September 16, 2026 · Health and Human Services · 26,663 words · 2 speakers · 56 segments
Welcome to the health and human services Committee.
I'm Senator brian hardin. I represent legislative district 48. Who knows where district 48 is? Three. Three of you. Well, there's more than that. So you keep going until you fall off in wyoming. That's where we are way out there. I serve as chair of the Committee, and I'll start by having the members of the Committee introduce themselves, starting with Senator fredrickson. Good afternoon. I'm john fredrickson. I represent district 20, which is in central west omaha. And dan quick, district 35, grand island. And assisting us today is our legal counsel, john dugger, our Committee clerk, corey bierbaum, and rebecca and joel are here to keep things rolling today. So thanks, guys, for coming in in the off season and helping us out. Today's hearing will be invited testimony only. If you've been invited to testify, please fill out a green testifier sheet located in the back rooms off to the sides and hand that to the page when you come up to testify. Written materials may be distributed to the Committee members as exhibits only while testimony is being offered. Please have at least 12 copies. Hand them to the page for distribution when you come up to testify. We do not accept oversize exhibits, that is, things like cds and thumb drives or other electronic exhibits as they cannot be transcribed. To better facilitate today's hearing, I ask that you abide by the following procedures. Please silence your cell phones. When you come to testify, please state and spell your first and last name for the record before you testify. We'll be using a three minute light system. When you begin, the light on the table will be green. Yellow will mean you have a minute remaining, and red means you have to wrap up your final thoughts and stop. Questions from the Committee may follow, but do not count against your time. With that, we will open with Senator elliot bostar in person. Thank you and good afternoon, chairman hardin, members of the health and human services Committee. For the record, my name is elliot bostar, that's eliotbostar, representing legislative district 29. Here today to introduce LR 481. An interim study to examine the fiscal and operational challenges of adding long term care services to the medicaid managed care program. During our most recent legislative session, Senator ben hansen introduced LB 832, which would have extended the state's moratorium on moving long term care services into Nebraska's medicaid managed care program. That bill was heard in this Committee, but did not advance. The purpose of this interim study is to continue that conversation and take a closer look at the concerns that providers and others have regarding the potential impact of managed care on the delivery and coordination of care for Nebraska seniors.
I believe it is important that we examine not only the fiscal implications, but the operational challenges, the impact on providers and, most importantly, the impact on continuity and quality of care for residents. Last session, this Committee advanced LB 1091, which allowed for long term care residents with special needs to be carved out of medicaid managed care. That legislation recognized that individuals with complex or intensive medical and nursing needs require a system of care that that prioritizes continuity of care programs, stability, and specialized oversight. LB 1091 ultimately passed on final reading 490 and was signed by the governor. Medicaid capitated, at risk managed care began in 2017. In Nebraska. Long term care services were not included at that time in recognition that the needs of the population served are more complex and multifaceted. In 2019, the Legislature enacted LB 468, which established a prohibition on adding long term care services and supports to medicaid managed care until july 1st, 2021. This date was then further extended from 2021 to 2023. The Legislature has considered this issue on multiple occasions and has repeatedly made the deliberate policy decision to keep long term care services and supports outside of the managed care system. Today, you will hear testimony from those with direct subject expertise, including those who have worked with managed care in other states. I believe their perspectives will help this Committee better understand the potential challenges and consequences of any significant change to the current system. And with that, I thank you very much for your time and attention. Thank you. Questions. Will you be around later for us to ask? Very hard and difficult questions. I have nowhere to go. Okay. Thank you. Tyler jewell, are you here? Thanks for being here. Thank you. Thank you. Good afternoon. My name is tyler josh. Tylerjuilfs, and I am the ceo of ambassador health. We are a family owned Nebraska health care provider that has been caring for nebraskans for approximately 50 years. I do appreciate the opportunity to testify on LR 481. I'm not here today to tell you that managed care is either good or bad. We operate facilities serving medicaid residents and have significant experience working with managed care organization, including across state lines. One question I continue to have about moving long term care into managed care is very basic. What exactly are we asking the mco to manage, particularly for a long term care resident? Our facility is already managing that individual's care 24 hours a day. We employ the nurses and cnas. We manage medications, meals, activities, care planning, physician coordination, and residents day to day needs. Before Nebraska adds another administrative layer layer between the state and the provider, I think we should clearly understand what additional clinical value the mco will provide, what measurable improvement in quality, resident outcomes, access, or taxpayer savings are we expecting in return?
My second concern comes from our experience with managed care and payment disputes. We have experienced situations where medically necessary services were provided and authorization existed. Yet months or even years later, disagreements arose regarding authorization procedures and reimbursement. A nursing facility cannot take back the care it provided two years ago. We are already paid the nurses and cnas. We paid for medication, food, utilities and other costs associated with caring for that resident. My understanding from our experience is that when disputes occur, the state may have significant oversight authority over an mco. It can investigate, require corrective action, and potentially impose sanctions. But resolving an individual disputed provider claim can be much more complicated. So before Nebraska moves long term care in managed care, I believe we need a clear answer to another simple question if the state believes medically necessary care was appropriately provided and should be paid, who ultimately has authority to resolve that dispute? Providers need meaningful appeal rights, timely payment standards, clear authorization requirement, reasonable standards, reasonable protections against retroactive recoupment and meaningful path back to the state when there is a legitimate disagreement with an mco. Long term care is also different from many other health care providers. These residents may live with us for years. Their conditions change. They may transition between skilled and long term care classifications. Go to the hospital and return or require increasingly complex services. Thank you for allowing me to testify today, and I'd be happy to answer any questions you might have. Thanks for being here. Tell us. Unpack that for us. How should that look from a perspective of who should solve that authority question? What? What does that world look like? What should it be? Well, you know, I think before mco, the physician would say and drive the order and then we would provide that would say and drive the order and then we would provide that care. You know, with mcos, it's always it's always interesting. They, they kind of want to manage that piece. And they've kind of taken a lot of the control away from physicians. So, you know, if you go through an authorized authorization and some of these circumstances, when we admit a patient, we get an authorization from an nco. And in all cases, before we ever admit an mco patient, we always get authorization. So throughout that patient's stay, they may go back to the hospital. So then you have to get another authorization. The states they they will rely on a qio. There's a pretty cumbersome appeal process if you have to go to the qio. But if a provider is truly providing medically necessary care and the state believes that, I do think that the provider should should receive payment for that care. Okay. So other questions. Yes. Thank you. Chairman.
So you mentioned in your opening about coming back after the fact, and I'm guessing that some of these have already been authorized to have that care to for that patient to receive the care. And then later on they come back and, and say that wasn't maybe appropriate or whatever. But what talk more about that. I mean, how does that happen? Yeah. In one circumstance, we got authorization before admission. And then this particular state that we worked with after that initial admission, if the if the patient would go back and forth from the hospital, we would then just defer to the state. And then the state was giving us authorization. Well, they were an mco state. And so the mco said, well, you didn't get authorization from us. Well, the qioaqio is an independent. They have physicians, they have nurses. So it's interesting how that qio would say, no, this patient is medically necessary. Plus we have a physician order that you know, needs to be provided care for. And the ambassador or one of our locations. So but because we didn't get their specific situation, they don't want to pay. Okay. And does that fall into like, I know, like, there are some people that, that are in a nursing home and they're receiving, you know, care there then like say they, maybe they go to a hospital and maybe a doctor puts them in a skilled care unit. And, know if, if that's, that would be separate from a nursing home unless the home would have that, that. I mean, that's actually a great question. And that is also very important is that most nursing facilities in the state of Nebraska, I would say almost all are licensed or duly licensed. So they offer skilled care and long term care. So, you know, if that patient has you provided a great example is in long term care. They for whatever reason, they have a significant change in condition. They go to the er, they stay at the hospital. Well, they can come back to that skilled and but that essentially the same location receiving skilled care. So then, you know, does the mco want a different auth. You know, how does that work. But once they get done with skilled and they're in that building, they're already there. So in our circumstance, the patient was already in our building and they they denied that care. Then the qio says, no, they they are medically necessary. You know, they need to be there. So. Okay. And that probably falls into like the I was going to ask another question on. So they're already there. They haven't had the authorization, but they need it. I mean, you need it right now. And I don't know how quickly that happens. If you actually need an authorization for something like that, how fast does that actually happen? I mean, if you're.
Just looking at like room and board or therapy, it's probably 24 to 48 hours. But if someone did not emergency room or had an emergency and then they went to the hospital and now they're coming back for skilled care, how long does that take? Yeah, if they're coming from the emergency to skilled orr again, that's probably going to be 24 to 48 hours, maybe a little bit longer. But if they're at your location and they say, you know, those services aren't necessary anymore, then that that is that is problematic. That takes a while to, to argue that appeal process. Okay. Thank you. Yeah. Other questions. Seeing none. Thanks for being here. Appreciate it. Randy jones. Thank you for being here today. Thank you for giving me the opportunity. Chairman hardin and members of the Committee, thank you for the opportunity to speak on LR 481. I'm randall jones, randall jones, jones. I'm director of aging partners here in lincoln. I'm speaking on behalf of the Nebraska's area agencies on aging. I threw out my testimony. I'll be referring to them as triple a's. Triple a's are the leading provider of home and community based services for the aged in Nebraska. Last year, we served 36,000 unique customers with direct, measurable services. Nebraska triple a's are currently providing targeted case management and service coordination to more than 5100 older adults who would otherwise be living in long term nursing, nursing home care, but are now but are living in their homes. By supporting people at home, we help them remain safe, independent and connect to their communities. For over 30 years, triple a's have provided unbiased assessments, care planning and ongoing monitoring through the medicaid aged and disabled waiver. Our system's strength comes from the unique combination of both targeted case management, but also home and community based services. Together, these supports together allow us to respond quickly, prevent unnecessary nursing home placements, and match services to to each person's actual needs for better outcomes. Mary rising costs in the system reflect Nebraska's growing senior population. In response, the triple a's continue offering cost effective community based services that reduce hospitalizations and support caregivers, and they delay or avoid institutional care. We also support recent state steps to manage waiver costs, such as rate adjustments, capped payouts and monitoring, which will help keep services predictable and accessible across Nebraska. Nebraska triple a s are nonprofit or local government. We are paid on a reimbursable basis and do not profit from these services. Beyond waiver coordination, triple a's provide transportation, housing, home safety supports, access to health care, fall and disease prevention, caregiving, social connections, and elder rights advocacy. These programs work together to strengthen outcomes for older adults. Looking ahead, Nebraska's triple a's are actively building capacity to meet growing demand as the state's population ages. As Nebraska considers adding long term services, long term care services and supports to manage care, we urge caution.
Other states have faced challenges. Most recently, indiana is a good example, including that include improper denials, shrinking provider networks, higher administrative costs and the loss of trusted local coordinators. Nebraska's triple a system works. We provide effective case management at lower cost, maintain strong local relationships, and help people stay safely in their homes before making major changes. The state should define the problem it seeks to solve and build on the proven strengths that are already in place. The state of Nebraska has invested greatly over many years to build a strong medicaid waiver network within the triple a s, that resource should be leveraged and included in the structure of any future medicaid waiver integrated care structure. Thank you for your time and consideration. Can you give us a paint one scenario for us? Paint a picture in our minds of how would the care of residents and skilled or assisted facility be impacted negatively by this? Paint one paint a picture for us. What comes to mind and make you go, oh geez, this just opens the door for blank. Sure. Well, one of my first concerns is that the. The cost of care is oftentimes with the other mcos in other states, what has been sold to be a cost savings has not reached those savings levels. Okay. So that's a concern. The other is delays in authorization. By a little. Or does it seem to miss by zip codes or light. Years by millions? Gotcha. The other concern is delays in in authorizing services. The other is inconsistency and care coordination. So our workers are with a family from entry into the medicaid waiver program until that person is deceased. And that provides a consistency of knowledge about family resources and connections to to the individual. Our fear is what we've seen in other communities. We've seen targeted case ratios of one person to 75 or more patients in terms of managing care. We're operating on a 1 to 45 basis, and that's necessary to keep adequate track of the patient and to make sure that there's enough visits to to ensure that care is being given. Okay. Very good. Other questions? Seeing none. Thank you. Appreciate you being here. Jay leanne carpenter. Cindy. Come on up. Cindy. Sorry about that. Cindy. Come on up. Cindy. Sorry about that. No, not at all. Thanks for being here. Thank you. Good afternoon, chairman hardin and members of the Committee. My name is cindy caddy. Cindykadavy. Senior vice president of policy for Nebraska health care association. On behalf of our more than 400 nursing facility and assisted living members, we want to thank Senator bostar for introducing this resolution. As Senator bostar noted, Nebraska currently uses a capitated, at risk medicaid model of managed care. Under this structure, the state pays each managed care organization, or mco, a set amount for each person enrolled.
