Public Health, Welfare and Labor Committee - Senate and House

OK, members, uh, we have. What looks like a long agenda, um, but I think we will be able to go through it systematically, just, um, just good morning and it's It's a week of Thanksgiving and I just personally want to say that I'm so thankful for our staff, um, for everything that they do, they're tremendous, and they pull us together and make us look good and I'm really thankful for you guys. Um, and I know we all are, so thank you for all the work you guys do for us, and we, we just appreciate you so much. um, also thankful for, um, you know, our ability to come here and serve our constituents and the great people of the state of Arkansas and, and, um, I just, sometimes we don't say that enough and I'm, I'm thankful to have the opportunity and the, the blessing to be able to do that. Um As we go through this, if you have questions, make sure that you, um, Pin in to your keyboard so that you can be recognized up here with your microphones, um, how does that work if they're a member elect? OK. All right, OK, and I, I do know that perhaps we do have some member Alex here and I'm excited to welcome you if you will just say your name for us and your, um, not sure if your mics are gonna work or not, they should just push that button and we will recognize you. Well, I don't need a like uh. Yeah, awesome, glad to have you. And I know Glenn Barnes probably doesn't need a mic either. Be in bars, glad to be here. Welcome. We're glad to have you. Are there any other member Alex with us today. All right. Thank you for both being here. All right, with that, we will go ahead and get started. Um, do you have any comments? All right. Uh, we'll need to, um, do I have a motion to consider to approve the October 28 meeting minutes, notion in a second. All those in favor say aye and oppose I have it, those meetings are approved. Moving on to item C, we'll have the presentation on the Arkansas poison and Drug Information Center if they will come forward. As they are coming forward, members, I just want to remind you of an upcoming event that is by the legislature, which is Christmas in the Capitol. And that will be coming up. You'll get an invitation that is for everybody, agency, lobbyist, members, members elect, everyone, Christmas in the Capitol, where we bring gifts for all of the children that are in our foster care, uh, system, and so you'll get an invitation coming out soon on that. Um, I believe it's December 12th or 13th, um, but I hope everybody will come to Christmas in the Capitol and bring gifts for, um, children that we have in our care. Thank you. OK, if you'll introduce yourselves for the record, then you may proceed. Thank you, Madam Chair. Committee, uh, I appreciate you giving us time here today. Um, Arkansas Poison Center and Drug Information Center is, uh, Business unit of the College of Pharmacy at UAMS, but it's something that serves the entire state, um, it touches every one of your districts in every county. I don't want to take too much of their thunder from their presentation, but wanted to just come and give you this informational presentation today to, uh, let you know, uh, how it serves your constituents back home and with that, I'm gonna stop talking and let the experts introduce themselves and give a presentation. All right. Thank you, uh, Madam Chairman, committee members, I'm Howell. Foster. I'm the managing director of the Arkansas Poison and Drug Information Center. Hi, good morning. Thank you all for having us. I'm Kevin Beth Meadows. I am an ER physician at UAMS and a medical toxicologist that works for UIMS and the uh and the Arkansas Poison Center and Arkansas Children's Hospital. Morning, my name is uh Ari Phillip. I'm also an ER physician and medical toxicologist, and I'm the medical director of the Poison Center. Excellent. Welcome. Well, I guess I'll go ahead and get started, um. No. There we go. So our objective today is to basically give you a brief history of the poison center. Uh, what our role is and uh, you know, discuss how our services provide high value care for the citizens of Arkansas. So what do we do? Basically, we are a a resource for the lay public and healthcare professionals. We're open 24/7, 365. Uh, last year, we dealt with just, uh, a little over 21,500 human exposure cases. And we also dealt with about 5800 informational cases that goes down from a human exposure case to about 59 per day, but something that needs to be understood about that. This isn't just one phone call, we give some advice and we stop. We average almost 80 follow-up calls a day. To these individuals and whether they're at home or in a hospital, and then we average about 16 informational cases a day. We reach every county in Arkansas on a monthly basis for human exposure, uh, so we are truly a statewide service, and we are staffed 24/7 by healthcare professionals. This is basically the group of us. This is the professionals that run the center. Uh, there's myself, uh, Doctor Meads, uh, Doctor Philip and Doctor Erika. Liebelt, who's on call today. She's not here. We had the pharmacist on one side, the nurses on the right hand side of the slide there at the bottom and then our public educator, Charlie Stutts, and that is the professional staff that is every single person professionally that works in the center. We've been operating for 51 years, uh, the poison center started with a grant in conjunction with the health department. And operated for one year, the term of the grant. At the end of that, the College of Pharmacy decided it was a worthwhile endeavor and ran the center independently until 1993. In 1993, Act 796, basically created the Arkansas poison and Drug Information Center and placed it in the UAMS College of Pharmacy Act 797 was appropriated but not funded. Then in '93 Act 797 got funded and the center went public prior to. that we were a professional only center. So we spoke to physicians pretty much an emergency departments. In '93, we began receiving public calls, then we went in-house 24/7 in May 1999, prior to that, the overnight call was taken by the UAMS emergency department. And in September of '99, we got our first federal grant money. Uh, I wrote that grant and I've written every other subsequent grant since then. Uh, we were regionally accredited as a poison center in 2005 by the American Association of Poison Control Centers, reaccredited in 2010, 2015, and 2022. And you see at the end there, there's a seven-year gap. They got a system to where we could actually do it electronically in my center was the guinea pig to start that system, so it was kind of an interesting thing for re-accreditation at that time. So how's this mission evolved? Well, as I've stated earlier, we started as a professional only center and then in '93, we went to the public and the number of calls shortly after that, we reached a point where about 85 to 90% of our calls actually came from the public. And only about 10 to 15% of the calls came from healthcare professionals. But over time that has changed in going back to more dealing with healthcare professionals directly in emergency departments and let's look at a little bit of why that is. In the last 15 years, we've had almost a 23% increase in adult cases. 72% increase in healthcare facility cases. In an almost a 92% increase in suicidal cases, which is going to be the bulk of those additional adult cases that we're seeing, but if you look at this, in children, we've seen a 200% increase overall in children in suicide type cases. And if you go to children 12 years of age or less, it's 800%. All I will say to that is I don't know the reasons for it. But we have a serious mental health issue within the pediatric population and it's not just in Arkansas, it's nationwide. Um, as you can see, we took almost 3500 suicide type exposure cases in 2023, and that required almost 12,000 follow-ups, suicide cases require a lot of additional work, us talking to the healthcare practitioners in emergency departments and intensive care units. It's uh it's much more stressful on the staff as well. Most of the home calls are pretty easy for us to manage and we'll see some data on that in a minute. So one of the things that we do provide is a lot of savings or cost avoidance. There are actually two pretty well done studies that show anywhere from 7 to $13 or say for every $1 you spend on a poison center in the US. These studies are old and there's a push to get these studies redone or another study done to look at this cost savings, but if we look at that model in this next slides a little bit busy. Um, if you take that we take about 21,500 exposure cases a year, about 15,000 of those originate at home, so about 70% of them now originate at home. Our referral rate is only about 15% on those cases, meaning that we keep 85% of those cases at home. We manage them at home if there's no problem with it, we tell them on the front end. Sometimes you get into something that is not poisonous or is not going to be harm at the dose that they got into it. So we keep those individuals at home if you look at that, it's about 12,750 cases. I do a survey of callers to the poison center every few years. I've done it 5 times since I've been the director and the one thing that comes out of that if you ask somebody if there was no poison center, what would you do? About 80% of those individuals say they would immediately go to the emergency department. Subsequently also polled physicians and if you ask them if a constituent called you and said, I have my child at home and they ingested some substance, what would you tell them to do? And oddly enough, about 80% of them also say I would tell them to go to the emergency room. So if we do that and even if there's a margin of error there and just look at 75% of those cases, if they went to the emergency department, and we use $2300 as the average emergency cost. For someone to go to an emergency department for pretty much an uncomplicated stay, almost an all day stay, but an uncomplicated stay. It's almost a savings of $22 million and that's on a budget of about $2.1 million. Uh, so when short Boys and centers save a lot of money. We also work with a lot of different groups nationally. We work with the FDA, also the CDC, which is a functioning arm of the FDA. We work for the, we do some work with the ATSDR, which is a functioning arm of the EPA, um, we provide data to the American Poison Centers. And we also do a little bit of work with the toxicology investigators consortium are toxic, which allows us to pull data with other poison centers and other toxicologists around the country to learn to better treat patients. We can't poison people and do studies on them, so we have to use the data that we're getting from existing cases. We also work very closely with a few of the state agencies. One is the health department. We have a very good relationship with the health department. If there is a disaster that is poison related, we will be the call center for the health department, most likely. Um, the governor also has the ability to stand us up in a disaster if necessary as a call service. Um, the Arkansas office of the Attorney General, we've been working with them on a few different things at different times right now, it is what I call gas station marijuana. It's these edible gummies that contain, uh, THC derivatives that are, uh, circumvented the farm bill. Um, The Arkansas State crime lab, we worked with them on some fatality cases back and forth to make sure we're getting, um, What we think the actual cause of fatality was on the fatalities that we deal with and we also work with the Arkansas trauma communication Center. This is a pilot project for snake bites, uh, the physicians are able to actually view through the trauma system snake bites in real time and that's a very interesting thing we would like to eventually expand that to other patients potentially. Um So, what, one of the things I was talking about was sharing data with the APC, the America's Poison Centers. They have a system called MPDS, which is the national poison Data System. Honestly, it's the worst logo I've ever seen. I don't know what that logo means, but it, uh, it is what it is. What this system does though whenever we have a case and we send it to our network, we log it in, we keep a medical record, if you will. When the 8 minutes of it hitting our network system, it goes to a national system. Now it is deidentified. status so which we're not sending out anybody's names, phone numbers, anything like that. It's completely stripped of all that. It's substance, age, that type of thing, maybe symptoms. This allows for algorithms to run in the background to identify trends, um, Todd pods, poison centers were one of the first group to really step out and say, tide pods are a problem. This was long before the tide pod challenge hit TikTok and the other online type things. These algorithms are pretty interesting. Some of them, you know, recently we had a case where we had a food poisoning case that had, it was a family of 3 over near Fort Smith, and they had muscle weakness. Just across the border in Oklahoma. They had someone that had called the Oklahoma Center that also had muscle weakness and then in that same time frame about a 6 hour window, somebody in East Texas had a food poisoning case where they had muscle weakness. That automatically trigger stuff for us to follow up very closely with those cases to make sure we weren't having a botulism outbreak of some unknown reason. So that's what this system is for. It doesn't like I said, it doesn't identify the patients it contacts the center that is related to those for us to do follow our education mission, we're in a, you know, we're in an education center at UAMS, so we do take students, but we also go out and try to educate the public, um, you know, we try to put ourselves out of business by getting individuals to poison proof their home, but at least have the phone number handy if something goes out, and we annually push out almost 100,000 pieces of information a year. Most of those are magnets or pamphlets. And we go to schools, we go to health fairs, new mothers, those types of things pediatrician's offices. But we also do public education. We obviously, because we're at UAMS and we have a, a service unit there. We take students at UAMS. We also take students that are both pharmacy and medical residents, um, And we're also willing to go out as public staff and give presentations. In other places in the state obviously given if we can work it into our schedules, so. A research mission, we actually do some research, um, presently we have a paper submitted to the Annals of Emergency Medicine on Alpha Gal related effects potentially to anti-ins. We have two antivenins available for snake bite. We had had one for almost 25 years. We had a new one and that came on the market and we were worried, given the number of patients in the state with alpha-gal that we may have a problem with it, and it turns out our suspicions were correct. We are seeing a a significant problem with that product. Um, You know, we also were collaborating with some other states to look at this and also looking for national trends in some data, but we do feel like, uh, anti-ves may end up being regionalized. We're gonna use one here and then other parts of the country that don't have alpha-gal may be able to use the other one, so, and we do case reports if we have interesting cases again, we will try to get those public. This is our funding history, uh, 1973, again, it was a grant. The AMS College of Pharmacy funded it until the summer of '93. At that point, uh, Act 797 was, you know, a non-linem appropriation put into UMS's budget, um, and for the most part, that was our budget for the first, uh, Uh shoot, how many years is that? 18 years, I guess, I, yeah, 18 years, um, at that point we got some chip funding via DHS that's CMS pass through money. We're only one of 9 centers in the country that get that money. In 2009, there was an appropriation