As the parent of two adopted children, adoption is close to my heart. Furthermore, with respect to the fact that one of our birth parents was seeking a Christian family, consisting of both a mother and father, I respectfully ask that you continue the religious conscience protections for these agencies. In a country where there is freedom of religion, we should not have to compromise in this. There are many secular agencies including social services for those who wish to refrain from our beliefs. This bill would not allow birth parents who want their children in Christian homes to feel as though they have a choice for their child. Furthermore, as Christians, we are not perfect, only forgiven. We know we sometimes mess up, but God, in his infinite wisdom made a way for forgiveness. There are many Christian birth mothers and fathers who have found themselves in a situation of an unexpected pregnancy and instead of abortion choose adoption and want their children raised in the Christian faith. The government should dictate what they can or cannot have for their child in this matter.

I support these the bills and anything helping the public get care from nurse prescribers, especially certified nurse midwives. These providers offer excellent services and outcomes for less expense and should be promoted where possible. Certified nurse midwives will always work with OBs, but it's hard for them to find a competitor to sign off on their practices.

I am currently enrolled in AGNP program and I can assure you my education and training will fully support me and our community with safe patient care outcomes. Once I complete my graduate degree, I would like to practice to the fullest extent of my licensure and certification. Please support this legislation. Per the Nurse Journal (2021). A nursing shortage has led to nurses working long hours with inadequate nurse-to-patient ratios, Weatherspoon says. This can lead to nurse burnout and lower-quality care. people now call for greater healthcare measures, such as the universal healthcare system proposed by the Medicare for All bill, that would provide health insurance for all Americans. “While this sounds good, it may escalate the nursing and physician shortage,” Weatherspoon warns. In the case of Medicare for All, more people would likely take advantage of preventive care, which is often the responsibility of nurses. In addition, more RNs may pursue a bachelor’s degree or an advanced degree to become an NP. This all leads to an industry that will require more nurse educators, according to Sullivan. https://nursejournal.org/resources/affordable-care-act-nursing-guide/#how-nurses-can-shape-healthcare-reforms

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

I am for nurse practitioner to be able to practice without a doctor being there

Please support this legislation. As a CNS, I see the immense opportunity to impact patient outcomes that is limited by current regulation. This would also better align CNS practice with national standards, competency definition, and practice in other states.

Please support this bill to allow the CNS team to function to the top of licensure and educational training.

I am writing to express my strong support for HB 1747 which would provide prescriptive authority to Clinical Nurse Specialists working in the Commonwealth of Virginia as Advanced Practice Providers. I have had the opportunity to work with a number of Clinical Nurse Specialists in my role as Medical Director of the Bon Secours Program for Diabetes Health. These are talented and dedicated individuals who provide a unique perspective in the care of individuals with complex conditions and bring a patient-centered approach to that care. Prescriptive authority would, in my opinion, greatly enhance those capabilities and permit more direct attention to the needs of the many patients they serve. This is particularly relevant as the number of health care providers who are able to provide this kind of care is in jeopardy at a time of even greater stress on our health care system. If I can provide any additional information which would assist you in your consideration of this bill, please do not hesitate to contact me at any time. John N Clore MD, MS

Please SUPPORT HB 1747. The challenges that VA’s restrictive practice laws have on advanced practice nurses to provide care to the citizens of the Commonwealth represents a barrier to timely, efficient, and available care to our most underserved populations. During the COVID pandemic, this was even more profoundly felt by my Clinical Nurse Specialist colleagues that could not practice to the full extent of their training to help meet the healthcare needs of our most vulnerable patients during patient surges despite having the training to do so. We are asking for the ability to form collaborative practice agreements with physicians to practice to the full scope of our training. The Medical Society of VA (MSV) has taken the position that they have “no issue” with this legislation. I am a recent graduate of a CNS program and had the privilege to precept with board-certified Emergency and Nephrology physicians and a board-certified Family Nurse Practitioner. However, when I pass my boards I will only be able to function as the nurse I have been for 24 years, not as an advanced practice nurse to the full extent of my training. Please support and pass HB 1747. Keep the Clinical Nurse Specialists (CNSs) working and practicing in the Commonwealth of VA to help meet the healthcare needs of our most vulnerable populations. Thank you for your consideration.

Please support. Michelle Longley, MSN, RN, NP-C, AGCNS-BC

Please support HB1747. The proposed changes to Clinical Nurse Specialists (CNS) licensing and inclusion authorization to prescribe within a physician collaborative practice agreement represent an importance step to support the care of vulnerable patients across Virginia.

