Aging, Children and Youth, Legislative & Military Affairs- House

Good morning thank you all for being here on this gorgeous fall day I appreciate you always be in here but especially on days like today and holiday we can whether I do not necessarily see a corner but we are not voting on anything today and as I just mentioned in this weather and on this week we have people that have come to make their presentation so we will proceed and I will turn it over to you representative maybe if you will you and your guest will recognize themselves yes state representative duly may vary but mollyrose waters from family connects international. Thank you all for making it out today I was a little nervous it's a holiday week and the rain so i'm so happy to see so many members here thank you for your time and i'm excited that some of you brought your children or grandchildren with you today cause it really plays into what we're talking about here today I once you all to imagine for a minute a base a beautiful vase that perhaps took an artist nine months to make. Hand painted most of delicate base in the world. Expensive. Now imagine that they has been placed somewhere. And it getting knocked over. That falls apart into a whole bunch of pieces and is really really hard to put back together I don't care what how much super glue you have or how many artists you hire very expensively to put that base back together it's never going to go back exactly like it was in the beginning I feel like that's what we do all the time here at the capital is we are trying to. Saul emergencies where you can't solve an emergency you can prevent the emergency though and that's where i'd like our focus to be moving forward we have a lot of problems that I think the program that you are going to hear about today can help us solve before they even become a problem. I want to remind everybody that are consider at forty point four maternal desk for every one hundred thousand live birds the meternal mortality rate in arkansas is the highest in any state in the country even more troubling ninety two percent of eternal debts and arkansas in twenty eighteen were found to be preventable maybe if a nurse had been by that person's side two three weeks after birth. Maybe that death of that mom could have been prevented. You're also going to hear. Umm how this can help prevent children from entering into our foster care program i've sad on this committee for so many years and over and over again we hear reports of how many children we have in foster career how many need to be adopted all the problems that are there how we need more workers. Well we're looking at the problem wrong we're trying to solve the emergency why not try to keep the family intact and help families get off to a good start in providing more help for new moms and new babies with that i'd like to have malia takeover and explain what family connects international is I will tell you I have been talking to the scroop for over you probably year and a half I have had many conversations with the department of health and DHS on this I had a bill presented in the health committee this last session and it was at the end of the session I didn't ask anyone to vote on it some of you are on that committee as well I didn't ask anyone to vote on it because I knew that we still needed more discussion I want more buy in because I think this is a chasing and tastic thing I wanted a different group of people to listen to it and that's why it's being presented in this committee today i'm gonna let them take over thank you so much representative maybe good morning everyone it's so good to be here with you all I am going to take a few moments to explain to you a little bit about the family connects program and then I will be bringing up family connects union county so you can hear about some of the work that's happening right now already in your estate I have expertise and toward treatment prevention so the work that you do in this committee as a line with my area of knowledge I think that there is room for us to talk about foster care and also prevention though and to talk about how we can prevent children from ever entering into the child welfare system. So I want to talk about work family connects is it's a universal new ornament nurse home visiting program what that means with it being universal is that in the areas where it's being implemented it is available for all families to voluntarily sign up for so it's a universal program a nurse home visiting model there is a nurse that goes out and provides these home visits with marman baby and they're typically in the home although in some family connects they do allow visits to take place at different places they are a flexible with that but typically they're in the home. In this is something that's available for all at no cost to the families so where this is being implemented there is no charge at all to the families to receive this service. Typically these visits are scheduled about three weeks post pardon and there is a very significant reason why it's three weeks post pardon so typically after mom has baby there's a gap in service for mamam's not going back to see her position and tell she's about six weeks post part. So we intentionally want those visit scheduled around three to four weeks so a health care provider is going into meet with marm and baby and check on them when there is a lapse in the here getting any type of medical care. And it is a registered nurse this person is highly trained and knows how to provide medical intervention and there's a lot more that goes into the visit other than medical and we'll talk about that a little bit but one of the main things that family connect dies and offers that's a different from some of the other home visiting models is that it is a nurse that comes in to provide the visit. So I wanted to share with you while amount just so you can kind of see where family connects is being implemented right now across the country all of the yellow dots are states where we are currently implementing the program it's not necessarily statewide it may be a community or region and different states but there are two states that are rolling out this program state wide that does take some time they're scaling up community by community in their state but just wanted to give you a picture and you can see the names of all of the states to the right there and then also at one thing I want to point out to you as that on the left side you'll see that from july twenty twenty two to october twenty twenty three over twenty two thousand home visits have have occurred in our program across the country which is huge just in the past almost year and a half. The. So fairly connects is an evidence based program and that's important because when we're talking about making investments we want to make sure we're making investments in something that's going to give us a good return on our dollar. In when you have an evidence based program that means it's been through a rigorous trial or two to make sure you're getting the the outcomes that you want to see for children and families if the model is being implemented in the way it was designed. So you see across the top it says rct that's randomized control trial those are the trials that are conducted to show that we are getting the results that we want to see. So there were two randomized control trials conducted and you can see on the last side of the screen. Some outcomes and maternal anxiety and depression so in the first one there were twenty eight percent less likely to report possible postpart on clinical anxiety and the second one it was even higher at thirty percent lower. In that second row it refers to infant father relationship quality so ensuring that that the baby and dad have a strong relationship the third ones around amend ER care so every reduction and a pretty big reduction around fifty percent. I've overnight stays in the hospital on the first year of life. And then the last one is around child maltreatment investigations so the first random as control show renoise control trial showed a thirty nine percent reduction and cps investigations for abuse and neglect the second one forty four percent. So this program gets some pretty remarkable remarkable outcomes and this last column I just want to show you a this right here is a specific to reducing disparities so what we see across the board across the united states and arkansas no different that we see desperately racial disparities in maternal mortality and this program has been shown to reduce those disparities. I want to talk a little bit more about what representative may be rementioned earlier around prevention and that I have a lot of knowledge and primary prevention in particular. So we'll retalking about prevention there's three different levels of prevention there's primary secondary intersheri prevention of tow maltreatment. What we really want to focus on is that primary prevention space and if you see there in the box it says universal home visiting as a primary prevention strategy now secondary intershare you prevention are important but when we think about primary prevention were also thinking about you know no suffering for children and families by having experienced any of the downfiles out in potential harmful outcomes you are maybe familiar with adverse childhood experiences if we can prevent advert adverse childhood experiences there's actually a a dollar amount on that that we can save and long run they've been able to figure that out it's in the millions of dollars. On the right side of the page you can see five protective factors and this this diagram here is about protective factors that prevent child mail treatment now there's not one single way that we prevent child mail treatment there a lot of different ways that we prevent child mail treatment but what researchers have found is the spot protective factors are the best way that we can prevent how many treatment these are the factors that when with their present and families we see a lower much lower likelihood. So if you look at them one is on the top right corner knowledge of parenting and child development so just knowing what to expect at different ages of your babies development and growth and your child's growth. The next one in the green block is resilient so after when we talk about resilience we talk about bouncing back but it's also being able to move through life difficulties and come out stronger on the other side in having connections to the resources in your community to help you get through those hard times. The bottom one is concrete supports those are going to be your basic necessities housing clothing food you know you think about for a new month that may be you know connections to programs like wick or dipers. And on the left side social connection so important for us to all have good social connections in our life and positive people around us. For new moms with babies maybe they need to meet other moms and parents and groups and get connected to other people who are experiencing the same things that they are and that's one of their things that family connect