The mco is then responsible for managing that individual's care within that amount. This creates an inherent financial incentive for the mco to control its costs by denying authorization of services, reducing provider rates, or denying or delaying payment. While this model may be appropriate for some areas of health care, long term nursing home care is fundamentally different, as we realize the department does not need legislative approval to move long term care into managed care, and that change could be made at any time. We wanted to express our main concerns. Some of those you've heard already. First is payment delays and denials, which create serious financial risks. Long term care facilities currently bill the state monthly and receive predictable payment the following week from the state. That cash flow is essential to meeting payroll and other obligations under managed care. Claims can be delayed or denied for a number of reasons, including technical issues with the claim form. As tyler said, an mco can also later determine that a service that previously authorized was not necessary and recouped that payment for nursing facility. This is not simply an accounting issue. The care has already been provided, the employees have been paid and the resident's still needs care. Our second concern is that reimbursement decisions can threaten provider stability unless limited by statute or contract. Mcos generally have significant discretion in establishing provider rates. Nursing facilities already operate on extremely narrow margins. They cannot simply absorb lower reimbursement while continuing to pay their staff. Third, authorization decisions can directly impact a resident's quality of life. The Legislature has recognized these risks. That's why our state is consistently excluded. Long term care, long term nursing facility care from medicaid, managed care. Our state is not alone. 23 states do not include long term nursing facility care in their managed care programs, and at least two states have included these services and later removed them. Indiana, for example. And you have a copy of that report with you reported $91 million in additional costs for nursing facility care under managed care, and 300 million overall compared to projected expenditures with the state. We should. Oh, sorry, I noticed we're out of time. We are. Tell me more about the indiana world. Just kind of paint that picture for me. So it's a little bit different model than Nebraska and Nebraska. All medicaid beneficiaries are included under managed care, but some services are included and some are excluded. Okay. In indiana, it is not the people that are under managed care. It's the services that are under managed care. So they had put nursing facility services under managed care. And based on that experience, I think it was like in the report gives you all of the details on how they calculated that. And we can provide more information if you need it.
But what they found was that when they looked at what the state would have paid compared to what they paid under managed care, because the managed care organization said they needed more money to coordinate the care for those individuals who are receiving long term care services. It came to $90 million difference. So because of the cost and because of other issues that you've heard, indiana decided, and it's it's a big deal once the toothpaste is out of the tube and it's in managed care, to move that back to the state is a big deal. But because of those reasons, they decided to move, pull out long term nursing facility care out of managed care and put it back with the state. Okay, 91 million is a lot of money, no matter what we earlier testify are saying we've got about 36000 people who are being served currently across the state. And I think that was right. That might be yeah, that might be under the waiver. Yeah. Yeah, sure. Indiana is bigger than we are. Yes. By population. So I'm just assuming it's it's more than that. Or people are being served, but 91 million is 91 million. Okay. What else do we need to know? I think just, you know, what problem would be solved by moving long term care under managed care, tyler pointed out. I mean, the main reason usually for managed care is to coordinate an individual's care. The nursing homes are already doing that. They're making the appointments, transporting the residents to their care, coordinating with their physician. It just adds another layer on top of that that costs additional dollars and can actually confuse the whole care issue. Okay, so we've decided several times Nebraska to keep long term care out. It seems like that's a good decision. And so at the very least, we would request caution in looking at that decision. Sen fredrickson. Thank you. Thank you for being here for your testimony. You said something that caught my ear. You mentioned like there's been a history or a pattern of mcos approving a service and then later recouping the payment for something that was previously approved. How often would you say that's occurring? I would not I don't have that information. I apologize, Senator, but we can get you that. Okay. And do you know. Why that might happen? So, for example, like what rationale is provided by the mco? If they were to say they did approve it and then changed their mind, do they typically provide a rationale for that? Or they typically say they have decided it wasn't medically necessary. And like tyler explained, in other states, you can appeal that decision, but it is complicated and, you know, you've already provided the care. Okay. So and what does that do? You are you able to share any details of what that appeals process looks like? So I don't have that information.
Again, we could follow up with you, Senator. We're glad to do that. Thank you. Sorry, Senator. Quick. Thank you, chairman. And I don't know if you know this or not either, but so right now, the percentage of people of medicaid patients that that a nursing home or assisted living facility can take. Do you is there an average for the state of of that percentage? Maybe that and maybe it varies from from facility to facility, how many medicaid patients they can actually have and be able to provide the care. So it's Nebraska's. Around 60% of the nursing home residents rely on medicaid for to pay for their care. Okay. And with the indiana model, do you think there could be? Because I know I'm sure there are some out there that aren't approved, right? I mean, there are people out there who are trying to get into a nursing home, or they're a family member is trying to get them in and they're not being approved for that service. Right. Or yeah, that's, I think, Senator hardin, when you asked that question, which is a good one of what does that mean for the individual that needs care? That's what can happen is you need that level of care. And your physician says you need that level of care. But if the managed care organization doesn't approve it, there's no payer source. So you're not going to be able to access it, whatever level of care that is. So like with the indiana model, do you think that that would be something where you would probably find that more people could have that care then, or is that something we would. Under now that they've moved it out of managed care? Yeah. I don't know if we have that data, but we can find out. Okay. All right. Thank you. Okay. Any other questions? Seeing none. Thank you. Appreciate you being here. Kirsten. Thank you. Good afternoon. Good afternoon. Senator hardin. Members of the Committee. My name is kirsten reed, that's kierstinreed, and I serve as the ceo for leading age Nebraska. We represent more than 90 aging services providers across the state. I'd like to thank Senator bostar for including me in today's testimony, and today, I'd like to take the opportunity to share some lessons learned from other states, as does consider adding long term care and home and community based services to the medicaid managed care system. We are asking that Nebraska simply learn from other states on that have already made this transition, and care. Carefully evaluate both the benefits and the risks of doing this. I will move manage our long term care services and supports into managed care in 2016, with significant projected savings. Instead, the transition brought financial and operational challenges, including increased payments to managed care organizations, risk sharing arrangements, and later having to put into place protections for nursing facility reimbursement.
Providers also reported problems with authorizations, denials and payments. In kansas. Their experience was similar with challenges can care includes long term care services and supports. The state has now added protections related to prompt payment, standardized credentialing claims, denials, provider education and independent review. Many after the implementation problems already occurred. The lesson is clear the rules and the implementation process matter. As Nebraska moves forward, I urge the Committee to require three things. First is a transparent rule development process, including providers, medicaid recipients, families, and other stakeholders that must have a meaningful role in designing the services. Second is a mandatory pilot period. Nebraska needs to test the model, establish measurable benchmarks, and correct problems with reimbursement authorization claims, care coordination, as well as rural access for statewide expansion. And third, protections need to be established in advance. These include medicaid rate floors, prompt payment requirements, standardized claim process and rule network protections, among many others. Finally, a cost comparison must be accurate and comprehensive. This means that savings should account for administrative expenses. Mco risk, managed care cost provider, administrative burdens, and transition costs for additional state payments, not simply comparing fee for service claims to managed service capitation. Nebraska has an opportunity to learn from other states and not repeat them. If Nebraska decides to move forward. Let's ensure that we design the program with safeguards, providing that everyone that receives care is able to test the system before it is put into process. Thank you. Happy to answer any questions. Kind of describe for me what. A mandatory. Pilot period might look like. How much how long do you think would be a reasonable period of time to gather the kind of data the the likes of which you put on this page? What's a meaningful period of time, you think, to kind of gather that to say, okay, we think we have a meaningful test plot? Yeah. That's a great question. I don't have an answer for you, but I do. I just didn't know if it was something that could be done in months and months. Or are we talking years. And years? I think, you know, most things that we test out in the state are usually a six month trial type program. But before we even get to that stage, we need to develop what the playing rules are, right? And that means getting everyone that is going to be impacted by this kind of around the table to set up what those things are. And I think that's the biggest thing that we can learn from other states is there wasn't enough time spent on what are the rules and how is this going to be implemented? Who is it going to impact? What are we going to do when there's problems? How far back can we go for these claims?
To that end, do you know of any states that have made this kind of transition that have done it better than others? I mean, is there anybody worth copying out there or has it all been bad? Great question. I'm sure there are some states that have done a pretty good job of this. And I think even in the corrective process, kansas has done a really good job of kind of going back and like, oh, maybe we should have done this so we can learn from those. That ball. Do you know, I mean, was it. I think they implemented it in 2017 originally, I don't know how long. The process of going. Whoops. I think it was a lot of whoopsies. I see. Yeah. Okay. Other questions. Seeing none. Thank you. Robert bell. Welcome to thank you. Robert bell. Welcome to Nebraska. Been in Nebraska for a long time, Senator, but I appreciate being in Nebraska. Good afternoon, chairman hardin and members of the health and human services Committee. My name is robert bell, spelled robert, middle initial mbell. And I am here today representing the Nebraska association of medicaid health plans, which consists of three contracted Nebraska medicaid managed care organizations, or mcos molina healthcare, Nebraska total care, and unitedhealthcare of the midlands. I appreciate this opportunity to provide the perspective of the mco on LR 481, which is the interim study on managed long term care services and support ml tss for. I think that's shorter, but we'll see. Well, fewer than 5% of medicaid beneficiaries use long term care. They account for 28% of total medicaid spending nationwide. Ml t s provides states with greater budget predictability by establishing a fixed, accountable financing structure that promotes care coordination, early intervention, and efficient service delivery. The result is a more sustainable, long term care system that supports individuals in the setting most appropriate for their needs, while helping to ensure medicaid resources are used effectively and responsibly. Ml tss supports a person centered approach by helping individuals receive services in the setting that best aligns with their needs, goals, and preferences. When individuals can safely receive these services in lower intensity community settings that better align with their preferences, the state also benefits from lower costs. And Nebraska in 2023, the average annual expenditure for an individual receiving institutional services were approximately $800,000 higher annually for than for an individual receiving home and communities. Individuals receiving less often have multiple chronic conditions and rely on a wide range of services. Ml ts creates a single point of accountability for coordinating care, helping reduce fragmentation and improving transitions between care settings. States that have implemented ml ts have reported improvements in health outcomes and reductions in avoidable hospital utilization. Nebraska mcos are already operate under established contractual performance standards that hold them accountable for both provider experiences and member access to care.
Current contracts require health plans to maintain provider payment preferences, thresholds exceeding 90% for claim accuracy and timeliness, while also meeting define service authorizations and requirements, including determinations within 72 hours for urgent requests and seven calendar days for standard pre service requests. Unlike traditional fee for service payment approaches, managed care allows for value based contract that better align provider reimbursement with mentor member outcomes. Mcos can also offer complementary supports such as care coordination, medicare medication adherence programs, enhanced transportation assistance services, and 24/7 nurse advice lines. Such programs also provide additional benefits and services designed to support caregivers such as respite care, peer support, and ongoing training opportunities. I have one sentence left. May I please suggest, as Senator bostar and members of the Committee continue to study this issue over the rest of the interim the mco o's, the mco and the association stand ready to provide more information and engage with stakeholders as appropriate. I appreciate the opportunity, and that was the most hard hitting point of that entire testimony. So I appreciate the opportunity to complete. Thanks for saving the best for last questions. Tell me this, robert. Clearly we we want to do things that are the best for nebraskans. Absolutely. It's a strange thing out there because we have older people going, gee, I don't think I trust nursing homes. We have another group of people that go, I don't think I trust insurance companies, and there's probably a lot of folks who say, I don't trust either one. And yet we're all getting older day by day. Sure. Or the government, they don't trust the government. They absolutely don't trust the government. And I'm I'm with all of them. And I guess my question is. How do we learn from some of these places like kansas, for example, where they did institute this, but it sounds like it was wonky for they did institute this, but it sounds like it was wonky for some time. Is there a way that we can bring this into effect in Nebraska without putting people through a long, painful process of. We know it's wonky and not ready for prime time, but we're going to force it down your throat anyway because none of us. Let's be honest, you don't I don't none of us wants to be a part of capitated care. That just is terrifying, right? Right, right. We would encourage you to make decisions right when you're younger to prepare for. There you go. But but not that doesn't always happen, right? Things happen in life. And then the state steps in and helps you out. I think, I think the key is I wouldn't want any Senator in the room to believe that hhs is just going to decide tomorrow to turn on a light or flip a switch, and then suddenly we're in ml tss. So we're in the managed care of long term care.
It's going to be it's going to be a process. You say painful process. There's also going to be a process before that process of engaging with stakeholders of, of working with the department, with working with the various trade organizations that represent nursing homes or other care, providing organizations in the community, making sure we work with our agencies on aging throughout Nebraska and all the good work that's being done and making sure that, you know, I don't know if we'll ever get to comfort with one another, but at least there's an understanding, I think, you know, how do you be transparent? What protections do you put in the contract that don't exist already? You know, I think some of the protections that I heard that people wanted exist in the existing contracts with the mcos related to some of the items that were brought up. But if there are lessons that can be learned from iowa or kansas, as our neighboring states that have this or other states, I mean, about half of the united states has us in their medicaid programs in one shape or another. Or also there's, you know, you might start slowly with different types of populations and then expand it as, as we become better at providing those services in Nebraska. And honestly, we haven't had a moratorium for three years. And, you know, the department hasn't determined that, hey, we're going to press forward just yet at this point. So and I think that would take a long ramp up before they would be able to do that. So not to speak for the department, of course, they could come in and speak for themselves. Any other questions? Thanks for being here. You're welcome. Appreciate it. Yep. Senator bostar. What have we learned? Well. First of. All. Thank you for your time. I think this has been a very useful conversation, I think. As we examine all of the ways that we could do this kind of a transition, or we look at all of the pitfalls that have impacted other states who have gone this route. And perhaps there are some states that, you know, have sort of made it through that painful process that that we've been talking about. I think the thing that that sticks in my mind is that none of it's necessary. And so, you know, as we deliberate on what the right way is to mitigate the pain that we could endure in attempting something like this, I would sort of start from first and foremost, we don't have to. And the Legislature, not a Legislature that that I've been a part of or anyone else here, but previous legislatures have decided to prohibit that transition from happening. I think. And I think we've seen why, right? Because even as we discuss, well, how can we do it? Everything is couched in how do we avoid worst case scenarios?
