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House | May 4, 2016 | Committee Room | Health and Human Services

Full MP3 Audio File

[BLANK_AUDIO] Good morning and welcome to Health and Human services, our sergeant at arms today, Young Bay Jim Morgan, Moore Inn, Rastol Salbay/g anD Martha Gutson. Thank you for being here with us today, our house pages is Madison Galloway Lut Hifca county Representative Heiger/g, Tyler Jetry/g Union County, Representative Orlip/g and Emily Walden, Wake County, Representative Dollar, thank you for being here And hope you have a great week. Opposed to gender item this morning is Danny Stanley, director division of public health so Danny you can take us away. >> Good morning senate committee members And Mr. Chair, I appreciate the opportunity to come and talk to you, give you a review of the continuation review program that we have for the office of minority health. As set out in session law from last session we were to look at at the office of minority health and arrive at some recommendations for you and to review the program and give you a view of what the program does and how it serves the state. The office of minority health is in Is in the division of public health in the department of health and human services. It was established [COUGH] in 1992 and that we're approaching a 25th year, it was established under session wall which did two things. Established the office And also created the Minority Health Advisory Council. The purpose of the council is to advise the governor and the secretary on issues impacting minority health in the communities of north Carolina. [BLANK_AUDIO] The purpose of Of the office is to serve as an integrated hub to give information around minority health issues, to give ideas,suggestions to the programs, to promote cultural competence across the division of public health. To our local health departments Is another non-profits in the community. We have two main focus areas or two main areas of work in the office of minority health. Which is Cultural and Linguistic Appropriate Services and Training or Class as I will refer to it as from here out and Community focus eliminating health disparities initiative. Back in 2014 in light of the fact that we appear to have a widening gap of health disparities in our state, we started looking at the office and said We can do better. And in 2014 we as a division informed the department that we were beginning to look at other states to see how they handle their offices of minority health, what work they're involved with, and how they approach Approach this delicate subject and important matter. Although their offices are not ranked nationally, we did check with the national office to see what are the basic steps to look at? Where have they really made advancements in utilizing the office of minority Health. We looked upon the names of the states say givers which is Oregon, Colorado,Washington, Massachusetts, and Texas which they held up as model programs from the national office. And said what are things that they are doing that we may /could learn from North Carolina. How can Can we improve our work? And what we found is some very common things. One, they looked at data. They looked at what health disparities and gaps existed, where there were health equity issues.They worked in multiple systems.Education, Justice, not just Health , but they took Took a broad based approach.They developed policies around social determinants that straddled or crossed over departments in areas

of the state government .And they did not have a focus on grant funding but more of a focus on advancing health policy and system Transformation.When we look at North Carolina, we see that we have two outliers or we had two outliers in this area. One we had an interpreter service program and I'll get into that in just a minute, and then we had the granting program which other states still don't have In 2005 talking about the interpreters service program, there was a $250,000 line item established to create a pilot project for what will help departments to provide interpreter services and the goal was to enhance the capacity in local health departments to serve those who have a limited English proficiency. I always tell my wife of course, English is almost my second language if you can tell from my Apple watch and dialect here. [LAUGH] The funding history from 2005 to 2010 remained at a quarter million dollars and then in 2011 through 2014 it had a reduction down to $239,000. And in 2014 we did not Not award grants to the local health departments. That program we have had 10 health departments who have been a continual recipient of the fund. We gonna have this listed for you on the slide. And they were expected To use matching local funds to be able to support the employment of an FTE. A full time FTE to do interpreter service. Some of the local health centers had sustainability issues continuing to sustain the effort and hiring [INAUDIBLE] And hiring bilingual stuff and a lot of the local [INAUDIBLE] found it had two narrow of the scope. One of the issues that we had was probably a matter of funding we had. It was not a scalable state wide initiative that we would be able to carry out and moved to other areas. The two main issues being we're very limited in our scope and it was not really scalable. What we had discovered though in looking at other states was, they had moved to an aspect of looking at culture and language in sort of a different light. Sort of a different light. They understood that ones culture impacted in the ability to receive services and how they accessed the system and what they did once they received advice from the health care provider. From the healthcare provider. And in class what we figured out was that it is a sustainable and scalable model that you could move and you've worked with communities and I will show you a map in just a second about the communities that we have been working in with the class services. The goal of class is to reduce the cultural and linguistic barriers to care, provide training and skills, resources to address the change in demographics and the healthcare needs of North Carolina, and it was targeted not only to our local health departments but to our Rural health centers, FQHCs, other non profits, community and faith based organizations. It focused on the nationally recognized cultural competencies and the The best practices around delivering services to different demographic groups. It was an evidence based program or it's an evidence based program that has been adopted and is used as a standard for accreditation at the state and the local level by National groups. It is broader reaching than the interpreter service program was and has a broader reach within the community, not just limited to the local health departments. Just to give you an idea of the activities that we've had since June of last year when we actually Took upon the spread of the class initiatives, have included the table which sort of outline the number of services and the number