nurses could actually provide referrals for it in the last one is social emotional competence you know as adults that we think of those as soft skills that's kind of how we talk about that you know knowing how to get along with each other but and we are talking about imperial saying you're talking about how his mom and baby how are they bonded. How do they understand each other how are they you know how does mom understand the emotions that a child is going through so I just wanted you to have this so you can kind of think about and family can act how these far protective parents are factors are being lifted up and i'll share you some examples. I did want to address why a nurse because that is one of the questions that I get so often why do we need a nurse to be the one who's providing this home visit well timing we talked about this a little bit earlier right that it's right there are three weeks post part of ideally in its really important that we have medical intervention at that time. Knowledge nurses have vary specific training they are able to identify health risk and concern and also be able to provide the education as well so mam is able to recognize if there are any result anything that she needs to maybe take note of. And the last thing is trust nurses are trusted there there sound over over again and polls to be one of the most trusted professions. So when you think about what happens then that nurse home visit when when nurse goes out to visit with mam and baby these are some of their family support matrix stomaines that they're looking at now the visits are usually about an hour and a half long and they're very conversational and nature but typically these are the types of questions that they're asking about so they're looking at the maternal help then emphat hells and also health care plans do they have insurance they're looking at town care plans though ask do you do you need some referrals to different child cares resources you have a plan in place already with what you're going to do when you return back to work. Parents car relationship management of infant crying best that knowledge of appearancing in child development. Household safety and material supports. Family and community safety. History with any parents and difficulties. And then the last section and that support for fear parents parent well being substance used in the household if here and emotional support so each factor is rated wonderful with is lowest as one the family has no identified needs for it with emergency intervention needed. Typically most families do have at least one need identified in the visits they may not be you know at a level for but the nurses are able to provide some kind of referral to them to community resources and if you were to go through this list here I guarantee you could match everything up on this list with that whole diagram that I showed you around protective factors that prevent child mouth treatment. So these are common referral examples so if you're thinking about what what type of referrals do they make to the nurses make and i'm not going to read through this entire list but please take a look at it so you can see and just get some ideas about what types of referrals that they're making these are the types that that we see over and over again and different communities across the country. I'm now going to turn it over to your neighbors here from union counties so they can talk to you a little bit about their program and then once we're finished and presenting will open the floor for any questions that you may have for us so thank you so much and i'm going to go take my seat up there to allow space here. Thank you if you'll just each introduce yourself before you begin thank you. I'm hiding club and mark I am a home visiting nurse in alderado arkansas am alice and stone and the director of women services at the hospital in a more so the program manager over family connects in our new home visiting program hfa. I'm having a nurse home visitor for family connects. Looking where trying to decide who's gonna be doing their talking and so our program started in september of two thousand and nineteen a little bit of back history on their arkansas children's hospital received a donation from some union county and he specified that he wanted the funds to use and union county and so children's heard found out about family connects in error. Reached out they have an alliance with our hospital and reached out to the director will allison and in the leadership and asked if we would like to start this program and so that's kind of how it got started we are totally funded by that green. We did visit from september and tell march of twenty twenty and then we switched to phone visits during covered had a long period where we weren't able to go out into the home ends so that was while frustrating for us but. So far we've done over six hundred and seventy visits and are population reach is between forty seven and fifty seven percent since it is a voluntary program both hand and I are nurses at the hospital so after they deliver the next day we can go into the room and ask them as they would like the home visit and so it have a very positive responses as far as how many sign up for a visit after that there are some that decide not to. Have a visit so that's where our number is kind of drop some and then. It has picked up with all them. Outreach to the community so. Um I feel like as far as a lot of people ask or why do you need a a universal home visiting program why not just focus on. Those said are really a need but every every mom whether it's a first time arm or one that has four kids. Can have different problems with each pregnancy some of the issues post per depression in anxiety we do a post part of depression screener and it is amazing I know hadn't and I both have. Been um. Surprised at how many do say that they do have inside the and some depression issues and a lot of mums don't want to say anything so we have been able to encourage them to reach out for help. In that. Goes across all economic. Levels and so it's just helpful for everybody maternal high blood pressure small you are saying. If a lot of mom's don't see a doctor don't go back to the doctor for six weeks so blood pressure issues can be very common even if they didn't have problems during pregnancy so picking up on that and getting help and and medication for that is very important. Inflict the feeling problems if mom's her bress feeling a wanna also. A lot of times they don't want reach out and say i'm having trouble with and we do have a lactation consultant that we can refer to to help with that since we know that broad speeding is important if they want to do that so education on info crying we'd talk about the period of purple crying which most babys go through and just. Stressing to the man that this is normal and giving them ways to connect work through that which probably I would think decreases the amount of emissions a lot of time small just take their babies in say their crime. And so we can educate with that safely practices. That's very important and just it is tight when they leave the hospital but reinforcing that and just being in the home and in saying what the environment is like. Talk here resources in. Parenting education sometimes we have a new mom said have never been around babies and then referring them to just paying ten classes and and things like that. You to have anything to add is since i've started this program without dinner fight a lot of needs in our community i've lived in alderatoma whole life except for college and had no idea what large need this is for every wine regardless of so they are economic status I was a nurse for three years birth maybe all they long but had I struggle with post part of depression and just needed an extra little you're doing good mom and someone to reinerate that I was doing a good job these ladies do a great job we have added a fired times of how blood pressure is you use postpone depression I don't know if you know anything about that but it said in our tamha. Malms suicide it's really bad informative feeding problems I want to touch on there because we know breast fittings the best for marms and babies both a lot of times marms just get really frustrated and just decide to bottle feed and while we as long as you figure by they were good we really like to promote breast feeding and also on the infant crying as well we have some issues with. Um. Now gosh said an invent death also in our community and that's a big thing i'm shaken baby send all these things we talk about whenever we discharge the very rarely listen to everybody's in a hurry to take their picture and get their right being the car seeking together maybe home so really going in the harmory innerating everything that we told them on dish charge because they always forget think about when you go the hospital and you've had a procedure done you forget what that nurse say I have no idea I can't remember where the instructions oh I don't know and if you've ever had a child you know that things are everywhere your life is turned upside down so just having somebody come in your home and just educating you. Touching in your resource that you may have we have tons of resources I had no idea what you mean had so that's really awesome thing that such an everywhere in arkansas is rule except for a letter up pretty much I feel like so you really have to know what community resource you have what's out there how can we help this moms how can we help these babies because we do want to reduce children out treatment arkansas and an all time high for older things that are not good so this program really identifies that makes it a better replace for marms and babies. The. Thank you are you ready for questions. Absolutely ready or not here they can't understand representative painter you are recognized thank you madam chair just a couple of questions one has a person has a mother reach out you guys is it by a referral from their their primary care physician how does that work. I we try and ketch everybody before they go home from the hospital we go in to the room we do try reach out in the community just to let people know we have three ob providers so they know about the program and hopefully they talk about it before delivery but in any bank and just call and ask for a visit but most of ours we we offer it to him before they leave the hospital membership they can manage your also to how many are cancelled have been serviced by and this may be for the young lady that was before you guys how many our candidates total have been serviced by you guys are taken service from you were the only program and always also six hundred were hopefully you guys will grow counties yes and that I think that was part of where children's was looking at if they wanted to start it and see how the program dead and I feel like we've done really well and come on a back county week we we should love to have you guys we started in union county we recently are going to magnalia so we have just recently started there but had is right that's the whole purpose of family connect everyone