And that just doesn't sound like a situation that I think we should be heading to. And so, you know, I think really the conversation should be around is the Nebraska Legislature repeatedly has decided to prohibit that transition from happening. And they, they and they've done it time and again. And I think we should be considering why wouldn't we do the same thing? What what's different now that that wasn't true then? Because it certainly seems like right now, it would certainly be a painful process, maybe one that we could get through. Maybe not. But either way. I think we should really be examining whether or not this is we want to copy the wisdom of those who came before us and, and pursue a similar legislative path. Thank you. It's one of those tough things because I can say with complete clarity, and I know I'm accurate in this, 100% of us will get older tomorrow. And so if we're lucky. Yes. And so the question is, what do we want in our lives? And it's, it's a difficult thing. And, you know, robert shared earlier plan well, when you're younger. And I think there's, there's truth in all of that. But I think picking the pockets of other states that have gone before us and trying to cheat ahead on the exam, read the end of the book first and see what we can try to accomplish in that way. So are you thinking you're going to bring a bill? Well, I you know, I think those conversations are ongoing. I mean, you know, certainly you were all here for for Senator hansen's legislation when he brought it earlier this year. But, you know, and to your point, though, about, you know, looking to the other states, we can also look to other states that don't that haven't done this. Kind of a split thing, isn't it? Yeah. And so, you know, I think, I think there's a lot to, to be gleaned. And again, you know, if the Legislature doesn't act, it lets it it leaves the door open for the department to do this sort of in any manner that it chooses. And I think therein lies a level of risk, too, because that's it isn't us making that decision. We can make the decision not to go down that path. But if we hold the door open long enough and someone's going to walk through and we don't get to say how they do it. And so I think it comes down to risk. Kirsten brought up the idea of a pilot oriented program and lots of pieces that are a part of that. Have you thought about that in terms of, would there be a way to dip a toe in the water and litmus test something, or is it in your mind? Does it need to be more of a clean break? That's a good question.
And I think I mean, to some extent, the answer to that question kind of comes down to how how can the Legislature. What's the right what's the right approach for the Legislature to do something like that when it's sitting right now with wholly within the domain of the executive branch? And I'm not saying that can't be done, but I think that, you know, that would certainly take some. But I think that, you know, that would certainly take some. Generously. Yes. Okay. Any other questions? Thank you. Appreciate it. This concludes LR 481. Next on the docket will be LR 382 and Senator fredrickson. We will transition the room. Listen to the room jumping from here to there. We have a guest. Senator clements was here. How many of you saw Senator clements playing his trumpet today on the field? We we listened for your trumpet and it was very strong. We really appreciated it. Thank you. I'm still. Playing for the huskers. They need me. They need they need you. And if that's how we win by that margin, please keep coming back and playing on the 50 yard line. So thank you. Are all of your people here that you can see john in terms of all your testifiers? You think, okay, very good, Senator fredrickson, take it away. All right. Good afternoon, chair hardin and members of the health and human services Committee. For the record, my name is john fredrickson. That's johnfredrickson. I represent the 20th legislative district in central west omaha. I'm here today to introduce LR 382, which is an interim study resolution examining the status of play therapy in Nebraska. Current regulations disallow play therapy. However, Nebraska child protective services training materials explicitly instruct new caseworkers to seek out trained play therapists for wards of the state. This causes confusion across the industry. In Nebraska's managed care organizations are clawing back services because of this conflict. In our regulations, I provided a couple of handouts for the Committee, including the regulations that explicitly disallow play therapy, among other therapies. I have also included a recent letter from our outgoing colleague, Senator dave murman, to the leadership over at dhhs supporting changing this regulation. I am happy to bring this resolution to continue the conversation. On behalf of first five Nebraska. They, along with a few providers, are here today to provide a look into their direct experience with how this conflict and statute has led to costly clawbacks and delays in services to Nebraska's children. Happy to answer any questions. Thank you. Questions? Okay. Thank you, chairman, and I don't know if you can answer this, but play therapy. Can you describe that to me a little better? How that. I can describe it a bit, but we actually have some play therapists who are here who I will defer to them because they are certainly the experts. Okay. Thank you.
Will you stick around for us to ask you very difficult questions at the end? I will be here for all of them. Magnificent. Janice sherman. Welcome. Thank you. I feel like I should raise my right hand and testify in court. Just have you spell your name. That would be awesome. Janice sherman, janicesherman. Thank you for the opportunity to talk to you all about play therapy. I am a licensed independent mental health practitioner and a registered play therapist supervisor with a private practice in glenvil, Nebraska. I'm here today to address concerns regarding current Nebraska regulations that do not allow play therapy. The systemic issues and how treatment is presented and offered to medicaid clients, and the severe financial consequences providers face for delivering developmentally appropriate, evidence based care to medicaid enrolled in our state. During a recent audit, Nebraska total care kleine back payments for my practice because I utilize play therapy. Nebraska medicaid regulatory updates caused by play therapy as a non allowed intervention. Play therapy is a highly researched, evidence based modality for young children who lack cognitive capacity to verbalize their trauma, and play is their primary way of communicating. More than 33 other state medicaid systems, including all of Nebraska's bordering states, fully cover this service, making play therapy a disallowed treatment for Nebraska only benefits the mcos, who use this disallowance to claw back money from providers. The child clients are receiving evidence based psychotherapy, and cpt billing codes remain the same for play therapy as they are for all other psychotherapies. The consequence of these recruitments is devastating in court involved cases. If a clinical observation is not documented, it legally does not exist. In one of my audited cases, in a four year old client, my precise documentation of play themes provided the critical forensic evidence required to support my court testimony. This documentation directly enabled the courts to intervene and protect this very young child from active grooming and sex trafficking by her biological father. In my audit from Nebraska total care, they clawed back funding for all of my sessions with this client. Because of the word play and the play themes were documented. I also want to add that this child did not verbally disclose what happened to her until years later. It was her play themes that described what was happening, happening to her at the time, and allowed me to advocate for her protection. This policy creates a baffling contradiction within our state government. Nebraska child protective service training material highlights play therapy and encourages new caseworkers to seek out trained play therapists for their state boards. Furthermore, under federal mandates, medicaid is legally required to cover any medical, medically necessary treatment for children, yet administered the administrative process to utilize epsdt in Nebraska, especially for behavioral health providers, is so ambiguous and untrained that the mcos are able to exploit this confusion during audits and clawback our payments.
This punitive and highly contradictory audit process nearly drove me to leave medicaid, the medicaid network, entirely, forcing providers to return payments for successful ethical and life saving treatments. Due to these policy inconsistencies will only worsen our state's critical mental health provider shortage. Thank you for your time and your dedication to our Nebraska children. Thank you. I just want to say that a a person that the senators here know and everyone in the room knows him, Senator dave murman wrote a glowing testimony of your testimony, and I just wanted to share that. Thank you. Tell us, because I think I think in plain language, we're looking at this and saying. Children learned at play. They don't sit down in nice, neat rows, and we swap them on the back of the hand with a ruler. And that's where they learn. They learn when they're with a doele. They learn when they're with a tonka truck. They learn when they're with a teddy bear, they learn at play. They express their play. They play. That's that's their work. They play. I think there's a suspicion. My sense is that a therapist could do nothing, let the children play because they're going to do it. I dare you not to have them play because they're going to play. That's what they do and call it therapy. And bill for it. Help us understand in plain language, what is the purpose of entering their world, their language, their mode of operation as a kid? And what's the difference between them just playing and what happens as meaningful engagement and therapy occurs? Kind of help us get. That center. Harmon a great question. I know my colleague doctor hall will explain more about therapy. And I know each other well, so I look forward to his his testimony as well. But we'll ask both of you that that same thing, if that's okay, because I'd love to get dimensions on this. Yes. Well, just like all therapeutic modalities, we are trained, we take training, extensive training, play therapy to become a registered play therapist. It is actually higher requirements than becoming state licensed. We children express through play. So we have to learn what are they trying to tell us? Children communicate through behavior. When a child has. Because they're probably not going to just pick a big multisyllable word and express it to us about capturing all of their experience. Yeah, well, and I've had some very intellectual and cognitive little people in my office, but when children experienced something traumatic, speech and language is one of the first regressions, developmental regressions that they that they have. So even older kids become silent. They, they withdraw. So giving them that medium to be able to show us what happened. And they do. And through our training, we learn how to connect with the child. We learn how to set up the space, our therapy office.
So they know this is a safe space. You can tell us anything and she can handle it. She's not going to cry. She's not going to tell you to stop. She's not going to leave the room. She's going to hold that space so that you can share what you need to share. And we are trained to watch for those things. We are trained to watch for repetitive playthings. We are trained to watch for playthings that align with a trauma narrative play themes that go beyond their developmental, normal way of knowledge. Give us an example. When you say play, we're adults and we've all, especially those of us who spend a lot of time in this building, this building drains you of any ability to remember, play in any way, shape or form. So remind us, what does it look like? Right? So, well, I bet you will look at your grandchildren, your niece and nephews, whoever look at their play a little differently. I know I certainly did after I was trained. They are expressing. So are you winning like a specific example of what. Yeah. So. The case that I was talking about in here, this child was playing out sexual adult sexual acts. This was something way beyond what her typical development or normal curiosity would know. Again, at that time, we did not know that she what she had really experienced until later on when she was able to tell this, that she was being taken to a sex house and she was being desensitized to watching adult yucky adult games, and she was being videotaped, she was being fondled. Those are the things that she was playing out, but not seeing with her actual words. Using dolls, using coloring books. Using toys, using whatever object connected to her, to that experience. But yes, in our play rooms we have there's certain toys to go to, certain themes, there's nurturing themes. You have toys for any, any way of them being able to express themselves. So I'm guessing because I'm not a therapist, janice, but I can imagine a world where any professional, when they see someone doing something, particularly in their own profession, they see someone doing something, shall we say, over the edge, outside the boundaries. Wait a minute. You're ruining it for the rest of us. Stop that. That kind of thing. Where does the play? Is there a place where the play therapy can be abused? And wait a minute, that's not therapy anymore. That ceases to be meaningful. And it's become usury. Is there such a place? Is there such a threshold? Yes. And I think even with cognitive behavior therapy, it can become a conversation between two people instead of actual using those cognitive behavior therapy skills. Any therapeutic modality is at risk for that. And how how do you guys check for that now?
How, what's the check and balance to make sure they are trained and they are doing their therapeutic modality the way that they should, and our inability to document those themes and those things makes it difficult for us to explain why we have to document that. Again, these play themes, when I go to testify in court and advocate for these children, I have to have it written down. They subpoena all of my notes. So if the prosecution says it's that you can't testify to that, that didn't happen. That is critical evidence needed in that child's file. Now being audited by the macos. Am I scared to put clay in my notes? Yes. It's a dirty four letter word. It's it's terrifying. Am I writing this progress note for the insurance company, or am I writing this progress note for my client? And ethically, it's for my client. So having to make that decision, having to make that ethical choice and know that if I do put this in the note, I am risking having to pay this money back for an evidence based, developmentally appropriate treatment for children is a position I don't think any therapist should have to be in. Kind of what age to what age does this become a meaningful modality? That is a great question. It's normed for up to age, I believe. 912 I might be wrong in there, but there are there are children who have have difficulty verbally expressing. There are children. My teenagers. You think they're going to sit down and just have a conversation with you about how they're feeling? No, but in the santee they can create something and then we can start talking about it and processing it. And then I gain insight into into their world, and I'm able to get them to either show me what is going on so we can talk about it, but it, it provides that safe distance between what happened to them. It's happening again to the toys. It's not happening to them. Again. Gotcha questions. Yeah. Thank you chairman. Can you talk a little about the process for appealing a decision by the mco and how that. Yes. That. So the first step was to do a line by line written. Rebel. And then if that came back, then it was a you had a choice. You'd do a fair hearing process was the final step in between that I was offered a settlement by the Nebraska total care auditor. She told me that if I settled that, I would pay a lesser amount, not including the play therapy sessions, because that was in the Nebraska statutes, but I would pay a lesser amount. But I did have to sign a non-disclosure agreement. If I did that. I wanted to be able to advocate for other therapists, especially play therapists. So the non-disclosure agreement did not sound like a great idea to me.
So I went through the fair hearing process, lost. And I did ask again about that lesser amount that they had offered before. And I was told, once you go through the fair hearing process, you don't get the choice to have that lesser amount anymore. So I was basically penalized for exercising my right to a fair hearing by thousands of dollars. I had to pay the full amount back. Okay. And, you know, are there other states that actually allow play therapy? Yes. There are 33 other states, including all of our bordering states. I did my training at wichita state university in kansas and trying to find out, you know, how long they have had play therapy accepted. It's like we've had it so long we don't even know. So. Yeah, it's it's baffling. And that it is a of a space based treatment that is not allowed and not really a good reason why it's not allowed. We don't really know. And one other question, I don't know if you ever work with any of the cases, child advocacy centers, and if they because I know they had when they did their forensic interviews, they had to find out what's actually happening to children. And they I'm sure they use different ways to find that out. Now, they're probably not dunning if they're seeking medicaid reimbursement for it. But but I'm sure that's something that they would probably use to actually reach their, their decision on whether that child is being abused or neglected in the home or sexually abused in the home. Yes, yes, I, I have not trained in forensic interviewing. I have not actually sat in on that. They're very protective about who can actually be in the room for those interviews. I have definitely requested those interviews for children. I have accompanied children to the facility and sat with them until they were ready to go back. And then when they come back out because they're scared, they don't, you know, they don't know what's happening. So I don't know the exact process that they use for those forensic interviews, but it would make sense that they would have to have some sort of a medium for the child to be able to express themselves. Okay. All right. Thank you. Thanks for being here. Thank you, I appreciate it. Appreciate it. Thank you, doctor mark. Yes. Thank you for making the arduous journey across. The state. I'm reminded a few years ago, Senator justin wayne brought a bill and it was against these map companies, doctor holt. And it was to say don't compress the picture of the united states of america because it makes the states in the middle. In other words, us approximately 25% skinnier, narrower than we really are. It's a long ways across the state, in other words, and hundreds of miles, 400 miles of pure joy. Yes, that's right, one way. Thank you for being here.