of participants that we have reached since June of last year. And a map here shows the counties that we have been working in And showing a broader reach across the state. Our second program are and the one that i think many of you my be familiar with is the community focus eliminating health disparities initiative. It was a legislative funded and mandate the program It's goal is to strengthen and improve the health care of North Carolina's major ethnic groups, African Americans, Latinos and American Indians. And it provides 12 grants in three distinct geographic regions through an RFP process. Listed on this slide, in the slide in front of you is the recipients of the Safebi funding. It is a mix of non profits and local health departments. isafebi/g programs has eight disease focus areas, heart disease, diabetes, stroke, obesity, infant mortality, low birth weight, cancer and HIV. In North Carolina and when comparing to other states this was something that stood out. This was something that North Carolina does to other states or not. Typically involved with [BLANK_AUDIO] And one of the drawbacks in talking to other states when we talked about the granting process This was the amount of time in subject matter expertise needed to pull out and carry on such work in a broad state, and limited resources to do so [BLANK_AUDIO] In this slide I'm just sort of giving you an idea of in a bulleted fashion of the limited reach. We have 12 organizations. It's not really a statewide approach even though it's in regional efforts. And one of the big drawbacks when you're focused on obesity, tobacco and The other areas, the subject matter expertise doesn't reside within the Office of Minority Health it exists in other areas of the Division of Public Health [BLANK_AUDIO] One of the a In 2014 as we were looking at this, one of the ideas that we noticed the states had was the use of the Office of The Minority Health to strengthen problematic areas. So, they would actually have staff people working in the chronic disease Area on issues such as diabetes and heart disease. And trying to address specifically how activities and programs could better reach minority populations. In doing so we formulated a recommendation which says re purposing of the Safeti funding to go more efficiently address health disparities in our state. And since our health disparities are such a significant level, and I'll give you in just a second, an idea of How that looks in the state. We recommended the funding state level for those activities. Right now we have 2.5 million currently in the Sapheti Grant program. And we had proposed we take the grant funding and move it to the contenaries/g in the open window system and put it out in Grants in HIV/STD. Community focused infant mortality and heart disease and stroke prevention which also addresses. Diabetes. And the hope is by doing this we can leverage existing resources that exist within that service currently and will be directed to non-governmental agencies as well. Just to give you an idea of some of the burdening of the conditions to. The minority population. When it comes to HIV we know that African-American men make up only 10% of North-Carolina population.

For 80% young men newly diagnosed HIV are African-American. Infant mortality. We know that American, Indian and African-American death rates are at least two times higher than the Caucasian rates and that disparity is growing. In 2013 the disparity is greater or was greater. Than it was in 1994. So our gap is not closed by our efforts and it does call us to focus on what we're doing and to do it in the most efficient way as that gap does not appear to be closing. In heart disease, we know African-American and American-Indian death rates due to heart disease is 1.2 times higher than the Caucasian rates. Stroke African-American death rate is approximately 1.4 times higher than the Caucasian rate and diabetes, African and American death rate is approximately 2.4 times higher than the Caucasian rate and American Indian death rate is approximately 2.6 times higher than the Caucasian rate. So we have a real high burden of This disease and it's disproportionate to the Caucasian population. With such repurposing/g of the safety funding and with the subject matter expertise that exists already across the division We hope that we could focus on the disease gaps in a more scientific and data driven model. Re-purposing funding would also help us allow for greater monitoring of the Funding through the established structure of the open window system. [BLANK_AUDIO] One of the things we look that is with the interpreter service program, it was a program by which we send mini grants out to ten health departments. In implementing class Requires teaching and onsite consultation and more statewide approach which has increased some of the operational cost for providing that service as opposed to sending out a mini grant which supports an FTE and so we had asked for some of the re-purpose funding to go into operations for travels and supplies in workshops in conference around the class standard. [BLANK_AUDIO] One other aspect we want to point out is we have a valuable resource in the minority health advisory council, and there was a period of time it had not convened. We worked with the office and worked with the council to get members appointed and reappointed to the council, and we reengaged them last year in 2015. And actually started their word to begin looking at this issues, he very issues, the very gap, and how the state goes about addressing them. And we think that that valuable asset needs more support and we'll be able to, through the operational funding be able to bring them in so they could actually meet. We've been resorted to some conference calls and other things in the inner room to try and actually support their efforts. The existing office minority health, starting health disparity staffing is for FTE'S and with those four FTE's we're planning to do quite a bit of work, of course expanding not just to our AB-5 health for class training. But covering all 100 counties. We have already started work with some of our community in faith based initiatives. To look at health equity and health strategies in the faith community to help engage people in accessing in care and we've expanded our efforts in sexual health in Balanced initiatives. [BLANK_AUDIO] One of the things that the four staff members have been working hard at is,