increase of $400,000 but it remained unfunded. Those were pretty tough economic times and if it hadn't have been for chip funding, I actually think our center would have either closed or at least pulled back 24 hour services. We wouldn't have been able to fund it. Uh, presently, our state funding is, we have a, a direct appropriation from the state of about $1.1 million. We get about, about 700,000 net chip money we do have to pay a, uh, A matching uh amount on that and then we get right now the federal grant is about $217,000 and we do some small contracts that really amount for a very small amount of money at about 15,000 that I won't take any questions. I appreciate your time. Yes, sir. We appreciate the information. It's always, um, for our members elect, it's really important. There's a lot of topics that the public health, welfare and Labor Committee cover and we try to get to all these different types of, of, of topics um that we can, are there questions? Let's see, Representative Pilkington. You are recognized, thank you, chair, uh, over here, uh, thank you for your presentation today. It was very informative. Uh, first off, I'd just like to give some kudos to your team, literally last week, my wife called Poison Control when she got some bleach splash in her eye and, uh, they were calm and collected and helped her deal with three screaming children and, and, and tell her kind of what to do. So I really appreciate that, and especially too as someone with alpha gal, it's uh good to know that you guys are taking that into consideration when you deal with snake. Uh, the question that I have is, and I'm curious about this, do you track a number of people who call with in which they've they've been poisoned and how many of those end up being fatal and which are non-fatal and then y'all's intervention preventing fatality or, you know, obviously I understand some people may have taken something, there's nothing you can do. What's done is done. Unfortunately, uh, but I'm just kind of curious, I didn't, I didn't see those numbers and I don't know if that's something you track or not. Yeah, we actually, we deal with about 2 fatalities a year. I think, I think Doctor Phillip can speak to this a little better than I can because he does all of our fatality reviews, um, most of those are in suicidal patients. I'll just be perfectly blunt with you and the deed is done by the time, usually we're involved. It's very rare that we have an accidental poisoning that leads to a fatality. Not to say that it hasn't happened. Right. Thank you. Representative Alan. Thank thank you, uh, Madam Chair. My question is dealing with snake bites. Approximately how many snake bites do you all deal with on an annual basis. You know, it varies a little bit given each season, but 125 plus or minus 25 bytes. Uh, most of the follow up, those are all venomous, yes, OK, uh, most of the snake bites caused by snakes that are in the woods or people that find snakes in their homes or yards. We could cut the snake bite amount probably in half if people would just quit picking them up. But I mean, the, the other half are accidental. It's folks working in their garden, you know, outside in the yard, children are, you know, more prone to stick their hands down and try to pick them up and things like that. Thank you. All right. Representative Mayberry. Thank you, Mr. Chair. Um, First of all, way back in 2015, I had you report to a task force that we had back then, the Alpha Gal Task Force, and back then when I started talking about Alfiel people thought I was crazy, um, that we have reactions to, um, that came from a tick bite to eating mammal meat or anything from a mammal and, and really stressing how, um, it's in medicines, it's in glycerin and gelatin, um, magnesium sterrate. It's in, uh, bovine extract. I mean, all these things, and that just seems so So off the, the charts like this woman's crazy. Um, how many calls do you get regarding this? I mean, it's obviously still on your radar screen and I'm happy to see that. But do people recognize that it's medicine that's actually causing it because most of the time people just think of it as being a, you know, I'm allergic to a hamburger. Most of our calls are pharmacist inquiring on behalf of patients that we do that. I can run some statistics whenever I get back. I actually have it set up if the staff will remember to click a certain box after that meeting, I made a box or a drop down window that if there was an alpha-gal related question that they could click it, um, and I can go back and run those numbers, um. But like I said, the vast majority are pharmacists calling the center wanting to know if we can help them determine whether or not there's something in there that is animal derived or mamaian derived well, and, and that is the hard part is that it'll list an ingredient as glycerin, but glycerin can come from a mammal or it can come from vegetables. So what is it? And, and is there anything out there, um, in the future that might give more, um, help in that way. I think this is my opinion. It's kind of gotten like the peanut allergy now. We will call companies and ask them and they will give us one or one of 3 answers. We test it and know we test our well for answers. We tested in yes or we don't know, but it's ran on a line that may have mama and derived products in the line at some point in time or they will just flat tell you they don't test it. So, It's, it's problematic. Robert Wood Johnson's foundation actually has a big Dedicated drug information center now to Alphagal and, uh, it's been a pretty useful resource. The problem is it's only there Monday through Friday, 8 to 5, so. Appreciate your advocacy. Thank you, ma'am. Great information. Representative Johnson. Yeah, first of all, thank you. You know, I'm also a practicing emergency medicine physician. I recently used the, uh, in the, the telehealth visit for a snake bite recently when trying to decide whether to give antivenom, and it was a very useful tool. It worked out really great, uh, you know, I, it makes me feel old to hear you say 1993, I was a first year ER resident at UAMS. The process then, Doctor Simmons was in charge and the process was, you know, the ER residents took all the calls after hours. And so as a first year resident I was answering the phone from people. in the public and it was the, you know, the number of, uh, the number of calls that you receive and sort of the breadth of the complexity and then maybe not so complex, right? I, I drank 6 cup of coffee, you know, how long am I going to be awake? Uh, I'm not real sure how to tell you, but, but when I think back on those days, um, compared to today when I practiced medicine, you mentioned the number of calls coming from healthcare facilities and how they've increased. I mean, I, I don't know how many prescriptions. drugs were available on the market in 1993, but I suspect it's increased at least tenfold, uh, in my practice time. And so one of the reasons I think that I certainly lean more, and I think a lot of my colleagues do too, is because there are so many different drugs in the market. It's very difficult to keep up, and we need experts to lean on when people come in and they've taken an overdose of fill in the blank. It's not always a medicine that we're readily familiar with. And so, um, do you I think that in, in your experience, would you say that it's a more complicated space today to practice, practice toxicology than it was maybe 20 years ago. Absolutely. One is just due to the severity of the cases and the number of suicides. I started in '93 as well in the poison center under Doctor Simmons at that time and uh I'm here because of him, so it. But I agree with you, the farmer Capela is much larger now than it used to be, um, and the diversity of drugs and the mechanisms by which they work are now much more diverse, so it is, it's much more complicated. There's no doubt about that. I will say this, our staff is highly trained and it takes a long time to get them trained, to get one of my individuals certified. It takes at least 15 months. So when I lose somebody that's certified, it's, it's painful because it takes a long time to get someone up to speed. Pharmacists come in knowing a lot of the drugs, but they don't know the natural products. Nurses come in with a lot of direct patient care sometimes. And that's, you know, really important, but they typically don't know the breadth of drugs and the bare breath of chemicals that are out there. Well, and this, this is also true with all the chemicals that are available, right? People will come in, you know, I'm always, I'm always leery of the guy walking in with a Walmart sack because whatever's in the Walmart sack is not good, right? There's a lot of times it's the snake that bit them, but also, you know, coming in with these containers of chemicals, cleaners. I mean, this is a very complicated issues and, um, I can't imagine operating in the state without the expertise. Uh, that you bring to the table when it comes to dealing with some of these, uh, complex things. And I'm grateful and always with the follow-ups to, you know, your staff, uh, if, if you don't know when you call poison control, uh, they always take your name, they always call back to follow up to check on the patient, see how things went. That's a very quality product you're delivering. Thank you, sir. I appreciate that. We try hard. Senator Hammer. Thank you, Madam Chair. On the subject of suicide, do you have a heat map that shows where the greatest number of suicides occur in the state by county. And have you done any studies of a correlation of maybe socioeconomic situations or other variables that might attribute to why the number of suicides in particular areas, or is it just all over the place. It, my, my gut feeling is it's all over the place. I can actually run numbers by county. I have not done that. That's actually a pretty good idea. thought to do that, um. But my feeling is just given. The sheer number of them and the breadth of them, and they're gonna come from everywhere in the state. I don't, you know, now socioeconomics, there may be something there, but I do know that age is there. There's no doubt about that, and by that you mean to the younger side, to the older side, I mean, it's across the board, but whatever's happening with our young. It's just different now. I mean, it. If we got a kid that was 12 years old that can that attempted suicide 20 years ago. We would all talk about it immediately and it's. It's just a common occurrence now, um, and that's a sad thing. So But if you want me to run some numbers, I'll be happy to run you some numbers that I can run, so I, I'll get with you offline. I mean, just personal comment, um. I think the direction our society going is attributing to a lot of it because of the coping skills, but I hope through the mental health efforts that we're going to try to establish that'll help. Turn that number down, but I'll, I'll get with you offline. I'm just curious if you had, uh, any comparison charts, but I'll get with y'all fly. I can do you something though. Thank you. Actually, I mean, I think this is a, a deeper conversation that I think would like more drill down and so if you want to send that, if, um, Mr. Davis wants to send that to me. I'll get it out to all the members of the committee, um, the different information that Representative Mayberry asked about Alpha Gal and, um, and as well as. Senator Hammer asked, if you don't mind, and then I'll get that to everybody in the committee and who's here today, um, on the suicides that you're responding to, particularly with the children under the age of 12. That's where you've seen and. Was it 800% increase. So an 800% increase in children under 12 that are are committing suicide attempting to, and is that 100% fatality rate, ma'am. It's Fortunately it's, I couldn't give you a, I, I can't give you a percentage number off the top of my head. I don't know the answer to that, but, you know, if we're dealing with 20 fatalities a year. You know, it's gonna be fairly small, so. And then, um, is that from how, what, what is the toxin? What, what, what are they using? It's almost always drugs, um, illicit drugs or prescription drugs, um, the last fatality that I can remember 1213 year old girl was Teslo Pearls, which is a cough medicine that's prescription. Um, we had another case with methanol, which, you know, obviously isn't. drug where they went out into the garage and drink, uh, fuel stabilizer, so. Most of the, most of the pediatric cases, in my opinion, other that are suicide in nature or more cries for help than anything else, so it's a gesture. So OK OK, well, I, you know, that I think. That's a, uh, I agree with you. There's a huge, we, we need to wrap our heads around that more and your information is going to be really critical and vital, I think, to that as we move forward. So any of that information you can get to us. I'll make sure that all members of the committee have it. Thank you. And if anyone wants to reach out to me on county specific data, I'm happy to run it for you. OK. Representative Gramlich and then back to Senator Hammer, and then we'll, we got to move on to the next agenda item. OK, thank you very much, uh. I'm a middle school teacher. I teach 6th, 7th, 8th graders, so I see a lot of this stuff. I've lost a few kids in the past from various things, so I mean, it affects people like me directly and then affects everyone in that school who, who's a sec, who's attached to that. So, um, and I would just ask for one other thing, not just the number by county, but per capita in that county. I mean, obviously, rural might have a different number than our more urban areas and so if we could get a little bit more granular on the information as well. Um, I would appreciate that. I should be able to run it with census data, so. Thank you, Senator Hammer, last question, we'll move to the next. Thank you, Madam Chair. I was wondering on the drugs that, you know, there used to be a campaign, uh, about we really focused on like drug takeback and we really focused on cleaning out your cabinets. I used to be a hospice chaplain 25 years, you know, and they, they would always, you know, we'd always make sure the, the drugs were taken out of the home. I'm just curious as far as awareness, do, have you seen a decline with what appears to be, um, not as much focus. In the advertising world, uh, to make people aware of getting rid of the excess drugs, or have you looked at that to see if maybe raising awareness of what drugs you have in the home, what drugs you have access to these kids would have access to, would it make a difference? I will tell you, um, it's a really good question and right now from my perspective, it's. I would say I see it a lot because I'm in a different pharmacy groups and they advertise when they're gonna be drug takebacks within their county and they're actually fairly common. So I see that pretty often. I'm not sure how well that's being. Advertised on the public side. I would think it's local advertisement and not statewide, so, and, and the number of, uh, Say 12 and under. What, what percentage would you assign where prescription drugs versus things like you tra a while ago where they went in the garage and they got what, you know, is not a prescription. I would be, it would be a guess, but I would guess it's probably 85, 90% either prescription or over the counter drugs. OK, thank you. All right. Thank you. We really appreciate you all coming here today and, uh, appreciate the the offer for follow-up information to submit to us. I appreciate it very much. Thank you so much. All right. Next, um, if everyone, I think what we'll do is, um, on this next item number D, um, if y'all will all come to the table. We'll try to get extra chairs maybe or, um, we'll take turns. playing musical chairs, um, but important conversation for today is follow up to the legislation that the General Assembly passed. Um, Representative Johnson, and it was my bill as