adults go into the past program and they receive pretty extensive services so we've identified that they have higher needs in the providers have been using group therapy not only to provide group therapy services but also to monitor kind of progress with clients and sell when seriously mentally ill people come into a clinic and they're in group there be then that there's a council that's looking at a group of probably about ten people and they can really kind of tell if they are. On medication if they're not on their medications if they've had some shift in in their functioning and then they can address that pretty quickly so that's one of the ways group therapy was being used even though that's not quite the definition of the medicaid service for group therapy so we are working pretty quickly to address that small group of people and we're working with the passes so we have our first meeting this week with the passes to say we've identified all the people there's about five thousand adults that are in the past that receive these services and so looking at that population in the moving it on down the line to see how many of them are getting consistent group therapy and is there some sort of replacement service that we can put into place so again we have that meeting with the passes this week will be coming on with a meeting with the passes and the providers of this service for theirs it's probably about fifteen hundred people that were talking about and looking at how that group therapy was providing a service that was a little bit broader than I think what the definition is in what we can do between their department the passes and the providers to really look at and make sure that we are meeting the full needs of that population but about fifteen hundred people. That's all I have already are there any questions for members of the. Alright see a nan a well item will stand reviewed. Next. Melissa weather ten dhs left and enjoy hill with aging it up behavior health services with the hs alright thank you guys we're on item l. So it and hours entitled development or screens for children but it hit several different documents for a for us at DHS so effective january one pcps will be able to perform am developmental screens on children and be paid to do so and we have been working with physicians and pediatricians to about this role and they're very happy and actually submitted a positive public comment. In addition to the pages that implement that change we went into the independent assessment me in yourself you guys may remember that. In order to attend an early intervention day treatment program we pay often to do a developmental screen they do the bately case medicaid will be paying for development screens for all children on medicaid we have notified optim that will no longer be paying for that portion of their contract effective april the first so we instead of optim doing the developmental screen that will allow him children to go to an eddie t were requiring that the family goes you are well visit go see their pcp and get that screen completed i'm with their physician or their aprn so in the independence that's let me know there was a one line in started which simply states that effective april the first that optim will no longer be doing those screens for us however during public comment period we received a handful of public comments from some of our providers in the aging space I am asking as to go in and make an additional change while we were promigating the manual and asked that we consider allowing tell a health for both initial and reassessments and the assessments that opt him does for a personal career are choices and living choices we agreed to allowing tell the health for the reassessments that is consistent with how we treat all of our populations right now we allow an id reassessment and behavioral health three assessments to be done be a telemedicine but across the board we mandate that the initial assessment for our program and community based program speed done in person. I'm happy to answer any questions in mrperiod hill is here as well. Alright. Representative miller you're recognized for question thank you madame chair so just to be clear. All of these programs are choices of bb in all this stuff the the first and national assessment it's always done in person. Yes sir and after that. They now were moving to where tell medicine for reassessments with me permitted. Yes are it's gonna be an option it'll be up to the client correct day we've been doing tell a health for reassessments for allowing the option for a clients with intellectual development disabilities and behavioral health for quite some time now and this is will be a change for the aging side but to make them consistent with all of our populations in a cbs base. So cross across all these populations reassessments tell help will be an option yes outstanding I like that. Alright any other questions. Oh i'm so sorry yes representative lady men you are recognized thank you mentioner well looking at the assessments. With the telehealth. Remote assessments. The cut on the comments. Refers to what we did during colbert when we allowed tell the health remote assessments under an executive order and then we passed legislation to allow that and I think this comment says it fell regulations. Also allow that initial visit to be banned tell her health. So why are we me more restrictive what's the purpose of us being more restrictive in federal regulations by allowing but not allowing the first assessment to be done remotely. As a great question and we actually talked about that internally this morning so we have consistently made the choice on the intellectual development will disabled side in the behavioral health side that we would like that initial demo assessment to be in person for various reasons we like them going into the home we like them seeing the environment we like them seeing them physically and i'll let jay elaborate but maybe some of those things are even more