engaging with the other staff of the Department of Health and Human Services and the Division of Public Health. And looking at what their program areas are doing to address health disparities and equity issues. We're continuing because it's just four staff members to try and work across the division in a systematic manner, really focusing on these three focus areas of heart disease or chronic disease HIV and AIDs and infant mortality. [BLANK_AUDIO] And I would like to ask or take questions at this time. [BLANK_AUDIO] [INAUDIBLE_AUDIO] For your presentation Chairman Dobson question. >> Thank you Mr. Chairman. Thank you Mr. Staley for your presentation, appreciate that. If what we are doing is not as effective as it could be if we re-purposed $2.5 million, I'm certainly in support of trying to make that happen. But with that re-purposing it talks a little bit about what those funds will be used for. I think the slide here talks about what enhanced subject matter expertise that already exists in these three DHHS open window services. So it talks a little bit about what those funds if we re-purpose that $2.5 million what it would be used for. But can you elaborate a little more? Is it more staff? What all would that $2.5 million got to if we re-purpose it? >> Thank you Representative Dobson What we have looked to do with that funding is again take it put into the subject matter areas, and then put it out try to build upon the granting services that we have in there. I'll use the example of HIV and AIDS just as an example. One of the areas we want to work in is granting to historically black universities and colleges. Again looking at that great health gap of air in the newly identified cases of HIV. We think we can make some inroads by targeting grants in that area. And therefore we're having folks who re disease intervention specialists from HIV and AIDS go out and work with colleges, universities to implement a grant strategy there. So we would use it in those areas, the three main areas as grants or grants going out to local communities. And we have Hoped to be able to actually build on some synergy or grants existing, maybe increasing the funding in those areas so that you actually have a bigger impact and penetration in that community. >> Thank you Mr. Chairman, Thank you Mr. David/g. >> Chairman I guess I'm gonna finish up the repurposing part. But in the section where you talked about the 50,000 providing operating funds for travel, supplies and conferences. And you talk about training, it's not gonna be a one shot so are talking recurring funding here in this endeavor? And also the two point whatever millions there are we talking about continuing, recurring funding but just moving it in a different direction? >> That is correct representative [INAUDIBLE] and thank you for the question, it would allow us to support the effort and continue the funding and and will continue the spread across the state of things like the class, efforts and standards helping reach of greater areas, and greater population of the state. >> Follow up. >> Follow up.. >> Have you looked at what the expansion state wide is gonna cost in terms of FTE's or supplies or whatever the expenditure might be, is that gonna be an increase going forward as we scale up? >> We looked at that and more other things in doing the re-purposing was look to keep it flat or level funding and we hope we can show our plan is to demonstrate just how effective that is, when we looked at other states they could see how just moving the investment can really make that much of a difference in the impact . So I think, our plan was to keep it at level funding. >> Thank you. Representative Earle. >> Thank you. I really want to commend the health department for what you've done. And I have served on the council for many years and say for a while

there were no meetings because there was some issues that we won't go into but I would just like to say that I think that health imperatives is an issue, you would think that at some point we would solve this whole problem but it just doesn't work that way, it is an ongoing process because you would find to bring new people in and if we look at it in a financial situation it's full of how it might impact the budget, this is a small amount of money that we are Talking about because if you can prevent someone from having a stroke or some other debilitating issue then that's a lot of money saved right there. And some of the The money that has been appropriated their were a lot of restrictions put on that funding and if you look on page 16 the grants that have gone out, these are in low wealth counties that probably don't have the resources to. To actually do what's been done. And I have gone out to some of in fact one of low wealth county that there is a good programming and that's what we are trying to do. We are trying to find good programs that we can model. Across the state in fact good partners that will partner with the council and with the state to try and make somethings happen. And this is 12 areas, 12 grants. There needs to be more Grants put out across the state. There is initiative working with faith based community and I think it's been very successful so and many many of us that have gone to the council meeting, we don't even ask to get reimbursed because we know that the travel of money. Whatever is just not there. And this is probably the only task force or group that there is really no money in it for reimbursement for travel or for other expense. And but there is. there is a good group of stakeholders that attend the meetings and I just think that there is anyway possible we certainly need to keep the funding as is and probably defiantly needs to have more funding to make more grants available. Thank you. Representative Insko/g >> Thank you. And I have some of the same questions. So both of these programs receive some funding right now. The class funding and then the CDF where it is CFEHTI, what do you call that? So but you're moving the, this service is in focus area is all that money is gonna be re purposed, is that right, I need an answer to a couple of questions so I can understand it. >> Sure less could be re purposed into those three areas so follow up. While on page 19 it's also to expand the class state wide activities, so could you say more about that like those on page 13 you've the class program activities living on trying to reach technical systems, is that where the money is gonna go into? And how much of that money will go out into this program of the original grant. Does that mean that the grant to this local agencies are gonna be eliminated. so since 2014 we've not actually issued the grant itself to the local health departments, there were a number of issues around the grants, one they were very limited in scope and if you're hiring interpreters service is a lot of times, it was to be patched used for and FTE And they would find one language, a person with bilingual skills in one language. And that was really limiting to some health departments as they have a diverse group of people walking in the door to receive services. So health services have hanged the way from the motto of hiring