well, um, on prior authorization. And so these are the different plans that, um, have been submitted to us for review by the passes and so, uh, we'll just let you guys, uh, There you go. You're figuring it out. And members in your packet that's gonna be items D1, D2, D3, D4. And I think there's a D5, yeah. All right. What we'll do is we'll go ahead and just start with Um, D2, which I believe is Summit. Will that work? Or however you guys want to proceed. Uh good morning, chairs, members of the committee. My name is Brad and I. I'm with Summit Community Care. Uh, I think, uh, with the chair's permission, I think it might be easier for us just to present as a group. OK. We've, we've really tried to, to mirror our policy as much as we can, uh, typically working with our providers, they really like it for us to have a uniform approach, so I think we've done a really good job of trying to do that here OK, so let's just all introduce ourselves for the record and then off you go. Madam Chair, members, members elect Cory Cox with CareSource. Madam Chair, uh, David Donahue, market president for CareSource. Good morning, Madam Chair, members of the committee. Uh, my name is Mitch Morris, CEO with Empower Healthcare. Madam Chair, my name is Lauren Grounds. I'm senior director of Medd management operations with Arkansas Total Care. Jack Hopkins, Arkansas Total Care. All right, off you go. I'll start off if that's OK, um, so, um, as the committee knows, Act 575 of 2023 required all health plans to adopt a gold card policy designed to reduce prior authorization requirements, um. As you know, health plans commonly require prior authorization for certain services before they are rendered, general definition of what we mean when we say prior authorization. Uh, the provider-led groups or the passes, um, we were exempted from Act 575, as long as we prepare a policy designed to reduce and in some cases eliminate prior authorizations for our network of providers, uh, and so that's the policy that we've submitted for consideration today. Uh, the goal in preparing this policy was to find that right balance between, uh, Act 575 and those requirements, uh, and balance that with the objective to uh reduce prior authorization, um, but, but. Uh, to balance that new legislation with the key goals and objectives that were established in the initial, uh, Act 775 of 2017, which created the PA program. By the way, we do appreciate the special provisions in Act 575 that were given for the past program, recognizing the nature of our special high need uh beneficiaries, which, uh, primarily represent Medicaid beneficiaries with complex behavioral health conditions and intellectual and developmental disabilities. So we definitely appreciate those provisions, uh, and do think that they appropriately recognize those special considerations for the people that we serve. Um You know, the past program was created to provide quality care with an emphasis on high touch care coordination. But also to help slow the spending growth in Medicaid and help reduce instances of fraud, waste, and abuse. A big part of fulfilling these goals is the judicious use of prior authorization. Uh, the use of prior authorization for some services is critical to ensuring proper care is provided at the appropriate level. But prior authorization is also, uh, helpful, a very important tool in maintaining contact with our beneficiaries so that we know the services that they're accessing as quickly as we can know that to support the goal of care coordination. Um, so this policy does create and it formally documents numerous exemptions to prior authorizations, uh, such that any provider in the network that provides those services is not required to pursue that prior authorization. Um, but for the reasons that I just stated, um, the plan is to continue a judicious use of prior authorization in certain circumstances to support the intent of the original past legislation and also to support, um, our very um critical job with trying to provide care coordination and high touch support for those beneficiaries. All right. Thank you. I think it's important for us to hear from all three, or everybody for. Thank you, Madam Chair. Brad and I again with Summit Community Care, uh, I'll just a second, uh, Mr. Morris's, uh, Words here in regard to prior authorization and gold carting, uh. We feel strongly that this is a, a good first step in policy towards lowering provider abrasion and making sure that our providers can do what they really there to do, which is to provide the needed care to our complex beneficiaries. I would add that. At least from Sumit's standpoint, this, this is a first step. We actually have a committee that meets at least quarterly that looks at the data as it comes in and makes determinations if there are additional services out there that may could, uh, be gold cardted as well. So that's something that we will, uh, commit to you all that we'll continue to do, obviously. The past program in Arkansas is, is unique because we are owned by Arkansas-based providers. We are provider led. So we, we continue to work with them, uh. To help with abrasion and to make sure our members are served, uh, but to to Mitch's point also to make sure that we're meeting the legislative goals of Act 775 for the past program as a whole. Madam Chair, if it's OK, let my CEO so you won't hear from CareSource twice. We'll let David speak. Thank you. Uh, I would just say from the CareSource perspective, the policy that we've implemented, like my colleagues have mentioned, we, we attempted to align our policies as much as possible for 4 distinct organizations, um, but we also looked at the requirements of the act and I have tried to implement a policy that will proactively look at, um, authorization submitted by, by our different practitioners and try and proactively address those those who would meet the criteria and then communicate with them, uh, in a transparent way as to what that criteria is, how they would qualify, uh, and what our process would be in terms of uh retrospective reviews. OK, so yours is a little different that it doesn't provide like a list of things that are already gold carded in what I'm reading. So are you taking a little bit of a different approach to it, or am I misreading that. I, I have not seen what the other passes have submitted in terms of what their requirements are. Uh, I will say from our perspective, what we've tried to do is anyone who meets that 90% criteria, um, based on, on their submissions, you know, that they would qualify. OK, OK, so it's more provider focused versus. Um Specific Instances. Apologies in terms of the the criteria for the for the different codes and. Yeah, I mean, what what we plan to do is, is look at the, the different submissions, you know, as, as Mitch noted, you know, the vast majority of the claims that we receive for our past are actually non-medical in nature because of the nature of the populations that we support, um, but so we're trying to look at for the medical claims in particular, the history of the submissions. OK, all right, all right, we'll just keep going down the line. Thank you. Appreciate it very much, I echo the sentiment of the uniqueness of the program in Arkansas. Total care, um, we also have considerations of uh other products, which I think is important to this discussion, um, and that we understand legislative intent to uh reduce or remove prior authorizations. We also, um, want to echo the, again, the uniqueness of this program, and I think that we accomplished that in our, uh, submission, um, and happy to answer any questions you guys might have. OK, we'll start off with Representative Johnson. Yeah, first of all, thank you. You know, uh, this is a complicated process, uh, as, as, as, as Senator Irvin and I learned through the session trying to draft a piece of legislation like this is challenging for a lot of different reasons. Um, I think we had good reasons for exempting you from the process, specifically as you stated, related to the nature of the people that are enrolled in the past, and some of the, some of the treatments that they received that, that maybe by nature necessitate prior authorization every time, right? Just like we did with some of the drugs that we looked at. And, um, so I appreciate, you know, the intent of working collaboratively. I mean, that's, that's what we need to try to do as a state, right? Um, I think that as we move forward into the next session, you're going to see some, you know, hopefully some amendments to, to this legislation because it's hard to get things right the first time. It's gonna be a work in progress just as this is a work in progress for us, right? A couple of questions about each, each of your specific, uh, proposals that the CareSource proposal, I understand, pretty, pretty. thoroughly just because it's, it, it very much mirrors what we were trying to do in the legislation. The, the two questions I would have for you. One is, um, what Senator Everson referencing that it looks like the other, um, at least not, not total care but empower and uh some that have given a list of things that have never required an authorization, right? They're saying these have always been goldcarted, primary care visits, you don't have to get prior auth, behavioral health visits, you know, just a laundry list of things. I assume. that you also have, have a list of services that you provide that are, that have historically not required prior authorization. Is that true? Yes, Representative, that's correct. So if, if it would be helpful, we can certainly clarify that, it would be helpful, I think, in as far as comparing apples to apples to be able to look in addition to the process you've outlined, which I think is very good around go-karting, what are the list of things that you additionally don't require PAs so we can compare those to the other passes, um, and then the other question I would have specific to your policy, um, if you do rescind a gold card, that, you know, in the legislation, we had an app. appeals process for the providers, uh, to appeal a recision. Um, I don't see an appeals process in this is your, is your feeling that it would default to the to the appeals process in the legislation. Have you thought about what the process would be if a provider had their gold card rescinded. What, what's their recourse if they disagree with the findings, certainly, that's a reasonable question, yeah, we would default to to the defined process, but I also think it's incumbent upon us. as a path to do that proactive outreach to the provider and have a discussion with them and, and have an open discussion. So in in ways of feedback, if we could get something like that outlined so that we could understand clearly what the process is because I think the way we've written the legislation, you're exempt from all the statute, right? And so you, if you could say in there that you default to the statutory recision appeal process, however you wanted to say that, that would be helpful, uh, can I ask more questions? Senator Hammer, you're up, you're up for a question. Do you care if I continue to ask some questions, um, so on and then on total care, um, You also have outlined a process that's similar where you're looking at a period of time trying to determine, um, are they, are providers meeting that 90% threshold. If they are, that's your process for exemption. I think it mirrors a lot what the legislation said, also mirrors what, uh, you're trying to do, um, uh, at CareSource if I mixed y'all up more than once today, it's on me. Uh, and then, uh, and then what you've done that I think is interesting that the others haven't is you listed uh some things that specifically will always require prior authorization, um, and so I think that's also a reasonable list for us to have, right? So if we're gonna try to have each pass sort of have a mirrored approach, it would be nice for, uh, the other three to provide us if, if there are some things that you feel like based on the nature of the services provided to reduce fraud and abuse that you need a PA every time, having that list assembled, I think is helpful. So I like the way that you did that with. care. And then on the other two, it's hard for me to see with the power. And with Summit, um, I don't understand with your two policies, how you're go-karting anything that you are doing prior authorizations on. So, in other words, you've you've given a pretty expansive list of these are things, and it's my understanding those are things you've never required prior authorization. That's not a reaction to the legislation. That's just, hey, here's our list of things we don't require PAs, um, if you do require PAs on something, it would be, you know, having an outlined approach to how you would, how you would give an exemption, uh, through a go-cart process, uh, if it's in there, I'm not seeing that and that's that differentiates those two plants from, from the other two. Yes, sir. So, so one thing that I don't have uh defined in the policy currently, but as we went through this over the past year or so, working to make sure we were properly responsive. We did add some services that prior, prior to that did, did require prior authorization. So those are not caught out in the policy, so we can follow up with that, uh, to show you some of those changes. Um, and then for, and then I think it's. also a good idea, like you were just saying, to identify some of those things or, or some of the key things that will continue to be managed through prior authorization. And just to comment on that, a lot of those are, are not like incident-based prior authorizations. They're, they're long term 6 months, 12 months prior authorization. So I think that would be another good point of clarity. Yeah, I think that would be helpful to see if, if, if you have now in reaction to the legislation in, in your efforts to, because I think the task was reduced prior authorizations, right? Well, I don't think we tasked you with specifically coming up with a 0 % go-kart that I grateful for that. I think that's a great approach, but another approach could just be we're gonna reduce prior authorizations. Here's what we were requiring PAs for, and now we've added these things to the list in response to the legislation, um, that, that would also, I think, be helpful from McClarty's perspective, recognizing y'all have worked collaboratively, but at the same time, you may not have seen each individual plan, um, I think that would be helpful to tell a line that as, as best we can. Yeah, and, and I appreciate what Brad said about you have a an ongoing committee looking at these things, and I think that's really a good point if you're going to look at this as a team approach, like, I would love for y'all to all collaborate together to figure out what's what you like about each other's policies and mirror those. And, um, and then to have that committee meet and review, because what I think has happened in the space of health care and prior authorization is that you have the payer and they are contracting third party for prior authorizations, right? And you're just like, yeah, OK, we're signing a contract, third party is approving, denying prior authorizations, but through that process, those contracts perhaps, perhaps may have been written in a way to reduce, and they just really strangled healthcare for a lot of individuals and they use prior authorization as a process to strangle down that healthcare. For patients and created a nightmare for any any provider that's just trying to practice medicine and help their patient, and I think that's where we have come to a place and now we're we're peeling it back and going, oh, wait a minute, we can't just sign a contract with a third party vendor to do our pros for us without understanding what they're doing, why they're doing it, and how they're doing it and how it's affecting the patient population that we're supposed to be providing coverage for. And it's affecting the partnership between the, the providers