Public Health, Welfare and Labor- House & Senate

I want to call a meeting of the public health to order this morning. Members the you know the holidays and the weather and we do have a real good turn out this morning a lot of some people that were presenting are not going to be able to be here as well. On item G. on the agenda. David cook is not going to be here this morning because there's issues with the virus. The other ones here they don't cancel so we will cancel that item. Because the COVID issues and we'll put that on a future agenda. Item S. we're gonna move that up in the agenda. And we will move that up above item II. Couple more now spends the next meeting of the house and Senate public health committee is scheduled for Monday February the eighth twenty twenty two at 10:00 AM here in room may. Also as a reminder fiscal session of the legislature will start on Monday they were the fourteenth. So with that men culture do you have any comments. All right we'll get right into the agenda this morning. First item is consideration to approve the December 6 man minutes do I have a motion. A motion. Okay. I have a motion all in favor signify by saying aye. All opposed nay moshing carries. So the next item on the agenda. I am D. the pace foundation. Has a presentation for us this morning and so if you all would we we have a. Mr Paul Ryan who is zooming in with us Mr Ryan can you hear us okay. Okay. And Michael kick is here of Senator Hammer. Did you want to go down to the table and. Introduce. Come back. A. What do you want to ask questions or answer questions. If you just go down there do Senate come back to see. Okay I do want to ask all of you to introduce yourself. And who you represent of. Mr Robb what we'll start with the people at the table and then I'll let senator Hammer introduced you Mr Ryan. So if you all would the entity's yourself the represent Senator Hammer. Kim Hammer state senator district 33. Michael Carrick UAMS. Kim if you would just please give Senator action for Mr Ryan sure got quite with miss Ryan several years ago when the legislature was kind enough to help establish the the pan pandas advisory committee and we have been progressing over probably 4 years now I guess of advancing toward getting things established to what is now center of excellence over you M. S. and miss Ryan is as it says on the handout sheet the co founder president of the page foundation which has been very instrumental in helping addresses rare disease in Arkansas in the past Committee meeting missed right gives an update and you were there a representative Ladyman as far as a update on a study that Arkansas is at the forefront of participating in and you're kind enough to add him to the agenda today because we want to expand of the knowledge base of legislative branch to know what's actually going on and how big of a deal this is so for our constituents that we're able to referred them to the center of excellence should they have anyone in their district that that they think may need to be seen by our center of excellence to miss Ron has been at the forefront of helping make all this happen so honored to have him here as a guest of German and away from Arizona. Thank you senator Hammer you can go back to see if you like thank you Mr. Up missed run. If you would just for the record please state your name and who you represent and if you want to give a little introduction about yourself is fine or just go ahead and make your presentation. On the. On. Not be a lesson for these diseases I it was impossible to find there were a couple clinics but they had geographic boundaries around and you can get in backlogs for I think it went on the east coast in armored one time got to be 2 years which is. So we for the foundation. Operation with you And I age to. Set up multi discipline clinics this is a very difficult disease so the multi discipline as follows capturing can't medical try to understand this disease which doesn't have blood tests is not a I mean we practice but it doesn't have markers that would show you off you're you're challenged in Tennessee has grandchildren complexes needs now discovered in the nineties of severe consequences to it I won't go into all the details thank you Michael brought a handout from your center of excellence has a pretty good handle on what disease and I am diagnosed second highest transfer all that it takes care of that issue. One is this is an enhanced on very similar OCD is caused by the lake strap or the flu I will days after the job is done with that disease on the Sunday happens Collins son on stage the injured will and Johnny was precarious occasions far I have that in my own family and really they within a week and 2 weeks got a child the unit recognize there are some barely member state won't walk in certain places for I'm to the point of suicide bridge you unfortunately I in Arkansas and and there's only so that could be really really severe and seen these kind of children the other day I was on the family's because. His parents is very high John what 47 on care and again with the lack of treatment around the country were involved in a really obligated to go for the formulation he's clinics and then do the research so that's kind of a no not Jana right around about 7 years and we made pretty good progress Michael I know again there but if you are. Your bring happen bring a map of the US and shoulder shall the. That's that's right that's that's part of the information that was sent electronically in a I'm sorry I didn't didn't have time to bring print out so I make sure that the staff the staff has a copy and it'll be distributed to everyone we have a center of excellence here UAMS the other places where one is located is at the university of Arizona there's one at Stanford there's one of Michael yes Sir could you move just a little bit closer to you as members you do have that map on your desk there so go ahead. The university of of Wisconsin Harvard and Dartmouth I believe for the locations for the school centers of excellence all across the country we're fortunate to be a part of such a powerful network of of clinicians as well as researchers and it is through the work of the police foundation in collaboration with the centers of excellence that we're going to do some things that it had previously not been done an incident study there's been some question as to how frequent how large of the of the of the disease population do we have this is qualified to be designated as a rare disease there's questions about appropriate ways of treatment and so we're a we're involved in one of the first clinical trials in the country of for this and so it's it's a unique disease unique and how it is diagnosed unique and how it is treated and we're grateful to have the opportunity you a masterwork with pace foundation we're appreciative of the support to senator Hammer senator Ervin representative cloud and representive Warren for their leadership and getting us and guiding us to this point one of the things that's that's most exciting and that I just references the incident study as well as the new clinical trial and I'll let Mr Ryan speak a little bit more about those that are that are taking place that through UAMS as well as some of the other centers of excellence strong. Thank you Mr. Mr right it we're having a little difficulty hearing you we can hear you but if the volume is low if you can move closer made right here. Well that. Better. A little bit but not. Let me remember my. It appears closer as that little better thank you okay so as Michael kind of talked about some of the studies I'm gonna leverage on that just a little bit because we won't have time today to get into all this but the center of excellence in Arkansas is only the second 1 in the country the original 1 was established in Arizona your doctors came out to the university of Arizona about a year point 7 years ago got training at the university for number of days and the nature of what you see on that map is what we use for all the research and clinical practice and so if you look at the map of the guy goes east coast west coast there's a couple more clinics that are gonna probably happened in Oregon and somewhere up in the north Midwest they all practice exacts a medicine that's why we have the other age help us formulate these multidiscipline clinics no the only ones in the country that they're that they all follow the same standards the same intake forms the same nursing practices 98 can't that collaboration moving we've stepped all the projects we establish our also collaborated between Asian a person so as Michael limited to a couple of mine a few more 1 of them is a nurse training program which we now use for new nurses in the country but also fellows at foreign universities to try to educate them on this the inspector not nurse program and the members are all the nurses of those connections scene in gone country the reason that we do a collaboration and we want the standard of care to be not only consistent but current so every time somebody comes up and they all agree on a new form they all have the same day it's the only 1 the only 1 in the country that I'll functions I gather in the nursing. The other one well I won't get into a family is a brain imaging study so this this is as you can imagine programs mental health focus. Very very tough to kind identify which part of the brain would start of the swelling is what causes swelling so we have now issued an brain imaging study we're going to talk about in March in our conference and 2 conferences you're not just 1 we collaborated with work there were also doing the microbiome world trying to figure out from a stomach standpoint when Kinsey Bactrian it produced and also what could in the world inflamed at break not focus so many of these studies and sent trusting me enough for the Committee on done with twins because if you look at it you've got 2 kids same household say water same parents same gene pool and everyone else and this 1 does not that's kind of where we're starting from to try to get a handle on why some kids kids some kids don't on the 2 larger studies that we started I guess both in 1221 and 21 we started the incident study of insurance study is a an interesting study so. Transistor's ease there been some studies around the world trying to figure out how many kids happens Reginald me questioning by ask that question how many kids have been say well. We decided in our inevitable collaborative way to have 3 universities university Wisconsin the University of Arkansas and dark with so you have someone from the south the Midwest and the east coast I try to take a look at this thing of course the covid came along so what was scheduled to be a pro suspected study another region take kids and tracking for a few years and and because kids aren't in school and they are infecting themselves in the same way we did a retrospective study 2017 to 2019 so data which is pretty massive is now being called out filed my bundle hundreds and hundreds of files to figure out how many kids have this disease it'll be it is the only 1 ever not of the world the rest of all been kind of subsection seating clinics and thank you it's like that so we wanted 1 that would be that would tell everybody how many kids have this now 1 side note if that a lot of kids have it that'll be like a kind of been ranked as a normal disease prospectively what's happened is other organizations like the national organization of rare diseases which is actually your part of the federal government has already listed in Spanish as a rare disease now rare and you know in common vernacular of the country is means something is rare that sort of true in the world of medicine in the world means something very very different where is defined in the United States is less than 200000 people have at 1 time. What it really does is there was a rare Act Zane's 1986 of the Arkansas legislature should be very aware of that allows a lot of money to go to rare disease so there are 7000 rare diseases United States shocked me when I heard that but there are and so it went yeah our findings find in fact invalidate a rare disease not the reason what you're aware of that is because that opens the door for a considerable amount of money there's a lot more money in fact president is in the rare disease and there is no more with cancers and heart disease our so just to be aware of I think it's really important study it is the first 1 over the other world every pharma company and well of course once it was reduced so we won't know that until we're ready but it's it's a it's a big deal cycle 1 that Michael mentioned that is also a very big deal is an IV IG study IV IG is a blood product that we yeah sure the kids that are really severe with this disease on the verge of doing something harmful to themselves or others. Essentially replacement of their mentions I mean in a layman's terms kind of what it is kind of booster means system as well but it yeah the hope is that it cleanses out some of the bad proteins and antibodies in their automated system replaces it with healthy ones so they don't have these massive headaches and and brain swelling that because these damaging behavior so that study has never been done there's been a few studies in age that there were small this is a large one the way it happened was paced went to all the pharma companies in the United States and make this product is only a number and one of them agreed to do it a couple years ago it is taken 2 years to get through the contracts the same thing on the A. approved which means you have humans took over a year point 5 to get the improbable does massive testing