Thanks for having me. So good afternoon, chairperson hardin and fellow members. My name is doctor mark hald, markhald, and I'm a licensed psychologist and registered play therapist supervisor. And thank you, Senator fredrickson, for introducing this interim study. You have my written testimony, and I'm going to highlight some key points. You just heard about how dedicated clinicians across our state face audits and financial clawbacks simply for documenting the word play. Because play therapy is currently listed in the Nebraska medicaid regulations as a non allowable service, this administrative decision places psychotherapists across the state in a tough ethical dilemma. How do I effectively treat young children in the most developmentally appropriate, evidence based way? When my state medicaid regulations are dictating? No. My role today is to explain what play therapy is from a neurodevelopmental and clinical standpoint, and why penalizing it denies Nebraska children standard medical care. When people hear the word play, they think recess games are leisure. But in pediatric mental health, play therapy is an evidence based neurodevelopmental intervention ranging from low to high structure. Play is a fundamental developmental need for young children. It is their primary language for expression, communication and connection. Many of you have likely experienced a version of this simple question from a child. Papa, will you play with me? That is a profound invitation into a child's inner world in therapy. Accepting that invitation is how we build the safety required for healing. As developmental specialists like doctor tina payne, bryson and george wisner vincent illustrate in the way of play, a child's brain develops from the bottom up. The lower brain structures governing survival instincts, sensory regulation and threat responses are active from birth. The higher cortical brain, which manages abstract logical thought, articulate verbal reasoning and traditional talk therapy, takes over two decades to fully mature. When a young child experiences acute trauma, severe neglect or debilitating anxiety, you don't ask them tell me about your emotional distress. Their brains are literally not wired to process trauma through adult verbal models, expecting traditional talk therapy to heal early childhood trauma is like asking someone with a broken leg to run a marathon. This is also why therapies across the lifespan, even for adolescents and adults, frequently use expressive and experiential modalities to access nonverbal subcortical areas of the brain, expressing a safe pathway to process trauma through symbolic distancing in clinical play. Therapy room toys are the words play is their language and the clinician is their compassionate guide. I'm happy to speak to your questions. Kind of unpack some of the same things that I put poor janice through a little while ago. Give me give us your thoughts on where does. Clinical intentionality and time wasting and play begin? Not an easy thing to do, I realize, in terms of differentiating always, because the children don't respond exactly the way we want them to when we want them to. Ever.
And so where does the play begin? Where does the therapy begin? Are there differentiators? Kind of unpack that for us. From your experience. When a therapeutic relationship is established, children begin thinking about coming into the playroom before they get their. The moment they hit the door, they're ready to go. They. Will pick up many times right where they left off during the last session. That's why we always keep playrooms very orderly, so that they know exactly where they can find what they want. They will go back. They will set up the doll room, the playhouse. They will go back to the routines they were doing before and engage, and they will replay things until I can witness it in a way that helps them discharge what they're trying to tell me. And they they don't even often yet know what they're trying to tell me. I had a young boy, he was four when he started coming, and I did the history with his mother. And she had been brutalized by his father when he was birth to 18 to 24 months. That relationship ended. That man ended up in prison. But the boy was terrorized with her along that journey. And when I first started to work with him, he would come in and he did not really play. He destroyed my office. He started finding things, banging them together, dumping all of the different tubs of things. And I kept trying different ways of trying to understand what was happening. But what what I surmised was he showing me the chaos that he still lives with inside of him, and yet he did not have any words to do that. His mother struggled to help contain him. He had sleep problems. He had enuresis. He had speech articulation problems. He had social problems. He was very hyperactive, impulsive, and he had trouble just sitting still to attend and respond to any meaningful activities. After about 4 to 5 sessions of that, I had a better sense of trying to make sense of what was happening for him. And I. I was able to begin in the waiting area and and I told him, we're going to have a little more structure today. To help contain that process. Because it was so chaotic, he was showing me he needed more help than following the play. And it was in that moment, I believe, that he began to feel like, okay, this guy has my back and will be with me on that journey. And over the course of 18 months, I still saw a lot of that. But I also saw human figures fighting with each other. I saw animals fighting with each other. I saw places be on fire. I saw armies fighting and warring with no resolution to those things. But over time it began to calm down. His sleep improved.
He was doing better in the head start program that he was in, and if he didn't have somebody to go on that journey with him. So in that case, there was no casual play. There was no difference. His play was very much like that at home, too. He just didn't have anybody that could make sense of it to guide him. When children have a story to tell, they're telling it all the time until the adults in their life sit up, pay attention, and make sense of it. That's terrifying. It was terrifying to be in the room with him, to witness that and experience that vicariously. But it's very powerful. And play therapists are trained to do that. In your experience, while I'm guessing it's impossible to guess how long the therapy may go, and let's be honest, that's probably the part that insurance companies or medicaid providers, so on and so forth, are nervous about is paying for things. When, in your experience do you go, do you expect the child to really begin to engage? The process might be the first time, might not be till 5 or 6 times, then it might be more than that, I don't know, but can you kind of talk about your anticipation as a therapist? Age of child can give us a range of your expectations of I think this is we had a good day today and I'm looking forward to the next time. Kind of how does that work? Those those arcs of completion are very hard to predict. Okay. The more severe the trauma, the earlier the trauma, the more likely it will take a longer arc. What happens is they'll tell the story in their play. We begin to add verbal narrative to that. You heard janice talk about that. The little girl she was working with eventually was able to tell her verbal narrative. But your story is your story. So at age four, 50% of this life, this kid's life was sheer terror. So when he's ten, that will be reduced and he'll have many more positive experiences of that life. We see kids do pretty well. They'll stabilize and they'll stop. But it's predictable. They're going to need more therapy across the lifespan because as they reach different developmental stages, they go back and they reprocess those things in different ways with different developmental language, cognitive executive function capabilities. But we do that as adults too. When we have a significant death in our life, both across the lifespan. If I have a death when I'm young, I reprocess that death across my lifespan in different ways. And so there's a similar parallel to that. There. There's not a simple answer to say, okay, well, you have this course of therapy, you'll never need it again. The more severe it is, the more likely they're going to need that off and on throughout their life to make sense of that.
Some don't. Many do. You're highly experienced and you have a lot of integrity. And if you were hired by, say, an mco. To come in and help us out mark, where are we being taken advantage of? At what point might we be taken advantage of within a play therapy situation? How might you coach them? Is there a place? Is there a way? Is there an indicator that you would look for and say, I wish this person wasn't doing blank or doing it this way, because that that is not helping the child. It cheapens it. I mean, is there is there such a world, such a place? What are the what is that criteria? Trying to figure out how, how to, how to coax the department and the mcos into saying, you know what? Maybe we ought to join 33 other states and become the 34th. Senator fredrickson hasn't brought a bill yet, but I feel it imminent. So. Well, in in our field, we talk about scope of practice. I don't do things I'm not trained in, which is really hard in rural practice. And we have lots of people across the state who we we continue to have a mental health crisis for our youth and for our little ones. And rules like this discourage therapists from working with with young children. Number one, I know people who have done it. And because of the situations janice described, won't do it anymore. We have therapists in the sandhills who need to see therapists, see children, and they know they need to play, but they haven't had any formalized children yet, so they will play with kids, but they try to do talk therapy while they do it. Sometimes it works, sometimes it doesn't. Then you have that same therapist or therapist with a similar situation who will say, I gotta learn more about it, and they'll do a whole series of trainings, but they may not yet be a registered play therapist. Just like me. I've been trained in cognitive behavioral therapy, trauma focused cognitive behavioral therapy. I'm not certified in those models, but I use them all the time. We see that with play therapists, prokop therapists who are not a registered play therapist, but use their play therapy as a psychotherapy intervention. That doesn't mean they're not competent. But nobody's ever interviewed me in the past. I, I worked with kids as young as nine months. You know, I'm a I'm an infant mental health specialist. Early on, 25 years ago, the medical director would call me and say, what are you doing? Do you know what you were doing? She would interview me to make sure that I knew what I was doing in the room with the child. I haven't had that happen for 25 years. She wanted to know that I was in the appropriate scope of practice.
I can tell when a therapist shouldn't be working with children in about five minutes. And so should the experts, so to speak, within the department or within the world of m c, s b. Well, you'd hope so, but that's not my experience. Is there a world? And I get it. Fundamentally, play therapy is not one of the modalities that's allowed. And so that's fundamentally what we're trying to change. Have there been administrative balls that maybe could have been handled better by certain therapists? I'm asking you to speculate. I know janice would never do that and you would never do that. But is is it something where maybe there are some therapists who have not helped their cause, shall we say, by being too spotty with what they have reported and how? And has that created a. Culture that has made it easier for clawbacks to happen? And I don't don't mean just in this in this category, but I mean in general. I'm only saying that because I've heard some of that from the other side, shall we say. I mean, what is your experience been do we need to do a better job of helping our therapists? I guess is my question to be thorough in their reporting. Are are you asking if the documentation is shoddy? Yes. Has that has that has that helped, shall we say, the other side to have a meaningful argument? I, I don't know how to answer that. I have not reviewed anybody's documentation that's been audited. Senator quick. I've dominated all of the questions. What are yours? Yeah. Thank you, chairman and I. One of my questions. And then first, I'm going to preface it by saying, you know, I'm big on early intervention prevention. And the earlier we can help children with trauma or any type of issues they have within the home, the more likely they can have a really good outcome. And if we're not allowing play therapy, what do you think can happen to some of these? I mean, I see that we're they can grow up and end up being just like their parents or doing some of the same things that maybe their parents did. And I don't know if that's something that you want to address or talk about. Well, Nebraska does authorize child parent psychotherapy and parent child interaction therapy. Both are evidence based practices for children. I tp 0 to 0.05 cit is, I don't know, 3 to 12 or something like that. Both are play based. Right. And so that's the irony of this. It's we already have two evidence based practices that are play based between parent and child. And if you look at that study, I included in the written testimony, we know that the most powerful interventions are parents child interaction. Because if I don't change the dynamics of the relationship, I'm going to struggle to make change in the kid.
That said, there are children like the one I described, like the one that janice described. You have to do the individual work first sometimes to, to get that change. I lost my thread. What was tell me your question again. Well, it's more about the prevention side and early intervention, making sure we have good outcomes for kids and. Yes. And and so. Without intervention, these kids are more likely to have long term problems. Yes. Well. They have more inattention problems. They have more trouble controlling going, wow, that really upsets me. And also, just because we play doesn't mean we ever don't do other kinds of things in the flow of those things. But the younger the child, the more likely it is to be a lot of play too. We use stories. We we tell stories. We listen to their story and integrate those stories. This is similar to what Senator hart was getting at. But we we're doing it. We just document it different. And I talk about executive function skills, social skills, attending and responding, paying attention, the games we play. But I'd like to be an ethical therapist who documents what I do. Yeah, I'm really I think the most important part is that outcome for that child, you know, but then we also have to look at, you know, some people would look at it, you know, maybe we could we're spending this much money now, but look what it's going to cost us in the long run. That child might go through. It's going to have he or she could have problems in school. Yes. And then end up in the juvenile justice system or foster care or later on adult court. And I've seen hard studies on that. For every dollar we spend in early childhood, of which early childhood mental health is one of those, depending on the study, the return is anywhere from 3 to $9 per dollar across the life. But I think that's by age 20 in there someplace. So because we keep them out of prisons, they are more likely to succeed. They're better taxpayers moving forward with lots of different positive outcomes. And I know what therapies do. It's just like we have a son who's struggled with reading in school. So instead of him reading to himself and learning that way, my wife would read stories to him. And so every child learns differently. Yes. And it's the same with with therapy, right? I mean, every child would have different interactions with different types of therapies. Yes. I have another little girl I was thinking about. Her mother died and she was in the home. Her brother was in the home. They found her dead. And well, actually, dad took the they thought she was still sleeping. They took the kids to school and dad come home to find mom dead from a. It was a medication overdose and she was very verbal.
She would look at me and say, my mommy died. But then she couldn't do anything with that. So she still needed the doll house and would set up these scenarios of the. The man, this human man figure coming home and finding this lady on the couch. And so she was processing all of that trauma in the play. She needed that medium to be able to process it, then to create the verbal narrative of it. I truly believe she would not have been able to integrate that like she did. If somebody would have just said, well, tell me what that was like for you. She did just shut down because it would then become a different, more intrusive process that you can no longer create this appropriate social, psychological distance from. And it becomes externalized rather than this always churning inside, which is early intervention developmentally appropriate. Our head start teachers, our preschool, our home daycare people are saying these same things. What happens is we don't play like that. And so it gets shut down. You know, aggressive play is denied in children rather than somebody going, whoa, you seem really angry. Tell me what's going on. Right. It's a it's a we. We shot it down. Yeah, yeah. Thank you. Yeah. Appreciate you being here. Thanks. Thanks for listening. Absolutely. Yeah. We also we appreciate you coming and visiting with our group, you know, and listening to this. You've heard me babble about this before. I've noticed no babbling, but lots of meaningful stuff. So thanks. Jodi. Angel trejo. Welcome. Thank you. Thank you very much. Okay. Good afternoon, chairman and members of the health and human services Committee. My name is jodi angel trejo. Forgive me for getting that so wrong. Oh, well that's okay. It's nothing like it looks on paper, right? But jody on langel hyphen trejo. I'm a licensed independent therapist from kearney, Nebraska. I'm formally trained in adlerian play therapy back in 1999, and had the opportunity to be recognized as a play therapist starting in the early 2000 in the state of virginia. So I bring a bit of a unique perspective. Having been trained, went to school here in the area, then moved out of the era of this area, moved to virginia, worked as a play therapist, trained many clinicians in play therapy, and then moved back. So I do offer a unique perspective of this. During my time in virginia, I trained many clinicians in this modality as play therapy is recognized and has been reimbursable in the state of virginia for decades. When I moved back in 2011, found that play therapy was not a recognized modality, and since that time have actually avoided again, as johnson and mark have talked about using the term and contemplated use of play therapy despite its benefits. So currently I lead a practice of over ten clinicians in kearney, working primarily with children and adolescents.