important on their elderly and aging side of the house. As much well and said so often that environmental scan that the optimus is a little is able to do in person really factors into the the tearing for for the beneficiary and it assistance and understanding what their needs really are so that we can provide in the river services that best suits that allows them to stay in their homes it under these programs it's very difficult to do when you're looking on a telephone or on a camera you only get a very small scan that was but for that initial assessment to be able to have that total view of of not just the environment but what are their minutes what what are the needs of that those beneficiaries that you do almost have to be in person in order to do that. So have you checked wife the federal government. Allows that I mean why other states evidently allow that. In a does this also you know one of the concerns is. If you have a schedule that visit it might take longer so the people might not get the service as quickly as they might need it so I think their number of questions here that. You know can you give me an answer that do other states allow it in what's the what's the thinking of the feds when they allow it. So you're correct so we check the cfar does allow it just simply hazard it's a section entitled independent assessments and it does say it doesn't differentiate between initials and ring assessments it just says independent assessments must be face to base in terms of in that could mean a camera right that we take it could be a teller how we have taken them position then we want to set that baseline we want to think these clients as as was sometimes our first touch with them in mini cases reassessments is a different ball game with we've already seen them they're already getting provided services were using object many times to do the first contact with some of these clients especially on the person personal care side so we're taking a more strangent luck now as far as timeliness I think we are looking at how to improve timeliness I think we're more concerned about the time that it just takes on how we currently have our system set up of the call center of type system where we call clients and often times they don't answer and then we're waiting on them to call back and we're doing their three calls system or optimist doing a three call system so we are looking at ways to insert better technology into that process rather than having to use live bodies to actually make phone calls to people to see if we can improve is that absolutely portal that we can have care coordinators are possibly providers go in and try to schedule is that using tax technology is there other ways we can do this to get clients to respond quicker because I think I will agree with you out I can say in the behavioral health in the id space sometimes it's very hard to get someone even on the phone to schedule even if it's a teller health reassessment. Well I understand there's difficulties in their situations like you're describing but i'm sure there is also a large percentage that that's not the case we don't know what other states do we don't know the success of the feds so madame chirac I would like to ask that we hold this until next meeting and try to find out what other states do do they do this early successful. Well I mean I know I had I hear you I mean I think. That would be legislative if you wanted to try to do that legislatively I mean this. You know i'm i'm. I mean I guess we can II don't particularly want to hold it at this point but but we can have more discussion in the future about it i'll defer representative later than we've so well we're gonna have to present this to rules next week as well we can get you that information between now and then if that would help and it's going to have to go I mean it's got a couple more layers that it's got to go through anyway we can get you that information for the end of the week and really answer any questions that you might have I mean II will just say like I think tell the health has a great use for it although i'm probably on the other side and think that the initial visit really should be in person or at the home and so that for me is important I mean I don't. And I think telehealth is great until you get somebody from india who's going to do a teller health is it on one of you know are consulted citizens I mean nap no offence that was incredibly offensed as I am sure but somebody from a different country is not going to understand arkansas I guess that was my point there but some of a little bit more on the other side of it I think that this is a good approach to get compromise to really embrace teller health and make sure that you're checking and read as it's can occur in that form and fashion but when you're talking about kids and all health a lot of times kids do not react to a television screen the way that they're going to react to somebody actually looking them in the eye and sitting down with them. I mean it's the same thing of your repairer. And if i'm a man I can't discipline my child over a television screen ain't going to happen if I sit down with them and look down in the eye and interactivate with them face to face its gonna be a lot more impactful on my child and so for me this is a very particular situation or I think you have to have to have inpatient in person visits worth children so i'm a little bit more on the opposite side I think of representative of lately perhaps but I think what you've brought forward is actually very good approach i'm gonna go to other questions representative pilkington and your recognition cannot I will tried you back on the i'll put you back at the end of the i've got burnt of people with questions. So if you're light back up up to let me let me go to everybody else and i'll come back to your representative. Oh I didn't hear emotion oh i'm sorry well i'll I thought you require I thought it was just a request. Well let me get it let's go to questions and then i'll