on the logic and saying you know and so it shall First National one ever done it's a it's a vote against and at the end of the presentation I'm gonna ask for your help I'm trying to recruit them because Mr returning other day in this study so those are kind of the majors toppings you folks are right in the middle of all of them I have a I have a second Hillman about 70 kids in the country on these clinic so I have my favorites not gonna tell you there are but you're definitely one of. I was born that way. But it's it's a secret standards for so it one of the things that I love about Arkansas not only your leadership your advisory committee which is in all for parents like you grandparents like me but it's also got some really sharp legislatures in their by Senator Hammer representative war and senator cloud I think became member the mall sorry but they've all been true focus champions of this and because of that what you ended up in my eyes which ended up with last year when you formally this committee which really got off the ground in June July time frame is one of the most collaborative. Session you can never get the break about it is a combination of UAMS Arkansas children's hospital the legislature a parent group Medicaid. And on and on and on I mean you couldn't want a board whatever to make sure the state in Detroit so I look at you guys from the outside in my little house in Arizona and I'm thinking to myself well and we wish to work rest the world was like Arkansas Arizona had the same experience it was just a gathering all these major entities and nobody said no I look at the votes that Senator Hammer ran last year I have a little bit of background I can actually find all there was a one negative vote any committee on setting up this center of excellence on the treatment for the children you should be enormously proud of that it just doesn't happen in the United States you they'll read any headlines done talking about this kind of collaboration some might think since you folks all of you and all those agencies that participated in this Senator Hammer knows I wax on about thinking people but you know why you deserve it so I'm gonna trying to move on to the one of the points in this meeting initial my mind and that's inside the 18 trial died aged trial has a protocol 96 pages. It's a normal state complex long as most trials are it is the same ranking is COVID. Covid was a phase 3 trial meaning that if it's successful in this state and measuring the efficiency of I've United you know these kids number does that help if it's successful. It's going to be something that looks Board medicine on tier right now I. B. IG and a lot of states the majority of states is not covered by insurance. I'll close as we know it will because we practice it out in your neck of the woods of the Department opened up in Arizona that it succeeds in these children to a staggering degree so it's not I don't think it's a medicine question I think it's more of a I think is the question 90 percent 8590 percent that's really what the trials measuring isn't whether works is how well it works but that trials. Maybe a year to 2 years actually get kids enrolled unless we take an aggressive effort most trial you don't see advertising you don't see soliciting of getting candidate so what I'm going to ask your reserve Arkansas today is to do me a big favor and use of the same duties that I talk about your senate the department of health Medicaid any associations that doctors have the AP the folks where you can reach. Basically intrusions Anderson but also some sports subsection instructions are already looking for kids to this trial crime yeah Jean typically you're going to get a kid that just got diagnosed with cancer pandas who needs IV IG Mr gone through all the insurance. Business you just a wrong this trial you're automatically yeah yeah we work with the parent company is that they for all travel expenses and that's important standpoint I want to bring up real quick and then I'm gonna. Be quiet for a while under any questions you may have caused a lot of stuff to the store. Because the former company has agreed to pay for the travel expenses of the kids 7 we spent only their parents coming with. Had started on the nation you were the first university for instance your qualify as they call initiated we go through all the steps to meet the protocol I mean it's a it's enormous it's a it's a shame that comes out looks at the hospital where it's going to be done it looks that the doctors are going to do it qualifies so I mean it to the Norman screening process you guys are the first sentence there is or was a second C. being isn't that one but I wasn't really happy about that dark with will probably be the third and after that stampers are rich UCLA are taking a little longer be a few months after until there was called initiated in other words they can start seeing kids so having insurance now but she wants. My background as a business person tells me a little bit of advance I would take it you've got an ability for instance you get a kid from paying. Right or or or Georgia or Florida or Nevada at the moment and your receivers only content that can thank you for all the expenses of going to these treatments so I would use that so I'm going to encourage you today to get means the Department of Health the university communications people the Medicaid communications paper losses major instead of a communications on the the Legislative one and get this out into the world primarily of the doctors but also is finding of the parents go to their doctors say I think you know my son's got this in your diagnosis and I don't have anywhere to go the center I'm going to put you know in this trial is to get this done grant program I have a house with insurers and not nothing it's all paid for I'm going. I think it's a great outlet right now so I'm gonna I'm gonna get on bended knee I thank you guys for a little help with that one because I think it's it would be enormously helpful to Arkansas to be leading the way on how many candidates you get to this thing to hi. Why am I recidivism and sit back to answering questions you folks. Thank you Mister prime. Okay did you have anything to add no Sir we have just to say that we are prepared to work with the different entities that Mr Reid had been had reference to get communication out and create greater awareness of this clinical trial opportunity. All right a committee any questions. Senator Hammer you're recognized. Thank you Mr the one thing I like to drive home is and I don't know Mr Ryan said this but thanks rent of $35000000 adventure give or take a little bit and as legislators educating our our medical staff back in our communities that if they do have a child that comes up and and their kids coming in from all over the state and also over our part of the region of the nation into the center of excellence that the more that we can raise awareness on this the greater seat at the table we're going to have to be able to participate in that study and that was really par what all this was about this morning is to raise awareness so that we can you know have the lion's share of that study to get our kids and to get the treatment thank you. Thank you Committee any other questions. C. 9 Mr Ryan thank you for this information thank you for recognizing how we work together in Arkansas we appreciate the statement you made and I think this was a good meeting for you to get your information out a lot of the legislatures here will probably pass it on in their communities so we appreciate you being with us this morning and Mister cake thank you as well. Thank you chairman I I'll tell you of a weird thing is that we're looking forward to when we get passes up some common thing is sick it back down in Arkansas in simple together my wife and I and the rest of the board we're gonna take the old board bring about this next time because you really are one of our favorite places your doctors and nurses have been amazing as have those of the legislature and Senator hammer and the advisory committee I mean it just has been a marvelous you guys should be it again very very cross over like a part of that chip thank you very much thank you Sir thank you Mister. Our committee we're gonna move on to item S.. A traveling nurse program. So Michael givens you would please come forward and. We have a. Trend the ray that pronounce that correctly. That's correct. The only zoom call so if you would we also had Johnny and trip here with us today so if you all would please introduce yourselves and who you represent I'll go with the folks at the table first. Yes thank you Mr chairman I am Michael givens and I serve as administrator for St Bernards Medical Center and Johns for Arkansas. I'm 30 internet that executive vice president of the Arkansas hospital association and I'm basically here for moral support today but if you've got questions of the aisle Now I'm happy to answer. Okay thank you would please enter this of the record. I'm trying to write the chief nursing officer for you I am pass. We appreciate your being here this morning before we get into it Mr givens I appreciate you coming in at the last minute some of the folks who don't know but we had the CEO of NEA Baptist in Jonesborough schedule for this meeting his wife had a baby about 34 days ago so he opted out on that and then I called Chris your CEO and I think he was on vacation and so you're the backup so we appreciate you responding so quickly and Ravenden from Jones were appreciate you being here just as an introduction. I haven't some other legislators have had people call with questions about travelling nurses how that program works the related to pay and travel and how for and so forth so what what what I would like to see is information being shared with this group so that we understand that program and what's going on there and House change so whoever wants to present first we do have a volunteer. That's right you want to go ahead and start. Our that's right thank you for allowing me to participate today by saying it was important that I be with my team as we are currently managing and new research that we're all working for because of that. As I said I'm. Officer here you a mess I've been in that role officially for a liver 2 years however working you're recognized for over 10 years I've been a nurse for 28 years and I must say that what we're saying is is nothing like the nurses that I've been fortunate to work with you through my career we've ever seen before I'll give you just a little bit background in may that we thought and then will lead to answer any questions as best I can travel nurses has been a role for nursing for many many years things about nursing in all honesty I I like to say it's one of the best professions that there is to have truly yes so many choices as a nurse and travel nursing when I was a young nurse I never did it but I work with people who did they tended to be young they were made of all and and they they took this as an opportunity to work in different areas and and to see a country in a different way. Travel nurses and then a method or nursing leaders to staff units or departments for many years you can imagine if you happen to have a unit we heard someone just had 80 if sent you had several nurses for any out or either babies are medically or he just experienced some turnover nurses graduate take advance rolls are 2 different things many would supplement that gap with travelers for what is what is known as a short term contract. It's it's not preferred to have travelers as your main source of staffing that's that's really not the intent. But it has always been used to supplement gas we know that there's a nursing shortage it's been that way for a long time I heard about it my whole career and I think we've seen times where it's been harder to find into still nursing roles than others and obviously what we're currently experiencing is definitely like nothing as I said I've ever seen before so we use travelers we have travelers your U. N. S. prior to the pandemic and we certainly added to our traveler numbers your U. N. S.. We love it when you honestly it's sometimes a great recruitment tool you can recruit someone to your city or your state and they've already been trying and and you know them and they have you and so you walked into this state is there and yet sometimes they want they want to move on to their next assignments so it's it's definitely a way of filling that gap so I don't know we here we work with a company and we that's all of our travel nurses they're interviewed by our managers to see their profiles when sure there licensure training is in place and a man and a do you receive an orientation at UMass it is more greedy 8 but we assessor competencies assess their skills and then they join our teens after they have completed their orientation as well. That is a little bit helpful backgrounds and with as as I said at lead to answer more specific questions that that come up. Yes good background thank you thank you very much. Mr givens can you kind of talk about the program at St Bernard's I mean how many nurses you have how you handle that kind of this similar to what what you presented. Absolutely Mister chairman be more than happy to and I think miss ray gave a good overview of what the program structured like and so at St Bernard's we need to have used travel nurses for about 5 years when we initially started using travel nurses it was due to some specialty areas for instance and we use the example of OB so we may have in women's and children's delivery in need for one or 2 nurses so we would actually host those nurses for short