to pill at the program and see how well in the end which I think would be fabulous so hopefully it'll spread across arkansas or something they can manage everywhere and malaya if you would like to come you may approach the binge I know you had said that after their presentation you would all take questions and represent my very reminded of representative pilkington you are recognized. Hang out. Thank you thank you very much that's an appreciate the question. By representative painter mine kind of piggy backs off that so be in in this area for such a long time and looking at it I mean everything that you'll are doing clearly I think we will see resolves and the longer I know you just started two thousand and nineteen is what it said so i'm sure they're connected the dad is lacking but i'm sure we'll get there but my question is scanner yeah if we want to expand this in the other states can you kind of walk me through like cost set up potentially and then third party partners you'll use I mean just if you had a way to like say like this is a blue pran to get to start in like johnson county where I represent. Can you provide you the blueprint I mean then you do right now just maybe a high level just just to get a sense how this will be replicated how hard it would be to replicate i'm just kind of wondering about this sounds like a great program and thank you for what you're doing I think is bless the happy. I can start in then if you all want to add anything about any expansion plans so in other states you know usually they'll pick a community and it depends you can look at a lot of different factors and how you take a community to start a program or expenditure program you know it since you already have a program it might be beneficial to look and see where they could explain because that would be an easier growth process just because they are already in this community and they're already expanding now we do have some fiscal modeling that we can provide to kind of tell show you show you what the investment is that front because there is planning that goes into this process it's not like you start implementing and then you start you know doing their specits the next day we have a community alignment part of this model so what that means that there are people also working on the back end behind the nurses to support them and help families get connected to resources so that nurse goes out visits with the family and then there is a phone call made or a text set to follow up with the family and say hey were you able to connect with that resource where you know is there anything else that that you need from us what can we do to support you so there's that part of it as well and that takes time to get all of that set up and because we do have to know what are the resources available raped so I think that if you are thinking about expansion you may want to talk to a union county first and see what they have in mind as far as expansion and then if you want to look at other communities we can do that we can run some numbers and and give you some cost estimates to see how much it would if you want to say you know credit and little rock we can take a look at that and see. Yeah I would actually out I would love that if you do that I think for us trying to improve the health of the state if we could find areas to go after you know I think i'd be really really helpful thank you. And i'm sorry that's just gonna say anything you want the whole committee to be able to get if you'll just get it to blake you can get that to everyone absolutely and when you're thinking about expansion does also think about you know where you have birthing hospitals that has to be a part of the equation and what you're thinking about how your expanding the program. And how you are going to serve families so if you're in a more rural area you know you're talking about nurses traveling longer distances if you're in a moral area which is fine that model works too but they're implemented in different ways between a rural community versus a more urban community like little rock so just going to keep that in mind now some merely partners of hours they will look at you know material mortality rates on the community level that's where there will go to implement first where is the greatest need for this program or there are other factors you could look at you know maybe there's been something happening in the community that you really want to work on an address and you want to build up that community in particular and that's why you want to implement there you can decide however you want to but we do have some ideas around how to make it successful so if you are going to implement we do have some a list can that you need to take a look at to make sure that you have all of those pieces and place in order to make it successful. The punished one in touch on the part and both in facilities in the state of arkansas we used to have thirty eight we have recently shut down to across a state so I know in my area in south arkansas my hospital is one of the only places that you can come and deliver maybe safely with obvious positions i'll be trying nurses history and doing the do everything there but that's just not common knowledge so I feel like that's a big thing so these home visitors are happened to go magnolia came and cross it all of these different areas that do not have birthing hospitals. I would just like to chime in for just a second so I did have a bill it was hb eleven oh three that was presented to the health committee and fiscal impact statements were put on there you can access that because it is an old bill that's still out there but dhs estimated so the bill that I had was setting it up in ten different counties or ten different areas as a pilot program eventually hoping that we would be universal and would be able to offer this all over the state as in new jersey does an organ um in the process of doing the fiscal impact that dhs put out there said that the state share would be five hundred and sixty five thousand dollars I will also say that we had to have cigarette do an actually statement on it to see how it would impact or employee benefits and basically they said that there would be very small impact virtually no impact to our employee benefits which I would assume would also go for blue cross and all the other major providers that are out there so it's relatively glow cost but that information is out there on the web and you can easily access it thank you. Representative bentley your recognized thank you thank you chairman thank you for being here today for the information you've given us I think looking at her statements to definitely something that we need to look at is a couple quick questions for you guys says we just get talking about cost. Do you think and I know that we have an analogy on our you very were we have a nursing storage or despite trying to get more nurses training so and if other states may be can answer this as anybody used maybe a well trained LP and they would we could fill in there if we have areas of the state that we don't have enough qualify to rains to be able to send them out on home visit so do you think if we had nurses that were least trained underneath the or a team approach where we had an an ran with a couple of lpns and eighteen at least fill in the gap you guys think that's a possibility since we have such a nursing shorter to this point in parts of the state that are desperately needing some orients so. My question really for this home visiting model whenever we go into the home we have to do an assessment our mum ambaby and that's not within the skeptic practice for an LPN so I don't feel like that would be better a very beneficial on my end. I have two nurses right now how did hate and who do the home visits and we reach i'll better rator that we can and starting magnolia so I don't. Forsee that being an issue and it's a fabulous job everybody wants to do it right around it happened to go by the guidelines. The way since this is an evidence based model it is set up for an orient to provide the visit in the future we may have some different ways to provide those visits but right now it's an orient that provides the visit I will say that across the country that is a question that comes up pretty often around the nursing shortage buy up with what we've also seen is that nurses typically are drawn to these possessions they really want to go out and visit with marm mb so it's not been as difficult to staff these possessions within the programs correct can I have a follow up chairman that's okay you recognize so just in union county I guess to use that grant funding to provide for this or is it been yes man we are ok. That's out of curious on the one at one last follow up so are you guys so you will retire I know like tation is so important so you guys train like consultants do still when you guys go out there are the orange pretty much. We are actually highly enough or sort of our like tatian counselors so which is like a step underneath the consultant we have one consultant at our hospital that we can refer back to and they can see her on an outpatient basis which is available service so that helps as well but I have far total at our hospital. Ok thank you thank you chairman. Representative shepherd you're recognized. Okay all right thank you good morning thank you all for being hit this morning miss waters I think my question is more so for you at the beginning of the presentation you mentioned in the financial impact of asis do you have that information available as a specifically relates to arkansas shield I don't know that I can port well let me see about arkansas specifically the numbers that I have but I know off the top of my head and they are national but I can look for arkansas specifically and see i'd be happy to provide you that information if yeah sure that with the board that would be great I would look to know about you know the financial impact the access have an on children in arkansas best and there I do know that they also have specific to tell mail treatment that financial impact as well okay thank you. Senator sullivan you recognized thank you madame chair do you know with the attrition rate is for programs like this you know we have last programs that we start with really good programs and really good at their goals were great programs were great but the population that's really impacted often ten that to access the programs so do you know what the rate of once you start so yeah i'd love to be a part and then at the end of the your program you have a lot of people drop out so do you know what they attraction rate is from signing up to dropping the program. Well I can and I can talk about the fidelity to the model and what their expectations are around fidelity. So we do have a certain year they have on here at the person of the population reach so in order to implement the program to fidelity we're asking that they reach a certain percentage of the population that's pretty high at union county as actually in a certified phase of the program so they are at the top level of the program they've been completely