and the payers and in a way that's actually not healthy or beneficial for the patients. And so I, I think that's actually what happened in in this whole world and why you've seen, you know, prior authorization legislation. I mean, I started it in 2011, um, actually representative Mayberry. It was because of a tick bite. Because the person that was denying the referral treatment for toxicology screening for Lyme's disease, argued with my husband on the phone that he was just some stupid little hillbilly country doctor that didn't know what he was talking about and they were in New York and there was no such thing as tick-borne diseases. I'm not making that up. That is what led me to the first prior authorization legislation that I passed. Because we know That that's not right. So I, I think, you know, this world has, uh, developed and, and kind of gotten a little out, out of our. Grasp when those kinds of things are happening. So, I really appreciate the intentionality that all of you put into this and and this policy just like Representative Johnson was, was um talking about. And I do think like as you go through this, that was one of my questions. Did you look at this and go, whoa, why are we requiring a prior authorization of this when we're treating people, you know, that have traits and need trach supplies. Absolutely they need that. That doesn't need to be a pro, you know, those, that's a since kind of a reaction. And that's, that's how I felt like prior authorization just kind of threw common sense out the door, and it was just this contractual, you know, agreement with a third party vendor to do pros. So without any intentionality consideration of the, the patient population that they were serving. And so, uh, and again, that's one of the reasons why we wanted to carve you guys out of it because we recognize that you are there for a very specific population that we desperately needed. Assistance and help with and managing. So, um, I think that those are just important takeaways, and I appreciate the different approaches, and I think it, I think it will develop in morph and I, I hope that it will with you as well, and we can continue this partnership. Mr. Hopkins. Yeah, I would just say that I think the uh the uh administrative burden is applicable to both uh payor and uh provider. So if, if there's, uh, if there's service codes or items that we think are redundant, we're, we're definitely pursuing those specifically, uh, on commercial less on pass more commercial too, which I think is a greater interest. Yeah, I like that. Mr. and I Thank you. And, and I just wanted to say we, we appreciate you internally. In more of these were appropriate or were even serving the pro appreciate that and, and I did just wanna follow up to Representative Johnson's, uh, question about Summit community cares, uh, you, you are correct that some of the items on here were items that were already since the inception of the PA program, but we did, uh, much like in power add additional on and so we'll, we'll make sure to, to break that out in a clearer way so you can tell what was before and what's in response to the legislation. I think that would be so helpful. I mean, for everybody, I think for y'all and for us and for providers out there. Right, Senator Hammer. Thank you, ma'am Chair. First of all, I'm not sure if Mitch may have you said this about legislative intent. Appreciate that comment because in other committee meetings in other areas, not every, uh, individual or group recognizes or gives us the respect for legislative intent, so appreciate that comment first of all. Second, on retrospective review, um, can you talk any one of y'all, uh, talk about that just a little bit, because my understanding or my thought of retrospect review. Is it going to be so much on the actual things that happened that didn't get prior prior approval that may result in what I would call a clawback from the provider because they did something without it, or can you just expand on that a little bit. And you want to go. Yeah, I would, I would say that uh clawback situation is pretty rare for us. I mean, most, mostly what you see is, uh, looking back, it's, it's oftentimes it's concurrent versus retrospective. So it's in a in a long term admission in many of those cases, um, where, uh, individuals been in an inpatient or residential status for a period of time. And so it's more of a concurrent than it is a retrospective. Usually when a retrospective from a clinical perspective happens, um, it's, it's us trying to work with. that provider in cases where maybe the 1st 3 days did not require a review, but, but once it hits a certain level, then we need to understand, uh, the clinical nature of that, of that stay, so that we can consider what's next in that course of treatment. Do they need to stay longer? Is it time for discharge? Um, so, but the clawback situation, uh, especially from a clinical perspective is a very rare occurrence. OK, probably the reason, and I'm, I'm. Working on memory, which right now isn't working too good, but this goes back a situation about 68 weeks ago where a constituent presented to a hospital down in my area, uh, to get treatment for pain and pandas and the primary insurance company said no, but one of y'all and I can't remember which one of y'all stepped up and said, yeah, we'll take care of the cost of covering the treatment for pain and PANDAS, which itself is kind of an expensive treatment. And so I'm just wondering, and what I'd want to be careful about is that in a situation like that, if there was a retrospective review where now it would come back on the individual or come back on the facility of the provider in cases like that, how, how would that be handled? Well, in our case, um, the beneficiaries don't, don't. providers are prohibited from from applying a balance of the bill to a Medicaid beneficiary. So, so in the case of the past for Medicaid, um, the beneficiary does not get stuck with a, with a due amount. Um, but you raise an important point when you're talking about um multiple payers, multiple sources of coverage, that can sometimes on a case by case basis, get pretty complex. One provider approves payment, I mean, one payer approves payment, one does not, um, and, and those can get really complex. And I mean, like you said, what we try to do is, is, especially with our local providers, you know, is, is work within reason, uh, and sometimes come to an agreement based on those specific circumstances that have presented. ed Um, those are pretty rare, pretty rare, but surprisingly enough, you do run into other coverage, multiple coverage situations in Medicaid. Right. And that, that was, which has a separate subject is that y'all were willing to do it, but the other primary provider, which is the name brand provider refused not to do it. So I appreciate y'all doing that get together in specific conversation about that. Last question would be this, when it comes to your community reinvestment dollars and the moving toward, uh, this, this prior authorization gold card standard. Do you see that that's going to have any direct impact on the community reinvestment dollars that you have or will this help. Manage those better and just, well the two ever connect in any way or fashion, and if so, how? At this point, I don't see any connection between those two programs at all. I don't know if anybody else has I didn't know the savings or the cost the heart of your question is, is this going to raise MLR to where our community reinvestment dollars are tied up. Um, we're not necessarily attaching this to an increase in MLR at this time. Um, we think we know our providers fairly well, and we think we know what our spend is and that goes along in conjunction with our, uh, partners at DHS, um, so no, I don't think those two things. OK, thank you. Right. Representative Johnson, just one more quick question, uh, recognizing that you're reached 4 independent entities. I'm assuming there are some rules and regulations about how How, how much transparency you can have in collaboration with what you're doing. I know y'all are trying to work together, but, um, are y'all able to respond to each other's, uh, proposals now that they're on the table and you can see them. Is, is there, to what extent can you work together? In what restraints are there from y'all working together collaboratively. I don't want to speak out of turn here, but I think that's important for the four passes to have the ability to be differentiated from each other. That gives greater option to our members specifically. So I, I don't want to give off the notion that we, uh, could or should be collaborative on every single aspect, um, but where things make sense to be collaborative, of course, we have those, uh, ongoing relationships between the four of us. Thank you. All right, I see no other questions. Uh, again, thank you so much. Appreciate the work with us. We really, really appreciate it because at the end of the day we want the best, you know, for our patients and our constituents, so, and Mr. Hopkins, I will see you in the field. OK, thank you guys. I'm also, I need a motion to, there's, I need 4, Motions to recommend to approve these, uh, policies. So we will go with D2. Do I have a motion to recommend to approve D2. So moved 2nd, all those in favor say aye. And nay. I have it That is approved. I need a recommendation. Do I have a a motion to recommend to approve, um, exhibit D3 motion and a second, all those in favor say aye. And and opposed I have it, that is approved. Do I have a motion to approve, uh, recommend to approve D4. Motion and a second, all those in favor say aye. And opposed, I have it, that is approved. And finally, do I have a motion to approve item D5, Recommend to approve this policy, so moved and second, all those in favor say aye. And opposed I have it, that is uh recommended and approved. Thank you. Also, there are public comment sheets listed out, um. Out there and if there are members of the public that want to comment, uh, please sign up on those public comment sheets. All right, thank you. Moving on to the next, um, item. Item E. We have a rule moving to rules. For review Good morning. Thank you committee. Lauren Ballard, Chief of Staff, Department of Energy and Environment. Bailey Taylor, chief administrator of Environment Department of Energy and Environment. Thank you, ladies. Please proceed. OK. Thank you. We are here today to present some amendments to Rule 36 of the pollution Control Ecology Commission. This is the first step before it goes to the full rules committee. Um, these rules govern our govern our tire accountability program that's the youth higher program as it's more commonly referred to. And these modifications essentially, uh, bring the rule into conformance with the law that was passed in 2023. So that was Act 713 of 2023. In addition, it also goes through and makes a few technical corrections to some names and things that changed after transformation. Uh, now we thought now was a good opportunity to do that, so we incorporated those changes as well. Um, As far as the changes that brought the rule into conformance. There were a number of those, including, um, the amendment that reduces the tire districts down to 4 tire districts. There was a, uh, the ability for the tire programs to enter into those interlocal agreements, um, the ability for the boards or the requirement that they draft and revise business plans that they would submit and there's actually, uh, that's already been done and has actually already come through Arkansas Legislative Council, and, um, uh, limitation on fees where the used tire. is the one who is seeking a permit, the limitation of a requirement of fee from those, uh, permittees since they are going to seek reimbursement for them anyways. And again, those are all part of Act 713 of 2023. So we are happy to, uh, answer any questions or provide any more information if needed. All right. Thank you. Are there any questions? All right. See no questions, uh, without objection, this rule is reviewed. Thank you, ladies. Thank you. Next item F DHS. Good morning, Laurie McDonald, DHS chief of staff. Good morning, Elizabeth Pittman, director of division of Medical Services. Good morning. Please proceed. Hello, today we're here to present the a follow up rule, um, to a role we have already brought to you. Uh, this is a rule regarding emergency medical technicians as other licensed practitioners when we brought the first rule to you, um, I believe last year it was regarding the provision of, um, treat triage and transport by emergency medical technicians. That role was approved by CMS and sent through, but through that approval process, CMS wanted us to go in and add EMTs is what we call other licensed practitioners, which is just a mechanism that CMS recognizes them as a paid provider type in Arkansas Medicaid. So this is that rule to follow it up. Um, it was approved by CMS. It retros back to the same dates as the previous rules, so there won't be any discrepancy in the time frame for paying these services, and there's no additional financial impact to this rule. I'm happy to answer any questions. Any questions from members of the committee? All right. Thank you for the follow up and seeing none without objection, this rule is reproved approved. Thank you. All right. Thank you. If you'll just introduce yourselves for the record, you may proceed. Good morning, Tommy Tarpley, the deputy director for the division of Developmental Disability Services. Jennifer Bris, director of the division of Developmental Disability. Good morning. This rule involves updates to the two, autism, uh, services, uh, programs done by Arkansas Medicaid first is the autism waiver, uh, which is provides one on one, and since the intervention services and natural environments to children with an ASD diagnosis and then also applied behavior analysis therapy services, also known as ABA therapy services available to children under the. PSDT program, uh, in the packet you'll see the renewal of the 1915C autism waiver, this, uh, renewals required every 5 years, uh, CMS approved the renewal included in the packet effective July 1st, 2024. Uh, it also includes updates in the autism waiver Medicaid manual, uh, Finally, on the ABA therapy side. It includes, um, inclusion of the ABA therapy services as an Arkansas State plan, uh, service as required by CMS and also establishes the ABA therapy, Medicaid manual, uh, which includes parameters around, um, eligibility criteria, service delivery requirements, um, clinician qualifications and other things, uh, in accordance with CMS rules, uh, finally, uh, Um, this will become the ABA therapy side will become effective, uh, with an anticipated effective date of January 1st, 2025. And I'm happy to answer any questions. Thank you, Madam Chair, over here, uh, this question, uh, you had a comment when you had the, the public comment period had to do with telemedicine. Uh, was that just an oversight, uh, Uh, you agreed with the comment. They said that some of the services would not be covered. Uh, if they were done by telemedicine. And then you agreed with the comments that particular service, it, it, we agreed with the providers submitted the comment, um, that those services could be provided by telehealth, uh, when appropriate. Thank you. OK. And, um, I actually, uh, do have a question. Um, one of the pieces of legislation, Senator Hammer is not here, but he I think he stepped out, um, that we looked at during the session, we actually passed, but it was vetoed. Um, with behavioral health and behavioral analyst, um, certification board in this manual. And one of the concerns back During the session, and, and I think the legislation that passed addressed that was how do we, what is the communication process between the national board and the state of Arkansas when you have a provider who may be um under investigation. What, what's that process of communicating with the national board, um, so for the protection and the, of, of the, of the