an interpreter service To come in and sit and actually be with that, they've gone to teller language services or lines. They've actually gone to hiring bilingual staff. So they've evolved in their practice so since 2014 we've not actually had the grants going out for interpreter services what we have done is utilize some of the funding to support more of the staff members doing the cultural and linguistic training, which is the sort of national standard the one that when we are looking for accreditation they are looking to see are you addressing cultural competence in your workforce in healthcare. >> So just for clarification how much of the money is gonna go to the class activities? [BLANK_AUDIO] if I could have a look to the office of the minority health director, Cornell Wright and I think it supports one FTE, I will ask him to see if he can clarify for me. >> Good morning, so currently there is about $209,000 available to be sent out to organisations with the re purposing possibly adding a few more, probably like I think adding $80,000 more dollars that we can send out to organisations to implement and adopt the national class standards [BLANK-AUDIO]. Representative Butterfield. >> Thank you Mr. Chair I have a couple, one is in terms of the models in those five model states that you talked about. And Nation wide giving grants is not necessarily a best practice, could you speak on that a little more. >. So what we found when we looked at other states the offices are minority health although when you look across the nation they are all in different stages or different areas or scope of work. But the one thing we found was they did not really have the subject matter expertise on HIV or AIDS or chronic diseases. They didn't have the epidemiology or the physician or the clinical practice aspects. Knowledge base within the office. And that was one of the limiting factors. The other was we couldn't find any other state that was serving in the capacity that did the suffeti/g granting services. So they would have a pot of money, they would grant out to organizations that didn't exist across in other states. And one of the reasons that when we ask about this in 2014, we said what was the barriers behind it. And then said well we'd love to give out money, but when we're putting out money we wanna make sure that it's targeted or that it is put out in a manner that is most beneficial and supports the work of our other parts of the organization. So they're all organized a little different. So some of them are not necessarily within the health and human services area. Some of them are within administration But they all wanted to make sure that they had the subject matter expertise if they're going out there and doing a program like the HIV AIDS program, that they're using best practice, current sites and thinking around addressing it in their activities and initiatives. Follow-up comment. >> Yeah. >> It's more of a comment than a question. I have gone to the opportunists/g industrialization centers in [INAUDIBLE] and I've actually observed some of the screening programs that they offer. And it's excellent I mean people discover some of the conditions that they have right on the site and the number of people participating is enormous so that's excellent. And I know they get grants. >> Representative Murphy. >> Thank you Mr. Chairman. This is more of kind of a comment and a future thought. Sometimes we live in the world of unintended consequences and I'm speaking about HIV AIDS in sub-Sahara Africa population is over 30% infected, in Swaziland it's up to 45% infected and they've developed large scale programs of male circumcision. Okay and that has been show to have a reduced transmission infective

rate for HIV. And several years ago circumcision was taken out of our medicaid population as being covered by medicaid. And now as we heard in this committee several months ago 52% of the births in the state are now with medicaid recipients. And so if you take it five years 10 years, 15 years from now in stead of spending the money early as a preventative measure. We're gonna spend a massive amount of again five, 10, 15, 25 years later to treating people for life long diseases. So I think maybe that issue needs to be thought its relatively cheap done and then the antenatal period and for $125 for one individual say literally 1 million dollar later on down the road. So just a thought. >> Any other questions or comments form the committee? If not thank you Danny and thank you the job that you do in all your steps. Next on the agenda is deputy secretary health services [UNKNOWN] Williams. So [INAUDIBLE] Williams you have the floor. >> Chairman Brisen/g thank you it is a privilege to be here today and I say that because I know in talking with with you individually and collectively how much you care about the subject we are gonna talk about how engaged you are in it. And we share your engagement and care. So it is a pleasure to talk to you about that. Perhaps it's because for 30 years I was an obstetrician but I think this is incredibly important that I put it in this context. for you as I always told patients the average age for women to live in United States now is 82 in the year 1900 it was 48. I was up in Forsyth county about a month ago with Representative Lambert for their hundredth anniversary for their and the infant mortality rate in Forsyth county in 1900 was 200 out of 1000. One out of five babies died in the first year of life. And right now we are at about 7.1, 7.2 out of a 1000, but as it has been pointed out one thing that gets us up everyday is we had disparities and we are incredibly focused on that. When we look at the scope of what we're doing DHHS, secretary Braiser/g who's asked us of all the important things to do that in four initiatives we do everything we can to allocate all of our resources across departmentally to try to tackle those challenges and those are and medicaid reforms and behavioral health, and our public health crisis with opioids and hepatitis C and the fourth is infant mortality. We were 50th in the United States in 1998, we're now 42nd but again it is something we get up everyday and if I can ask you to remember any one thing about this presentation today, we're gonna go through some slides, we feel so strongly that we're at the point where we need to implement things that work. So implementation is the word that we kind of live buy. It's interesting to Representative Earl's point. The last century was really the triumph of public health, there was clean water, vaccinations and antibiotics. That's what increased the lifespan from 48 to 82. This century will still be public health but it's not going to be that Straight forward to Representative Earl's point, especially as we look at these disparities, it becomes more complex, the reasons are more multifactorial and so therefore we feel like we have to apply multifactorial approach. So again I'm just going to go through these slides Again we look at this continuation review as an opportunity to tell you the challenges we face and the solutions that we are providing. We have worked on this very diligently and again have worked on it through different departments. If I could boil down on February 9, Secretary Braizzer said, and we think this is incredibly important, if the average lifespan in this country is gonna be 82, it's just vital that we start people off healthy. Recalls again to the point that was made I think by Representative Murphy, that if we have more Morbidity and disabilities at this age, we will probably be dealing with those for many, many years into the seventies. And so it's just so important that we get off to a good start. So Secretary Braiser/g said that a healthy community depends on healthy bursts/g and healthy bursts/g depend on preventative measures