certified. I will say that I don't see as much drop off you know as the program spent implemented for a long period of time it seems like it stays pretty consistent and if anything it grows because the more that people in the community learn about the program and hear about the program and that it's normalized the more people are automatically kind of expect to have those visits before I get there that's all good but if their program is being run in other states we are to have some idea if with the cost projection is in ten counties and so we get seventy five carries and we're going to implement something state wide i'd like to know have an idea of won't you start the program this is who stays with it and is that the population that were really trying to reach because admittedly arkansas taff we're not doing well but if the programs are out there and we don't know that we're really touching the people that will need at the most i'd be concerned about that with the real actualized value of the program it is if you could get some numbers from other states that appreciate thank you and you know I know you're mentioning about you know is it is it matching up and is it meeting the needs of the community and one of the roles of the community alignment specialists within the work is to actually look out with the needs of the community and say are they are they meeting the needs of the community are they aligning with what the needs of the community are so if if they're not then we need to look at that and figure out how we we can reach people who are maybe night taking that the offer of the service and that's part of the role that they have but you don't have to look at that which I don't have the top of my head we don't know we don't know if we're really achieving what our goal is well and I know that that's part of what they do especially when they're going through the early implementation phases so during those early implementation phases they're receiving a lot of support from family connects international from the home office. In their implementation folks are actually going over all of their numbers with them and a light of detail to look at that kind of stuff and identify if there are any if there's any misalignment happening and help them problem some up and come up with solutions but i'd be happy to take a look and come to see how it's matching up and if it is meeting the needs of different communities one of the things that I hear is that it does seem to be and the what happens as the community partners if they notice that you know someone is an eye a group as night taking the home visits for whatever reason they try to rain storm and come up with a new strategy how can we ensure that everyone feels comfortable with taking this home visit although it's still completely voluntary and people have an app you know they have the option to decline a visit if they want to as well so thank you march critical we have the data where people see is often different than what the evidence is thank you I don't have the data but I will tell you doing it day to day with these two ladies we do see moms that have been first time moms that continue to sign up with family connects with every baby that they have regardless of age social economic status arm so from what we see the account there are numbers out there we do see that it's working the only community that we've had a little bit of trouble tapping into the latino community and we worked on that in are doing better in that seat so. The. Senator live you recognize thank you man share number. Piggyback off on some things that senator suddenly say. Here so and so you are collecting the demographic data correct it's a as far as the financials so you should be able to produce those ports relatively quickly in regards to what demographic I mean whether the spreadsheet demographic so economic demographic is falling into the the person that your servicing is that is that a first time yes okay so then that that would be good that that this is going to be some good information are amexical back to a few things i'm excited that you are on a target is the promire prevention model there are me so I have a a bad ground of public health so so when you say primary month years ago so i'm happy to see that you are this is a premier prevention model. I'm comparing though some of the things that you said in your model to some of the things that you're seeing they were seeing in here i'm really interested in there in fact father I mean i'm interested in all of it but the infrastructure do you are could collect march that may data also like if if the mother single mothers okay collect it so then so you are going to be able to provide that report as well our. Okay in the end. Are these billable medicaid services that you want to providing I know that you are said that you have a a grant from children's hospital it up from up familiar with there but are these billable medicaid service at you all provides some available summer night in certain states they are i'm saying though in this day it would like like when you're providing the services I know that you have a grant but are some of the services that you're providing are they billable through medical the lactation support it is notation support is that the only is that pretty much that on the. That's the only one that I know of for sure but i'm not the expert on that I can't speak to that okay so if you could get the if you could get the services that you provide. And I just want to see if they're if they're billable medication services are not because that would that would go a long ways and see and if this is a skellable program throughout the states go here now can you keys key move closer to speaking to the michael so since we are funded through children's we can ask tyre green one which she is the head of arkansas home visiting network and she would know the answer to that we don't know much of help the funding on. Ring and. Madame share and came back into the everybody because it and you have a few other questions thank you representative duke you recognize. Thank you madame chair and I have a couple of questions to so when I get done on the top back in i'm gonna pick you back where I would do all I think you're back in today i'm gonna piggy back off of a representative question because the nurses that was one of the questions I had written down and btw I think you for which i'll do I think it's great so I don't want my questions to be perceived is. That i'm not. They're not supportive that this system I benefited from something similar in a. My my first my daughter was where she was a premium so I had I had someone come into the house to help with some things. But I always had to look at thems of II look at things from what could go wrong or what was the negative one there so my what my concern is she addressed a little bit with the nurses but one thing segments as you said was everyone that the nurses all love this and my concern was not that you would have been able to feel your job the nurse is there my concern was more with the nurses shortage are we gonna lose nurses to this so that was my first initial question because that is a problem that we are struggling with so what your answer on that one then i'll hot back in again thank you. Umm I don't feel like with this program just like I said with elderly I have two home visitors and we service the whole community of being in county so you won't lose nurses by the masses and I think nurse retention and retainment and recruitment is a whole nother issue beyond this committee that needs to probably look at so if you would like to look at that I would more than welcome but I don't follow please okay one tiger. Parts for a station break again. I think because we have three mikes on at the same time well for now with mine but yep right if if whoever's answering will answer and we might can cut down on that ringing okay sorry that's what I was trying to fix now what we ask me I just if I had to care about fault you may question so is there any difference in I am not in the middle call filled at all is there does it make any difference the rule of versus urban area with that nurse is shortage as far as what it may play out and I realize you may be guessing on some of this but you are in other states so have you seen an impact on that in other states. I haven't seen an impact and other states even our rural communities there they seem to be able to recruit nurses and that at night impact the nursing shortage in that area. If anything there's probably more concern and a more urban area when they're where they are actually a lot more nurses. But even if they're pulling nurses into the program it's actually I think are probably a benefit to the nurses to have an option that could maybe give them a little bit of a reprieve from what maybe you know they're stressed out and i'm sad about you know whatever role that they've had previously in the nursing film and would like to do something different that this is actually giving them something to do that's a little bit different and remain as nurses I will say that and unfortunately they haven't released this to for us to publicly share it yet but we have heard some early data around that the nursing shortage is more about a reflection of nurses who have active licenses but aren't actually practicing right now. So this would be potentially a way to bring those nurses back into the field. Senator hammer your recognized they thank you mancher are you just handling referrals out of children's because the grant is based at children or did I misunderstand that. We. See anybody that delivers that lives in union county. So even though it's funded through children's. It's available for any resident of your new counting and making it now said sweep expanded that that was that the question yet well I was just wondering yes you answer the questions not just exclusive to just cause the grand is out of children's doesn't mean it's only based on referrals that you receive our children you'll see anybody and since two thousand and nineteen you've seen six hundred and seven if I sold the number correct how many nurses do you have. Just taken an eye and I worked by myself for quite a while alright yeah madame chairman question to the chair please you may. The the subject of that I think is a critical subject because it will help formulate things going forward I was just curious if the chair would consider asking the group to provide the data to this committee and could that be shared with members that are interested in following this because of if we're asking about data there's got to be a place for it to go in there's got to be away for to be able to get to us as legislators and just curious what the chairs dot charge for is how that can be handled yes certainly I mean you're already going to get the doubter to blake and then. We can disseminate that to the senate and the house. Ageing committee and then go from there is that acceptable yes ma'am and I was just wondering how often the group could provide that data because we'll have a physical session coming up and we'll get a general