family and the patient. So there, there would be no known communication that I know of between DDS. I'm not sure on the Medicaid enrollment side as to whether there's any communication there, I would have to defer to. EMS on that, on that specific. Issue. OK. Yeah, Melissa. Thank thing. Hi, Melissa Weatherton. I'm director of Medicaid Specialty Populations and Senator Urban, you're correct. This was one of our concerns that I think we talked about during the last session, just not having a state entity like we do for the other types of clinical services we provide, and I am, I do not believe that we are contacting the national board with an issue, but I'll also say that since we have set up this program, we have not had anything rise to the level that would be submitted, um, to some sort of oversight board. Um, we take action based on, you know, under the Medicaid regs, we can take action of suspending or just stopping their, their ability to provide services for us. Yeah, I mean, I, I think, you know, I, I mean, I'll just, you know, in somebody's been reported to a board for an ethical violation or they're under investigation, um, a violating the law, um, you know, we have a in the state of Arkansas that will deal with that licensee. Well. In this, we, we don't have that and so there's a concern there, and, and we don't know what that communication process looks like, so somebody could be under the national board being investigated or looked at, um, but there's no communi there's, what is the process between you as Medicaid and that national board entity, there is no process there, and I think that's a real issue and a problem, you know, whether if, I mean, I understand these national board certifications or whatever we wanna move to that, but that remains my concern because we, our job as a committee, in my opinion, is really should be about consumer safety, public health interest and making sure that we are Doing our job that those that are licensed, but if there is no license and there is no entity, there's no place for anybody to go to, that creates a problem or, you know, we've just bypassed that and we're washing our hands of it, but it's some national board, well, OK, if that's the case, we've got to have a process of communication that's established that we know so that you can take action. That's the concern. And I, and I think, you know, and it's been a concerned, um, by the president of, of their, of their board who worked with Senator Hammer and Representative Clowney. I believe Representative Cindy Crawford, um, also was maybe been involved with that, but I, I think it's really important that we look at making sure we have established that especially in behavioral health, if people are not licensed, so I, I would ask that we kind of revisit that. And I know it's in the process of what we're proving here today, but, um, I think that you would have had a lot of public comments about that on this rule, um, and they just told me they missed, they just completely missed it. They just missed the deadline and they just missed that it was coming through. So my ask is that you would reach out to Mr. Rocky Hayes and have a conversation with him about that, and I think that would be helpful and beneficial. Again, one of the reasons why we bring public health rules here to this committee first before we go to. rules so that we can work through this because they're always usually sometimes complicated. So if you don't mind doing that for me, I would really appreciate that. Are there any other questions from members of the committee? All right. See none without objection with that caveat that you reach out and just check. I would appreciate that. Thank you so much. Thank you uh without objection, this rule is reviewed. And approved. All right, item 8. Do we have anybody that's going to present item H or? OK, so, um, members, this is a motion to approve, um, Item H requires us to approve Arkansas legislative study on mental health and behavioral health. Uh, to approve this study. So do I have a motion in a second, all those in favor say aye. And opposed as habit that is approved. OK, next we will go to item I. OK. OK, if you will, uh, introduce yourselves for the record, please proceed. Sure, and I think we have a a PowerPoint or yes, cool, OK. And also we do have, I do have some packets of information. That we can leave with whomever after we get done if you would like. All right. Please proceed. OK. So, Um, I am Tom Massa. I'm the um executive director of Disability Rights Arkansas, and we, um, OK, right, so they're working on the PowerPoint, so we'll just go ahead and um begin all have in our packet. OK, thanks. So as I mentioned, I'm Tom Massa. I'm the executive director of Disability Rights Arkansas. I've been the executive director since 2013 and I have been involved in the disability rights movement since 1987 and. I'm Thomas Nichols. Apologize. I'm Thomas Nichols. I'm the director of legal and advocacy services. I've been with Disability Rights Arkansas since 20016 and I've been a practicing attorney since 2009. Thank you. So I just want to kind of briefly give you an overview of disability rights Arkansas, um, the work that we do, and then turn it over to Thomas to kind of get into the nuts and bolts of the programmatic, um. Um, work that we do. So, uh, disability rights Arkansas, our, our mission is to advocate for and enforce the legal rights of um all people with disabilities here in the state of Arkansas. Um, we are part of a larger network called the Protection and Advocacy Systems. And the protection and advocacy system was created and in the early 1970s. And it was Here we go. Um, it was created in the early 1970s, um, and interestingly enough, it was um Geraldo Rivera, who was a journalist who um Borrowed a key, went into a state institution, uh, Willow Brook, and exposed and, um, all of the, the maltreatments and issues that were happening, um, in that facility. And, um, as a result, there was a settlement that was reached in 1975 over the conditions in the facility because there was a lack of oversight and accountability, um, and how we, um, how individuals were being treated, um, as you can see, um, kids and adults were unclothed with bruises. Um, they were eating with their hands. And they had broken bones. Um, they languished throughout the institution with little to no treatment, no education, and just sat there, uh, with no oversight or accountability. And then, um, And then in 1975, Congress passed the um. Developmental Disability Awareness Act, which granted authority for an independent organizations to go into these facilities. I'm in monitoring and to ensure that individuals um were treated with dignity and respect, and they were getting the services that they required. Um, the protection and advocacy system. is independent from state and federal government? Um, we are, like I said, we, we go into these facilities with our access authority that Thomas will talk about. Um, and then in 2025 we're going to be celebrating as a network 50 years of being around advocating on behalf of individuals with disabilities. Every state and territory has a protection and advocacy system. There are 50 nonprofits. 4 of 4 of them are in states and the states, um. State government, one in law school, 2 in legal aid, but the remaining are 150 nonprofit organizations with the board of directors all doing the same work in terms of advocating on behalf of individuals with disabilities. Here in Arkansas Um, we're gonna be celebrating 47 years. Um, we were, um, received our first grant in 1977. Um, in 1980 we were incorporated, um, as advocacy Services Inc. And then in 2010. We changed our name to Disability Rights Center of Arkansas and then in 2014, we changed to disability rights Arkansas. Our budget, we have a budget of $2 million. A board of directors with 11 members. And a staff of 24. As a result, um, we are funded by 9 different um 9 different grants that come into the agency, um, as I mentioned, um, the first one was the development of Disability Awareness Act, and with all disability and all human service organizations, we like acronyms, um, so I'm gonna do my best to make sure that I spell them all out. Um, but the first one was the protection advocacy for developmental disabilities. And that program came about in 1977, which essentially authorized who we are and what we do. Um And that program sits within the administration and community living, which is within the Department of Health and Human Services. Our client assistance program. That, that came about in 1984 and that runs through the rehabilitation Services Administration through the Department of Education. And that program allows us to advocate on behalf of individuals who are going through the vocational rehabilitation services system here in the state who've been denied or trying to get services through that, through that program. The next one is the protection and advocacy for individuals with mental illness, and that came about in 1986, and that program is housed through the substance abuse Mental Health Services Administration and allows us to advocate on behalf of individuals with serious mental illness, living in a state facility or in a community um receiving treatment or services. The 4th 1 is the protection and advocacy for individual rights, and that program came about because there were family members whose loved ones acquired their disability or got into an accident, um, and they were not eligible for those other three programs and so Congress wanted an entity to be able to help, um help them advocate, so they came up with the protection and advocacy for individual rights in 1993. As I mentioned, that program covers, um, all the ones that are not eligible in the 1st 3. The, we also operate a program called the Protection and Advocacy for Assistive Technology that came about in 1984. That gives us $50,000 to serve the entire state, to assist individuals trying to gain access to assistive technology, services and devices. The next one, the protection and advocacy for beneficiaries of Social Security. is a program that came about in 1999, and that allows us to advocate on behalf of individuals with a disability receiving SSI SSDI who are trying to maintain or gain employment, um. From age 4, from age 16 to 64. The next program came about is our protection advocacy for traumatic brain injury. That again, that program gives us $50,000. to serve the entire state of Arkansas. For it to assist individuals who acquire their their traumatic brain injury after birth. The next program, protection and advocacy for voter access. is a program that um came about. Um, as a result of um the um Bush Gore um issue and allows us to assist individuals trying to access at the polling location, educate elect um election officials to ensure that voters with disabilities know their rights and are able to access their polling place and also work with the state officials as well. Um, our last program that we have is a, a relatively newer program. And it's strengthening protections for Social Security beneficiaries, um, the representative payee program. That program is operated through the Social Security Administration and I forgot to mention that the protection advocacy for beneficiaries of social um social security also runs through Social Security Administration. The representative pay program is a relatively new program. Um, all of our cases are directed through Social Security Administration, any individual who works in that program has to be cleared through Social Security Administration, we cannot provide any information to the public, to anybody, um, based on our security. We get directives from Social Security to go out and look at um beneficiaries and to ensure that the funds are being spent appropriately and they're not being exploited, so that is the work that we do under the uh representative pay program. Overall, so with all of those 9 federal programs, you pardon me, what do you do? How do you, how do you manage and serve the entire state on a budget of $2 million. Um, while we investigate allegations of abuse neglect. Um, exploitation in public and private settings. We provide representation and advocacy for individuals with disabilities regarding their rights. And we do that by developing priorities and objectives at the beginning of every year. We solicit input from the public. We look at our our cases, and we also, um, Work with our board and the board comes up with our priorities and objectives, um, every year. Um, our current year priorities, we have 7 of them, and they're listed up there, um, abuse, neglect, exploitation, education, and employment, institutionalization of youth, access to Medicaid or assigned to a pass? Voting Self-advocacy training. And outreach and education. And this is the part that I'm going to hand off to Thomas Nichols to talk about, uh, the cases and the work that we do. Thank you all. Um, so, again, my name is Thomas Nichols. I'm the director of legal and advocacy services and so in that role, I supervise either directly or through, uh, other managers, all of the case and project work that we handle at our organization, uh, we have several different types of cases that we handle, um, uh, you kind of some categories that they fit into, obviously when someone calls our office, that's gonna be a separate case types or in. s uh, where we try to find referrals for individuals if we are not able to assist them, that's, uh, the first, uh, the second would be assistance with self-advocacy. Nothing is more powerful than being able to help an individual with a disability be able to help themselves and to give them the tools that they need to become, uh, better advocates and so we always try to find opportunities, uh, to assist individuals if they need uh information or resources to be able to uh go and do for themselves. Technical assistance that is assisting people who are not individuals with disabilities, uh, whether it's a family member. Uh, or a third party, uh, in some cases we've assisted providers with evaluating, uh, uh, how policies or locations, circumstances might affect an individual with the disability. Um, individual advocacy, that's what you all would probably consider a case, right, that is we're representing an individual as their lawyer or were representing an individual as their advocate, trying to help them achieve a goal, uh, that falls within our grants and our priorities. Investigations, so we, uh, probably the most well-known thing that we do is we investigate abuse, neglect, and exploitation, public and private settings, um, uh, so that is naturally going to be its own case type whether we are told, uh, about a situation that arises to the level of abuse and neglect or whether we uh discover, uh, circumstances that appear to be abuse or neglect through our monitoring activity. He said, I'll talk about in a moment. And the final case type is not even a case really. It's projects, right? So we do a significant amount of, of research, education, outreach, uh, we have helped many of you all who had questions about policy and all of that falls within, uh, our systemic efforts to try to make the world a better place for people with disabilities uh as a group and that falls within our projects category. So as I mentioned earlier, uh, obviously someone calls our office, uh, we treat that as an intake, um, I believe I, I don't have the numbers in front of me, but I think over the past fiscal year, we had approximately 1800 calls to our organization seeking assistance. Uh, and so, obviously with a staff of, uh, I, I believe. 