Before, during and after pregnancy. So it's very holistic. If I could state to you the axiom we live by is we want everyone in North Carolina, we do 120,000 deliveries in North Carolina every year 65,000 on a Medicaid. We want everyone who wants to have a child to be as healthy as they possibly can before they get pregnant. We wanna find a doctor for them. We gonna get them on pre-natal vitamins we want to make sure that any morbidities that are gonna affect their pregnancy that we identify preconceptionally. The third Thing is and this an interesting part of it. Is that we know in the United States 50% of all pregnancies are unintended. That doesn't mean unwanted but they are unintended. So the third leg of our chair is that we want to identify anyone who doesn't want to be pregnant and help them accomplish That goal and work with them and as an obstetrician again we have new ways of doing that that we can avail to patients that are very very helpful and work very well. And the fourth thing is, you know I tell people Belinder Petifer who is beside me who's probably the strongest advocate for this program in the whole North Carolina thinks this is a community approach. This is men and women and grandparents and grandmothers and brothers and sisters and it's everybody. So, moving through this again I just wanna press upon that this is very much a multidisciplinary approach. This affects Medicaid, this affects mental health Health, it affects the DPH, it affects our 85 health departments, 67 of which provide prenatal care in many of our rural counties. They are often the only provider. We have 30 counties in North Carolina that don't have obstetricians. We have 70 counties in North Carolina that don't have enough physicians, especially primary care physicians. So I say that we're holistic and our 1115 waiver. We are as purposeful as I know we can be to correct that and we think that working with our five medical schools and our residency programs, that part of all these is making sure that we turn out obstetricians and other providers of for these communities. Again Secretary Brajer is very purposeful that he wants to make sure that we're all working together to do that. And really I think if you look at the 1115 waiver you'll see the fruits of that building on some things that we've done very well in North Carolina like the pregnancy medical harm through community care All of those are very integrated into the waiver as all the local health departments. You have in front of you a 200 page report that addresses all the things that we are doing in this space now and all the things we want to do. I'll cut to the chase so to speak this is our whole plan Is to build on everything that we are doing now and we had a state wide summit in March and in 2017 the secretaries asked that we present to this body a broad scoped program to reduce infant mortality building on what we are doing now and what we've done in the past. It will be evidence based, it's evidence informed and is best practices. Again focused on implementation. We know smoking is a part of this, we know early access to prenatal care is part of this. We know that 17 hydrostatic projection is part of this but you have to implement those. Again In your report I'm more than happy to answer questions today, we have 12 maternal health programs and 20 child health programs and we've outlined for you as programmatic as we can the goals, the missions of those the goals the objections, functions and program and we have staff here today to answer your questions We know how much this means to you. Again in this we have the funding including the FDE's the problem we are trying to address the link between the funding while we do what we do and our recommendations going forward. Again realizing that these are complex problems, these don't In themselves just to clean water vaccination and antibiotics. The social determinant of health we know play a large part of this. And that's education, that's poverty, that's nutrition, all of those things so we would argue this is a societal problem so we are very collaborative in our approach and work with 9 government agencies. We work With academic centers, we work with other governmental agencies. So that we believe that as you target where we are now as opposed to 200 out of a 1000 or 100 years ago, that you have to look at systems, that you have to be very collaborative that you Have to take a long view.

This does not lend itself to immediate gratification unfortunately. And then you have to match resources. We know that certainly pre-conceptually you have to look at the health of the mother as she comes into pregnancy. So, we recognize that health is an intergrated Continuum that there are various stages. But what we're looking at now are really the social determinants of health before you're pregnant, during your pregnancy and after pregnancy. And so again I think representative Earl pointed out, and I know Danny did, and Cornell, that much of our attention is also Also on our inequities. Our African-American infant mortality rates are about 12.8 of 1000. For Caucasians it's about 5.1, for American-Indians it's about 9.8. And so we get up every day thinking about that. And Cornell and I were up in Nash County, representative Butterfield about three weeks ago. You saw what you saw and it's amazing. I would encourage everyone to go up there and see what they're doing with their faith based communities. And so we're very excited about using Cornell and his contacts and in many of our counties we have a very strong faith based communities that we can help implement some of these programs. So when you look at the impacts on the health of mothers and their babies, we work very closely at our summit in March which we had from all around the state. The Duke Endowment, Kate B. Reynolds, The Phillips Foundation I think [UNKNOWN] was there. We can't thank them enough for their assistance, but we think that while we were allowing them to start pilot programs that in a perfect world the state would then pick those up and broaden them in scope and scale. And so we work very closely with them. And we always try to push those forward. So I think the basic questions that we thought you wanted us to answer today is why do we do what we do? We have lots of programs. We have a very complex situation to fix. We think the ideology of our infant mortality is multi-factorial. It's not as simple as a vaccination or getting clean water. So because it's complex and it is systematic we approach it in different ways. So the first thing we do Is we try to put resources where the problem is. If it's as old as 2,000 years ago then a physician goes to those areas where they're needed. So we certainly are looking very closely, but geographically and areas in which our highest numbers of infant mortality. And we also look between rural and urban areas and are those different problems. Is infant mortality a different issue in Durham as it is in Raleigh or Avery County. Are they different? And so that really gets to, what I would I tell you is, the take-on/g. Is one size does not fit it all. Every community won't respond to every program because of their, just different factors. And so as much as it was simple, that we could just roll out one program, and that we'd give to everybody, [INAUDIBLE] big state. We've got 50,000 square miles and 10 million people, and it's first the pathology and the resources are different in different places. And I always had, parenthetically, we have 2 million more people coming here. By the year 2030, we'll be the seventh largest state in the country, 12 million. So what we're doing here is really important because the scope of this issue just gets bigger. It just gets bigger everyday, as I said we are the largest provider of obstetrical care in the state of North Carolina, in our medicaid program. So we are very purposeful about, looking at each community through our 85 local heath departments, and our pregnancy medical homes, and trying to roll out programs in those areas that we think make the most sense for those areas. And I'm happy to say that as we collaborate with our non-profit partners, they do the same thing. Certainly, the federal government, Which pays many of our block grants, and pays our money, often will mandate that we go to specific areas. So I think it's important as we try to match resources to needs, one of the things you have to remember is sometimes we are constrained by our funding sources, our federal, partners and both our state partner and non-profits.