term contract initially when we did it it was it of course was due to the labor pool within the region not enough RN's or LPNs available within the region I that we serve and being the main tertiary care facility and the main trauma center for all of northeast Arkansas of course we get transfers in from all over that region of the state so we have to be prepared to take care of patients that we receive on a daily basis we actually started with to travel companies so the first one is in Arkansas has had a long standing history with them nurses from the Philippines and so we actually use a a nursing program that's called guardian nursing out of Nashville we're we actually Bryant nurses from the Philippines onsite 2 Arkansas and actually they worked for 3 year contracts and many of them actually stay and end up being permanent nurses at our facility I'm in addition to that we begin to use a short term company now the way our company works is we use a company that's a clearing house so we started out with the company called a quality a switch many of the hospitals in the state of Arkansas use and that company we provide them the number of positions that we need and they actually go out and source the candidates from different travel companies so they're more of a clearing house where they use several different travel companies to actually place those nurses so what we do is we actually determine our needs we provide those to call the state post those positions they come back much like Mrs ray. Shared provide as candidates were able to interview those candidates and then they give us a bill rate that bill rate is the rate that they bill us it's set by really other rates nationally and based upon that we either accept or decline the travel nurse to actually work for that short term contract those contracts usually range from 6 weeks to 12 weeks and you can continuing contract if if that travel nurse so desires and you also desire I when we started that we didn't have a great need we just needed to supplement but I I will share that COVID has significantly intensified it as we've had to add additional staffing for additional beds if you just look at December of last year compared to December of this year we're caring for approximately 50 additional patients that day more than we word December of last year and so when you have a labor pool that is already strained and you have to add those bads that's where travel nursing becomes that benefit or that option because you have to stand beds up very quickly to meet the demand of covered within your community and really the only option is to utilize travel nursing so hopefully that gives you some perspective into how to use that same Bernard's. Yeah when I was talking to Mr Chris barber your CEO last week when he was on vacation I think but yes Sir he mentioned to me and I know you all have a big footprint in northeast Arkansas you get multiple hospitals get multiple clinics even some in Missouri I know that he's here in Tennessee so you've got a big footprint there but a crystal me the you might have as many as 100 travelling nurses at peak times is that that kind of a good number maximum number maybe yes so presently do the surge that we're seeing COVID we actually have over 100 travelers and in our system so it exceeds 100 at this point in time. Thank you. Okay what we. Johnny and you have anything to an. Okay we have some questions. Representive love you're recognized for a question thank you Mr chairman here and so I guess my first question is this is what is the rate that you're paying the company for these travel nurses and I'll take both from you M. S. and same in our what what's what's that that that over all right because I'm pretty sure it's not. Any other ideas employment company so you're paying a rate so what what's that right. I don't mind going for so when you actually look at the right rate presently from an average it exceeds $150 an hour now that is what we pay the company they're not set the rates for the nurses we they just give us a bill rates okay in so what what we'll learn give me the average rate of what we would pay a nurse that that is actually living in Arkansas will kind of give me a give me that that figure. I may defer that to miss ray I was not prepared to answer that question so I don't have it. At State that the same on that I really rate our bill rate to that travel company is is very similar to what was mentioned sometimes it it also fluctuates a little bit based on an area of specialty I'm U. S. also has over 100 travelers covering all of our areas right now and you are in starts out just over $22 an hour I believe that I believe that is accurate I don't have those exact numbers nurses go out from there based on years of experience so that the range of a nurse's salary can be pretty wide depending on where they are in your career. So give me give me the average of a new career nurse I mean I don't want to I don't want to compare this no this $150 number to a $22 number so so we'll just say mid career nursing thank you M. S. one of what are they making. I don't have the I don't have anything with me. I'm good at state in mid thirties an hour okay. All right and then also when you have S. has a nursing school how many nurses how many nurses not only that we're graduating but how many nurses are we retaining. I ask you how many nurses yes that's retains at U. N. S. from its nursing program yes I'm. I have sorry I don't. Go ahead all right so this is what I'm trying to get to I know that you M. S. as a nurse in a nursing program I want and I want to really know the number of nurses that we're truck which retaining in the state because. You will or would we're paying $150 an hour. For nurses. In a word graduate nurses and we're not retaining them either something is wrong with our pay scale that we're we're we're paying in in Arkansas or it is something totally off of were saying we're yes I will graduate 200 nurses from UMass and 150 leave the state due to the fact the paid I mean I'm I'm this is what I'm trying to get to. Because this $50 number regardless of what the 4 panel agency or whatever we're paying. In so you we're we're saying the star nurses $22 an hour and we're we're willing to pay a company $150 a our what and what are we. I don't want to sound like this what are we doing I'm I'm a. Can somebody explain to me how we get to the point where we're paying $150 an hour well we're only willing to pay $22 an hour for starting numbers. I mean I'm I'm the only one in this room that thinks that is just absolutely. Nonsensical. I mean we have to really look at this you all I mean because we are 1.$6000000000 from the government to to do things with them we're not addressing this issue. This is absolutely crazy to me. With this question yes the question is what we get what are we doing about that and that's the question Mister chair. That that is the question what are we doing about. I thank you from your minutes are taken from the are taken from the chair. One know that I can answer that but I I think one thing that we have to really keep in mind that $50. You know that doesn't. The $22 would not include benefits is that correct. The correct correct so you have it you have a benefit they can be as high as 50 percent I don't know what it is plus you have traveling cost and all that so you got to be careful of talking about that $50. Comparing it directly to $22 an hour it's not apples and apples I don't know what it is but but there's additional costs. Do this I cannot see that yet that you're nervous we we just got to be careful about that result of love I'm not no no question Mister chair but here's the thing. It doesn't matter if it's $150 to accompany $150 it doesn't matter you know why because the money is still the same if we're paying it we're paying. If anybody can explain to me how we can pay something they should be look different then explained to me. Mr chairman can 9 yes please based upon a thought that you just shared that is absolutely correct and would like for the entire membership of the committee to understand the bill rate is the rate that we pay the company we are not privilege to what the nurse makes that that bill rate does include all of their travel expenses includes basic healthcare costs city it it includes a specific additional costs that they have with leading from wherever they are actually coming to our location to travel so to your point that rate includes all of those perspectives that rate does and then float so right now that's what our rate is if you go back 2 to 3 months ago that rate was well below $100 so it's totally right now contention upon the COVID. Pandemic in contention upon where the hot spots are with hospital admissions so if the state has significant hospital admissions you're gonna see that rate rise to the level that are presently is if the numbers go down it's going to drop very quickly so it just depends on the timing during the pandemic I had never seen rates this high before this is also and I think miss ray would probably say the same thing we we don't specifically like paying those rates either but the other option or the other choice is to actually close beds and so when you're working in a community serving the community with patients that are ill either you find a way to keep your beds open or add beds so during the pandemic I know you invested we did several at the request due to the volume we were seen across the state actually added beds so 1.we had 75 ICU beds 2 years ago we only had 32 so when you make that change so dramatically dramatically and so quickly with the labor pool as training stresses it is with our ends there really hasn't been another option but I did want you all to understand that that rate does Evan flow based upon the needs within individual states with the message here is my last question have you all raise the pay of your nurses in the last year to. Yes we have we actually do assessments every single year and I can speak for St Bernard's miss reckon speak for you M. S. but yes we have. And we also one of the things that we do is we actually give our staff the first opportunity ought to also work additional shifts if they so choose we actually pay them incentive and bonus pay to work additional on top of their okay let me let me ask questions you're not I mean I understand pay is is a significant issue in any job but I think availability and supply and demand is another issue here I mean you might raise that the $40 an hour and still not be able to get nurses if there's not qualified educated experienced people out there so the issue and at representative level right he raised the question you know there's a problem we we know that we have a nurse shortage when the we've had that for a long time so what are the other issues are are there other issues that might be addressed. A like education or increasing class sizes I know one of the big issues with nursing up in northeast Arkansas leases is teachers I think in the nursing program and granddaughters in nursing up at the U. of a and there's not slots available you know so I mean is there any suggestions or anything that can be done in that arena other than the pay. I can start I know miss ray may want to add to this as well I actually have had several conversations with Dr Gordon who is the chair of the nursing program at Arkansas state university and that to your point Mr chairman there needs to be additional instructors in the program to be able to expand the number of slots that are available to graduate additional RN's from that perspective I think to also answer that question I think in ensuring that we're doing the best job we can to make nursing attractive to young individuals within high schools across the state encouraging them to going to the field of nursing and how important it is in in giving incentives to go into the field of nursing so to your point you do have to go all the way down to to the root issue which I think is the labor pool with within our state and address it at that perspective that a you you were right on point with your comments associated with the need for additional faculty additional slots and additional nurses within within a state ms rated you have comments on the. That led to and as I said at the beginning nursing is may the best profession that there is an increasing that pipeline is critical I'll give you an example I had a goal of hiring around 100 new grass this past summer that may graduation and we were only able to bring on around 60 is in the low sixties that there just wasn't the pool then here we have our winter graduates that we're bringing in now and use different schools all over the states not not just UAMS and we hope to bring on 60 and I think I have somewhere around 20 that have accepted positions so far yes that is nurses have lots of options lots of choices but it's also the class sizes are small I don't have privilege to the numbers that are graduating from UMass we have to go through the college of nursing for that but we we lost faculty in the college of nursing last year just like with lost nurses are into the front lines apple TV are are retiring and they're also changing there your past their their professions and and areas that they are practicing so increasing the hotline I was a high school student you went straight to a community college and it will lead to CVS target and really find individuals who want to come into this profession and support them and help them make that happen. Thank you we have other questions representative Alan you're recognized for a question thank you Mr chairman my question is to miss rate this rate as we graduate nurses