24, we're not able to assist all 1800 of those individuals and so, uh, we try to make sure that somebody doesn't walk away empty handed if they're looking, uh, for assistance. So we try to find resources for them. We try to refer them to people or organizations or agencies who can't assist them. Um We also try to develop uh explainers, uh, self-help guides, uh, frequently asked questions to try to give people those tools ahead of time. Uh, and like I mentioned earlier, we provide technical assistance to third parties even if they don't have a disability if it will, uh, help make the world a more accessible and better place for the population we serve. I alluded to this earlier, abuse and neglect, uh, so we, uh, monitor facilities. We sometimes we'll just show up at facilities to, uh, talk with the residents to talk with the staff, uh, to provide education and access to. resources to the individuals who are living there or receiving services and we're also looking out for, uh, signs of abuse or neglect or exploitation. This is, uh, uh, one of the areas that we work in that's expressly mandated by the federal law that created our grants. And either through our monitoring activities or based on information that we receive, uh, at times we find it appropriate to investigate, which is another uh uh mandated role that we have as the protection and advocacy system for the state, um, we can investigate sometimes as the primary investigators that the state has not been made aware. Obviously, we always let the state know when we received information that rises to abuse or neglect, and we've been able to substantiate it. Sometimes we go back in after the state or other agencies have investigated, uh, an incident, uh, because we believe that the, uh, investigation might not have been as thorough as those individuals might have deserved. As a result of our investigations, we are permitted, uh, under our federal laws to do public reports or private reports. We can report those to the public, uh, through, uh, publishing a report on our findings, or we can report it privately to state or federal officials. Our story I won't dive into this, but, uh, federal law, uh, gives us that ability to be able to go into institutions, uh, public and private, anywhere where individuals with developmental disabilities, mental illnesses or any other disabilities after the passage of the ear grant that Tom mentioned, uh, we're permitted to go into those facilities if individuals with disabilities live or receive services at those locations. That's not all we do, right? We have, we have a staff of 5 who handle abuse, neglect, and exploitation, and granted that is, that is not enough to handle, uh, the types of, uh, the number of potential investigations and monitoring that we could do. But we also, uh, handle cases outside of that, right? We have uh uh one full-time attorney who is handling uh special education cases and I tell all of our other lawyers that none of them are immune because this happens to be our number one request for assistance, uh, just between August and now we've received, uh, over 150 requests for special education assistance, and that's just the start of the school year. Um, special education cases take a lot of time, as you might, uh, be aware there's typically hundreds of pages of records every single situation is a niche issue, um, a very, uh, a niche issue of a niche area of law, right? And so they take a lot of time and a lot of effort, um. But, uh, we have a great relationship with our Department of Education, uh, and we try to handle as many special education cases as we can, uh, however, we don't receive a grant that is just to assist with special education, uh, like we do for access to vocational rehabilitation services or, um, access to voting or access to assistive technology, right? Those are very specific subsets. So we are having to use our grants, which we could use. for monitoring and investigations for people with developmental disabilities, mental illnesses, having to carve out some of that to use for what is clearly our most demanding area of individual representation. We also work uh in employment, right, whether it's trying to get people access to vocational rehabilitation services through, uh, our state's organizations like Arkansas Rehabilitation Services or division of Services for the blind, um, we have a grant that's just to represent people who are having difficulties with that. We have two advocates who assist with that, and they also uh assist with helping people who have barriers to employment, as Tom mentioned under our uh protection and advocacy for beneficiaries of Social Security's grant, um, as long as somebody is receiving Social Security, we can help them work to get off of that benefit through employment by helping them remove barriers to employment, whether they have a job and are looking to advance in that employment, whether they're seeking employment whether they are subject to employment discrimination. We've helped individuals file complaints to the Equal Employment Opportunity Commission, uh, and help. usher them through that process, so really beginning to end if there's an opportunity for someone to go to work and they have a disability, uh, we, uh, we should be a place to call if they're having difficulty accessing those services because the state has wonderful resources in place to be able to give an individual what they need to be able to go back to work, so that should not be a barrier. We also help people uh who are under guardianship, right? It's, uh, it can be fairly easy to get a guardianship in our state, and it can be really difficult sometimes to remove a guardianship, especially if that guardianship is abusive, neglectful, or unnecessary, uh, right now, uh, we are assisting several individuals who were subject to exploitation, uh, by their guardians. We've assisted people with terminating guardianship. That should have never been put in place in the first hand, uh, sometimes guardians who haven't been, uh, who haven't reported to the court and uh well over a decade, uh, whether it's an accounting uh or report to the court of uh how the individuals are, um, uh. Health wise Uh, and we also assist those individuals when there is a violation of the words Bill of Rights. You all passed Ward's Bill of Rights with the guardianship reforms that happened several years ago, uh, and that has allowed us to be able to get in and assist individuals who are being abused or neglected by their guardians. We also assist with access to Medicaid, uh, the individuals you had, uh, here just moments ago from the past, uh, all, all of the passes, they are all familiar with our work because uh uh we have carved out uh an area of Medicaid that is, again, I feel like I've said niche there's probably the 6th time, but it's a very niche area of not just the law but of Medicaid law, right? It's managed care organizations, they're subject to contracts and different regulations than typical. Aid providers, but they're also subject to the regulations that all medi uh, all Medicaid administrators are subject to. So, uh, our state's legal aid organizations, they have developed the, uh, the expertise to be able to handle all Medicaid, so we've carved out this one little place to be able to provide people assistance and right now we have one attorney who that is probably 90% of his case load right now is handling, um uh uh individuals who are trying to get services through our state's passes. Uh, we also look to, uh, help. People who are needing services, whether in the past or not, who were trying to get it through the early periodic screening diagnosis and treatment program it's characteristic of Medicaid, uh, And also we have an assistive technology grant and many of those, uh, much of that assisted technology can be provided through Medicaid and so we, we put that in our Medicaid category as well. Uh, Tom mentioned our representative payee program. This is a fascinating program. Uh, it allows us to go in and audit representative payees for those of you who aren't aware, uh, if an individual is receiving Social Security income uh from the federal government, uh, somebody can manage that for them. Sometimes it's a family member, sometimes it's a facility, um, sometimes it's just an organization and so they are required to keep an accounting just like uh most. guardians would, right? How are you spending this individual's money if you are the person who is managing it. And, uh, for a number of years, we handled auditing representative payees every so often, uh, based on when Social Security would tell us to, um, and then it worked so well, uh, and produced. Issues that Social Security could then follow up on and in some cases, uh, prosecute, uh, that they decided in 2018 to provide us a grant that is actually our second largest grant allows us to go in and audit, open the books of those representative payees, audit them, make sure they're not stealing anyone's money or mishandling anyone's money or uh abiding by all of the regulations. So again, another extremely niche area of the law, the Social Security. arms which uh uh the operations manuals, uh, that representative payees have to follow, um. And like Tom said, all of that, we can't even use our own laptops for it. We had to do it all on Social Security laptops, provide that information directly to Social Security. They have to have their own database that actually belongs to Social Security, um, so it's not one that we get to report about what we do as much as we like to talk about what we do, um, but that program is, uh, is active in, in, in existence and uh uh very much of value and the federal government. Well, yeah, so that is the, you know, an overview of who we are and what we do. We're happy to, you know, take any questions or comments I have. So when you talk about Social Security, are you, is that anybody who is, um, on Social Security disability funding or also Social Security, just regular Social Security or both, so for our protection, so we have two grants for Social Security, right? So the representative payee one, right now we're only handling, uh, those cases directed by Social Security to look at, and those are always going to be SSDI, uh, Social Security disability insurance or supplemental security income if they have a representative payee or other grant were, were you asking about our auditing grandeur, both like any and as it related to Social Security funding. Right, so, uh, for our other grant protection and advocacy of beneficiaries of Social Security where we could remove barriers to employees. Uh, to employment, uh, that is specifically SSI SSDI, uh, so no survivors benefits not Social Security retire. Got you, got you, got you. OK, OK, so it's SSDI, correct? OK, that was what I was, I was curious about. So for example, like I actually had this happen, but um, I, a financial institution contacted me because there was an individual who was being taken advantage of, um, by somebody. And And I eventually tried to visit with, it was an elderly person and they were basically being scammed by, by someone. And so, is that a case that you would be able to help. It was an elderly individual who, and it was a financial institution that, I mean, I think he, he's the one that personally called me, but then try to get him help. Well, and so that's where it uh working through kind of the algorithm that we have in which grant would we even be able to serve them under so if they have a representative payee obviously we go in and out the books because representative payee should be the one who's handling those assets. And then if it was if it were a barrier to employment if they're between a certain, it's focused on SSI. OK, perfect. Thank you so much. OK, we will move to um Representative Lightyman. Thank you, Madam Chair. Uh, Madam Chair, I'd like to pour the water before I ask my question. Yes, please. Um There's a group here I'd like to introduce in the audience, um. And you all have a handout that talks about their organization, but they're very interested in the rights of disabled individuals in Arkansas. Uh, the name of the organization is Families and Friends of Care Facility residents. And uh this is made up of volunteers and parents and other interested individuals. Um, for people who are in, uh, Human Development Centers. So my question, um, I have a number of questions, Madam Chair, if you want to cut me off and let someone else and put me at the bottom of the list, just yelling I'll stop, do you want, do you want other questions first and then I'll come back to you. No, let me ask a couple that'll be fine. Your handouts are handout 1112, and 13, and those are from Resentative Ladyman. Uh You all cover a lot of bases, a lot of things you're into, uh, my questions primarily have to do with, uh, uh, people with intellectual and developmental disabilities. And Um, one question, you had your priorities for 2025. And under different headings abuse and neglect was the first one. Uh, you mentioned that you go in and monitor facilities, uh, so. Why do you only monitor abuse and neglect in facilities, uh, what about people that are disabled, that are not im facilities out in the community when they get out there. Why do you not monitor those? We do, uh, Representative Ladyman, we've monitored schools, we've monitored, uh, uh. Uh, supported employment locations we've monitored, uh, HCBS settings, uh, settings in which home and community-based services are occurring. Well, what I'm really talking about are, uh, like group homes and those kind of things, uh, uh, places or individuals who are in living quarters and they have people that come in for 24 hours or 8 hours or whatever, um. Because a lot of these folks from HDCs move into those programs. And some of them, quite honestly, failed to operate in those programs and have to go back or they have difficulties, uh, and we, we see data about the facilities, I don't see any data about people that are out in the community. As far as, you know, failures, what are abuse, I don't see anything. So do you do that? Do you have those numbers for people that are not in facilities. Uh, well, I've What I would hope is that the state would publish those numbers because the state is also investigating abuse or neglect and and if you do it. We've not gathered that information, you know, we've developed a database that has, uh, uh. Uh Invest investigations conducted of abuse and neglect for children who are in uh psychiatric residential treatment facilities because that was one of the focuses that we had one year, um, we thought that the state should publish this data and so we are publishing it so that other states have an opportunity before they send children here or, or people who are in the state have an opportunity to learn more about those facilities before they send children there, um, we, I, I don't believe we published the data. Base on human development centers yet, um. Or places where, uh, people with, uh, intellectual disabilities are receiving home and community-based services, but we have gone there. We just haven't done a data collection project about it yet. Is that something that, uh, I know that you're, you're, uh, employees show up at the Human Development Centers. And, uh, so what is their process? What's their procedure? I mean, why do they show up? Do you only come if you get a written complaint about someone, or do you just show up or how does that work? What's your process? Well, that's frankly, that's the way it has been lately, um, because we, we would love to have a, uh, uh, ongoing monitoring presence at every facility in the state, but, uh, as of late, the more complaints we receive from a facility, uh, we're generally going to be going to that facility more often. So you don't go to a facility unless you receive a complaint? No, I'm saying that that, that frankly is how it's been happening for the past year or so is that we have had more uh incidents that we've had to investigate rather than being able to consistently monitor, but we still go and monitor at the state hospital. We still go and monitor at, uh, public and private locations, um, like I said, we've, we monitor, we, we did have an initiative, uh, that, but for, um, uh, law. of some personnel recently, uh, we were, we had a monitoring project at facility or locations, uh, like you suggested where people, uh, are receiving home and community based services. OK, let, let me move on to access