I do serve on cacs. I train a local head start early head start programs and do trainings for esu. So working a lot with administrators, teachers, and other clinicians. My role today really is kind of highlighting the contradiction contradictory nature of the current regulations relating to play therapy and court orders. Currently, the courts have ordered and are ordering play therapy, child parent psychotherapy and pcit parent child interactive therapy. All modalities used to treat children. While each modality serves a role play, therapy in specific, is the one form of play that can access preverbal trauma in an individual setting with a child. This is crucial for court and dhhs mandated cases, specifically because those cases in which a child has experienced physical and or sexual abuse at the hand of an adult needs a private space with a trusted adult to be able to share that. The other two modalities discussed by myself and by doctor holt require that a parent or carer be present in which we're working on the dyadic modality, the dyadic interactions, to support that child's development development. When we think about a minute, I put some things together, but given our conversation, I'm going to talk a little bit other than what I'd written in relationship to that. When we think about children who have experienced sexual abuse, they're not going to want a parent present. If that parent was in fact involved in the complex trauma, right? So we might have parents, family members who are somehow connected to these individuals. It's incredibly difficult for children to talk about this process because, like mark said, it's so intrusive to say my dad or my uncle whom I love and have had really positive experiences with, has also hurt me. And so what happens is children become very inhibited. They internalize that emotion, and it starts to come out as anxiety or aggression or other forms of of behavioral presentation. So part of our role becomes how do we help them organize what's happened? Share that in a way other than verbal processing and move through that trauma. So, so the other behaviors start to subside. I see, I. I can't think of a delicate way of asking this. And so we're going to put it out there and we're going to talk about as though we are the, I don't know, let's let's pick on south dakota gandy let's say we were in the state of south dakota. Senator quick. And let's say that there were therapists in south dakota. And let's say that south dakota did not allow play therapy. I wonder if there would be therapists who were really doing play therapy, but they can't invoke that dirty four letter word play. I wonder if, in essence, they got to do it anyway and they just call it something else?
Doctor hall kind of intimated that a little while ago, but now that we've had that little discussion somewhere else. Is that part of what goes on across all of Nebraska? Because children are going to do what children are going to do. Sure, sure. They're going to. Play. Sure, sure. And in all people know, I own a child care center. I walk in and I watch them do what they do. You know what? You don't have to talk them into playing. You don't have to twist any arms in there. You don't have to incentivize it in some way. They do what they do. Birds fly, fish swim. Kids play. For sure. Yeah. And so what do you do with a troupe of ten therapists? What's it like? And they come to you and say, how do we do this? You know, I think I think what you're hearing today is, is let's train people aren't going to go to trainings though, or want to be trained if in fact it's not an approved modality. So what I've seen that differs from virginia and Nebraska is that it's, it's approved. So people are going to trainings, people are getting trained to be supervisors. And just like in child parent psychotherapy, which I'm also trained in, we go to a training that lasts for 3 to 5 days. I can't even recall at this point. And then we have ongoing supervision through zoom calls or telehealth with a trained provider that ensures that clinicians are providing evidence based practice that follows fidelity, because that's really what you all are talking about, is how do we know clinicians are following fidelity? Well, we have to train them to do that to train them in the state of Nebraska. I think we have to actually approve the modality. And I think that's that's helpful because we can stand in, you know, we can pass a law and shove it down someone's, you know, that's what we always do. We. That's the way it works. Our branch of the world government, we make laws. That's all we do. We don't enforce them. That's the executive branch's job. And so in a nutshell, I guess I'm just looking at this and saying, okay, how do we take that next step? Yes, I, I get it. We pass a law and that's within our purview to do that. But I'm also looking at it and saying, how do we protect against. Being taken advantage of? And I so I appreciate what you're saying. And as doctor holt said earlier, and janice said earlier as well. Yeah, any and all modalities can be done in a questionable way. And so it's about training. It's about accountability for the modality. And we have some we have some formats in that for child parent psychotherapy and other modalities that include play, but also include parents or a carer.
So we can take some of those and look at, you know, I wouldn't be the best one to to decide that. But looking at how do we make sure that there's formal process in training that ensures at least offers some guardrails for clinicians to ensure that we're not going off to the left of just following play? That's unstructured and unmeaningful. Okay. Yeah. Senator quick. Yeah. Thank you. Sherman do you know, I don't know if you know this or not, but like for like university system or state colleges for behavioral health, do they teach any of these type of, you know, all therapies for therapists or do you know? Sure. I would say in the state of Nebraska, I can't speak for uno. They may have a play therapy class. I know that you and kay does not. So unk has a clinical mental health program that does not offer play therapy. They do offer development across the lifespan. But really what happens is, is in my experience anyway, we we get our degree. That gives us the green light to to practice. Then we have to go for more training for play therapy, which is, you know, my basic training was 40 hours and then and then ongoing supervision beyond that. Okay. And you mentioned working like with the esu and with headstart. And when you talk to them, I mean, is it more about what they can recognize within a child who's playing and maybe being more aggressive or, or just sitting in the corner by themselves or whatever? Yeah, there's a really good question. So it depends on, on the population that I'm working with and who I'm training. So as a, as head start and early head start programs, I'm providing the mental health intervention. So I'll literally look at, as they're called, ask, which are ages and stages questionnaires. And so those are these basic screening tools that they utilize to look at, is this child at risk or are they showing. Behaviors that would say this child is at risk or in need of referral for other services? So part of my role becomes training teachers. What do you do to support the regulation of that? And oftentimes it can be through the process of play, or it can be through positive behavioral interventions, but then also helping them make referrals to other, other organizations, edu, other other agencies. So sometimes it's training. And then sometimes, like with esu, I'm working with other clinicians on how do we work with children at this capacity? How do we help them process through trauma? And there really are stages to play therapy. There's there's some formal process and there's all different types of play therapy, but definitely important that our clinicians are trained to some capacity, in my opinion. Okay. All right. Thank you. Yeah. Thanks for being here. Yes. Thank you all very much. Appreciate it. I appreciate the consideration.
Someone named sarah howard. Thank you. How are you? Well, how. Are you? Well, good. Thanks for having me. Absolutely. Chairman hardin and members of the health and human services Committee. Thank you for allowing me to testify today. My name is sarah howard, spelled sarahoward. I'm a policy advisor at first. Nebraska first five Nebraska is a statewide public policy organization focused on promoting quality early care and learning opportunities for Nebraska's youngest children. My position at first five is focused on the area of maternal and infant health policy, because we know that healthy moms and babies are critical to ensuring the long term success of children in our state. I'm here to testify regarding LR 382, and I want to thank Senator frederickson for his attention to this issue. I will tell you, I walked into this play therapy. I know I always have to, like, breathe after I give my first paragraph. I walked into this conversation about a year ago trying to figure out what the problem was. At first I thought it was a credentialing issue. Some of you might remember that jodi albrecht had passed a bill related to art therapy. Right? And I was like, is there not a credential? But it turns out there is a credential. And then I said, well, are they not billing correctly? And it turns out everybody's billing correctly. But what's happening is when they document that the service, a part of the service was clay, then the managed care companies will come back and claw it back based on the regs saying that you can't. Bill clay. So the challenge here is, is layered, right? Janice has paid back over 30, 000 30, $30,000 for one small provider in glenvil, Nebraska. That is an enormous amount of money when we're talking about the entirety of the state being considered a medically underserved area for mental health, particularly for children. But I recognize, Senator hardin, your challenge of how do we make sure that we're not being taken advantage of by these therapists, with this particular service being provided? And I think it was articulated very well. How do we know that talk therapy isn't just having a chat? Right. And that goes back to the way that we credential licensed mental health practitioners and licensed independent mental health practitioners. So if there is one who is acting outside of their scope offering play therapy inappropriately or just playing that family, that child and dhhs has the opportunity to go after their license, they can lose their license, and they would not be able to offer this service or any service in the state of Nebraska if they chose to act outside of their scope. And so to me, that is the guardrail that we're thinking of when we think of how do we make sure that dhhs is not being taken advantage of?
At the same time, I will say dhhs clearly is is a siloed organization that we have all recognized some of those challenges, challenges, and the division of children and family services is recommending play therapy for the wards of the state. And so to have medicaid, who is the main payer for most of the wards of our state, not pay for a service that that another division is recommending feels like the two halves of the whole are not talking to one another in order to do what's in the best interest of children. And I know that that is the goal of this Committee. That is the most important part of of the work of children and family services, but also the work of play therapists. And I have hit my light and I appreciate your speediness. I'm happy to. Share your thoughts. You know, the last, the last things I'll mention 33 other states make it super easy to build play therapy. And the other thing is, if a bill were to come, I would wonder. I would have a curiosity whether or not this bill has a fiscal note, because as you can tell, the therapy is already being billed under the general therapeutic code. It's just when you document that play was a part of it. So there wouldn't be, in my view, any type of cost to this because the service is already being billed. It's that clawback that we want to prevent for the providers. Still with me? Okay, epst was mentioned epst is early periodic screening and diagnostic testing for children. It's a federal law. It says that if a provider says that it is medically necessary for a child to receive a service, and the service is available in that state, then the state must cover it. So for us to have a specific exclusion on a therapy that is supportive for children under epsdt is actually not allowed. And so at any point, a child could take standing and sue under epsdt. So I think having this exclusion specifically opens us up to some liability as a state for an eligible child who was eligible for that service to be able to file suit against the state. Those are my best arguments. Thank you for your time. Those are good arguments. Thank you. I appreciate. That last one. It's never handy to be well sued. No, no. And I think, you know, particularly with with the state who do not have the the type of legal support that you would want for them, but those are the ones who are being impacted the most by this exclusion. Okay. General. Quick. No, I think she did a great job. Thank you. It's almost as though she's sat here before. Yeah. Okay. Thanks for being here. Thank you so much. Thank you for your time and attention. Thank you for your role.
Senator fredrickson, do you have any other thoughts you would like to add? Yes. Well, thank you to the Committee. Thanks. I also just wanted to take a quick moment to thank all the testifiers who took the time to be here today. I know folks traveled far distance to share their experience and their expertise. I think a lot of the key points were hit pretty well. We just want to highlight quickly, you know, play therapy. I think it's one of those things where oftentimes there can be it can be misunderstood sometimes about the therapeutic value. And I think the testifiers did a great job of highlighting for the population that this is targeted for how this can also be a, an effective tool, not just for the well-being of the child and the well-being of their development, but also in the cases that were outlined. I mean, the ability for law enforcement to be able to identify perpetrators behind. There was the case of the the sex trafficking that was that was mentioned, that was able to be really identified through through the through this modality. So I think that that's something for us to keep in mind as a Committee, not just for the well-being of the kids, but also for the tools that law enforcement need to be able to do their jobs effectively as well. So happy to take any questions from the Committee. We are speechless. Okay. Rarely does that happen, but I appreciate it. Thank you. Thanks. This concludes LR 382. We're going to move on to LR 383. And just a little bit. Hello. How are you? How's it going? Good. You had a good summer. Astonishingly busy. Yeah. Which is. Not a very good thing to do. Yeah. Yeah. How about you? It was okay. I had some family transition, so it's been kind of a hard summer. And. Yeah, so my husband and I both lost our grandmas within weeks of each other. So sorry. So. Yeah, but I'm here, so. Oh, dear. Are they local? His grandma was not. She was in wichita falls, texas. And then my grandma was. Yeah, I was her caregiver actually. So I was paying attention to Senator bostar hearing and his lr because she was in skilled nursing. And then I did home hospice for her actually. So yeah. Oh goodness. Yeah. That's yeah. But we're here now. So. Thank you. Senator. Hi. I'm doing okay. I have to go meet someone real quick so. You'll miss all the good stuff. But it's fine. John, if you can take it over, I'll be right back. Okay? Yes. Of course. Thanks. We're just starting. Yeah. Okay. We're waiting for you. Senator spivey, you are welcome to open on LR 383. Thank you, vice chair fredrickson and members strong, one member of the health and human services Committee for the opportunity to speak today.
I am ashley spivey, a shleisp as in paul, I v as in victor e y. And I am proud to represent legislative district 13 in northeast and northwest omaha. So today I am introducing LR 383, which examines maternal or perinatal mental health in Nebraska through three core themes data assessment around quantifying the true prevalence of prenatal and postpartum mood disorders among Nebraska residents. To understand the scale of the issue, infrastructure and evaluation, auditing existing health care networks, insurance structures, and community resources to identify critical gaps in accessibility and care delivery. And then lastly, strategic policy development, generating evidence based recommendations and statutory frameworks to guide future state legislation. So you all have a packet of information in front of you that has my lr. It has some one pages of data because we get a lot to consume. So hopefully the visuals are easier. It has an overview just around perinatal mental health as well as again, some other kind of key takeaways. So hopefully as the testifiers go, you'll be able to follow along. So we have an intentionally curated for expert testifiers that can speak to first the data and landscape in Nebraska on perinatal mental health. Our next testifier will speak to maternal health in general, and it being a key priority within the maternal mental health landscape. What practitioners are seeing firsthand as a serve mom. So we have an actual practitioner here. And then as well as sara howard again, to come and speak to some policy recommendations and starting points for us to consider. So my ask is really that the Committee makes a commitment to work alongside my office, as well as other ecosystem partners, to put together a a maternal health package that includes maternal mental health as a priority. We talked a lot last year about a momnibus. I know people have a little bit of angst when they hear that word again. However, I am looking across the ecosystem and industry to say what is a comprehensive package to address some of the complexities and intersecting work that is in front of us through policy. So when preparing for this hearing, I was really debating on what I should speak to. So one, I don't steal the thunder of all of the testifiers, but can really engage each of you on this important opportunity. So I've decided to take a moment to humanize this conversation. And, and really the data points that you will hear. So I have a 12 year old and a three year old, and I often speak about them on the mic. And I think as I've been reflecting on my experience being a mom in my in a parent that with my 12 year old, I think I had postpartum depression anxiety, but I was in survival mode. So I'm not quite sure. It's hard to kind of put in context those experiences.