session up cajal report that data say on a quarterly basis or with your data system within your program how sophisticated it is at how much are you able to keep up with it and collect it such as which you provided today. We actually have quarterly kpr snapshires that break down the different demographics and everything that you wanting is that also are you just warning biscore budget. Type data. Man mention. Yes and I can just give you a general I don't think you can send more data than this group wants to read so okay. It's mainly just the number like the number of visits maybe that turned down you know where you've offered and it's been turned down those candidates things may we could have some offline conversations to develop that out or could visit with the chair and we could work to get it and just it was what you're doing and what's been asked about data to give us a clear sense of moving forward to where if it's great productive we do need to get more money because of me return on investment so we have that conversation documentary. So we can just forward on that to blake every time I get it how about that sounds good thank you representative mccore your recognized. Well first well thank you for what you're doing this is something is very much needed. And thank you for the results that you're getting. This is following a lot of a little bit more along also on the funding model I see that family connections internationals are five or one c three public charity organization. So in the other states how is that funding model working. When you have federal state phones and a private. Non profit charity how is that working is there anything that you could give us on that. The. Am different states find this model in different ways so there are funding their model on the community level and then we provide implementation support at family connects out of so the model was originally developed at duke university and then we provide the implementation sport to help them actually implement the program. You recognize. So I understand you correctly then we would need to be looking at local grant funding models to get this program started starting rather than just a. Lan adam and a state budget is that correct you could do both you could do one of the other some states are actually billing insurance for it as well summer billing medicaid for it typically the community partners do have rated funding so they have a light of different sources that they are using to pay for the model and it really just depends union county as a little bit different because they have a like a single thunder but most of the other community partners have multiple funding sources. And instead of just once some started the program using american rescue plan dollars so that's one way that they funded to get it started and then they're looking at how now to sustain it and they're bringing in different funding to sustain the model so that's just what example some have also you know just recently passed an estate budget a commitment to state wide experience and that's happened as well better typically it is braded typically it is multiple funding sources thank you represent if car you're recognized. Thank you medicare in preparing for this done some research myself and I notice where the your head talked about the the race disparity but i've discovered that that there's a higher rate in african american mothers are sold it with the cdc and I was just curious to see if ya had been able to identify any causes while that such a high rate in what strategies you are using or what time your next steps are to alleviate that. Are you i'm referring to them up mister mortality rate disparity there are a lot of different reasons why that disparity exists there's not one singular reason why you know researchers have talked about just ongoing health problems that are systemic and nature and the black community and and the communities of color. And there's also a lack of access to resources at times depending. There can also be a distrust of the system at large that prevents. A family is from engaging more so in the health system. There are really a multitude of reasons why that disparity excess if you think about the family connects model though and how it provides connections to the community resources believe that's probably in one way that we're doing those disparities you're bringing in someone who's a trusted medical professional to provide connection to community resource. That's probably one way in which it's being reduced i'd be happy to follow up and send you more and depth information though on the disparities and why they they exist. But there are a multitude of reasons why it's not it's not just one all right thank you and thank you thank you for your work thank you madam chair. Just noting that our chair had to leave so i'm now taking over thank you ok representative pierce. Sorry stiml. Yeah thank you thank you madam chair I have a two park question here and obviously you can see by the amount of these years and we have that we see the need for post pardon mental and health care in in the state of arkansas but the two park question here is for the nurses appeared to table so do these clients have phone numbers your personal phone numbers and obviously in in amongst doing this you're going to develop relationships with with these mothers ends of their struggling one day and they're really have any breakdown can they call your personal cell number and will you answer there in in in the furthermore to the proper. Way they need to go whether it's mental health or or health care. The. I'll tell you personally that I give every one my card that has my personal cell phone number on there should I do it that's questionable I do but that's just me I know both hardly inhate and have discussed that issue with their clients when they're having a breakdown I know for effect heyden has given out her number multiple times and even made someone at a facility because she wanted to know that she was there she was getting help so it's very intimate right net personal interaction is important I believe in this. In in this sector thank you. Representative duke thinking madam chair so I think representative of clerical attached on my second question was on the funding models as far as the community and so. I'm gonna I will may follow up with you afterwards i've actually been texting with somebody in northwest arkansas about this so my third question would be do you do faith bait when top up referrals and resources are they also sent or utilized faith based resources and as a getting complicated whenever you start using any state monies. As far as referrals we do refer to like fee banks there is some counselling christian base cancelling that we can refer to. I'm. I guess I don't know as far as the question well there some of the conversation weighs about just emotional support and different things like that and I am assuming. Independently you're able to do pretty much whatever you want if you want to send him to a church if you want to send him to a churches pantry if you want to send her to a minister for counseling all that's opened up so do you utilize that because I do think that's an area I like to look for answers on a local level where they like to look on a state or a federal level and so that's kind of where i'm coming at this and is there have you had run into e issues that the states that are coming in now with state money to to help with your programs as far as limiting so I guess one would be to be a guess both of you guys as you're doing this more on a state on a national level and then ask on the state level I feel like since words small community it hasn't been a problem I mean if we're in the home and asking if they want cancelling you know. Do you want. Christian base counseling and stuff like that but as far as. State money and yeah you know the way that typically the agency finder is set up that's kind of like the directory that the community partners use that have all of the local community resources the community decided what just that's what goes enter that resourcei we don't really have a say in what goes in there we can make suggestions as far as types of programs and services that are available to the community but they are the ones who are actually putting that together i'm not aware of any issues around. Making referrals to different types of agencies around being faith baster or not i'm not aware of any i'd be happy to take them when the network but i'm not heard. Any concerns around that when they have state funding I think it's up to the community to decide you know where they want to refer people to so it's really on them to make that decision. Follow. Thank you for your attitude so like I said there's a lot about this I really like what always concerns me is whenever government money starts getting mingled in with private entities or groups they are doing such good things it may not be now it may be five years or ten years or twenty years down the road where those that money comes with strings so as you proceed on this with your mot you just. For you all that would be a caution I would have and even for this committee that we don't want to take something there's doing a great job and mess it up so we need to be very cautious as we move forward on how to support you all on what you're doing but also not restrict you in your freedom on what you're doing thank you. Representative pilkington thank you madame chair or kind of start on a way back to representative are certain senator loves question. I'm i'm curious to all ever do any sort of tell a health visits when you go in visit I mean I made if you've got a nurse in the house you can set up a. A laptop have a teller visit bill. I mean within thirty thirty days you can do a t c m code which I know pre lucrative and then you know after that you know just a simple code so i'm just kind of curious you guys do that to help with it's kind of making a financially stable. Our the model for a family connects is in home visit. Covered through everything after window so they'd so it's we could do modified home visit which is over the phone not doing the fizzle call assessment there's still allowing us if we have somebody that said no I don't want you to come into my home will say what can we at least call you the model is still letting us do a phone visit this is just a one time visit I don't know if we mention that but just a light touch visit and then referring out to other programs so gotcha yet now I just imagine. You have to one time visit though you could still you know if you've got an appearance on him who can have that visit I mean obviously they can build for it which is. You know when he'll pay forward essentially they're doing an assessment in a valuation so I just so that was just curious about another question I have is with hundreds do you ever work with hundred families. We've just started that in our community and i've been to a couple of other meetings okay and and and one less thing and I just think this is for just that the benefit of the committee I know there's in some discussion about papers organizations