authority. You mentioned that, uh, under the Developmental Disabilities Act and the protection advocacy system um. It has reasonable unaccompanied access to facilities to conduct fully investigations of incidents of abuse and neglect. Uh Do you only use access authority when there is an incident abuse reported. And, uh, it, it says reasonable. What's the definition of reasonable and who decides what reasonable means defined by the statute, reasonable, unaccompanied access, we can only rely on what, uh, uh, local districts in the circuits have said is reasonable. So how do you determine if you can go on to a HDC unaccompanied and go in and talk directly to an individual. How do you determine that? Well, the law doesn't determine it. I mean that's very difficult to say based on this hypothetical circumstance, I would say, what I'm hearing is that some of your people show up at HTCs and wander around the site. OK, we, they don't normally let just everybody. Go in and wander around the, you know, where these people live, this is their residence. If you're just going out there without any. Reason. Why are you doing that? I'm sorry if I gave you the impression that we just go there without reason. I mean, we've been doing this for 40, 40 years now. Well, it does, it does happen, OK? It has happened, that people go to the sites, they, they really don't have a complaint. Um So, I'll move on. Uh, guardianship. Uh, you talk about you assist with terminating and or limiting guardianship when abusive. Uh, neglect or unnecessary guard unnecessary guardianships exist. Um How do you monitor and investigate abusive, neglected, or unnecessary guardianships. What's an unnecessary guardianship. Well, it's usually one where, uh, an individual had a transient, uh, illness or disability that has resolved, uh, and they no longer, uh, usually a provider, uh, with permission from the individual will contact us, um, because the individual is totally uh uh capacity they have capacity, um, and so they do not require a guardianship anymore, and so we can't determine. them ourselves, right? We have to go to the court and give the court evidence in order to be. Well, you made a statement that I totally disagree with. You said getting a guardianship is easy. Speaking as a person that, that's got a guardianship, it's not easy. Even if you're a parent. So I disagree with that statement altogether. Um, uh, Madam Chair, I'll, I'll stop and put me back in the queue and let someone else ask a few questions. All right, Senator Chesterfield, you're recognized. Welcome. Thank you. Thank you, Madam Chair, for allowing me to ask a question, as I am not a member of the committee. I appreciate it. Could you tell me, uh, do you work with rehabilitation services in the state of Arkansas and in what way? So yes, we, um, we are, we do work with Arkansas rehabilitation Services and employment looking at, um, ways to increase competitive and graded employment, um, we're a member of the state rehabilitation council, uh, we provide input into the state plan that gets submitted every year to rehab, uh, rehabilitation Services Administration, um, you know, we, um, and there's often times where we get calls from some of their clients who are trying to access services and so and so then we for that individual to to get the services that they're entitled to under the law. You surveyed the state as to how they're doing in treating our people who are disabled. How is Arkansas doing? What do you mean by survey the state in what areas of the state providing services. You monitor. Various entities to see how they're treating our disabled. How is the state of Arkansas, in your view, doing in providing for its disabled citizens, or is that considered a loaded question? pretty loaded, but I'll let Thomas respond. Well, so are we doing a good job? I know we can do better. Everybody can do better if I were to be uh uh completely fair. There is more work for us to do, then we have time in the day and staff to do. What area of the state provides you with the greatest challenge. Uh, the, the areas where there are a dearth of services, right? Like East Arkansas, South Southeast Arkansas, um, some of those areas that are, uh, somewhat provider deserts, um, especially with regard to a lot of our, um, A lot of our education cases, right, lots of times they're very open to bringing, uh, uh, behavioral health professional like independent behavioral health professionals in in order to provide really substantive, uh, consultation for a school areas of our state are the ones that provide you with the greatest challenge in providing the needs. For the individuals with disabilities. Is that what you're telling me? Yes. All right, thank you. Thank you, Madam Chair. Thank you, Representative Wootton. Thank you, Madam Chairman. Let me stay from the outset, I'm not a member of this committee. But I have constituents. And from them I've heard that It's not necessarily. Fair To say That we're failing in some of our HDCs. My, my fundamental concern is you, you, you're board of directors prioritize according to your statement each year, what you're going to do and look at. And my concern is how many members of the board of directors, do you have that have people with disabilities that are in institutions. Currently? Currently, Currently none. Um, my, my board consists of individuals with disabilities, um, family members with individuals who live in the community, and there are um individuals just of the general public, um, it just, it just varies. OK. Did they set the goal? This part of your mandate to eliminate the HCCs in the state of Arkansas. So our priorities is looking at eliminating the abuse, neglect, and exploitation in the facilities. We, there is not a priority that says that we are going to have a goal to do away with the HTCs. No, I've I've been, I've been in the state for 11 years and if they were going to close, they would have closed a long time ago. There's no, I don't see any in the foreseeable future. What we're advocating our goal is to ensure that individuals who are in the facilities are are free from abuse, neglect, and exploitation. They're getting the appropriate services that they need, um, to eventually, if they can to move into the community. Follow up, if I may, madam. You don't have a goal established to do away with them, but yet you measure how successful you think they are in doing their performance without abuse, or do you just go in and evaluate and make uh suggestions, recommendations, or even so far as rural violations or law violations are concerned. I would, I would love it if we could go to facilities and look at things like education. Active programming, um, supported employment transition services, uh, social, uh, opportunities, but we believe that the abuse and neglect, um, should take precedence over that. Well, I agree with you, but um The, the problem that we're facing is one that so many of these individuals are they can't respond to anything. But yet The recommendation seems to be at times to close the facility to put them back out in the community-based oriented or private homes or community-based facilities is, is the impression that's being left with residents, and that's where they have a great deal of concern. They have a great deal of concern relative to the, the uh salaries and compensation of nurses and others in care for. facilities. And yet I look at the governor's budget, and it was $65,603 last year for this year and for the next year, 0%, 1 of the only items in the Department of Human Services. So It looks like to me. From an outsider looking in that a goal of your organization or maybe not of yours personally, but if you are organization is to do away with the human developmental facilities in the state of Arkansas. Is that, is that a correct assumption? I'm sorry, you're, you're reaching that conclusion, uh, right now. Our infrastructure, I, I don't know if you, uh, heard the conversation that I had with, uh, uh, Madam Chesterfield, but we have a dearth of services all over the state, whether it's uh supported employment services, whether it's education services, whether it's access to community-based services. Right now, we are struggling in order to try to make sure that our past organizations are actually providing the services that they promised to provide. And it's not always a, uh, the fault of, of the facility or the, the passes, but, uh, a result of the workforce shortage that exists and so I don't think that our state could withstand closing all of, uh, our facilities, considering the community supports and services that are in place right now. Perhaps if we get to a time where we are not overwhelmed. with abuse and neglect investigations, and we're not overwhelmed with, uh, service, uh, uh representation trying to get services from the passes and where we're not overwhelmed by trying to get access to special education and related services, maybe then we could talk about whether the facilities are necessary, but that is, that is so outside the realm of our work plan of our our strategic goals. We're talking past each other here, OK? So you were saying that you do not have a goal. One more time. That you do not have a gau to close these facilities in the state of Arkansas. That's, that's not, that, that is not in that is not, it is not the will of the legislature is not the will of the executive. It's not the will of the judiciary. They, uh, that's been tried a decade ago or do you work for the federal government. So we are a private nonprofit, so we do not, yeah, so we don't work for the state maintained by the state. No, we have by the federal government grants, we just, we just received the grants from um the. The departments. We are not part of the state. We're not beholding the state. We're not part of the federal government. We don't, um, we don't, we don't act on behalf of the federal government. um, we are a private nonprofit um entity, and there's, and I want just, if I may just follow up with Thomas, he mentioned there are so many issues across the state. Um, you know, our, our budget is $2 million and as Thomas mentioned, the number one calls that we get our focus on education. We do, I know the focus is on our monitoring efforts. But we do so much more and serve so many more people um in the work that we do and trying to ensure that they're, um, safe, that they're getting the education supports, that they're getting opportunities for employment that they are getting access to health care services. There's so much more to what we do than monitoring the abuse and neglect, and I appreciate your comments, but There's a lot of opportunities here in the state. And if we just focus solely on, um, the HDCs, all these other services and supports that people may need, go, go without any um attention, so I think we're trying, we're trying to spread our resources where we can, um, but there's so many opportunities in this state to, to do that. I just want to make sure that you're aware of the fact that there's a thought process out there that that's what your goal is. And in order that you can guard against that because in my opinion, these facilities are desperately needed and need to be maintained and need to be funded. More adequately, I, I, I'm aware of that I've been here for 11 years and it's been reminded of me daily, so I'm fully aware of what's the thought that's out there. Thank you. Thank you, Representative Wootton, uh, yes, sir, sorry, we, we just need to move, move on and I'm, I'm trying to give everybody latitude. It's a really important subject, Representative Mayberry. Thank you, Madam Chair. Um, so during one of our children, Aging and Youth Committee meetings earlier in the year, we had a woman who uses a wheelchair for mobility, come and make an emotional plea to legislators, um, about access. I mean, I'm talking physical access, ramps, elevators, um, where a sink is, where the soap dispenser is in the bathroom in public restrooms and, and all that and, and just how difficult it is to make those changes. The only way to really make those changes. It's federal law, and so you have to report something to Department of Justice, which there's really no way to enforce anything. And that's the frustration. So we did hold a committee meeting, talked about lots of different ideas, things that are in place to try to help in, in some ways, um, but I've been trying to figure out how could someone on a state, you know, in the state of Arkansas, make more of a local complaint. So, um, actually the, um, girls state, this came up in, in a discussion with Girls State, uh, that the, uh, one girl state representative, her mom uses a wheelchair for mobility, was a former Miss Wheelchair, Arkansas, and, um, it It was something that even the, even the teenagers were, were very committed to making sure that we, we do something about and the idea in that little meeting was to work with the fire marshal's office, um, since they're in the enforcement of, of what is done, um, you know, but it is difficult, easy when it's a future build, but difficult when it's an older building, and the belief out there that if it's an older building or built before, uh, I forget the exact. 90 something. If it was built before then that they don't have to comply and that's really not the situation. They do have to comply. Um, so my, my question to you is, how possibly could disability rights Arkansas be used some way in that. Is there maybe a Department of Justice, uh, grant that could be utilized to hire an attorney that just deals with this, so someone in the state of Arkansas that's saying, look, there's no parking spot. I, there's no ramp to get into this building. I can't, I can't wash my hands. I can't use the bathroom. I don't go to this football game at the high school because there's no bathroom there for me to use. I mean, that's what we're talking about. If there was no bathroom for everybody in the public to use at a football game. You wouldn't have anyone attending, right? Everybody would stay home because in a 23 hour time period, you're probably gonna have to use a bathroom or the concession stands definitely would close down. Without a doubt. Is there, is there an option? Is there something that maybe we just thinking outside the box that we can use you to, to help with. Yeah, we, we want to be in a position to be able to help people with, uh, physical accessibility issues. We used to do a lot of physical ex access when our board, uh, developed that priority, um, and they might again, uh, we actually do have in our strategic plan, uh, working through, uh, one of these access cases because as you might, uh, uh, be aware if the facility if the place if the business if the area says no, right, your option is. You got to sue them. Right? If they say no, the Department of Justice can come in and sue them or they can sue privately, right, but that's about the extent of it. If they don't have a building authority there, um, and you know, we've had some success handling, uh, cases by referring them to those, uh, uh, building authorities, those larger cities like Little Rock and Hot Springs and, and Fayetteville, they have some building authority that can go in and evaluate those cases, but you're right, and you know, I, I pinged on when you mentioned. uh, when you mentioned the, uh, uh, the state's fire marshal, um, It is, uh, a bit more challenging when you have, uh, something that is older because those plans have already been approved, that building has already been built, right? And they had to make those changes, but I would also say that, um, on the front end, I think there could probably also be more, uh, done because I, I believe the state fire marshal when they approved these, these plans, um, they're approving the plans, right? So the architecture uh develops plan, uh, they go to, they approve it to make sure it's accessible, but then I don't know that. they then go once the building is finished to make sure that those plans actually adhere to the final product. So if there's some change