from nurses who I know is your goal and the goal of state of Arkansas is to maintain nurses but whenever we have a pandemic like this you will have some nurses that would rather go work in a pandemic then the work here because once they go to work in that pandemic they can make more money of travel and then being right here in the state of Arkansas so part of our shortages that I know that when nurses graduate we want them to stay here but when the pandemic kit they went where the money where is that true. Early on we saw a little bit more back and we have over time I I tried it sometimes finds the reasons why people leave or got down you know the money right now it is alluring to 2 nurses if you think about our new nurses graduating today student loan debt trying to pay off the vehicle support their family and it is hard to compete with with those with those amounts that they're able to make and I travel environment I try to also remind our new grads as they need them why it's important to stay in the state of Arkansas courthouses specifically talk about you and that's what makes us special but if you think about getting back to their community we need to find ways to keep our nurses keep them here let them grow grow as professionals let them attain specialty certifications help them you know they want to be educators that we so desperately need also in the schools of nursing we've got to find ways to keep them in our state okay so I have always been a nurse in the state of Arkansas never gone anywhere else in as I said I know and disrespect an army obviously I'm gonna talk about you invested 30 grass that talk about what makes a special with a level one trauma center right what brings people to you and ask what brings the people to stay here in Arkansas and I didn't got to continue to focus on that and we need to find ways to increase the height lines that we have more circulating nurse is in the state to even work with to begin with. 1 follow up if you will notice in the employment market now you will see the signs in various restaurants and businesses that say help 18 and I never thought I was said they will make Bills fan often somebody 1670 miles an hour to come to work to make bills when they normally was paying minimum wage since the pandemic it is just extremely hard to fund good employees that want to work and the the medical field is no exception so would you agree that the pandemic is partially driving the cost of of higher prices the higher wages will met for medical workers. What are making choices and it's it's hard you know healthcare is hard work taking care of patients in our hospital that is very difficult and challenging work it was before pandemic now you add this that the virus on top of that you ask your concern you also add everything else that's happening with their families I always tell people that you know healthcare workers have had to deal with pandemic on every angle they have children they're having to manage and schools just like everyone else an active control working characteristic individual sometimes they're short staffed it is it is very very frustrating and that is certainly then escalated I would stay and help your workers so it is it is a very challenging time to hire and hospital in any role not just nursing that honestly any role it's time. And the same not only in the field of nursing that at St Bernard's several opportunities and and many other different departments from nutritional services to environmental services and it is due to the present situation. All right representative Bentley you're recognized for a question. Thank you chairman right here Mr brown a couple quick questions and I would been on this a while but is couple quick questions do we consider $50 and are something we might turn into the Attorney General for Presque price gouging some of the you considers limit the chill go I'm is it so maybe Jody I can answer that. Hi yes and as you're very well aware I've been working with my counterparts in other hospital associations across the United States to try to figure out the answer to that question too many states are there specific statutes don't necessarily cover at a private contract with an entity that is finding a particular profession like nurses and and letting you work within those constraints it's private contracting and many of the state laws don't go on don't take that extra step in their statutes and we're looking at what that might look like but we have to be very very careful some other states who have tried to put caps on what they'll pay for the contract to the contract entity and have not been able to find the nurses or to achieve and gaining those nurses into their areas so it actually made their problems worse when they try to do something about that particular of pricing structure so we're investigating I don't think anybody has the answer because it is a supply and demand issue literally all over the country but please know we are trying to figure out how to do it in a way that makes sense and that still rewards those nurses who we desperately need in our hospitals doing the work every day of the last thing we want to do is minimize how important they are in all of our discussions I had because they are incredibly important to the health and well being of all patients and all our cans and and so we we have to be very very careful in how we solve the problem but and obviously the first step is identifying the problem which you all have done it and we've done to and try to come up with creative solutions that can help us get to the in game which is having more nurses and to pay them appropriately. Thank you follow UP chairman of this okay yes so getting back to do you guys use any local staffing agencies like I know we have some here in Arkansas they use local nurses so to try and use those as well to do use local Arkansas staffing agencies to help you out. So we actually have several steps that we do the first thing we do is we actually internally have a way that we offer additional ships to any of our nurses that want to work additionally and they can as I insured before earlier they can receive an incentive payor bonus pay then we actually have what we call staff support that is an internal department that we have so we may have for instance where being a large system we have several hospitals that we have someone that may work at our hospital Walnut Ridge that on the weekend wants to come and work for us so they they do it through our staff support group that we have internally so we do have several options that we do locally and then it travel truly was our last resort that as we talked about before with the volume increasing so quickly so I'll just use a an example when we increased our ICU capacity by 10 beds during the last surge that required 25 RN's per week to be able to staff that so you can quickly see that when you try to staff 10 beds in a 2 week time period and bring 25 R. ends on board to be able to staff those 10 beds how becomes a significant time issue and how how travel options were the only options at that point in time. Thank you what we have the same programs here we do get the incentives are offered that to our staffers for any extra ships we increase those incentives over time and it just and we also have a role and a concurrent also if there's a nurse that works elsewhere on campus and they can pick up extra hours as well weekends evenings that are and that work with that now work schedule and then we also brought on in our extender role during so that he could that had to and we talked about it again this morning targeting individuals who are in and rolls and they later away from the desk side for some time I'll be an example of quality are in that today can come back again I may not feel comfortable taking on a full assignments because they have in a way that we trained and comfortable to come and assist nurses especially on those days or shifts when we were very very tightly staff based on the searches that we are in that time. Thank you givens you you mentioned something there but adding the 10 beds and there's another thing that we haven't talked about is growth and in northeast Arkansas as you well know we've had a lot of growth I know in Northwest Arkansas the same way and even prior to the pandemic I was at a meeting in toward the new addition to Saint Bernards which is a huge addition and I if I recall right crystal me that you couldn't even use those rooms because of personnel initially and that was before the pandemic so there's another pressure issue there on growth at least in northeast and northwest Arkansas how does that affect your staffing. Mr chairman to your point prior even to the pandemic as we opened our new tower and I I will share that that was a benefit to us because we had not opened the new tower and then the pandemic yet we would not have had the bed capacity but prior to that northeast Arkansas is growing is not growing as significantly as Northwest Arkansas that is growing and we see more and more healthcare coming to John's role in both hospitals in Jonesborough had seen dramatic growth prior to the pandemic and so to your point we were already walking into a case a shortfall in our labor force and that's why we had already begun to use travel companies at that point in time just to fill some of the gaps that we had but then when COVID hit and we had to increase that dish no bag capacity so we bet went back into our Medical Center and when we built our new tower we built all new ICU beds and we built 46 right after the pandemic started we had to go back in and take our previous I. see you units redo them and open them back up and as I shared before we ended up in the last peak being at 75 ICU beds within the the Medical Center not all of that was COVID part of that where were individuals that probably delayed their care during COVID and now I'm they can't wait any longer so they need the heart procedure they need that surgery so both are factors as you pointed out Mr chairman. This rate I'm sure that you may be on some situation I know some of the things that we've approved the legislature the new cancer center and some other things that you bromate you A. M. S. so what what is it do your staffing is a lot more pressure there. That same situation it's again why I heard it trying to get as many new graduate each class is at all times the year we know we need more we need more nurses than we have today and we're gonna need more as we continue to grow I honestly hope that some of the things that that people are considering nursing as a profession see that there truly is stability there's there's always going to be a job for that so yes it is definitely a challenge as we as we look to the future we continue to grow. Senator Hammer you're recognized for a question. Thank you Mr of let me ask you first of all Mister givens D. what percentage of your staff are going to be let go because they didn't get the cobra charter give me the update on your numbers please. So we actually finished are go live on November 1 and we actually had 43 individuals that left our facility that to our knowledge many of them secure deployment with other healthcare entities within the region. So. Not to be callous but you're here expressing concern but yet you let 43 of your staff go given the court litigation and legislation was passed this last session I mean why why should we listen to you. When you look at that 43 that 43 year all employees those are just nurses okay so just a small number of those would be nurses but when we looked at the situation with the pandemic and we looked at what was going on we made a decision on what we felt was first of all say for our stat status for staff service for our community as a whole to prevent the continued spread of the virus and that's what prompted our decision at that point. And miss a miss ray what about UAMS. We have an adult. I'm sorry I didn't hear you. We do not have a vaccine mandates okay very good of. Then the other question is we also gave money as a legislative branch to hospitals I can't remember Mister givens if yours was one of the ones that receive some of that money in order to help offset the cost of of hiring nurses and there was a requirement with that a gentleman's agreement if nothing else that there would be no in state pirate teen I'm just curious some of the reports were getting. Is that nurses are leaving their hospital going to work for an agency either in state or out of state turn around and maybe going to work for the hospital right down the road do you happen to know we want to dollar Jody and you know what the percentage is of nurses that are working under agency contractors that are actually in state nurses that have left their place of employment went to work for the agency and are now working for a Arkansas hospital or facility. I do not know those numbers to you. No I I tried to look for that and I've asked to one of the aggregator companies if they know that answer and they don't know that answer either so we do hear that that does happen in small in small numbers and it happens a lot in small places so we're we're definitely paying attention to it and watching it from the nurse's perspective he or she is able to make more money maybe by doing that so you have to be really careful and also in in how you design that opportunity for those nurses who are also trying to explore and better their own salaries at the same time I by taking advantage of a supply and demand issue. And and the Mr Vance some issue what's going to be the hospital's policy when the pandemic hopefully goes away and things don't necessarily return to normalcy because