And again, example is our Title V Maternal and Child Health Block Grant, requires states, usually 60% of block grant funds for primary and preventive health services. And our substance abuse, prevention and treatment block grant. They require very specialized services for pregnant women with substance use disorder. And I'll just tell you that if you spend time in Terral and Martin/g in Washington county. I've been to 80 counties so far this year and I'll make all 100. You walk away with an incredible sensitivity that is, you shift resources to one place, you've taken resources from somebody else. You're spending time in Carroll County it doesn't have a Doctor. That weighs on me.You think about that, as you're doing that. And so again we're incredibly appreciative for our legislative and our state budget support, as we are for our federal and non governmental support. And so as we look at this, trying to match resources to problems we're in some ways, some times like an airport controller where we have money coming in from different agencies. We had different needs, we have to kinda/g direct the flights to the appropriate runway. And that's clearly where we're headed next year, to roll out our large program. Again we have three broad goals. Lowering our infant mortality, improving birth outcomes and improving overall health status of children ages Zero to through to five because again I can't stress them out enough that the average life span being 82 years now for women.It's just so important that we get off to a good start. And so looking forward what's our vision? We think that , I repeated this at the very beginning but I'll repeat it again. In 2017 we hope to roll out a very targeted state wide program in scope and publicity to say if you're thinking about getting pregnant, we wanna help you, we want you on prenatal vitamins, we want to help you quit smoking,we wanna found out where you're gonna go when you get pregnant, we wanna help you if you're hypertensive or diabetic or diabetic. We want to get those in good control. So let us help you. Some people say well Dr. Williams, that's very nice but I don't wanna get pregnant,I don't want to be pregnant. So we want to help those patients too. And we want to help them through our funding situations and our providers, and making sure that there's somebody they can see and that's some great programs down in Gaston county, I just down in Charlotte talking about their rolling out. We have now with long acting reversible contraception and a year ago this time, I was [UNKNOWN] because we put them in patients as young as 14 to older. Because they work very well patients get benefits from them and again we just want to make sure that we help all our patients have the health outcome that they desire, then finally again back to the lenders point we don't think this is just a single gender issue, we think this is men, it's women, it's communities, it's faith based, it's non profit, it's everybody. So as we roll this out, we prioritize by purpose geographical areas, we will put resources where we have the highest disparities and our highest morbidity. We'll use our local health departments, we'll use our primary care providers, we have 1700 obstetricians in North Carolina. We need to distribute those and we're working with residencies in our waver and our medical schools to get them out more in areas where they're needed, we're gonna make sure we incorporate substance use, we know we have a problem with smoking, we know that increasingly opoids are a problem just as they are for all society. We talked about faith based communities, I'll just give you an example. My mother was born in white store in North Carolina and I won't embarrass you by asking where white store is cuz it's gone now. It's gone down in Antison/g county but down there when I went, it's very impressive what they had, they had 40 churches in Antison/g county and they used those churches with navigators and that's something Cornel is really interested in, he's helped me a lot and up in Nash county that's what we're doing so we're very interested whether it's temples, or mosques, or churches, there's a role there for talking to people about these health issues. We also again always wanna use our community partners. So what are these things we wanna implement. We talked about, okay, do we really need to figure out that smoking is bad for pregnant women? No. We know that so what we need to do is how do we get to pre-conception care to women bore they get pregnant?