So long ago, I had to go back to work when he was only seven weeks, I was guardian to my youngest sister. So I was a new parent to a teenager and then a newborn. And then my grandmother really stepped in to care for him. And so I was not with him most of the time because I had to work and provide. But with my second son, that experience was a little bit more different. I'm older, more stable, and I have the honor of really working in the field of maternal and child health. And so I felt like I was really in tune to what I needed to be successful in my pregnancy and postpartum, just as myself as a mom versus trying to work on behalf of other moms. But that was absolutely not the case. I found myself in a very dark place and I was not sure how I I got there or really how to get myself out. And so the reason that I can sit in front of you today and have this conversation and serve the amazing people of district 13 and be alive, is because I sent a text to my good friend because I scared myself. I could not communicate to my husband. I could not communicate to my ob, who I think is one of the best practitioners in the state, but rather a friend that I only knew for a short period of time. I reached out to her to help me because I didn't know where else to go. So eight months after the birth of my son, my youngest son, I posted on social media to share what I was sitting with because I felt like I could not just be alone. I recognize the privilege and position and access that I have, and yet I was still in a place that I did not understand and again, navigate how to get out of. And so I hope that by posting on social, a lot of people connect through social media. Now that my experience in being very vulnerable would make another mom or family really feel seen and not alone. And so from that, I want to read a couple of the responses that were on this post that had over 140 comments. So this is december 12th, 2022, eight weeks postpartum. This is me bringing my second son into this world has been a whirlwind. It feels as if moms, we have to pretend being a mom is all rainbows and unicorns, and if we don't, we don't deserve motherhood. Well, my truth is that it's hard and I have struggled. I hope this post affirms another mom navigating all the things. Postpartum depression and anxiety are real. I couldn't bring myself to even say the words because it would mean I was a failure. I failed my sons and my family.
Hormone changes, physically healing, sleep exhaustion, and wanting to take care of my family created the perfect breeding ground for ppd for postpartum depression and anxiety to take over. I felt guilty. Why did I bring another beautiful soul into this world? And I can't even keep my stuff together. Basic things like texting, phone calls, checking, email, showering all overwhelming. I was paralyzed with fear and isolated myself. However, I am thankful for my village, for lifting me up, making sure I didn't sink. And not everyone has a chosen family who would move the moon for you. I am grateful to my partner for loving me through this time, for being by my side however I needed, even though I couldn't articulate what I needed. I share this to say birthing a baby is hard and motherhood is even harder. So please give yourself grace. It's okay not to be okay. Find your support system and lean on them. Your feelings are valid. Take it moment by moment. So from that text, a couple of the responses that I want to highlight include. We're in the trenches. It's so hard. No one tells you. No one speaks about it, so am I. You are too. It takes a village. You articulated this so well in your transparency is appreciated. It's okay not to be okay. And grace for all the space in between. Going from 1 to 2 is quite overwhelming, but taking it moment by moment with grace is key. It is so real, and we have to continue to share these moments with each other. Thanks for being vulnerable and honest. It's really common and has nothing to do with your work as a mother and person. Thank you, thank you, thank you. You are not alone. And now we know none of us are. This stuff is hard. I didn't even know anxiety was a thing. After my second baby, I only had. I only had heard people talk about postpartum depression, so I couldn't even articulate that I had anxiety. I experienced what you are going through. It does get better one day at a time. Thank you for your honesty and normalizing that this is hard. I couldn't put my finger on why I was so sad and sometimes inconsolable after I had my eldest daughter. I felt alone and certainly didn't feel empowered to say how hard things were. I don't remember my doctors talking about it, and I struggled to find the. I struggle to try to fit the perfect mom. I got this mood. I also experienced ppd and anxiety after both pregnancies and. What worked for me was therapy and sleep. This was me. Thank you for sharing this. It hit home when I had my youngest daughter. It was right in the thick of covid.
I was so paranoid of getting her, of her getting it that if you weren't immediate family members, you weren't seeing her or me. My partner was working nights, so it was just an overwhelming, exhausting experience. Being a brand new mom along with was terrifying, but then adding all the changes our bodies are going through and wanting to make sure baby is good while we mamas are just maintaining my ppd. A was and is all around feeding, making enough milk, having the right formula because she had reactions, feeding her the right foods, pressure to have family meal time versus getting her fed. The list goes on. Absolutely real. And honestly, it took me having my last and fourth child to admit such. I used to think some were just not as strong, but it can happen to even the strongest. I'm crying because this is also relatable. I can relate to this message when I was pregnant and even still, as my children are much older now, we have the responsibility and opportunity through policy to truly create supports that prioritize the well-being of moms, babies, and communities. I thank you for your time and engagement, and I'm happy to answer any of the questions that the Committee may have. Thank you. Questions? Will you remain absolutely. Chair. Great. Awesome. Kelly nielsen. Welcome. Hello. Thank you for your time. Chair hardin and members of the health and human services Committee. My name is kelly nielsen, kellynielsen. So I'm here to share more about what the data tells us about this issue for our moms, children, families, and communities here in Nebraska. I've worked in Nebraska and health care and public health for over 20 years. The findings I'm sharing today come from a landscape assessment I completed as part of my doctoral studies with first five Nebraska. But I am here representing myself. The most important message about maternal mental health in Nebraska is that it's common, treatable, and when not treated, it's leading to preventable harm for our families. Across each stage of pregnancy, women are impacted. 1 in 5 Nebraska women, so 20% report depression within the first three months before pregnancy. This is important because it impacts their risk of worsening mental health conditions, as well as the health of themselves and their baby and their family. 1 in 6 experience depression during pregnancy. Nebraska hospital association data show that approximately 3750 deliveries each year, so about 15% of births are to women with a behavioral health diagnosis. And that number is almost certainly low. 1 in 4 Nebraska women report needing mental health services within the year after birth. And importantly, 30% of those women report that they cannot get the help that they need. These rates tend to be worse than the united states and overall are increasing. It is a statewide issue. Rural Nebraska carries carries a heavier share.
Rural women report higher rates of depression before, during and after pregnancy than women in urban areas. At the same time, more than half of Nebraska counties are maternity care deserts and more than 1 million Nebraska lewiston in designated mental health professional shortage area. The combination of a lack of maternal health care and mental health care is a combined risk factor for our families. Coverage matters to depression during pregnancy is nearly twice as high among women with medicaid in our state, compared to women with private insurance. Medicaid covers close to 40% of pregnant and postpartum women in this state, highlighting the importance of ensuring access to care for this population. Rates differ sharply across communities as well. For example, postpartum depressive symptoms are nearly double for women from minority populations, specifically black and native american populations compared to our state overall. When untreated, mental health has significant impacts on a wide range of family and community priorities, birth outcomes, infant and child development, family stability, health care costs. Studies show untreated maternal mental health costs approximately 32,000 per mother child pair, and that is due to increased health care costs, missed work, reduced economic productivity. It impacts children development. I'm going to skip some of this because I'm going to run out of time, and I want to hit a couple more really important points. So a lot of impacts, also a lot of potential severe consequences. So our own maternal mortality review Committee in Nebraska found that mental health conditions were the underlying cause of 15% of pregnancy associated deaths and the second leading cause of maternal deaths in our state. But importantly, every single one of those was preventable. So I hope you take away the issue that maternal mental health is common, treatable, preventable, and we have tremendous opportunity to do better for our families in Nebraska. There's a lot of information in the full report. I hand it out an executive summary of that report with my materials. And then there's also a data visual in the materials that Senator spivey shared. So I appreciate the time and happy to answer any questions. Thank you. So I'm. Not surprised things are more challenging in rural areas than urban areas. Why is the us worse than other places? Nebraska is worse than the us was my comment. Yeah, Nebraska is doing worse than the us. Yeah. Okay. Gotcha. Yeah. Senator fredrickson. Thank you chair. Thank you for for being here, for taking the time to testify. So you mentioned kind of some of the work that you've done and the research you've done in this area. The one question I have. So sometimes, obviously with mental health data, sometimes it can be difficult to track just based on oftentimes we are under collecting because of the lack of self-reporting, for example. With your research is this how do you come up with the. All.
The data, all the data for this self-report is this sort of medical records? I mean, help us understand. Yeah, absolutely. So several different sources. I did work with Nebraska hospital association. So they were able to give us their data, which is based on claims. So that's where I shared the number of deliveries that are to women with behavioral health diagnoses. There's some additional data from the hospital association in the report as well. We also have a data surveillance system called the perinatal. I'm gonna get the acronym right. It's prams. I'm going to get the acronym wrong. It's in the report. So I'm not going to try. But that is a telephone based survey that goes out from the department of health and human services that that essentially interviews women about their experience after birth. And that's an evidence based tool. It's managed through the centers for disease control. So it also worked with dhhs to get access to that data to do some of the analysis. So those were really the main two sources. I also did stakeholder interviews. So I interviewed 12 in the report. So some of the themes around access to care, stigma around accessing services and reporting needs, etc. Siloed systems of care. That's all in the report as well. So it really was a mix of information that we put together in the report. Thank you. Senator quigg. Thank you, chairman. And I don't know if you can answer this, but, you know, even, you know, having enough providers, but even the, you know, students coming out of university system or the state college system, I don't know if you would know how many students are actually would, would work in that area or is it just a variety of different therapists or is there a specific therapist? It's a great question. So one of the things that came out through this work is it is very difficult to track providers that have specialty training in maternal mental health. There is a certification through postpartum support international to be a perinatal perinatal mental health practitioner. And so I don't remember the number off the top of my head. It is in the report of the number. It's something like 55. It's it's a relatively small number of these trained individuals in our state. So there is an opportunity to formally train therapists in this, but also just more broadly support the workforce that's treating pregnant and postpartum women to be able to have these conversations, to be able to understand and identify the need to make referrals and overall strengthen the whole system. So we need more specialty trained therapists, but we also just need more better support the broader workforce, if that makes sense. Okay, okay. I know my wife well, my wife's, she's labor and delivery nurse for 44 years.
So, and I know she from time to time they would, you know, someone would come through having a baby. And I think they would recognize maybe there was some other issues going on. And they would I think they would try to address that by getting them to the resources they needed. But it's a lot of times it's after the fact, too, that they've left the hospital and gone home, that it's happening. And. I know they go in for their doctor's visits, but they're not there very long for, for a doctor's visit. So maybe it doesn't recognize them. I don't know, unless women figure it out themselves or a family member. I don't know how else they get the help they need. Yeah, there's a there is a lot of opportunity, and I know sarah will speak to several of the policy opportunities that we identified in this study that I think could support a lot of what that experience has been. Okay. All right. Thank you. You said preventable and treatable. Would you use really small words and go ahead and help us understand maybe courses of treatment or that type of thing that would fall into that, which is here's prevention and here's treatment. I am not a clinical provider, so I would not be qualified to answer those questions. But what I can share is the earlier we identify folks and help them get into services, and there's a wide range of what that could be. And again, I'll let others speak to that. That can be community based services, clinical services, hospital services. But we know that the earlier we can identify needs and get folks to whatever the right services for them, the better the outcomes are going to be. We're going to we're going to lessen the impact of the condition, we're going to lessen the healthcare costs. We're going to reduce the burden on the family, on the health system, etc. The earlier that we can help folks. Okay. Yeah. Any other questions? Thanks for being here. My pleasure. Appreciate it. Lee cook. Welcome. Thank you. All right, all right. Good afternoon, chair and members. Of the health and human services Committee. My name is lee cook. Leighcook. And I'm a psychiatric mental health. Nurse practitioner and co-director of the reproductive. Psychiatry program at Nebraska medicine in omaha, Nebraska. This is my first time testifying. I have been invited to provide my input and expertise regarding maternal mental health as part of LR 383. Thank you, Senator spivey, for bringing it forward. My program treats pregnant and postpartum women with mental health concerns. Many cases involve depression and anxiety, but we also treat conditions such as obsessive compulsive disorder, bipolar disorder, and postpartum psychosis, which can escalate in a matter of days and is a true emergency. There is no profile for a typical patient because perinatal mental illness spares no woman, they are 16.