I'm afraid we're gonna have this challenge for awhile as far as the salary disparity the discrepancies. What what is the hospital's policy about nurses that have left going to work for an agency and come back because I know people that are staying on the front line at the hospital they worked for for years just a dedication loyalty and then come back and and I'm also kitchen when that there's maternal strife going on between the staff because you've got those that have stuck it out versus those that have left and now want to come back and watch what's the overall attitude about how you're going to address that. Yes Sir I can only speak from a St Bernard's standpoint and I have visited with our team and have asked those questions those exact questions that you just brought up and actually what we're hearing from our nursing staff is they're very thankful that they were bringing additional resources to the table because the volume is so significant it's not manageable and so many times they may have to work we're probably short staffed would be the terminology that would be used so all the resources that can be brought to the table they're very thankful out that's why we've done incentives and bonuses for our own staff as to once the pandemic is over individuals coming back from traveling you know that's a difficult scenario to be and that if you if you don't have some policy where you take them back you're still going to be short from a nursing perspective so there has to be a balance there to ensure that we have adequate staff that are available to to work in our facilities as I shared before I do think one of the things you will see is as the pandemic does slow down we see those rates go down so in the first surge the rates went up in the rates went down in the second surge the rates went up and then the rates went down and now we're seeing the rates at the level that there are there at because of the surge that were presently in so I do feel that those rates will go down probably dramatically down as we come out of the the COVID the president search that were in and the last question is financially how are you as a hospital sustaining yourself. Paying that $50 rate I mean it's and I don't I don't have a you have or maybe that's proprietary you don't want to discuss that but I'm just curious what the future holds as far as the financial stability of your facility and if that's a reflection Jody and across the board. Well I'll speak to St Bernard's I would say it's difficult it's extremely difficult and it it is an issue that we're dealing with every single month and and you know St Bernard's a large hospital I I would be extremely concerned for the smaller hospitals within the state as well Jody and you want to add to that. Yes most definitely I think you all know Arkansas business publishes in October a list of hospitals and I'm kind of patient revenues especially for those not for profit hospitals that are listed any way prior to covid we have lots of our small rural hospitals that have almost no margin or negative margins I think people believe because hospital care is expensive that therefore there must be huge margins in it and that's absolutely not true at personnel is almost always that the highest being that we pay for the costly S. thing within our facilities so that more costly staff are at the harder it is to actually keep doors open for hospitals so and we know that our small rural hospitals are working very diligently your help and both of providing care site funding in an Afro funding to offset some of those expenses for a short amount of time was absolutely critical and we cannot thank you enough for the assistance that you gave us I hope that we don't need you again but I'm telling you with that surge numbers the way they are now and staff out due to isolation and those kinds of things already we know that there will be more demand and we're hoping to be able to sustain what we have right now. Thank you Mr. And and if I could just add I also on behalf of the hospitals want to say thank you because to your point Senator Hammer we actually when we were asked increase for instance I see you that capacity the that funding went to provide the nursing care to be able to provide this bad so thank you all very much as well. The representative Wardlaw you're recognized for a question. Thank you Mr. We won't change directions and I've got 2 different type questions but one direction is. We we pay the hospitals on a cost based reimbursement basically when we look at Medicaid and and even Medicare how how we account accounting for the cost difference in this in these rates that were paying these nurses when it comes to the travel nurses verses are regular nurses we've already heard average nurses around 30 Bucks an hour we're paying upwards of $100 plus for an hour on travel nurses we heard that back in August September when we allocated all this other money so when we get to the next budget cycle. Well we account for the money that was given in Saint Bernards in the list I got money back in August so as Jefferson so as Bob is so Searcy how how will that be accounted and how with those calls reports look when we see on this next time and I think Jody and probably the right person for this question. So N. as you all are well aware our hospitals are reimbursed very differently Medicaid is actually by far our worst payor were paid on a per day rate for most hospitals are a couple of exceptions are critical access hospitals get what are allowable costs which actually almost never cover the actual cost of care and UAMS and children are also treated a little bit differently from the perspective of that teaching hospital in a university hospital and things like that most of our PP S. R. P. B. S. hospitals prospective payment system hospitals and basically get about 800 or $850 a day no matter what they're doing to a Medicaid patient and we make up a little bit of that with our own hospitalists estimate I but it still doesn't get us to cost based reimbursement so for every dollar that we spend trying to take care of a Medicaid patient and we only get recovery even using our assessment for those hospitals that qualify up to about $0.70 of that I will also remind you that the last time any outpatient rates were changed for Medicaid it was in 1992 the same year that the soft drink tax was implemented to try to help the Medicaid shortfall and we got a decrease so we actually were paid better in 1991 for outpatient rates than we have then we are paid right now so we're working very diligently we know that we're under the rate review program with the Medicaid office to try to have these discussions to talk about the rates because they are really pretty well for Medicaid and Medicare to your point representative Wardlaw is a little bit different Arkansas is also and not in an advantage state because of the area wage index so when we have an area wage index in Arkansas that significantly lower than surrounding states that means our Medicare reimbursement is actually significantly lower than and neighboring state because of the way the federal government reimburses us and those systems I. I'm happy to expand further so to go further that if they're only getting 70 percent across back today are you have a bunch of these hospitals go bankrupt because this higher pay or what's going to be the result because all I'm hearing and I just read an email from Jefferson area showing that they were having to hire all these more travel nurses than normal because of the shortage so where's the money coming from that are using to pay these nurses today. Those that that is only 70 percent then they'd they'd have the money to start with correct and that is exactly why we are so grateful to the legislature for giving us those federal dollars that flowed into this state to help us offset the X. those expenses that that is the way we've made it this far. Okay. Second part of my question is we've talked about the nursing shortage in nursing schools of we've all participated in meetings after meetings of the last year and a half and Jody and I appreciate you being part of that participation Senator Hammer as well and and represent Bentley to. One of the biggest discussions there that has resulted from those monthly and and sometimes weekly meetings has been that we're major shortage for instructors and I I haven't heard that part of the discussion today are that part of the the theme but what what is y'all's idea from the hospital side and I and I've talked to some people in long term care this is where I am employed at border where y'all's perspective on how trying to help with the instructor shortage and what you'll see happen and we end up putting schools in all hospitals how do we how do we fix that. I'll start from a statewide perspective but obviously I'll want to hear from Israeli and and I'm sure Mister givens has extra stuff to say to that's important I'm one of the biggest things that we do and as hospitals not only do we try to recruit and retain and do all those things but we also offer clinical sites and for nurses who were in schools so we've been thinking through how we expand those sites or make them and do them in a way that it is more efficient and so that we can have more students circulate through that's definitely helpful I also in our discussions we are trying to think through how in the world can we help offset and teacher salaries I know our hospitals don't necessarily have the money to do that but the state might so if you are willing to explore how we can increase the salaries of those nurse faculty member so that you can keep them teaching and expand and increase the pipeline and were also all yours if you all have suggestions of us and we also talk with other states a lot about the same problem because if this isn't just an Arkansas problem at this is definitely a nationwide problem. I agree with that championship you talking about the the pay issue that is that my understanding for many years people as nurses make choices as I said I have lots of choices and and teaching educator is is one of those roles but they they have to also way that station they weigh that against the the other opportunities and I think it's it we have a harder time recruiting nurses into those roles because it often is that a cat for a nurse to go become an educator. And I would agree with both of them the only other thing I would add is how can we innovate in that field so we've been talking about it St Bernard's how can we provide the clinical instruction on our own accord somehow have some type of relationship where we provide the clinical faculty as team members that we already have employed at St Bernard's that are an ad John Francis to the Arkansas State University program and how we how can we collaborative collaborate and be more innovative in in bringing resources to the table to assess but I would agree with Jody unanimous raid that we've even seen where instructors have left because they could make more salary as a bedside nurse so if you have that issue in that problem then of course the route has to be addressed which is is the pay at the faculty level. Mr chairman I still have a couple questions well if you would go to the bottom of that bunch of people have questions the man again Senator Gilmore you're recognized for a question thank you Mr chairman my question was basically stolen by representative Wardlaw so I appreciate him bringing that up but before I was in a part of this committee or part of this legislative body we have had this discussion on going about how do we get more nurses into the pipeline and sort certainly the the teacher ratio a student ratio is a problem and I think that's not new information to this body so certainly we have to do something to address that and I think this conversation is helpful if only it turns into action and so I think that we need to be committed to doing that but again not to belabor the point causes eloquently made by the representative. But the question I do another question I do have was there a shortage of nurses prior to the pandemic. Absolutely. Absolutely right so of course so this is not a new issue for you all you for higher travel nurses for years and it's been common practice mainly because of specialties the required that you can always feel or find people to hold those positions whether it be in pediatrics or cardiology or the list goes on and on and on and so again this is not a new issue certainly made worse due to the pandemic it's a supply and supply demand issue and so the issue is again going back to we need more nurses coming out of school and so we need to be very mindful of putting the intentional where it needs to be and that's getting amount so that you can Hiram and that you can pay them great wages and that you don't have to hire travel nurses if at all possible so again there and there's a lot of other factors that I think that we as a body need to address as well the drive the cost of health care malpractice insurance being one of those that's a huge factor there's a lot of other things when it comes to tort that's the the major factor as well as a lot of issues that I think that this body needs look at addressing the future hopefully we will but again not to belabor the point and I'll let someone else ask questions and I'll which talking now thank you thank you senator representative when you're recognized for a question. Thank you Mr I wanted to come to ask this question is I'm I'm assuming and normal market corrections whenever you have a labor shortage you increase the salaries that helps fill that may obviously there's a funding issue there and we're talking