I think of all the statistics that depress me, I saw the other day we do about 90 grands a year in DPH, for about $900 and one showed that for many o our patients, they don't enter pre-natal care until they're about 15th, 16th week, and I can just tell you as an obstetrician that kinda just devastated me. That is just so crucial, we know there's a direct link between that and pre-term labor so that is something that we just feel like we can fix that that. Smoking sensation same thing, we are doing better and we are very thankful for the programs that done that. But it's such a huge cause of mobility. I mean, patients would come to me all the time and say they were 38 years old. Did that bother me and I would say as you know, there's an option for you if you're not smoking, I can work with pretty much anything. Smoking is just devastating to babies and moms. Substance use again we think it's so important to identify those patients. I've already mentioned early access to prenatal care. We're very proud of our pregnancy medical harms, we have incorporated that in to the waiver. We've incorporated our health departments that we're so thankful that 67 provide pre-natal care, 79 drops in predastaron/g there's some interesting very good work been done in Chapel Hill with that by an old friend of mine on thorp and we think that has real promise and again I'm very thankful for our academic partners around the state. Our five medical schools in our A-hex in our hospital systems. I've already mentioned long-acting reversible contraception. We think that is vital in the promotion of breast feeding. We think that's really important. So we had the sermon in 2016 we brought everybody together to make sure everybody knows as we go in 2017 what everybody is doing, again we think that's going to be a holistic approach as we try to reduce our disparities and reduce our overall number. And we are very thankful, the legislature last Fall gave gave us $2.5 million to address three priority areas kind of in a pilot program. Belindo/g was very instrumental in organizing two programs where everybody came in and we kind of thought shared and secretary Resia was there and very that was in January, and then had our state wide summit in March. We also think that you can stop just when the babies born, we need to take it out five years so everything we are doing is align with that. And again what we are doing is evidence based, it is screen for depression, domestic violence child mental health, screen new born hearing maternal substance. Our state lab does 120,000 test every year thanks to your funding that identifies genetic diseases early that if not caught can cause great morbidity. looking forward moving ahead we are continuing our coordination being very collaborative. We are making sure children are vaccinated.We were I think one of the second highest vaccination rate for gardisil in the United States this year and our overall vaccination rate is excellent and that credit goes to our providers and our DPH staff that's just sweat equity,that's just making sure that everybody is out there working hard at it.We wanna make sure that if there are other developmental issues we identify them early because again in our present situation we will work with those from many many years.we always know nutrition is important and again we talk about substance use especially smoking,positive parenting skills and that will stop them already know one suggestion from you Representative Murphy wants me to do more circumcisions we just point out as a urologist that obstriction be circumcision so I I'm gonna question that advice, but I'll take it under advisement I promise. >> Comment please. >> [LAUGH] >> We correct them. >> [LAUGH]. >> Thank you Governor Williams and Chairman Dobson Thank you Doctor Williams, we appreciate the presentation,the time and thought you all have put into this and I look forward into working with you going forward.Two quick questions not related to one another. On page 16 I think you talked a little bit about this, legislative Directed allocations from existing federal block grant funding may not always align within a plan sustainable cohesive approach to improvements in maternal and child health,

can you talk a little about that and ways that we can address that issue. >> I'll start out, Representative Dobson thank you for Thank you for the question and turn it over to Linda Petfor/g. One thing that the cause our funding sources are multi strained and our programs are directed to certain areas and multi factorial, one issue we're now at is about 20%, 23% Then I think it's about block grant funding is directed. And again as you travel around the state you realize that every time we do that, we take money from somewhere else. And so we think is we move forward one thing we need to be really cognizant of is that we will Probably at some point we're looking at new money to fund some of these programs. And I'm gonna let Belinda address that if she doesn't mind. >> Belinda [INAUDIBLE] Head of women's health fraction and the department. Dr.Whims is correct. What we have seen more recently is the maternal Maternal child help block grant for instance is a funding source that comes in federally.But it a level funding.We don't get an increase typically for those funds.And when the budget bills are normally passed at times other things that are placed on the block grant and when those things are placed on the block grant then that means we've got You've got to reduce funding in other areas. Typically where things have come into the women health part, other block grant where we've seen reductions are new items are placed on the block grants, so then we in turn have to reduce the funding that goes to local health departments for maternal health services as well for family planning services. We've seen Things. Similar things on the child help fund as well. So new items are placed on the block grant, there's nowhere else to take it from.So we do take reductions, so the same communities are being impacted because those funds are being reduced.>> Just to comment on that, I look forward to working with you or to make sure that we don't We don't tie your hands and make sure you don't have the flexibility and the autonomy you need too allocate those funds if necessary. Specifics as we go forward loved to keep that dialogue open on that.Second thing separate issue on the $ 2.5 million That the legislature appropriated last year for competitive grants process to fund local health departments. That was a pilot and a trial. Something that we tried. I think it's been effective, I think it's helped in a lot of ways. And if you can't answer it now maybe we can work on it later but some ways in which we can improve that program to where it's open to all, I've had some complaints on the way that the legislature, not really complaints but just some concerns from the more rural areas on how to address those issues. So if you could talk just a minute about that and maybe we can work together on that as well to make that program more effective and broader to where everyone can see the results of it. >> Yes, this is the Belinda [UNKNOWN] again. We have heard some of the complaints that you've heard from some of the smaller communities. One of the things that we decided early on is that we were trying to basically get the largest bang for the buck. So when you're dealing with $2.5 million and we're putting it up competitively. As stated earlier we've just funded five local health departments for these funds and we did put some caveats on it, so we basically said in order for you to qualify for the fund you had to show that either your infant mortality rate was at a certain level or that your disparity ratio was at a certain level or that your child poverty numbers were at a certain level. And that you had at least 1000 births in your community in order to apply for the funds. What we did do is encourage the local health departments to work as multi-county teams, so even though we just funded five health departments and those funding begins June 1st, we're actually impacting 13 communities. Because they chose to pool and do some regional approaches. So the challenge for us is just when you're dealing with $2.5 million And we're extremely grateful for it. We were trying to reach as many families as we could with those resources. >> Follow up. >> Follow. >> Thank you for that. And again, I think it's been a good program and I think it's off to a good start, and I hope we can build upon hat we've accomplished and I look forward to working with you all to To continue to improve it as we go forward. >> Thank you. >> Representative Pitfall/g >> Thank you Mr.