have been a private non profit I would just like to remind everyone you know we have baptise health mercy healthy adjacent vincent with a lot of faith based on private organizations that receive money from the state receive money from the federal government they're still able to do they need to do and still maintain their mission so that I know I am to the conservative our committee members but I would just say in reality there's probably really no reason for concern or a law about that it happens all the time so. Letting folks in your community now all the grace resources that you guys provide or do you just people get to know you're right up about you know when they're in the hospital or those kind of things. We've tried to do some community outrage the three of us have spoken at rotary and service league and just trying to get it out and end up again community with that. And then both had nine actually work. In the hospital some like I worked last week talked with them arm about the visit and could sign up so a lot of it is just personal interaction and then other moms. Spreading the word about our program thank you venture. Thank you these were all really great questions I don't have anyone else in a queue I just want to kind of wrap it up if if that's okay and remind everybody that I did have a bill HB eleven of three there were fiscal impact statements they are DHS was heavily involved in coming up with that we also had a employee benefits division and segal put a fiscal impact statement which basically what the bill wise was for ten communities to start this and that they would and can bill medicaid and can bill insurance companies and so the the I said earlier the state share was five hundred and sixty five thousand dollars the annual estimated total impact was two million three ninety four but again you would get some federal dollars to compensate for that just to give ever one an idea of what what numbers we already have that are out there that can be looked at so thank you so much for sharing this information and i'm very delighted that we had such great positive responses from members here any member who would like to work with me on this feel free i've sat down with many members and over the past year and a half with our console children's hospital with the hospital association DHS and the department of health this has been kind of worked for two years trying to get this information together and and all that so thank you for coming all the way from north carolina sorry you're here on a rainy day but I do plan on taking you out a tour of the capital so don't go anywhere we'll head over there in a minute thank you for making all the way up from elder very yucky long drive so we wish you luck and continuing to do what you what you do and thank you for helping those new mams and new babies get a first start in life thank you okay kind of continuing this conversation. Mary bintley has has brought a guest with us and we're going to let her talk about how we possibly can have nurse mid wives there's been quite a bit of discussion do we have enough nurses in the state of arkansas to do this and we have nurses who know a whole lot about new marms and new babies and they are possibly an untapped area so i'm gonna let bring in introduce yourself and explain what you do and how you think you can help. Okay. Good morning i'm brennan's strike and II don't want to think representative maybe in representative bentley for inviting me here today. I'm here as i'm I was elected as the legislative chair for the american college of nurse midwives arkansas affiliate I was raised in literach I went to the interview university and became a certified nurse midwife in two thousand and fifteen and moved back to northwest arkansas to work at a birth center that was there and for about five years in rogers unfortunately the person are closed. Different story but close in two thousand eighteen so I wanted to share a little bit and II think so much of what family connects is doing is tinge until the person I am really inspired by what they're doing I want to share a little bit about who cnmes certified nurse midwives are what our capabilities and our license is and then also some things that were working on right now and I don't want to put anybody on this but I don't know if I can do this but I wondered if anybody would be willing to tell me what a certified nurse midwife is can I do that. And you member when I respind. Anybody but her. No responses okay I can do it that's fine okay. Did them. So there are some common misconceptions and certified nurse midwives are either masters or doctorally perfect trained nurses so we're on the same level as a nurse practitioner and our scope of practice includes pre natal care interpart in which means delivery and then post pardon as well we also provide gun ecological services throughout a woman's life span and can provide primary care to women in our care as well we also care for a new morning's up to twenty eight days of life and in america we can provide just sexual health services for male partners of the women who we care for to make sure that things are not spreading back and forth so the missed conception often is that nurse midwives are are not as well trained maybe as as we would help somebody delivering babies to be but like I said I was trained at benderbell university there are many nursement wives working at vanderbilt with physicians i'm not under them so. We can do homebirths but ninety five percent of the nursement wives in america and in our state are doing both in hospitals are burning centers so i'm not really here to talk about that part of things today. Yeah. And then I do think that we are really part of a primary prevention model in terms of staturing complications so care given by nursement wives has been shown again and again to be really excellent care we reduced the number of interventions for marmin baby we provide. A lot of bedside support from so that she can get through the labor process a healthfully and then also we have really high patient satisfaction rates and as nurses you know we we were initially trained as nurses as nurses it's really important for us to think about our patience sort of entire while being not just are they alive. And this doesn't mean also that we oh so sorry in twenty twenty one as many of you may remember we packed past act six o seven to allow independent practice for nurse midwives this is the national standard and I think you all who voted for that the national standard is that nurseman wives are able to practice to their scope of practice not outside of it what we're certified and license to do without the supervision of a physician and it's been shown that in states for this is allowed there are normal more nurse midwise practicing that voscope of our care doesn't mean we don't continue to work closely with physicians obviously we we know the limits of our abilities and we know that are patience can and do and need a higher level of care very often so it's part of our are practice and are training to continue to get that care in tandem with other healthcare providers. So right now there may be some other numbers out there but we did just some internal. Arkansas nursement for free group numbers there are fourteen of us providing four scope care in arkansas so eight in a ums there's a really well established practice there of certified nurse midwives who as of just a couple of years ago are taking their own patience through the whole experience of pregnancy and post pardon they've been really successful there's a lot of demand for their services they're also helping train residents there and i've heard just anecdotally that some of the residents have said that the training they got from the certified nurse midwives was really excellent and that they really enjoyed having that perspective as well by contrast in missouri there are hundred and forty nurse midwives practicing in different parts of the the state there so they have about twice the population and so five times as many nurse midwise practicing there tennessee has a three hundred this is as of twenty twenty texas has six hundred so we're really behind in terms when when we consistently then low and the numbers of nurse midwise practicing in our state. Some of the challenges that we face in arkansas and that were working on right now is equitable reimbursement for medicare and so medicare and you may have heard about this from nurse practitioners in general it's about seventy to eighty percent on the dollar that we're getting reimbursed for the same services obviously I know is in her smithwife i'm not going to be doing a cease section i'm asking for reimbursement for that but if I do a normal baginal delivery I don't get reimbursed as as much from medicaid and obviously that drives the private insurance reimbursement as well. And nationally we've seen the states where that's equitable or we get a hundred percent of what physicians are getting then more people are likely to be able to establish practices that drive in the state. There's also a job competition and this is a I think I think of arkansas we have oace of maternal health care and we have deserts so the oasis obviously being north misarkansas where I live central are concerned where it's a wonderful place to learn read your kids and as a provider establish a practice so there's a lot of competition in northwest arkansas we've seen that people are very territorial and I understand they want to be able to work and and serve their patience and so it's just been a challenge to get maybe people ask why there aren't more not nursing with free practices but I really think your ms is making strives and that i'm looking at ways that we can bring more and nurse midwives to the state. Um the the flip side is that in um I think it's thirty seven counties in the state there are no obstacle providers period so the deserts that we have people who are driving hours to to get prenatals they're driving to get post part and follow up until deliver their babies. I think personally this post part of use is so important and it was great to hear a family connect so my partner and I as certified nurse midwife and I northwest arkansas are working on a project were claimed the her side prenatal program where we would actually be delivering along with other with rands and like tation consultants postpart and home visits and so we've worked with the northwest arkansas council in this and you all had mentioned a lot of the really good topics that were working on right now is how to fund it with considered some private employer program so there's there's precedent for employers paying for pieces of this as part of their their healthcare benefits package but we would also like to be universal we'd like to make this as available as possible we are hoping to get funded in twenty twenty four to pilot carol madison and franklin counties and northwest arkansas to the rural counties to the east of kind of the urban area we think that between the two of us we could we could touch five hundred families lives by providing a weak one and week three post part and home