about the difference between the sweet spot of elevated nursing salaries and the $50 a year an hour for the for the travel nurses is there a reluctance to go to the more permanent solution because the funding sources temporary. I would say so in talking with many of our members I think that that is true I I again margins were so been prior to the pandemic or even in the negative especially for patient revenues that we just haven't been able to afford it and so if there weren't funding sources coming in now to help offset the extra expense we would be in a world of hurt. And so then everyone would extrapolate from that then once this year we've got this major influx of federal funds to deal with the current pandemic but after the pandemic is over we're still we're going to be in worse shape than we were in before prior to the pandemic. Due to the growth that we're seeing that Mr the chairman referred to earlier and that is probably accurate especially in specific areas of the state like Northwest Arkansas northeast Arkansas by the metro area we already struggling with that nurse vacancies prior to the pandemic I think coming out of the pandemic I'm not for sure that we will see the volume dropped dramatically for some time to come it may not be covid but it's a it will be care that we're providing for those that possibly delayed their care didn't see care during the pandemic I as I said before I do feel that the rates will come down nationally so I don't think that hundred and 50 will be there right I think it will come down because we've seen that happen each because your point and supply and demand if there's not a significant demand for the surge across the entire United States then I think those rates should come down but but the point that you're making which is a valid point is is what is the balance how do we increase the number of nurses within the state and how do we come up with you know what that with adequate funding is to to be able to provide the appropriate a starting salary for nurses across the state as well. Thank you thank Mr. Senator Hammer you're recognized for a question. Thank you Mr you know up as I say just for time required distraction so with the acknowledgement that we had a nursing shortage before and we just paid that they'll continue to be a nursing shortage and even though they'll be some correction is the pandemic goes down do you think now is the time that when it comes to the teaching institutions that are competing for the same students and the methodology of which they have traditionally gone about teaching and dealing with things from a traditional do you think there's a commitment from the industry that this is the time may we need to move away from some of those traditional things as long as it doesn't compromise quality of care of the proof of the student we're putting out. You know I love to speak to that. I think that's one thing that has enacted taught us is in a nation he added we're gonna have to use that whether we're talking about how we deliver direct high quality care whether we're talking about how we educate any of our healthcare professionals we've learned that is then works although it's a little different you're not in writing but individuals such as now but we we can use technology we can we can get it to a certain point however at least with nursing and other healthcare careers there is that moment statement that we are in need them you know more. To learn how to take care of patients by by doing so especially any of the curriculum that we can as we lead up to that moment that we can support them and I always supports them whether they need to work on the fiscal or that they would they need to work around we need to make some of this asynchronous as much as possible and tell it gets to the point where we truly do need them presence. And and here's the reason I ask questions what I'd like to ask is we can as legislators. Come up with ideas from our perspective in the there's been tell know how may meetings represent Wardlaw mention that various people have been having I think what would be good is if the institutions in the hospitals the nursing homes everybody that needs nursing staff at every level not just our hands but at every level if you all would present some nontraditional approaches even if it means increasing greater collaborative agreement among the teaching institutions the trial would bring to us what those recommendations would be understanding that you've got conform to accreditation standards and those things that you know are basically out of all of our control that are dictated by federal level and and you all bring to us what you think or some good recommendations. Getting outside the box because inside the boxes which kept us in the box so it's time to get out of the box that's what I would would request that you all do for us and and I'll let you do for would you agree or disagree thank you. Well to answer directly we would agree and so I know that Jody and we'll take that back to the Arkansas hospital association and discuss it with with all of our hospitals across state. A representative Holcomb you're recognized for a question. Thank you Mr up for taking my question first I'll be real brief I want to go back and kind of piggyback off what representive love and senator Hammer ask up it's important we get an answer to how many nurses in Arkansas or in our traveling nurse program because what I'm hearing from the nurses that are seasoned nurses that are nurse supervisors there are discouraged by the fact that they've been there the hospital for years and they get someone coming and working in their facility on the same floor this making twice or 3 times a salary but even the nurse supervisor on that floor is making so I think it's important we get an answer to the question of how many of Arkansas nurses are going from city to city that are connecting to do that because when you brought up the fact that you're yourself up missed given that you're trying to recruit from Philippines not knowing Joint Budget we were talking about this program we're talking about funding and money to get nurses to come from other states but are we taking advantage of that program up but by going from city to city so I think it's important we get an answer to how many Arkansas nurses or or or doing that and kind of what's going on there so thank you Mr for taking my question. Thank you representative. That's the last question that I have here and we spend a lot of time on this but it's a very important issue in our state in the nation as you said Julianne but you know the first step in solving an issue is recognized that we have a problem and then find the problem and I think we've gone forward here and sharing information to do that I think the education piece is very important I miss my granddaughter she's at the point where he's going to a slot in she's got a look at other schools of them want to use that because there's no slots available and that just raises the question that we don't have enough teachers so I think that's a very important issue but thank you all for being here in France in these questions I appreciate it thank you. Thank you Mr chairman. All right Committee will move on to item II. A new patient navigation program there's a hand out on this so if you all would come forward. So another very important program here that we're going to discuss. So if you would please introduce yourselves and who you represent. Follows. Hi my name is Michael beer on the director the Winthrop Rockefeller Cancer Institute. Hello I'm a poor Johnson the executive director of the Cancer Institute. Per on the health issue and I believe the community outreach and engagement component of the Cancer Institute. A major Jenkins I'm the associate director for administration at the Cancer Institute at UAMS. Well it's very important subject Mr my you're recognized to present. Thank you I'd like to thank the chairs and all the committee members for their invitation to us to come present on this important topic it's an honor and a pleasure to be here. I will say parenthetically you've had the introductions here but I will point out that none of the individuals who occurred to me here today would be here except for the wonderful support it comes from the state of Arkansas to the legislature since I've hired all them within last year thank you. Okay. There was a problem okay our topic and I'm I might my comments will be brief so we have enough time at the end for some discussion and questions if there are any the topic today is to look at as you know the with with the Rockefeller Cancer Institute is pursuing an C. I. causing nation this is a complex and competitive extremely competitive process what we really want to focus down on that third bullet you see on the left part of the slide a community out reach engagement program and this is a program that addresses and research is the needs of the catchment area enterprise research and cancer center what is the catchment area for us is the entire state of Arkansas I will point out that this particular element is relatively new the national Cancer Institute added it 6 years ago before that there was no community out reach engagement and see I decided appropriately in my view that was important at cancer centers or NCI designated actually help people cancer patients within their catchment area now we've been at it for a relatively short time but because we have absolutely the best leadership sitting to the right of me. Made a lot of progress already if you look at the right side of that slide the path to committee are reaching gauge when we start with the world research network we were blessed by the fact that there was already existing a rural research network through the C. T. S. a grant that exist that you M. S. run by the PI lord James this research network is spectacular extends throughout the state I it was mostly focused on non cancer so rather than reinvent the wheel and duplicate issues through the help of per on Corey we've been able to integrate cancer into this role research network and so essentially allowed us to jumpstart what we're doing cancer navigator program incredibly important I'll cover that in the second we've established a community advisory board there's been ongoing collaborations statewide organizations a number one C. Y. organization courses Arkansas department of health now they've been a little preoccupied with COVID but they've been able to give us at all the attention that we need and so I consider that a very positive collaboration and then finally a lot of work on Community cancer education and screening resources I'll get into that in a second where we're going is the catchment area needs assessment sounds complicated it isn't we reach out to sensually the entire community within the state of Arkansas and we ask them what they think their needs are you from a cancer standpoint on that directs ultimately the claims of research and services we will design and finally the endpoint that NCI is interested in it or the our is the read out on this how much research funding have we obtained they want to see high impact journal publications they want to see the data in openly they want to see this committee are reaching gauge when impacting. Cancer outcomes in the state of Arkansas now we're less you think the only reason we're pursuing is is because of NCI designation I put this light in because I think there's a moral imperative here they go essentially beyond the NCI process meeting what I've listed these are just a few concepts but they're important our Kansans deserve equal access to state of the art cancer screen regardless of ethnic economic and geographic differences you should be able to get a mammogram you should be able to get pass or even if you live in a very rural area of the state or Kansas should easy understandable appropriate access to state of the art cancer management now this is the one that causes trouble because usually what I hear is well that that exists what's the problem well when you think about the complexities of the healthcare system the way hospitals work well the diagnostic tools the difference between the local community clinic in a hospital it's actually very complex even for somebody who spent their entire life in the healthcare system sometimes I find myself asking where I should go if I need something fairly simple so we need to focus on this to make sure that no matter where you live in the State of Arkansas that you can get to the right place for the right care that may be local not a problem or Kansas should never have to leave the state to gain access to an accredited bone marrow transplant program and cutting edge cellular therapy I will bring to your attention the namesake for the Cancer Institute with R. P. Rockefeller when added state for his bone marrow transplant now that was a number of years ago but we feel this is absolutely imperative M. I'm proud to say that we have the only accredited bone marrow transplant program in the state of Arkansas and it is growing rapidly it's absolutely first rate and it's finally cellular therapy what does that mean well you know then we can now program cells. From the. Patient's body to go back into their body and basically kill and eat the tumor cells this is cutting edge work it is complex it's actually dangerous to give we have it up and running a UAMS we're very proud of it we already have a couple of success stories patients who literally would not be here. With us. But they're cured. Our cans and suffering from cancer should never be denied axis oncology clinical trial or die without being offered and pro rate clinical