Chairman. Dr. Williams has got a report for us on the opening of Cherry Hospital. Thank you Representative Pendilton/g. We talked about these earlier this week and I asked blind to check on this. But we anticipate receiving the certificate of occupancy on June 15th to the 30th. And once we receive that we get 90 days to move in so we think that we anticipate. Being open to admit patients on September 30th of this year. >> Follow up. >> Follow up. I would like to you all I'm always you all to come back and pledge but their is somebody who knows it right now. I know we've done programs right now, I know we've done programs in the past, try to help. Get more doctors maybe we've done it in positions assistance in those practice I don't know, but I will shall redo this, is not greatly encouraged. But I would like to see us discuss a program that we give scholarships to people who go to medical school. Let me. Medical school PA or nurse practitioners okay and that each candidate doesn't have a doctor that they would give a scholarship for a doc and either a nurse practitioner PA cuz a doctor can't work 24/7. And only do the counties who Who do not have this. Now in the military if you go to a military academy you owe the military five years, then if you are lucky enough after you've served, normally you gotta serve about three or four years. Then they will send you to medical school you owe them five more years. And one of the things I think we don't need to do this in counties like Wake county. We need to do it where their is none. And in keep in mind in the military you are assigned wherever they send you. So you forks would say okay we got this three of them, you can pick one of them if not we will assign. And you people come up with and then they still have a contract that's very, very binding and I just think that's secure how she can go get a doctor to go live in swan quarter in High/g County, you're not. So this way you make it worth your while but you don't give them a choice, they will be assigned. >> Representative Speaking something very close to my heart in the waver and the report was submitted to the General Assembly on March 1st. We have built out into the waver a plan that we would build out our residencies on the GME funding was taken out by the last session to come back with a plan. To your point I think that That to get doctors into rural areas and other providers we know this statistic. We have 131 medical schools in the United States of which we graduate 20,000 medical students every year, about 640 in our five medical schools here in North Carolina. And at the end of the fourth year 97% of those medical students Of the 20,000 will identify they're not moving to a rural area. They will self identify. I'm almost positive they're not putting that on their application when they apply to medical school. I think that something changes. Our old model of taking people and having them pay back a loan While in some ways effective, if you really look at the literature out of Mississippi and Alabama and Pennsylvania and talk to the American Association of Medical Colleges, you have to take students from those rural areas. And we talked to ECU and Chapel Hill and looked at their board scores and there are plenty of kids out there From our 70 rural counties, our health professional shortage areas that have SATs of 1450 and 1400, but they probably just don't have the opportunities. So we are a little bit ahead of you. We are proposing with private funding to set up a program in which we'll identify probably about 20 students a year and accept them straight out of high school into medical school as 41 of our 131 medical schools do in the United States, and can put them into a seven year program. And we will pay for their education. The model we're using for that is West Point and Annapolis. We fully that 18 years-olds, are capable of identifying at age 18 that they are willing to give service. We know that 35% of all the military comes from rural areas, because people from rural areas have a [INAUDIBLE] you have to give back to the land, give back to get going, and so I'll be very excited about this. We are in in the formative stage Ages, but if I can say this I feel very, very strongly that the qualities that a 18 year-old would identify whether it is to serve their country to say that they want to go to every county or iii or any of our 70 counties,

what/g really are qualities we are looking for doctors that they wanna serve people who are under served. So I'm sorry for the long soliloquy here but it's something that we think is very important. >> Follow up? >> Follow. >> Ask for one. >> [LAUGH] >> Smoking cessation talking to everybody in the room on this. Representative [INAUDIBLE] I introduce the bill last year to fund seven million dollars smokers, smoker since sensation in North Carolina it did and it worked and so we're gonna be back with asking in for seven million dollar one time appropriation and try it and let's see how it works. Cigarette smoking about 35 years ago life insurance company started charging people that smoke a 35 percent self charge for disability, life insurance and individual medical insurance because they knew how much damage it does to the body. And if they're doing that I have plans to only smoke one cigarette. And I said, well this question was, have you used tobacco in the last 12 months? So you get off of it and we'll come back give you another urine test. and most of them do cuz they don't like paying the premiums, but I'll look at these stats on, we call them E cigarettes which the real name is electronic nicotine delivery systems and that has grown in the last five years, 900 Percent for high school students and 600% for middle school students. So that right there is delivering is not like it's harmless to you it's not it's very very dangerous. I hope that you all would consider a one time appropriation on 70 million. and let's get on with saving lives. >> Thank you, any other question or comments, so if not I think you're not in the [INAUDIBLE] of formula. Come in MB and leave us today and giving you report and thank you for you and your staff, the work you've Do and we honestly do thank you for looking at it it's all about children. It's all about the unborn and the born the we wanna see come to this great stage so thank you again and [INAUDIBLE] meeting is adjourned. >> Thank you Chair [UNKNOWN] [BLANK_AUDIO] [BLANK_AUDIO]