come back to you there's a lot of people with questions and oh okay well i'll come back to you representative helping to you recognize for questions i'll just yield my time to represent a lady okay sender boy but we have other people that was my point have people that have questions thank you manager so I like the idea of in person don't misunderstand me but I want to hear how you address my my concern we have a nursing shortage and at some point tom when you have a nursing shortage you're paying more for the nurses so now i'm gonna get into a fortibility so the other smart people I know that you've probably thought about it but before I make some kind of assessment i'd like to hear how you answer that or even so under the under the independence as I mean all I could think the first thing is and nurse is only required for the ageing independent assessments that's not the requirement for the behavioral health of ideas different requirements for each assessment type. Even if we were to go tell a help then it would still be a nurse that would be required because that's what's on our contract and that's what's in the me and your for that particular population so it would still be a nurse doing it it would be a nurse doing it tell her how. And I would I would just like to clarify and we're talking about the aging side but for a personal care we do have around little under two thousand to three thousand children as well getting personal care so and just want them I don't want to make that as an elderly only type service on where when we're talking about initial visits it's also children as well. Do you have other questions okay representative. Consolidate. Thank you manager yesterday if if I heard you write you there's concerned about not being able to get people on the phone for these visits as well so if we can't even get him on the phone for a visit how do we expect them to get that in person visit. I would say and I could pull the data I would say we have a harder time with the behavioral health population getting them on the found than the other two population so let me not generalize that across the board we have a hard time getting the behavioral health population to answer the found and schedule their independent assassment so we've been going a different route with our care court pass care coordinator is trying to assist us with getting those scheduled so maybe I misunderstood you you were saying you you have a hard time getting the patient okay it's not the provider oh no server now now there now they they they really have been a very good partner to s especially during the public healthy mercy wine down they have done any more misamount of independent assessments for us to make sure people that really needed and were eligible for medicaid coverages stayed in our programs they've been am amazing so at any point in the past or currently didn't have you have you used tell the medicine for that initial visit necessarily not even through coverage or three thousand not even though it's been okay by the fed you just not used it we took a pretty hard thing it's that we wanted that done in person. Okay thank you. Okay I have a represent it you're good okay and got back to a person of ladies. Yes thank you manager well I appreciate you could get that information about other states before the rules meeting and we can talk about that then but you know at I understand what you're saying and we want to make sure that people you know are taking care of you don't want their home condition is but I mean I i've had one of those people come into my home. And I mean can't you assess whether a visit is necessary or not by talking to someone I mean not everyone is a bad parent or caregiver would you agree I mean so if you have that initial contact. In in things don't seem quite right then you can have that visit in the reason I say that is it it cost us money to make those business we have as the seller said we have shortened the nurses it seems it's money makes more efficient it speeds up the process so if we could make this word it would help in a lot of ways and still protect the people on the other end of the phone but if you can try and this will call and if there's concerns then do a visit I would just think we need to have that discussion and see if there's a compromise that we can do to help the system be much more efficient I think we're happy to have that conversation I think I would just say that I think. And you and mrs lightenment are different very involved care givers that that often is not the case with a lot of our clients they don't have bad because they don't have guardians so often times we're trying to schedule with individuals that don't have that kind of support system yeah I understand but there we know a lot of people who are the same they're carrying people care givers so I just think we don't have that debate so thank you manager so III hear you and I say yes so but the assessments on the patient and the assessment is the patient and the services for the patient correct it's not necessarily an assessment about the care givers correct no it's not okay no I hear you representative and II agree with you that there needs to be that conversation as well I think the rule as it is is is i'm i'm good with the rule as it is but I agree you did we do need to have a little bit more of a further conversation about what he's talking about which I think is a separate a complete separate issue and I think a very good one to have so I apologize I misunderstood it what and II appreciate a representative clarifying that as well because you know we want to make sure that we can get those folks a partner with us to help us worth reaching those patients that are sometimes difficult to reach. Representative he'll continue our question thank you so just so i'm clear on this arkansas when we pass this rule is going to have a higher standard than the federal government correct. So what we did with this rule we added two sentences we said is it yes or no I mean is