trial I am embarrassed to tell you that there are women with metastatic breast cancer breast cancer goes to different organs who will die in this state never having been offered a clinical trial that should never ever happen we will change that. And then Arkansas should be conducting us we should be conducting research relevant to the cancer needs of its citizens and I gets back to this whole theme of what coming out reach engagement should do now where the numbers of go through this very quickly because numbers tend to put people to sleep but the story is not necessarily good if you look at these 2 charts looking at both incidence and mortality rates and take a message here if you look at the top line which is the average over 5 years is that the Arkansas rate is considerably higher than the US rate both in incidence and mortality rate that's not where we want to be. How does that break down grantee early if you look at the left part of this like you're actually looking at specific cancers in their incense over 5 years the change red is not good blue is good there's a lot more read on that chart and blue so we need to work on this and then on our right side is simply a linear plot looking at the incidents in the historic trends for cancer in although there's some lips up and down that's because of how we define certain cancers don't be thrown on that the general trend is more cancer as you go on and that's not what we want now we have a complex problem because is not only increasing incidence in a number of cancers but we have a heterogeneity within the state of Arkansas so you look at the right side you see incidents in rates in Arkansas by county and it's color coded so the blue I'm color blind so if I get this wrong to make fun of me the blue portion of it is the rural areas the grain are the urban areas and if you can see the numbers you'll seen that cancer incidence rates are actually higher in the role rural areas then Irvin it may be easier to see that on the left side where the colors are more bold and you can see the dark. That red dark thank you. Dark red areas those are areas where the instances the highest that's in the Mississippi Delta and the south very rural areas. And and so we need to address this we need to go into those areas find out is this an ethnic issue is a lack of access to the key to the cancer management system is this perhaps a an epidemiology issue with exposure to certain things that's all going to be within the scope of community outreach engagement how does the program actually work well this is a summary slide that Korean pro provided to me the middle part at slide shows the community research model is commonly use its I think spectacular and simplicity we assess community needs we design a research to meet those needs and then we are essentially have improved cancer outcomes you've already met the leadership that the best of the best in the primary responsibilities are on the left part of that slide we need a community Vice report to tell us what they need are we need to understand that and then to address those needs and then develop a cancer patient navigation program which links all of it together now we've again in a very short period of time made a lot of progress this is the community advisory board I apologize for not having pictures we don't have pictures of everybody so I deleted them but you can see the names of the more important issue is the sort of the right 2 columns first of all geographically they are very diverse they cover the state as best as we can see me in this will probably evolve with time if you look at the middle column the connection I think again reflects the diverse nature of this community Vice record that we desperately need we have doctors we have nurses we have pastors we have cancer survivors we have experts in family violence and disease prevention we have community health advocates we have a librarian we want to represent the community we want them to tell us you know. I can get a pap smear because I don't know where to go to where can I get a mammogram why is it every by my family has cancer these are the issues the needs that we need to know about this slide reflects the talent sitting to the right to me. I believe you okay in terms of the progress they've made in look at that number in 3 months so what are navigate this is navigator program and I I can't action not because some rises light yet without throwing out of kudos to representative Ferguson C. here. One of my first meetings when I came here legally in 2000 December was to meet with him with his vision for a statewide navigation program so it was very important to hear that and to know that this was of great interest in so again kudos to him but Cory and per owner team of done a lot of work in 3 months navigator's support patients their families and caregivers by identifying and resolving barriers again system seems simple but it is in particular if you're living in a rural area they provide community inpatient resources cancer education preventive screenings care navigation Hanson the coordination services in 3 months 9 navigators been hired 880 persons touched by education care navigation 840 hours of community navigation navigator training in 41 community outreach events attended across rural areas that's a lot of traveling okay thank you if you look at the map you see faces now associated with the different districts what I would predict is going to happen in the next year is that this bench will get deeper it will fill out so that we can reach all areas of Arkansas to help dower cancer patients and to provide the general public at the appropriate cancer screening and preventive our information. I can't finish this up and only have a slider to left without discussing the mammal van program if you're not familiar with this then you're missing out on one of the exciting aspects of the Winter P. Rockefeller Cancer Institute the member the ends are mobile vans they are large you see a picture right there because they're carrying or the mammography equipment and they drive around areas of the state mostly rural but not only rural where they provide free mammography. This is absolutely critical. Important I and we are enamored with this program I will point out to you we have to member vans one is broken the second one I like to describe as having 3 tires meaning it needs to be fixed I have committed 3.$5000000 from the state legislature and from the State of Arkansas to build 2 new member vans which will be delivered in June and then additional mammal van which is probably and misnomer because it'll actually carry a load does C. T. so we can do more bill low dose CT scanning of lung cancer lung cancer is the number one killer in Arkansas on those vans we are going to attempt to put pap smears colposcopy colorectal screening are and if it's the low dose CT we will have tobacco cessation counseling. So this will be delivered to people who generally don't get this because either can't navigate the program or the right in the middle excuse me for the expression of from a guy Grove New Jersey out in the middle of nowhere so this will help tremendously. So may finish up the last slide this is the CEO we vision statement I got a different statement from Corey and parolee was more of a global view I want to be little more concrete we're going to provide mobile vans vans for breast lung colorectal screening for all underserved and under represented populations especially in rural areas we will provide access to clinical cancer clinical trials including our phase one unit which of the new drugs I did not go into detail as you probably know we U. M. S. signed a joint venture with Baptist health the largest health system in the state we will be providing all of their cancer care so that allows us to bring these clinical trials to a number of their facilities including Fort Smith elder radio and of course in Little Rock I think that'll jumpstart our ability to bring these important clinical trials to patients. We will fully now the Kansas services are Arkansas well on that way thank you Korean pearl and we will conduct cancer research relevant to the Arkansas populations I will finish by making one of the comment that Michael KKS me too is that if you do want a more global view of where we are and our progress and see I designation we're happy to sponsor a meeting of this committee at UAMS and Winthrop Rockefeller against you any time that fits and we can go into more graphic details about how the moneys are spent in where we are thank you. Thank you does a lot of good information we do have a few questions be ready to answer some of those Senator Hammer you're recognized for a question. Thank you Mr thanks for the presentation looking at the burden of cancer in Arkansas of the handout that you get enough think it's round Page 5 the incidence of most cancers in Arkansas rising what DO tribute the reason for the rising cases in the areas of the cancers that are identified. You will be in. Okay yeah well I think it's my from my perspective it's likely multifactorial I think we have a we continue have a terrible problem with tobacco abuse which is not getting better also that's gonna lead to head and neck and lung cancers I think we have a problem in both. Cancer screenings so we're not identifying the pre neoplastic lesions these are the lesions that occur for instance on the cervix or in the breast which are not fully cancer but their premium plastic because we don't defy them the patients then are identified or diagnose the time when they have full fledged cancer I also think there's probably other components as I mentioned in the presentation from an epidemiology standpoint could this be issues of something in the environment that's going to take some hard core research which is why community are reaching age is important I think to explore that probably want to add anything to that. Nothing to add I think that there are increased prevention efforts we can and should be doing and then screening I think one of the The incidence rates are alarming what's even more alarming to me are the mortality rates and that we are not finding and treating the pre cancerous of levels early enough to be able to have strong survival rates. Thank you Mr. The representative Bentley you're recognized for a question. Thank you all thank you for your portent for informative and thank you for for rural state Rep thank you for the vans and the commitment to use more brands out there is crucial for folks out there to get that I think I have additional health initiative a committee at risk entails a lot more about the digital health that reach that you guys are doing what you recently started with that as well. Yeah I'll I'll maybe start and so you M. S. as a whole is looking at digital health outreach as well as really getting more into the rural communities I was born and raised I don't know if anyone even knows what is in that same year in county part of no go Arkansas which is literally in the middle of nowhere I I will take doctor beer there soon I'm and and so this the I think making sure that there are the digital platforms in connection in the rural community so that we can offer telemedicine also so that we can help support the providers who are in the rural areas is critically important it does lean to the CO eat in that we are able to really build upon those relationships so the rule providers that were working with across the state we're working with them on the digital health platforms also on the cancer out region screening and then as we have the community health workers throughout the state it's going to be critical that they have the technical technology available to them to be able to reach back to the physician's both at UAMS and locally to get the support they need and so I'm it is very intentionally enter twined and that we do not want to recreate wheels we want to make sure that we're supporting the role providers for the cancer outreach as well as the telemedicine efforts throughout the state and happy to to dig more deeply into any of those but yes it they definitely are interrelated Dr beer yeah I'll just I'll just add that I've had a number means just stand for about this and I think I think the feeling was for the first certainly first year year point 5 and again Code smacked right into this which kind of cuts will track a little bit but for the first year year point 5 I was ain't ask for lack of better term the lo hei. Ain fruit to get the cancer center to the next level so that was a lot of hiring aye reorganization of the clinical trials officer Jamie joked undertook and it was building seo we did your health felt a little bit fell a little bit behind that but it didn't stop Joe from establishing all the digital health so the I think the plan is is that will now bring in we did have those been somewhat agnostic now we'll bring in cancer because I think that's a real area of opportunity for us the point I'll make which I mean are made clear is that we do work overtime both on certainly digital health issues I do a lot telemedicine but also on the mobile vans that we are not committed to bringing these patients to little rock to the mothership it makes no sense we'll bring them to the expertise that is present locally so there's a mammography in a suspicious mass mass and some hospital in that area can do a good stereotactic biopsy that's what the patient goes we don't want to be in a position of competing with our colleagues. All right see no more questions I had one question unlike pages looks like page 6 maybe we have the state map. It appears the instant rates are lower in areas where they have