that's made in the building process we've seen some, in some cases, schools get built, um, without, uh, having that secondary, uh, uh, the secondary eyes on it. And so it could be. It could be years before you find out that one of these places is accessible, um, so how can we, if, if they call us, you know, one thing that will absolutely do is uh contact the place, uh, that is inaccessible, provide them our FAQ on accessibility, provide them with the Department of Justice guide on accessibility, uh, and follow up with them to make sure that they either have or intending to make those changes, uh, but you're right, we use a lawyer to do all of that. And litigation is awfully costly, uh, and if that's your last resort, um, it, it is very costly and expensive, more so than just staff time. Uh, but, uh, we have also helped people, uh, make complaints to the Department of Justice, and they have a mediation process, uh, at times that they can employ if of course the facilities or the organization or the business or the place is amenable to having a mediation, and that's totally free of charge except for staff time. So there's a few different ways, but I, I would love it if the state developed an, an office of, uh, that has some enforcement authority for those cities. That do not have, uh, the building authorities to go in and challenge those uh those places that are physically. We can talk about this for a long time, but just wanted to kind of open it up and maybe we can talk afterwards. Thank you. Just looking for solutions. Thanks. Thank you. OK, I'm gonna circle back to Representative Ladyman and, you know, I think, um, I will give you a copy of the handouts that he has provided with the families. I think it's a great opportunity for collaboration and discussion with the list of all these individuals, and I hope that that continues. I think it's an important balance and and appreciate, I really appreciate, you know, I, I helped start the Social Security disability fraud unit, um, working with SSDI and so that was, you know. very interesting to me because that is a huge component of SSDI. There is so much money going out the door every week and I'm, you know, close with the people that the director very close with him and my father actually worked there, um, as a physician who reviewed um Who reviewed requests for disability, but really important to start that that Social Security disability fraud unit, um, but making sure that people know, you know, OK, we need to get you back to work. And I think that's really a, a, a focus that I didn't know about that you work in, in, and I think a really important one, particularly those that are managing those funds for those elderly population, and I, I have personally witnessed that and seeing that kind of exploitation and abuse, and it, it is, it's devastating and, and tragic. Um, Representative Ladyman, and then I think that's the last question we have. You're recognized. Thank you, Madam Chair. Uh, well, let's go back to the Human Development centers where I stopped a while ago and uh. Maybe this'll give you an idea of what Representative Wooten is, is referring to here, um, in 2015, your parent corporation. Presented a suggestion to Congress to eliminate all sheltered workshops nationwide. These programs provide purpose and independence for people with intellectual and developmental disabilities who are not capable of obtaining competitive employment. Why would your corporation want to eliminate these workshops. Are you referring to the National Disability Rights Network. The P&A, the, your, your parent group. You said you were in 57 states, it's that group So yeah, so, um, um, national disability Rights Network is a um is not our parent association. We, um, they are um a membership, um, all of the 57 states and territories are members of. They don't dictate the, the work that's happened in the state, um, all the, all the, uh, protection and advocacy systems, you know, identify their own priorities and objectives based on their individual state needs, um, they are um a member association just like any other member association that develops uh public policy at, um, within, within Congress. But you do collaborate. I think a member of your group went to Washington and presented before a committee. Recently saw the video, um. But This particular um Eliminating these workshops, Congressman Steve Womack, I've got a video I can show you, uh. He He opposed that because it's a good thing and this, this money would have gone away for all states. So I mean, you collaborate with this national organization, right? So, uh, do you collaborate on your goals or your goals similar to their goals? So our, um, so our priority objectives are unrelated to the National Disability Rights Network's, um, goals we again look at what the needs are of the state and the board focuses on what are the needs of the state and um you know, you just, I just want to clarify something you had mentioned that we had somebody speak um in Congress. That was unrelated to our national associates and that was a request from a member of Congress to to present unrelated to our national association. Well, there were statements made in that committee meeting in DC about closing human development. centers. Yeah, it's a video you can look at it. Let me move on. I'll look at that. Also in 2015, your organization, I believe I've got that right, sued the state of Arkansas to require the state to close the Boonville Human Development Center. Why did you do that? We didn't, we didn't sue the state, uh, to try to you know who did? I have no idea in 2015? Yeah, no, we, we had no, and I can verify you can go look it up. It's it's, it's out there. Uh. So Is it the goal of your, I don't know what you call them, I call them your parent corporation. To close all human development centers and if so, why? We uh Representative Wootton already asked you that about Arkansas, but is it is the goal of your oversight group, your parent, what do you call them? Our technical assistants, uh, provider, is it their goal to close all human development centers don't, I don't have any insight into what they're, well, I'll tell you there's 7 states that have, I may have the number wrong, 6 or 7 states that have already closed all their facilities, and they have made. major problems out in the communities where these people have gone. I know of cases right here in Arkansas where a person went out of the HDC, went to a group home, had to spend nights in jail 3 times because the people in that facility could not deal with his uh situations. So those kind of things are happening all over, um. And it is the goal of this whatever this national entity is, uh, to move everybody into a community setting and a lot of people work in a community setting, but as Representative Wooton said there are individuals that cannot function in the community, and it does not turn out good. And, and I know situations like that. Um So let me ask you this, uh. Do you promote the HDCs as a service option to people. With I and DD when you're trying to, to place them or help them or whatever, is that an option that you all would look at to place people in an HDC versus a community setting. We don't, we, we're not doctors or Uh, so we, we don't place people in a facility and we, we certainly don't, we certainly don't dictate their care. So no one comes to you and ask for help. To, to be, to place an individual with uh DD or intellectual disabilities. Nobody comes to you, don't get to make those decisions for them, right? So we, we, I'm not talking about making you don't get to make those decisions for them, right? So we, we, I'm not talking about making do you do you, do you lay out a continuum of care. No You don't tell them, hey, this is the place to go. You don't do that. People don't come to you where to, where to go receive their care. Well, let's move on. Uh, do y'all request for you from the HDCs? Uh, no, we request them from the, uh, uh, privacy office at the Department of Human Services. How often do you do that? I have, I, I could not give you an estimate. It, it wouldn't surprise me if it were weekly. Uh, we asked for all kinds of information that, uh, we believe it should be public and have asked DHS to, uh, you're so you're asking at least at least weekly for an Foa from an HDC. I had to guess, I believe that it would be weekly. Well, lastly, uh, who has oversight on your organization? Uh, I know the HDCs, they have two organizations that come in and do audits. I've seen those audits, at least the one in Jonesboro, and they always pass in flying colors, uh, who, who are you? So we are, um, again, um, a private nonprofit organization, um, and every, um, every year we submit our program performance reports to our funders, um, and they review them. They do, they, they do their due diligence. We have financial audits every year, um, but again, nobody oversees. As, um, pers, I mean, we, we, we report on our every year, like I said, our 9 federal reports, they're all public information, um, you send those to your funders, meaning federal organizations. They they're required part of you're working in the state of Arkansas with Arkansans. We need to do what Arkansans need and want, not what the federal government wants, so there needs to be some oversight when you're working in Arkansas, you need to have some. Uh, I think Some input into this body. Uh, so that we know how you're implementing and I, I, I, I hate to get on you like this because you're doing good work in other areas, but I think in the HDCs based on what I'm hearing and Representative Wooten said similar thing. uh, there's some issues in the way you work with the HDCs. It is out there. Uh, this organization that I talked about a while ago, they, they can give you those situations if you're interested. So there needs to be some communication between you all in this body so that we know that you're, uh, work and your goals align with what the state wants. So I'll just end it there. I, I do appreciate y'all coming and I, I appreciate the information you, uh, presented. Thank you, Madam Chair. Thank you. Um, are there any other questions from members of the committee? All right. Thank you guys so much. Appreciate the presentation and all that you're doing. Thanks, thanks. OK, folks, um, Members, we will move down our agenda the next we have is, um, a bunch of ISPs, um, so just. As professional courtesy. I, we generally approve these ISPs as a matter of professional courtesy. It doesn't mean that we all like them are all going to vote for them. That's going to be determined during the session. So, if there's any one in particular that a member wants to, um, Take out of this, we're gonna batch these if there's a member that is a sponsor of one that wants to pull it out of the batch and discuss it. Happy to do so. If there is a member that wants to pull one out that's not a sponsor of one of them and discuss, we're happy to do so. So I'm just going to uh offer that and so is anybody want to pull anything out of any of these ISPs and discuss them individually. All right, see none. um, then we, uh, will batch these and without objection, these are adopted. And again, the offer is, you know, we do have subcommittees and if you're a sponsor of an ISP and you want to bring it before one of the subcommittees, just let me know. I will work with the chair of our sub and Representative Johnson. We'll work with the chairs of the subcommittees and if it's an issue you want more information about or you want to bring it to light and you want others to talk about with you. We're happy to help you get that scheduled. Um, all right, last item on the agenda is a update of Act 974 if Miss Franklin can come forward, uh, we will present that. Thank you. Good morning, Mary Franklin, director of the division of County operations, Arkansas Department of Human Services. Good morning, Christy Putnam, secretary, Arkansas Department of Human Services. Hey, Laurie McDonald, DHS Chief of Staff. Good morning, members. We have provided, uh, an update to you in the form of a handout that you. got earlier and I'm happy to walk through that handout or happy to answer questions, however you'd like to proceed. Um, just members, if you want to, well, just just do a highlight overview. It's already 12:30. I'm, I don't want to lose members. So go ahead and just provide us a little bit of an overview. Certainly this document walks through, uh, the different requirements related to work and training in the SNAP program, uh, it walks through general work requirements, uh, which applied, uh, to 16 to 59 year olds were generally they need to register for work, take a suitable job if it's offered, not voluntarily reduce hours or quit, um, And it also goes into further detail about how the able-bodied adult without dependence often referred to as the Abod time limit is part of that general work requirement and this group is a subset of all the individuals that have the general work requirement in SNAP. And if you're in AOD, you are between the ages of 18 and 54 with able-bodied and without dependence in your home, and if you are part of that group, uh, you. can only receive SNAP for 3 months out of a 36 month period, unless you are, um, Meeting that work requirement or exempt from it for some other reason or doing an activity that is. And allowed activity. Uh, on page two, we have provided. Uh, a list of those who have been discontinued in SNAP related to that able-bodied adult without dependent. Time limited work requirement. Uh, the first closures for that after the pandemic happened in October of 2023. And, uh, to date, there have been 4,907 closures related to not meeting that AOD time limit. Um We all, we, we do offer at this point in time, a snap employment and training program that is voluntary, uh, and over the last, um, And in 20, uh. 24 fiscal year federal fiscal year 2024. We have served 2,561 individuals in that program. We have referred over 20,000, 20,519 to that program during that same time. And um are continuing to understand, uh, the intent, we believe, of the Act 974, which is to encourage those to work and sink train training that will improve their ability to work where they might normally be exempt from that general work requirement. All right. Any questions from members of the committee? All right. See none. We appreciate that you're here to present this report. Look forward to working continuing to work with you on all of this, um, members, I'm not sure if Senator Chesterfield is still here. She's gone Um, but I want to recognize um Senator Deborah, I mean, Representative Deborah Ferguson. Um, Deborah, you have been an incredibly valuable member to this legislature and particularly to public health. And, um, There is nobody else that has such a great level of expertise and knowledge and compassion for the people that are patients, um, then you, and you have just been a tremendous source of inspiration, mentorship and knowledge and friendship to me, um, personally, and I just, I am, I am gonna miss you so much. I think we all are going to miss you so much because you just really have brought an incredible amount of expertise and knowledge. policy, particularly, um, for this legislature. And so, we're gonna miss you. I'm not sure if you're gonna be here in December or not. So I saw that you were here and I wanted to take that opportunity, but you have just been amazing and we, I, I personally, and I think I can speak on behalf of everybody in the legislature, you, you have been a wonderful colleague, and we're going to miss you so much. Thank you so much for your work. Don't be a stranger. I'm gonna call you all the time. Um, I would say the same thing with Linda Chesterfield. I know she served on education, but she was so, so important on public health issues as well. So thank you again. Um, if there's any other business to come before the committee, the marathon Public Health November committee meeting on Thanksgiving week. You get brownie points for being here, members. We are adjourned.