There are 43 first pregnancy and fifth every race and every income level. It's your neighbor and your constituent. Here's a case we see often a woman screens positive at her six week postpartum visit with her obstetrician, and that will be appropriately refers her for psychiatric treatment. But the wait to be seen is often 8 to 10 weeks. During that time, she is back at work, not sleeping and certain she is failing her baby. Some of these women reach an emergency room before they ever reach our outpatient clinic. At that time, when the appointment finally comes up, she has to reschedule because she's already spent every hour of leave she had on pregnancy and the crisis that happened while she waited. By then, finances are a concern, and the stress is worsening her relationships and her ability to parent. She eventually improves with treatment, but she and her family never get that time back. Untreated maternal mental illness does not stay with the mother. It changes how an infant is fed, held and spoken to, affecting child development and increasing costs to the state and its citizens. We have very little to offer a woman who is too sick for routine outpatient visit, but not sick enough for hospitalization when hospitalization is needed. Nebraska has no mother baby psychiatric unit, so treating her means separating her from her baby during that vulnerable time. I support universal home visiting and standardized screening, but a screening score is not a diagnosis, and identifying more women without expanding the capacity to treat them will not change outcomes. An option for you that could change access fastest is a statewide perinatal psychiatry access line, where any provider in Nebraska can get same day expert guidance in treating these concerns. That model is already operating successfully in nearly 30 other states. Also, helpful provider training with clinical decision support and a cross-sector commission with real administrative support behind it, of which you will hear about in the upcoming presentation. Thank you for your time. I'm happy to answer your questions. Thank you. Senator fredrickson. Thank you, chairman. Thank you for for being here and for taking the time to testify and share your expertise. So you kind of highlighted this. I mean, obviously, this is a wide reaching concern. There's knows no age, no pregnancy, no, you know, there's it can happen anywhere. Yeah. There seems to me that. Sometimes it can feel like it's like, it can feel a bit overwhelming. Like how do you tackle a concern that we feel like we have minimal response for? So you mentioned a couple of things like the universal home visitation or screening process. What would you say would be if you had to identify like maybe 1 to 3 priority areas, like if the state were to do something about this, what would you say would be most effective? I think the access line would be incredibly helpful.
I am a nurse practitioner. And so my primary role in treatment is the evaluation and then treatment primarily with medication treatment. And so I see a lot of ob providers in the omaha area are they've worked so hard to get more comfortable with addressing these concerns, but it is not their specialty. And so having that additional support from us who are trained in this, I think, would be very helpful so that we can address more women appropriately without adding more providers necessarily, because they are few and far between at this point. So that's one in particular. So so other states, I'm sorry to interrupt, but you said like the access line would be a kind of like a hotline. A consultation line where. Yeah. And it is intended for providers who are typically prescribing medication and they can get specific consultation on the most appropriate medications or evaluation to be doing with a patient when there are concerns that it's not a very clear clinical picture, there is also ability for us to be directly involved. Then, if needed, after that initial consultation. And who steps those lines? In other states. Reproductive psychiatrists and providers as myself? Yeah. Okay. Thank you. Senator quick. Thank you, chairman. And I know we have like a and I don't remember the number for that mental health line currently, but can that be added to that somehow. The bridges to mental health, I assume you mean. Yes. So that is a great resource that is intended to just be used educationally. And so the difference there would be the consultation versus education. I think it's a great option. I will be honest with you that not very many providers are aware of its existence. So I'm not sure it's being utilized as well as it could be. And I think part of an access line that would be very helpful is our showing our faces and knowing these individuals. The other thing about the line that's in existence already is that it's not necessarily Nebraska providers. And so my hope would be that by having us as providers here in Nebraska, that we know the population, we know the geography, we know that these providers know us because we've had that face to face interaction. And so I think that can help to increase the utilization of it. But I do think there are things that we could probably work with them if they were open to that. Yes. Thank you. Yeah. Other states that do this better than us, and if so, who are they? I mean. I lived in Nebraska my whole life, so I think Nebraska is amazing. But there are states that have made advances in this. Massachusetts is one in particular. North carolina also has made advances in this. There are states surrounding us that do have access lines and have more administrative support or collaboration amongst public entities to help support.
What sticks out. To you about massachusetts and north carolina? Are they doing the line or are they? Yes, they are. Doing the line. The line. They are doing the line, but they also offer different levels of care for women besides just outpatient, as we do here in Nebraska. Okay, great. Any other questions? Thanks for being here. Thank you. Doctor sarosh rana. Welcome. Thank you. Good afternoon, chair and members of the Committee. My name is sara. So this is saroshrena. I'm the chair of obstetrics and gynecology at unmc Nebraska medicine, and a maternal fetal medicine specialist. And I created this program called embrace Nebraska. I've been only been in the state for exactly one year and one month. I came here in august of 2025. So I care for some of the sickest pregnant and postpartum women. Embrace is a state wide program, which we kind of created to improve maternal health for all nebraskans. It offers a standardized and not to overwhelm anybody, but about a ten component menu for all engaged sites. And currently we have about 17 engaged sites. We offer postpartum blood pressure monitoring. The program called stand hypertension, which I created when I was in chicago. It's entirely based on telehealth and kind of a closed loop system for monitoring blood pressures for six weeks. Postpartum use of angiogenic biomarkers, which are these blood tests that I was actually part of developing these and getting the fda approval to stratify patients who have hypertension, who will potentially get sick and perhaps use that information for managing patients better offering programs, mfm, telehealth, because the distance is a big problem, the average number of distance that the miles that people have to travel is one of the largest in united states to access mfm care and providing mfm counsels through telehealth and remote ultrasound reading, preparing things like simply a monthly mfm on call calendar, nursing education. We are actually quite heavy in simulation. There is no standardized simulation actually across the state, so we are going to do that even for ultrasound, trying to create a maternal transport. Nebraska does not have a maternal transport service and creating some innovative projects, such as. We are working with ge to actually improve ultrasound scanning across the state. It'll be surprising for you guys to know that about more than 50% of the babies are born here with major congenital heart disease, which are not picked up in ultrasound. And these babies may require intervention just soon after birth. And also, obviously we are big into site visits. So you can see our map, a little diagram here of who we are. So we have kind of big major pillars, which is really partnering with health systems, community engagement, program assessment and education. So I want to give a message. I know my light is yellow.
So I'm going to talk a little bit fast is my message today is like maternal mental health is not really separate from maternal health. It is really one big part of maternal health. And I would say three things. One, we actually know who is at risk. So one of the programs I'm trying to develop here is called bloom. And it is really based on my blood pressure programs. It's surprising to know that 52% of patients who have hypertension also have a history of depression, anxiety, or ptsd. And women who have preeclampsia are four times more chance because obviously they are sick. The baby is going to be in the nicu. So if we see a patient with hypertension, like I'm a big hypertension expert, I'm actually treating only half of her because she also has other conditions that are not even paying attention to. The other thing that I noticed about Nebraska and I practiced in massachusetts, I was in bosn for about 12 years. It's we have nowhere to send these patients, so even I can send her. So a lot of hospitals are closing. You will. 52% of our counties are maternity health care deserts, and 88 of the 93 counties have a behavioral health workforce shortage. So there's nobody here. So mother can drive for about two hours to deliver. But in that entire time period, nobody will ever find her depression. Nobody will ever treat her depression. And some of the rural counties, the postpartum depression can affect as many as 1 in 3. So 33% of the patients. And third, I think there are solutions to it. So, for example, we have built pathways. The stamp hypertension program that I built is running like across 20 different states, variety of health systems. We started that in Nebraska. Since I came here and in Nebraska medicine, we have enrolled over 200 patients. We have 99% of the patients leaving the hospital with a visit scheduled before they leave. And more than 90% of the patients have their blood pressure control at six weeks. So we can think of programs that will actually be practically implemented if we actually want to do that. So, for example, this blood pressure, the mental health program is very much based exactly on that. We're going to hire our own therapist who's going to do telehealth consultations with our patients and then escalate care. So I do agree, like having somewhere with the therapist can actually call up to a psychologist and a psychiatrist will be really great. So I think this model can reach rural Nebraska. One of my goals is put this blood pressure program is as many hospitals as possible and access to biomarkers for everybody. So hopefully if the pilot works for bloom, we will be happy to enroll it out to all our other sites. And also, I think services should be reimbursable through medicaid and private insurance.
So my request is that we should support policies that make maternal health and maternal mental health screening timely treatment, a standard of care. So we should really stand up and say, and by the way, the maternal mortality, mother's dying in Nebraska is so high, it's much, much higher than all our surrounding states, about 35 per 100,000. And I agree majority of these deaths are hypertension is one of the common killers are preventable. So you adequately screen them, you diagnose them, you treat them. This will not have an impact on them. And I personally feel they should not be like, I should not be running around finding funding. They should not be a pilot. They should also be. I feel like a mother's zip code should not really define whether we will actually treat her this way or that way. Okay, you're far away somewhere. Sorry, you have no resources. I can't really help you. That is all I have and I'm happy to share more information about embrace. Would love to come back and talk to you about that. Any of the other programs, blood pressure program or the mental health program? Thank you very much. Thank you. Senator fredrickson. Thank you. Thank you for for being here and for your your testimony. You you mentioned towards the end something about like kind of zip code determining outcomes. And that's something we think about a lot. And we talk in here a lot about obviously urban, rural, kind of the disconnect that can occur with health care access. And I'm just kind of curious. So I know you've only been here for a year or so, but, but in your year here, what have you been able to identify? Are there specific barriers that you're seeing from those kind of bridging, like the urban and rural areas for access or? Yeah, so we have actually talked to a lot of people since I've been here, like literally more than 500 zoom calls with people. So access to care is a barrier in Nebraska, but access to quality care is a bigger barrier. So access to care is I'm going to find you a doctor, but turns out a lot of people don't even have access to ob doctors. So it's the family medicine. So we're actually working on a program to have a family medicine, ob fellowship, because a lot of these family medicine folks are not even trained to do what they are required to do. The other thing we also found, and again, there's so many layers of it. The other thing we also found was that. So that's why when we talk about. So if you talk about a thing like transport. So we went and asked these sites and there's a map there. We went and asked these sites and like, how do you transport? Like, so if you get a mom who's sick, like, what's your immediate steps?
People told us, well, sometimes I'm the only person and I'm also the editor. So then if I'm arranging this transport, which can take many, many hours because you have to call your local ems, turns out sometimes the local ems is staffed by voluntary people. And I literally talk to animals, people, and I won't tell you where they were. And I was like, what do you do if you have a pregnant woman who's like actively laboring? Like, what kind of skills do you have? And they say, oh, doctor, we try to strap their her legs so she doesn't deliver. I'm like, wow. So there is like a lack of it's everywhere. So then we're like, okay, what if we tell you that there is a phone that you can call at Nebraska medicine and we will arrange the transport for you so you can go back to clinical care. You don't have to be on the phone trying to figure out who's going to come pick up your mom. And one of the things I noticed here, and I take call very frequently, I'm like a clinician, I do clinic, I scan patients all day long. I when I'm on service, I'm like, wow. So I asked the doctor, whenever a transfer comes in, I'm like, how long did it take you? And it can be hours, eight hours, nine hours. So obviously, like some of the things are very practical that we never even escalate to the level of, you know, you guys to say, okay, what is the policy? Nothing. We just need to create very, very robust and closed loop pathways. And it goes for your mental health. It goes for. So for an example, if a mother has hypertension and she comes and delivers, guess what are the chances that a somebody will talk to her about her hypertension? B tell her she's at risk for postpartum hypertension. Majority of deaths from hypertension actually do occur postpartum. Tell her you're at risk for heart failure. You know, tell her this is the phone number that you can call in emergency. Give her an appointment before she leaves 30% nationwide. So and that is here too. So like, so that's why I got into this path is like, we have the knowledge. So no new knowledge needs to be created here. Nobody needs to find a new drug to treat preeclampsia, which by the way, I work on that too. But that doesn't need to happen here. We need to hand a blood pressure cuff to each patient and say, measure your blood pressure. And if it's high, this is the number you call. So I think it's like the problem in the state is not so much knowledge. There is some gap of knowledge too. But just like there are just no pathways, it is really left to individual providers to fend for themselves and figure it out.
And, you know, we are equally responsible for that as a big health institution to not do this for, for, for, for a state. Thank you. Sorry. Long answer for your question. Thank you. Tell me a little bit more about your stamp program. You said it remotely monitors. Yes. Postpartum. Yes. So it is a patient centered program. So I have actually figured about it. So if the patient is in the middle it has multiple components. One is provider education. So we have everybody do this you know annual course. And we teach people that preeclampsia does not end with your delivery. So that's like provider education. Then we have patient education. We have each patient watch a video about postpartum hypertension. What are the perils of having preeclampsia in the first place? And again, I literally wrote the textbook. The knowledge is you have preeclampsia of hypertension. You get delivered. You you are good to go. No, patients with preeclampsia have higher risk to have heart disease ten years later in life, as much as cigarette smoking, two two fold increase. So provider education, patient education. Then we actually hired a nurse navigator who goes. So we take a list of all the patients who delivered with hypertension. It's in there. You know you can look it in the epic. This nurse navigator goes one on one, has a bag, tells the patient about postpartum hypertension, gives her a blood pressure cuff, enrolls her in a remote patient monitoring program. It's an app very simple. They download on their on their phone. And through that app, they're connected to epic. And then all they have to do is to check their blood pressures twice a day. That's what we tell them to do. It's closed loop. So there is a cloud based service that we can hire who are nurses sitting around. And there are we have to develop these workflows so it beeps anytime in the system. Anybody has severe hypertension and their protocol is if you get this beep, you call the patient within ten minutes and say you recorded severe hypertension, what's going on? And then downstream, they're going to call us and say this patient recorded severe hypertension. What should I do? Send it to the hospital. What what else. Part of the program. We're also making an appointment for them before they leave the hospital. I mean, when I developed this program, like how, how, like, how important is that turns out very important. A young mom is not going to go home and call. This was a chicago university of chicago call line again and say, hello, I got discharged yesterday. Can you make an appointment for me in two days? The other problem was these appointments didn't exist. The reimbursement for a postpartum visit is so poor. It's part of your global pay. So these clinics didn't exist.