actually cancer treatment centers or hospitals so my question is I know up in in Craighead you know we have to hospitals that have cancer treatment centers and I would imagine Crittenden being close to Memphis and then in Northwest yet western regional improbably mercy may have cancer centers how how are you coordinating with those treatment centers I mean the to share data and information that has that working or have you got that far yet. It's so the big step forward on that was the Baptist was a J. was a joint venture with Baptist that was our first foray which was a big I mean it essentially took a year of negotiations for 2 big health systems. The gathered together right the reason it's it took time and the reason why I am pretty excited about is what you're just saying we we took extra time to make sure their epic which is there any record their epic version was identical to ours because it wasn't we had modified the UAMS version in in the reason why that's important is we need to consume Leslie talk to each other about patients are being seen in both systems more importantly when we go to NCI if we were to tell them yeah we got this joint venture to cancer network but by the way we can't really talk to each other through the record. They left us out of the room so that's been a huge step is it's almost finished not quite but that's a major goal in making sure that we're communicating with our partners now that's Baptist that's not Washington regional that's not highlands oncology and other components we're handling them individually so for instance I have a very tight relationship with that is back who's sort of the manager the highlands oncology group we are actually going to place researchers into their we're not going to compete with them it's ridiculous to compete with them they're very good they're very good oncologist but we're gonna have our research nurses and see our rates up there so we can offer clinical trials through them. And therein in next on our list will be places like Jefferson regional Washington regional. To describe this philosophical theme we go. Bearing gifts and me we we want it to work we don't want to compete and we think we're bringing an academic version of oncology which they don't necessarily practice so that should synergize. It makes sense yes thank you for that all right see no more questions thank you for the presentation. All right committee what we're gonna move on to the think item H.. That's where rent so we have a rule. Department health. Standards for nursing education programs. So if you would please introduce yourself and who you represent. You're more public health. Suited for director of the board of nursing. Good morning David Dawson general counsel for board of nursing you're recognized. If it's okay with the chair I'll go back chapter by chapter now we have 4 chapters that are up for review are subject to one general provisions for the board of nursing. Page 1 - 1 B. 2 is result of ACT 449 and the 3 is at 607. Page one - 3 the definition of collaborative practice agreement is that clean up due to changes in practice of a PR ends. 1 - for consultation definition is a result of ACT 449 consulting physician definition changes clean up Koper scribe is a result of Act 651. And the definition of full practice authority and full independent practice acts 412 an act 6 of 7. Definition of medical procedures at 449 periods that you're going perioperative risk ACT 449. Page one - 7 a cleanup of you might wanna move a little closer to the Mike I'm not here you will be better. As a result of E. and then F. is active 111 adding or fees thank you ever been in rule. Page one - 8. Number 3 is clean up G. is waiver of initial licensure fees is ACT 725. H. on record maintenance is clean up. That was on chapter one. Committee any questions. Seeing none. Thank you for your presentation. I have 33 more chapters go ahead. Okay the next this chapter 5. The only change is 65 - 3101110 was added for Act 439 and 11 is ACT 1050. Your senate Gilmore you're recognized for a question. Yes I'm sorry I I don't actually have a question it's more broadly than specifically to the rules and I don't know if you would even allow it but perhaps we should get through the rules but my question was in lines with some of the questions previously about nursing shortages and other things so maybe we should move through the rules and come back. If yeah let's do that okay thank you. Okay saying no more questions may proceed okay chapter 6 Page 6 - 1 we had clean up and Hey and then number 3 is at 7594 is acts 757 and A. B. is clean up. That was on that chapter. All right any questions. The representative Gonzalez you're recognized for a question. Thank you Mr I want to go back to the first thing we're talking about on ACT 449 you said you changed the definition of consultation. That. Okay. So you change the definition of consultation in the rules it is it identical to what was in the statute that we passed. Last session I believe so yes. Can you tell me is that is not normal but because in in one of these questions on the okay I have the same favor that we do. What is questions that was asked of you all was. Why we were why you were. Not putting that in rule here but then it says the. We've always operated under a legal opinion of something is and statute we're not required to repeat it in rule so why is it that you are repeating that in in a rule or. Did you change anything do it again. The world's sure. This is just to provide more. Since since we have a pretty comprehensive list of definitions for other matters we included in here just to make sure we had a outline for the practitioners to be able to access and to understand what what the statute required. Yeah go ahead. Can I see some of follow up represent yes please sometimes are nurses don't go back and read statute the rate the rule and there's certain things that we feel like or important enough for them to understand and get it right that we will repeat it in rule okay all right I just had a question because it said right here yells response was that you don't repeated if it's in statute so just question why that we try not to because it gets very redundant right but some things are just important enough that we have repeated rule okay and it is repeated identical to what was passed in the statue there's nothing added to it or taking away from it at all okay thank you. Okay did you complete chapter 7. Chapter 7 okay there was one change to your own which 7 - 6 we added the definition of unprofessional conduct. It was ACT 346. All right any other questions. The representative Wardlaw you're recognized for a question. Thank you Mr. I talked to Mr Gilmore outside a few minutes ago but just out of curiosity where we at with the rules on that on a high school program was passed during the session and what we see when do we think those rules will be complete and come to the committee okay part of the pilot project is changes on 6 - one. Then there's another piece that we did not realize this that has a specific thing and rule on 6 -. It's it's later in this chapter that says that you have to be a high school graduate it's in the proposed rules that are sitting on the governor's office now so you should be seeing them very soon so that will be out of the rule before it ever affects any of these power prop LPN programs okay thank you. Okay Senator you're more. Did you want to ask that question now the. I think you don't you've covered all your rules right yes on this one. So again Mike my question was in line with what representative Wardlaw aspirant we were gonna be doing this most of the day. Following up on on each other's questions but obviously you heard some of the discussion you know we're seeing out here from the previous session about shortages of nursing and everything else I do appreciate the fact that you have or expeditiously moving through an problem getting some of these rules ACT 7251 that myself and representive ray carried in session should help hopefully with that waives the initial filing fee our licensing fee for nurses I would I know is very broad question but I'd like to just get your thoughts on things that we can do to improve getting more nurses into the pipeline are there other things we should look at you know I I as far as reciprocity I think we're we're good with reciprocity with other states but just again more broadly what in your opinion can we do as a body to help address shortage of nursing our nurses. Well at first I want to thank you all for increased appropriation for student loans L. doubled our funding which helps us you know have people go to school at no cost out of their pocket which is helpful I believe money helps. So we do appreciate that 1 thing that is been talked about in several meetings up in in is possibly tax credits particularly for faculty you know we've talked about and some of the committee's about giving money to faculty tax credit is another thing that might be something that's can be sustainable over a long term period loan forgiveness a lot of our physically educators we keep hearing about slack of educators and some of those educators come out of school graduate school in 304050 $0 that they have to pay back and then if they are teaching at a lower salary than they would make it the bad side then that really gets into the issue of you know our state the bedside paid my money back it's easier to do so some loan forgiveness I think would help to. We the board of nursing has approved over 70 programs in the last couple years trying to increase the pipeline I've got 2 more programs up for approval this week anticipate they'll be proof so making things I mean you can't make people want to be a nurse are you can't keep amend nursing but sometimes tax incentives help making things easier form increasing the number of eget 5 packaging that was something that was mentioned earlier is at it Michael G. that way we can have more students in the programs if we have more people in the clinical slots helping those individuals get their clinical experiences thank you for Mr yes you're recognized. This is a discussion and you guys are having with higher read and is hi read indicated that they're looking at options with you all I assume I assume this will be a discussion you would have with higher at because I do think that there you know part of the problem is with you know faculty in addressing the student ratio and all of that so is this. Is there a conversation there between not specifically between us and them but they're part of the group for Senator Wardlaw senator Hammer and the great that's been working together by representative Bentley and having discussions of what we can do has been a big part of the. Discussion and it's going to take everybody coming to the table. You're welcome I certainly hope that we move exponentially in getting some of these issues addressed with thank you can I I do appreciate you working quickly to promulgate rules were ACT 725 thank you. Thank you for your presentation. With no objection this rule stands review. Next item on the agenda is I. Review of rule which updates the instrumentation and methods of alcohol testing equipment personnel. Bill would come board. Please enter self in the represent thank you Mr chair members of the committee on Larson to and general counsel point 5 with me Laura Bailey. I'm the director of the office. You're recognized thank you were here today for the review of the rules for alcohol testing and we presented these to the board of health on our October 28 meeting and we had a public comment period between November to December of 2021 and we had no public comments received at we have authority to promulgate these rules under the criminal code entitled title 5 under 565 to a 1 into for this rule at dated the list of approved instrumentation and other methods and also updated the certification information we have are subject matter expert Laura Bailey here if you all have any questions. A committee any questions on this rule. Seeing none. With no objection this rule stands review thank you. Are moving on item J.. Review a rule which sets standards for the business of cleaning and transporting septic tanks. Thank you there and again I'm Larson I'm general counsel and I also have with me Terry Paul he's the average G. for the environmental branch and Chuck Thompson is our managing attorney and we're here to present the rule for review on septic tank cleaners this updates the rule to add in language to comply with Act 135 and 725 of 2021 and we have our subject matter experts here to answer any questions. Any questions from committee. Seeing none with no objection this rule stands reviewed thank you. Okay moving on to item K. E.. This is DHS. A rule which authorized home health providers in pharmacy providers to administer the COVID 19 vaccinations in the home or similar settings. So if you all would please introduce yourself and who you represent. They Westerman mark what are Human Services and Elizabeth admin Division of Medical Services you're recognized I thank Mr so the rules actually what you just described this was approved as an emergency rule by exact scope subcommittee back in November this is allows a home health agency or pharmacist to provide a covered vaccination to an individual in their home is this just to ensure that individuals are home bound still have access to vaccination with that we'll be happy to answer any questions. Any questions from committee. Seeing none with no objections this rule stands as reviewed thank you for your comments thank you members. A committee that is everything on the agenda the link the meeting we are German.