care is it. So similarly again I really think family connects has a lot of overlap and and we don't want to recreate the wheel but we're looking at how as nurse midwives we can address especially those families who have higher risk whose have had higher risk pregnancy isn't our higher risk for complications and we've also been approached by our thunder to look at how we can improve pre natal health with a service so at the end of pregnancies some of you are may know that women need to testing additional surveillance during their pregnancies we would offer we would plan to offer that in home as well so it's also not a nine stress test someone who need to get those twice weekly at the end of pregnancy and that's the service that we could provide in the home if they're not able to make it to their providers office and build for those services. So again that's just sort of a heads up and and sort of a background on what we're working on in arkansas. Um. You are now a lot of the statistics light of what's going on but we want to let you know that we are here and I mention there are fourteen practicing I think that nursing shortage in account that somebody's shared that a lot of people are not able to practice or not wanting to practice full time for you know I challenges the nurse midwife is we want to be able to practice the way we retrain to practice not necessarily the way a physician tells us to practice so that limits us and I think that we. We're interested in in serving were interested in working there about twice as many nurse midwives in the state who are not working in our current field doing other jobs i'm personally have been a stay at home on for the past four years and am ready to start back into the work force but I think that. If you build it they will come so i'm open a questions okay thank you so much for your presentation we're going to start out with representative ten. Yeah. Thank you madame chair so i've got a couple but just going to carry could you go to walk me through what a typical day for a mid wife would look in like a primary care setting or something like that obviously they're not all going to be in birthing centers but on birthday centers all over the state we don't have any go ahead so could you kind of walk me through you know what what would that look like if you were going to put one in yet they can not go. You know clarksville medical clinic if I were to say we want you to hire midwife it's we need it for the community what would they're a temple day like them look like as I think a lot of people just think. You know like the bbc show called the midwiser something like it's all about delivering babies every day and obviously it's not it's a key gonna walk me through that absolutely so my experience has been in a birthing center but I think it's it's parallel we also saw gun and clogical patience there are patients for kind of closural services so anywhere from probably 10-20 depending on uh the kind of the time that you're spending with a patient you can see about tender twenty patients in a day and so we would be seen people for prenatal visits on the same schedule that a physician would although it tends to be a little bit longer with a nurse midwife in the room so whereas a physician might have the nurse do a lot of education and usually nurse my wife's will do a lot of education for the patience on what to expect during pregnancy labor and delivery and then we also would see patience for postpart and visits so the person or where I worked we actually did a home visit we would have patience delivered the birth center then at about forty eight hours we would go to the patient's home do sort of that kind of wrapping up the post pardon care for them at home and that would be either we would go ourselves or a nurse we go to their homes but then we would see patience for gynecological visit so it's very similar to what you would seen a physician's practice. Nurse midwives also a ten deliveries obviously so again I mentioned i'm i've been a state home mom for the reason I haven't jumped back into the work forces my husband works full time and travels quite a bit for work so I knew that being on call in having small child and wanting to build a family was not can do so bet and women who who practice nurse with no free full time are taking call sometimes sometimes they're on shifts so maybe they'll do a twelve or twenty four hours shift at the hospital that's how it works at ums they'll do twelve hour chefs and then maybe rest for twelve hours go home do they're on thing and then going to the clinic the next day or vice versa so there's lots of different iterations that does that answer your question yeah yeah I know that that does it by thinking is if we were to do what we need to do to increase the number of midwives obviously there's like said there's not all there's the lack of birth in us was only thirty six. You know we were to put one in you know some of these counties what were they do all day I guess it's kind and obviously. The other service is you mentioned and i'm images due because you meant about the equitable medicaid reimbursement rate so on a pps rate from the feds are you also not I said equitable from them or is it also disparity. I think you were to work for a clinical at like a critical access hospital so sorry and obviously they were to bill for your services and get a pps rate from the feds would that be different or the same I do not know that's fine I don't know I do know that in northwest arkansas there's a group called ob hospital a scroop and they're actually national so they employ physicians and nurse midwives to do what are called hospitalist services so if you think about physician ob practice they're seeing prenatal patients kind of logical patients during the day they are doing deliveries but they can always get over to the hospital or they want to have a night off whatever so the hospitalists have really uh of created a nice what's the word. A cushion or I safety network for hospitals when say that just so the hospitals can be at the hospital all the time so physicians who are at home and want to come in and deliver their patient can't make it there's an accident something there's that there's a hospitals there all the time and that's evident speech that having a hospitalist available twenty four seven. Reduces more better than mortality if all the kind of do things right away as the patient come in comes in the only hospitalist groups love us nurse midwives because we drive business to them and I say that because we can't do see sections I get it you know i'm so in a rural area you can't have a hospital without a position in then that's not what we're asking for you need we need to be able to deliver patience in a place where it safe but if you have a hospital that needs unnursement wife and a hospitalist the hospital skin can take the higher acuty patience and the nurse that wife can deliver the the more normal happy patience does that make sense that makes sense and the one last thing if i'm given the level to your. I've come across the term maternal health aprn i've seen that you just I work in healthcare outside of this and so when you're in your presentation I was kind of curious you explained me kind of how maybe a midwive and maternal health april. Would differ do they not I mean I just and that's really just sorry it's going to come across recently about a grant I saw you a mess is hiring a maternal health appearance and I thought that's why not a midwife I guess is my first question and then absolutely there are there is a certification for women's health nurse practitioner a parent they just do everything outside of delivery so they can even do prenatal visits I believe I don't know if they can do the whole scope of a pregnancy but II know at least step until twenty eight weeks um but then they don't touch women when they're in labor and then they can take it back up again later and that training is I mean really it's just for people who who in and if they tend to have more of a focus on going to college services maybe even women who are going to remain appies and helping them with hormonal things like that nursemidwives all are trained to do deliveries although some of us can work we you know we can work as a women's healthness practitioner in and tuesday do deliveries as well if that doesn't work trust makes purposes thanks so much and representative bentley. Thank you chairman thank you for your time thank you brian for driving down here today so we passed this body past a great bill on twenty nineteen two larry as for scope of practice explained to us where the hurries why was it not been taken to effect like we wanted at two one pass that bill so would stop on us at this point absolutely it has really over overall then a very successful bill just in the in the fact that we are in name have for practice authority don't need a physician supervision we used to have to work with the board of nursing to get a uh supervising physician signature to practice interparting which means do deliveries so sort of the meeting potatoes of why were there we had to have a physician sign off that we were working under them and nationally that's not the standard that's not the model and that's not what has been proven in research to work well I mentioned before that we're retrained in certified to practice independently. What we know how to practice and to refer to clab rate with physicians as needed we don't need to be sort of baby sat or or or watched by a position to make sure that we're doing that that's just something that we are retrained to do just like you would imagine a family practice physician knows that they're not a brain surgeon and so they are going to refer out to a specialist for that as well so what we've seen in implementation is that the board of nursing had some confusion at first about what that meant and that people who had their licenses where the clarity position before were not really being allowed to drop that but I think we figured that out that's kind of gotten resolved. Another issue is that we are not correct me if i'm wrong on this or not. Credential providers through a lot of hospitals so hospital credentialing privileges obviously if you're going to do deliveries at a hospital you have to be able to be a provider at that hospital and that's another challenge to setting up new midwest practices so if I in the new graduate or if i'm coming from another state and I want to open my own practice here I might be used to being able to be directly credential through the hospital but the way it's worked sometimes and are concerned that physicians set up the rules for credentialing and hospitals and then don't allow appearance to be independently credential so even though our state license says that we may practice independently the hospitals are not allowing us to practice independently. And then like I mentioned that medicaid reimbursement which drives of the the reimbursement problems or reimbursement figures is there anything I missed a follow up chairman that's okay um so is there any insurance companies that are not acknowledging the fact that