So even if the patient wants to come back in and see somebody, there is no place for her to see. So what we did, we created and then covid came. So we converted. So all these appointments are telehealth. So it's very convenient. You can even like you don't even have to be on the video. So we make this appointment, we have an app who's trained. The other thing part of this is obviously I'm a physician, so I also looked at all blood pressure protocols from the time she delivers to six weeks and gave people knowledge about how to treat blood pressure. So a little bit extensive program, but essentially it's a, it's a remote patient monitoring bluetooth monitor and an app that connects the patient to the health system. And I have extensively written about it. We have patient surveys. Everybody likes it. You know, this whole thing that you're young, you're not going to use your app. Now that is it also actually reduce black and white disparities. So there was a very large disparity in chicago between white people and black people accessing care. And it totally eliminated it. There's actually this program won an award from jco in 2023. Well, you have on your hand a map. Yes. And it shows critical access hospitals. That's a kind of a green star for those of you playing along fqhcs community hospitals, rural health clinics. I see 19 stars wearing braces, engaged with various facilities throughout Nebraska. I'm just guessing you're batting a thousand that every time you contact one of these types of medical centers that they're saying, yes, yes. So this is my this is a static, but this is a live document. So on the x axis is the health systems on the y axis is the programs that we offer. And yes, is each y just on this there are 90 yeses. Yes. So pretty much everybody. So this was really good exercise for me because I came here, I had this vision, so I had to sell it to Nebraska medicine for them to hire me and give me a package, which is what, how it happened. I said, if you give me, if. You that way. Yeah. I said, if you give me, if you give me resources to do this, this is my dream to do this at a state level. And they said, yes, we will give you resources to hire people to do this. I have a manager, I have nurses who work in it. And then I had some ideas, but one of the things we did was, and thanks to a lot of people in Nebraska medicine, connect me through. And I mean the Nebraska hospital association to go to these health systems.
So we first talked to the ceos to make sure it's okay for us to talk to the doctors, and then actually dug into how do you manage your blood pressures? What kind of education do you provide your nurses? What kind of sonography are you doing? What kind of machine do you have? Do you need? Do you have I mean, ge is so advanced. They have all kind of ai assist. We are stuck with these machines, with these people who don't even know how to scan, like, what are we doing? So we actually sat down and we took lots and lots of notes and obviously had the zoom meetings with them. And then we came up with this. And then we then now when we go, we first present. And out of these 19, no. Two programs chose the same. It's very surprising actually. Just put an abstract at smfm that not two programs chose the same category of ten. But I can tell you transport. Everybody said yes. Okay. Biomarkers. Everybody said yes. Stamp. We have 9 or 10. And I stop there because I'm like, I just don't have enough manpower to put this blood pressure program at every single person who's saying yes. So some of this is limited. These yeses are limited by our bandwidth at this point. I mean, I have about a 16 people team, but I'm I also have research. I do clinical work. I do other things too. But for example, nursing education, everybody said yes. Can you give us an idea of how much does it cost per person, like with the blood pressure program to get? Oh, it's all reimbursable actually. Oh, it's 100% clinical care. Okay, so the we don't even charge anybody anything. We just give them our protocols. Actually, I have several grants, so I had to create a toolkit. So it's a toolkit, literally a one page document which has links to all, everything. And we just give it to people. We give them. So I developed protocols. It's very simple on a piece of paper, it's like yellow. The blood pressure is this do this. The blood pressure is this, do this. So essentially it's not going to cost health system anything and it's reimbursable. You can build for billing, for enrolling a patient and providing education. That's why having a nurse is good because the nurse is a billable provider. The rpm services remote patient monitoring is also billable. Obviously, it slightly increases your rates of readmission because you're catching people previously. They're just be sitting at home with severe hypertension. Nobody cares. But now they will be brought in and treated for their hypertension. So you kind of reimburse there too. But I've done I just recently got an nih grant based on this because I want to do remote patient monitoring from six weeks to one year and engage the patients for long term blood pressure monitoring.
So this is all reimbursable. It's not going to cost the health system. They do need some stuff like obviously a nurse educator. Maybe we do. I did also hire a community health worker because the disparity between black and white can only be eliminated by the right kind of people. It's not me telling the people. So we actually hired a community health worker, which was extremely helpful to me in my program in chicago. So yes, some some cost to it. But again, all billable services and this can all be done in a hub and spoke manner. So a lot of these smaller hospitals like geneva fillmore, they only do like, I think like 100 deliveries. So they will only have 30 patients in a whole year. How many people I'm going to treat to teach, to treat them. So I said, I can take care of that. Like your patients can get tele health appointments through our system. And we can just like make sure that you are getting those blood pressure reads if your doctors want to look at it. So yeah, so there are ways to actually do that at a, at a level that each individual person doesn't have to invest into it. 17 of the year. 19 locations that you have indicated on this map are in rural areas, right? That's the whole. Idea in omaha. Yeah. I came here saying that obviously I want to improve Nebraska medicine and we do great medicine. And, you know, patients are coming to us, but that literally is not our goal of our program. Our goal of our program is to actually improve care for the patients where they are. So when we talk to the providers, we say, we can improve your ultrasound skills, we can improve your sonographers ultrasound skill, we can put ai technology so that your sonographers can connect with us in real time. I can give you biomarkers. You can stratify your patients and call me. I can give you a calendar. If you have a phone call, you can call me because at the end of the day, there'll be very few patients who need to be dragged down. I was literally talking to a to a provider somewhere and I said, how do you send your patients? Like, where are you getting your level two ultrasounds? And if you find something and they said they send the patients to methodist eight hours one way, I'm like, wow. I said, have you ever thought of telehealth? Like, can I not talk to your patient through a screen? I mean, I don't even touch patients anymore. I'm a consultant. I just talk to them. This is the ultrasound lady. This is the plan. So I'm like, have you thought of she's like, nobody wants to do telehealth. It's like, it's difficult. And I was like, it's not that difficult. I mean, you obviously need to do it stuff.
But yeah, so some of these things are, and by the way, some of the solutions that we create here are will be something that we can do here, which we can then teach other states how to do it right. And obviously, riepe dollars are large, but those will be like a perfect use to like do some of this stuff. And so say, and even if it doesn't work, we can check that off and say, oh, doctor said remote patient monitoring should work for blood pressure. And it just didn't work here because of whatever reason. But in our in our hospital, it's working really well. And I think the next in line is like mary lanning and beatrice because their community connect sites, they have our own it. So there'll be some id structure to be developed around these. But I think some of these stuff that we do is a national problem for a lot of rural states. I talked to bill about what you're doing. So bill is actually funding this program a little bit. And then he actually got me. I'm not a mental health expert. I have to tell you, a maternal fetal medicine specialist. I have a lot of specialty in hypertension. I've written a lot of literature around it and work with who and gates foundation and all that. So he actually brought me into the mental health because I, he funded the stamp program and it's just such miraculous results. And he's like, can you please create a telehealth program for mental health? So I think we're just like backing it up and he's going to fund a little bit pilot. But yes, he's a big proponent of a lot of this things. Yes. I sure thought I was over the plate. So yes, that sounds very, very meaningful. Any other questions? Yes, ma'am. Thank you. Chairman. I was going to ask last year, I had a bill to allow for reimbursement for blood pressure monitors for pregnant women. Does that fall into this? Would that. Yeah, that'd be great. So this is mostly remote patient monitoring postpartum. And the reason I got into that is that during pregnancy, people are seeing their providers. So there are randomized trials right now done to say I randomize you to remote patient monitoring during pregnancy and your usual clinic visits. And that doesn't really change your entire pregnancy outcome. I'll take it with a grain of salt, because some of this is actually done in very well resourced countries. So sweden has done a trial. Remote patient monitoring doesn't help in pregnancy. I can tell you, if I do a trial and I did write a pcori, they didn't find it. I think it will work for our women. I think just even simply handing out a blood pressure cuff which can be covered by your bill is huge advancement if it comes with education.
So you can tell, hey, check your blood pressure at home. If it's high, you can call your doctor. So yeah, along the line of education and just awareness that hypertension is a major killer of young people and you should control your hypertension along the lines of exactly this. Yes. Okay. All right. Thank you. Any other questions? Thank you. You're welcome. Thank you so much. And I think we're done. Yes. No. Sarah howard is here. Just teasing you. I. You know, I appreciate it a great deal. I appreciate a. Little humor at the. End of the day. Okay. Chairman hardin and members of the health and human services Committee. Thank you for allowing me to testify today. My name is sarah howard, spelled sarahoward, and I'm a policy advisor at first. Five Nebraska first five Nebraska is a statewide public policy organization focused on promoting quality early care and learning opportunities for Nebraska's youngest children. My area focuses maternal and infant health policy because we know that helping moms and babies are critical to ensuring the long term success of children in our state. I'm here to testify on Senator spivey's interim study. LR 383. And first, I want to thank Senator spivey for her commitment to maternal and infant health in Nebraska, but also her willingness to be vulnerable in this space. I think it's really hard to tell personal stories and to share experiences of birth and postpartum depression and anxiety, and just to kind of bring us back to a solution because I think for maternal mental health, it feels very big, even when I think about it and my own experiences, my experience was very limited. I had really bad anxiety. I would wake up and think that the baby had stopped breathing, and I'd be like, how are you breathing? And he's like, oh, why are you waking me up? And to me, that was a very mild postpartum anxiety. Now, when I think about how huge the issue is, when I think about kelly's research, it's like, we've got to decide as a Legislature and as a state to start taking bites at this elephant. And so I'm going to make some recommendations in terms of policy directions that the state could go in to really start to tackle this bigger issue that is impacting not just mothers, but we know that when mom is struggling with her mental health, that impacts baby, right? We it can correlate with failure to thrive. It can correlate with developmental delays for baby. And so I think there are a lot of opportunities here. So the first one I'm going to recommend to you is sort of a cross sector commission around maternal and child health overall, that has a subset focused on mental health for mothers. Other states have really started here. And for Nebraska, we're really starting from zero. In a lot of respects.
Texas is one of the 13 states that has required a statewide strategic plan around maternal mental health. Oh my goodness. Okay. The next one I would recommend would be requiring perinatal screening, mental health screening in statute. This helps with the early identification that leigh cooke was talking about. We already have a recommendation for a screening and statute from LB 900 905 from 2022. You can also improve billing. So there are three ways to improve billing. One is to make sure that a mental health screening is included in the child's benefit. So because mom will usually present at the well-child visit. And so you want to be able to bill a screen at that time. The next one would be to bill integrated behavioral health care, which is when an ob provider sees that there's a problem, you can do a warm handoff to a mental health provider, but you can't bill on the same day for that second service. And so allowing that same day billing for mental health services. And then the third one is to ensure mental health billing by community based providers. So Senator spivey has done a lot of really good work around doula reimbursement and community health workers. Senator hardin has worked on. Those are those are folks who can also bill for mental health services. I have two more, but I will pause. We want you to share those two. I will say the other two are a little bit. They're quite sad. The other ones that I will recommend is one, we need to make sure every maternal death in the state has an autopsy. So every single year, there are a handful of maternal deaths that do not receive an autopsy. We do not know the cause. And so that means that our maternal mortality review Committee cannot review those deaths and really give us a good idea of what's going on with maternal mortality in this state. So missing 2 or 3 deaths means that we don't have a full view of what's going on for moms. The last one I'm working with Senator jacobson on, and this is around perinatal bereavement policies and hospitals. So making sure when there is a loss that all of the staff surrounding that mother and that family are well trained to support that mother during that mother and that family during that period of time at the hospital. And so those are the last two recommendations that I think are really great opportunities to improve maternal mental health or to start eating this bigger elephant. Thank you for the extra time questions. Thanks. Thank you. We appreciate it. See you tomorrow. Senator smith. Thank you, chair hardin, vice chair, frederickson and members of the health and human services Committee. I really appreciate your time being the last hearing today and just your engagement on this topic.
A couple of things that I wanted to uplift and just to kind of center us as we head out for the evening. And so maternal mental health or perinatal mental health is really important into the maternal and child health landscape. And so my ask in my opening was that you all would be committed to some comprehensive policy, because I think a part of the issue is that policies are done in silos. And so we're just talking about mental health over here, or maybe. Nurse visiting programs, doele reimbursements versus thinking comprehensively. And so I am working on a package that I would love to be in partnership with each of you on to really understand the scope of the issues and opportunities here and what are accessible interventions that can really make an outsized impact for mom and babies. There is a bill at the federal level that I just wanted to flag around an office of maternal and child health, and so it would create funding at each state level to be able to have this office. And so I'm kind of the package that I'm bringing will mimic what is at the fed level to have here. And I do think that we've already started to make a headway on that within the Nebraska perinatal quality improvement collaborative and the work that they are doing there. Senator fredrickson, to your point, the data is underreported. Missus howard talked about like, okay, you have these kind of evaluations at the infant visit and at and at your ob appointment, and it really is self-reported. So there has to be a space for people to feel safe and secure that if I self-report, they're not going to take my kids. If I self-report, what does that mean for me? And so I think that it's not just about universal screening. It's about what does that screening tool look like? And what are what is the infrastructure that is around that as well? On the workforce side, I just wanted to uplift that. Nebraska medicine has the only specialty clinic in the state around perinatal care. And so when we talk about access to care and what does that mean? I think there may be some opportunities with the rural health transformation project to be able to think about new programing, like the family ob residency and some other pieces there. And so I'm thinking about that for my appropriations hat and what does that look like? And for me, really centering policy on screening and billing, workforce access to service, and then patient, patient centered approaches. So again, I really appreciate your time in this. I know that it is heavy and it is a lot, but I don't think our reality has to be here. We can really have an opportunity in the next biennium to really pass a meaningful policy to support moms and babies across our state.
And so with that, I will be happy to answer any final questions that the Committee may have. Thank you, chairman. Not really a question, but just want to thank you for your story, too. Thank you. Yeah, I've spoken about it on the mic sometime, and it feels like I'm ten years ago that we were in session. But I think that's important. So this policy making is I want to be able to support families. And it's personal too, right? Like we all carry that into how we approach what we bring here. So thank you. Very good. Any others not thank you. Thank you chair. This concludes LR 383. And our lr is for today.