it going to be a higher sandwich or not currently we have a higher standard than we'll continue us having a higher standard currently or legislative burden. On then the federal government actually if I could jump in I think the compromise was working with some of the providers and internally they could see fr reads face to face and by giving the reassessment a telehealth option that is audio visual hipper compliant then we are trying to assess and me in the middle if we can have that initial assessment be in person face to face and then the subsequent reassessment face to face on an audio visual hippie compliance so it can't be done over a telephone we what we have to be able to see the patient so I think while we are trying to set the base line in and give the patience the best possible care that we can by working with providers so just i'm clear it it is more parts of them the feds it goes against the legislative intent of the telemedicine law that we passed in point twenty one which allowed audio I mean well it it may it may not fit these state definition of the law that you passed but i'm also governed by a code of federal regulations to claim state and federal money I have to be audio visual compliant on hipper so according to the federal according to the federal regs i'm not trying you know. You know i'm not trying to pick an argument i'm just saying I have to also adhere to the federal rags. The feds will not allow us to do audio only. Okay thank you for that just an and if the federal legislation says face to face that's a matter of interpretation unless it's explicit correct so it's it's it's weather I mean it's subject of us or whether we are. More stringent that the federal government or night. Because it's the way that your interpreting face to face okay. Representative consolidated you recognize a question thing that i'm sure so that. It's rare is another question so you said it's going to be a hepa compliant. Audio visual right what what does that look like does anyone have that in their homes at possible heaven homeworks. Okay what does that look like then so what is it I do it right now with like my my child's dermatologist I mean I can do it on my found as long as my phone has a camera and the cameras turned on and it has the crack software on it and I sign all the forms online it's not overly stranger I think it's it's just more than that audio it you have to have that tooway visual live camera feed so that the person giving you the care can see you and in your talking in real time so basically you know through a through a secured app that that's exactly right they send me a secure app to do it in okay thank you and that probably works on ipad laptops laptop. Perfect. Any other questions. Alright see nan i'm gonna get with representative ladyman though and per and item on the agenda for future meeting. Umm alright and see none without objection this item or see and reviewed. Next item ma'am. Our next item is rule that will allow our agency to extend the payouts for the work for stabilization plan under the arpany at seventeen finding that dhs received and then secondary to that is a is an amim to our living choices waiver to make our rates. Our present rates permanent which is eighty one dollars eighty five dollars for in urban versus a rural facility rather than reverting back to the pre public health emergency rate of sixty seven twenty five. Okay. Ended that will have a. Any questions. Unless. Right nine this item stands reviewed thank you but accessed item. That should help those facilities out tremendously or does folks. Good afternoon mary franklin director of the division of county operations with department of human services. We are implementing this next rule to comply with the federal consolidated appropriations act of twenty twenty three and this rule will extend continuous eligibility to children under age nineteen for twelve months that's twelve months from approval to renewal and then at between renewals if they remain eligible at renewal at that twelve month check in there are a small number of categories that are exempt from this simply because by definition these categories last less than twelve months anyway and that's the medically needed group some of our foster care spend down categories transitional medicaid. There is a fiscal impact on this because and we calculate in that looking at a historical closures and then estimating the additional cost where those cases to remain open the twelve month requirement for continuous eligibility and when did not get any public comments during the comment period for this rule would be happy to take any questions. Okay are there any questions on this room. All right. Seen no questions this item seems reviewed. Last item. Good afternoon martin admit dhs provider services and quality assurance. Thank you item o is related to changes that we will be making to the out one and out two manuals as a result of act three thirty five that pastor in the legislative session that particular act is related to minimum training requirements for assistant living facility employees as a relates to domentia in all times. We had no public car made snow physical impact and we also worked with a rally ahca and all timers are considered making these changes. Yep so yeah and that this is great i'm glad that we were able to hear the presentation by mr cooker earlier says nice to book enthus meeting with this role are there any questions members of the committee. All right good work there's a lot more work to be done obviously I think in this area very difficult on patience but. See none that's the item stands reviewed. Alright is there any other business come for the mechanic committee. I don't see any will see everybody at christmas and the capital next december the eleventh there is a children youth. Children and use meeting I think that morning at ten. So check in there but then come over to the supreme court right alright with that was seen no other business we are adjourned thank you members.