you don't have to have a position there and are still requiring a position to be there so can under getting the savings effects that could be parcel by allowance to the budget smooth after practice. Yes blue cross blue shield is a big one that we are working with a couple of nursement wise in the state are working with arkansas has had some challenges with that as well as another midwife and north mister that they're not recognizing **** independent providers and so therefore they don't know how to reimburse the nursemen wipes who are practicing independently and obviously if you can't get reimbursed for your services you can practice and that and end and I don't think this is not public knowledge the the person I worked for a lot of the challenge of staying open one of the reasons they closed was because we did some services for free we were a toll of being a reimbursed bible across the shield and we were not and I won't i'm not really testifying in a court and I think I can say that without it it's pretty widely now yeah. Thank you could I be one more follow up chairman is that okay so as we're talking about wanted to improve material health and arkansas can you give us a real quick word some different as you see in the midwife model vs and observations model so how they would benefit um the women and the children here in our. This. Yes I mean I mean think about that for a second. Um. And I was saying like in a follow up visits that those kind of things reducing. Yeah see sections and increase in breast feeding those come things that we've seen the data that we've seen that you guys can absolutely make a difference in so I think really i'm so glad that the group mentioned the primary prevention model at whether is since I chose to become a nurse midwife instead of an obstation is because some people call nursement wipes the the experts and normal so we really see pregnancy and childbearing as a normal physiologic process but we're also not blind to the fact that it can go horribly arrive that said you know as nurses we know that if you're able to help people kind of steer people in a healthy direction if you're able to give people the you know the resources are direct people towards the resources they need to be healthy um that is it is ideal is superior too to having to come behind and clean up the mess so is in hers midwife. For example I mention that nurse would waves are often at the bedside with their patience throughout labor and delivery more than physicians just because of. Who we are in what we do we don't have to run off to surgery i'm not saying there's not a role for that obviously there is I had AC section myself. The being able to be at the bedside has been proven to improve outcomes without a higher level interventions vaginal delivery um. Being able to get more successful rates of breast feeding amongst. Patience who delivered with an environment supervised by a nurse than wife and we are also we mentioned earlier that kind of being able to bill for visits one of the things that were working on in our in our perspective program is that nursemidwights can build for and post part and visits whereas nurses can't always with especially with the newborn and and we are able to do lactation services as part of it here as well and we really like to promote press feeding and kind of preaching the choir here. But I think that I think that there's room for everyone and I think that especially. In a more rural state you know we we are looking for academy reimbursement but we also are paid quite less and we're expecting to be paid less we know that I think the average salary nationally nationally for a nurseman wife is about a hundred and twenty five hundred fifty thousand or is it physician might be double that so if we're looking to plug more people in an an increased access to providers throughout the state were kind of a cost effective solution for the ad and then and i'm not trying to take all of it as sometimes physicians will accuse nursement rights or trying to take all the normal delivery is away from them and and I don't want that to happen either but I do think there has to be some some sharing on the playing field other country as other states do this really well where nurse midwives are sort of the first point of entry for if you look at new zealand australia that's the first person somebody is going to see in their pregnancy and then if it's decided that. You know maybe they have a health condition that makes them um need a higher level of care there they're older they for me II had a pre turn baby like i'm not eligible for my own care anymore and that's okay I don't need to be but. There are so many women who need. Just quality care and and really what as a background and nursing provides us that hands on just like the ladies were tight map before sort of comprehensive approach the holistic approach to care that we as nurseman wipes our points to give. One last question if that's okay and real brief those does nations that have more midwives and we have that midwife model is there much more outcomes better than we have the united states yes yeah among developed countries we are the worst worth I think were thirtieth and in the world in terms of maternal and infant outcomes we are really really failing our moms and in arkansas we are the worst of. The worst. Yeah we're going to do something different thank you thank you an and next i'm gonna have senator hammer I think had a question and I have to apologize to him how quickly my mind already forgot he gave me a note asked family connects folks and so i'm gonna let him also ask that question that he wanted me to ask that I forgot to ask so we may end up having one of you come up and answer that question but I think his question might refer to you by an end so will start with that when and I apologize senator hammer. Thank you material problem appreciate you coming back around to me for the young lady at the table for like ask few questions one is are you having trouble getting physicians signing off on your collaborative agreement that you need we don't need it anymore and we did absolutely we had a lot of trouble in I think the challenge like I mentioned I think it was too fault I think it was them not wanting to take on liability for our practice which I totally understand but honestly that's actually not ever been the way it was set up. I'm an independent provider anything I do i'm liable for but there is an as sort of a stigma around taking on it and a pure end nurse practitioner nursemidwife and also there's territorial peace of just wanting to continue to provide care in the places they've been providing care which I definitely understand but I do think they as the state grows and as we're looking to fill the gaps from eternal here at the healthcare that can't prevent us from expanding okay but II guess I got the impression while I go from you said that that was still a requirement he had to have a working agreement to decision such as so some. Some of the insurance companies are not acknowledging that the state passed independent per practice for a nursement wife's and you say that was blue cross much that is one of them. Yeah i'm i'm actually not sure who else are but i've heard that there are other so i'm I can get back to you on that and i'd like to get back because it's yeah my understand may be represent bent can we in on this but my understanding is that we pass the larger that you could do this and there should be no reason that the insurance companies are not reimbursing you and if they are not reimbursing you and that's what losses to do then we need to get them in for every committee explain because they they are gripe in all the time about how much we have legislators have caused them money because of the legislation we passed and yet if this is an opportunity to provide services improve quality hell and save money and they're not reimbursing you that's a problem and and so if you could provide that to the chair maybe the chair could push that out to the committee members as to which ones are not I think they'd be I think they'd be worth following up on. Do you you heard the test money that the other group that was before you as far as your followup with those that you see to help address the issues that they are covering through their program. What do you do as far as follow up once the baby is delivered and the question is do you have trouble with translation say what to hispanic population or maybe and even in the marshall each population up in northwest if you would please so yes we have not implemented our program yet so we planned a pilot in twenty twenty four but those are absolutely things that were were thinking about and looking at we I think I mentioned we would provide a one week and a three week post part of visit and also tell a health so many mentioned how health as needed replained it sort of track our patience for the first twelve weeks after a delivery uhm. Getting them to make sure that they can reinforcing them following up with their provider who did the delivery at four to six weeks as scheduled and then with the pediatrician as well but with the wait we will be hiring nurses as well the two of us are my the woman I am gonna be working with stick spanish so we plan to put her with patience who are our spanish speaking the martially is population we haven't hired anybody else we we don't have any money to hire them yet but we plan to prioritise hearing somebody from that community as a nurse to to help us as well but that is a challenge in and I think like they mention the connections the community connections that we would refer people to afterwards there's a lot in the community so we don't want to replace any of that we really want to become a resource for will provide sort of the medical care that mums need for followup and then and then direct them back and then probably they will feed those those resources are also hopefully feed people to ask in and bring people to ask who they think need that kind of follow up post period but that definitely is a challenge. Did that answer your question yes member much so and I appreciate if you have information that verifies the insurance companies you're not willing to pay you could you get that to the chair please or stay up I think that if that is the case and we can parify that there needs to be a a reckoning day thank you. Thank you seeing no other questions we appreciate you bring in forth this information and senator hammer did you want to hear from family connects on that question i'm sorry. Now we're getting okay okay okay I think you know that's okay that's okay I bid just before I dismissed everything I wanted to make sure that all the questions were addressed and i'm sure there is more about really appreciate you ladies taking the time out of your day to to be with us and share this information and inspire some ideas so we can help new marms new babies and as senator love kept mentioning the dad's to and that that is a really important part of the family. Saying together preventing all the problems that we see later so thank you if there is no other business motion to adjourn