Vote YES for HB1747: I currently practice as an adult-geriatric cardiac intensive care unit Clinical Nurse Specialist (CNS). I work collaboratively with Critical Care Physicians, Nurse Practitioners (NP), & Physician Assistants. I have a doctorate in nursing from ODU took advanced pharmacology courses side by side with NP and Nurse Anesthesia students. In 2010, the Institute of Medicine recommended to remove scope of practice barriers for APRNs to practice to the full extent of their education and training to help meet the increasing demands on healthcare, with a combination of an aging population without an anticipated increase in physicians. The impact of my role in ICU is supportive of the nurse-related measures to improve outcomes, such as wound / skin care, prevention of hospital-acquired infections, nutrition, and mobility. Prescriptive authority would reduce delays in prescribing core nursing-related treatments, consults, and equipment. This allows the critical care providers to focus on the specifics of the underlying acute disease process and related procedures. It is now time to break down legal barriers and allow us to work to the full extent of our education and training. Vote YES on HB 1747 in support of Virginia CNSs and the patients we serve. American Association of College of Nurses. (2008). Consensus model of APRN regulation: Licensure, accreditation, certification and education. Accessed from http://www.aacn.nche.edu/education/pdf/APRNReport.pdf Institute of Medicine of the National Academies. (2010). The future of nursing: Leading changed, advancing health. Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

HB 1747: I have practiced as a Diabetes Clinical Nurse Specialist (CNS) for 1yr and working alongside physicians and others to ensure patients receive the right care. Although I was educationally prepared and nationally certified to deliver advanced nursing services to this population, my ability to impact the health of Virginians with diabetes has been hindered by the limits of the current law. I can’t prescribe the medications or diabetes supplies that are vital to improving the health of the over 600,000 Virginians with diabetes. There are just not enough physicians specializing in diabetes to care for this exploding population. Virginia needs more clinical experts in diabetes care, and Diabetes Clinical Nurse Specialists can deliver that care, improve long-term health, reduce diabetes complications and reduce hospitalizations. Medications are a central focus in managing this condition, and Clinical Nurse Specialists, like myself, have the knowledge and skill to intervene. Like other CNSs working with chronic health conditions, we need this change in the law that permits the prescribing of medications and medical supplies. Clinical Nurse Specialists expect to continue collaborating with our physician partners (as we always have) and are pleased that the Medical Society of Virginia does not oppose this effort.

Thank you for the time to review this critical bill. I am a certified clinical nurse specialist practicing in the state of Virginia at a community hospital managing patients who have complex diabetes. I collaborate with providers (physicians, physician assistants and other nurse practitioners) to assess, diagnose, and make recommendations for care. My scope and impact is limited by the law that I do not have prescriptive privileges. As our particular hospital is overflowing with acutely Ill patients, often times there is a delay until my recommendations are implemented by other providers causing delays in care and ultimately recovery. Prescriptive privileges for clinical nurse specialists would enable us to not only practice to our fullest extent but to be able to provide advanced nursing care in an efficient and timely manor which would directly impact both patient outcomes and hospital system care coverage and benchmarks.

HB 1747: To the honorable members of the Health , Welfare and Institutions Committee, please support the passing of this bill to allow CNSs to practice to their full intended scope by allowing prescriptive authority. The passing of this bill will allow CNSs to continue to provide comprehensive patient care and give us the ability to ensure that each patient has the appropriate medications, supplies, orders, and etc dependent upon our specialty. Thank you for all of the hard work and support that is done each and every day.

HB 1747: I have practiced as a Diabetes Clinical Nurse Specialist (CNS) for over a year and a CNS for 7 years, working alongside physicians and others to ensure patients receive the right care.  While I was educationally prepared and nationally certified to deliver advanced nursing services to patients, it wasn’t until I began practicing in the area of diabetes management that I realized the impact of the current law on my practice and my ability to provide care to the top of my education. My ability to impact the health of Virginians with diabetes has been hindered by the limits of the current law. I can’t prescribe the medications or diabetes supplies that are vital to improving the health of the over 600,000 Virginians with diabetes. There are just not enough physicians specializing in diabetes to care for this exploding population. Virginia needs more clinical experts in diabetes care, and Diabetes Clinical Nurse Specialists can deliver that care, improve long-term health, reduce diabetes complications and reduce hospitalizations. Medications are a central focus in managing this condition, and Clinical Nurse Specialists, like myself, have the knowledge and skill to intervene. Like other CNSs working with chronic health conditions, we need this change in the law that permits the prescribing of medications and medical supplies. Clinical Nurse Specialists expect to continue collaborating with our physician partners (as we always have) and are pleased that the Medical Society of Virginia does not oppose this effort.

Please support!

HB 1747: I have practiced as a Diabetes Clinical Nurse Specialist (CNS) for over 30 years, working alongside physicians and others to ensure patients receive the right care. Although I was educationally prepared and nationally certified to deliver advanced nursing services to this population, my ability to impact the health of Virginians with diabetes has been hindered by the limits of the current law. I can’t prescribe the medications or diabetes supplies that are vital to improving the health of the over 600,000 Virginians with diabetes. There are just not enough physicians specializing in diabetes to care for this exploding population. Virginia needs more clinical experts in diabetes care, and Diabetes Clinical Nurse Specialists can deliver that care, improve long-term health, reduce diabetes complications and reduce hospitalizations. Medications are a central focus in managing this condition, and Clinical Nurse Specialists, like myself, have the knowledge and skill to intervene. Like other CNSs working with chronic health conditions, we need this change in the law that permits the prescribing of medications and medical supplies. Clinical Nurse Specialists expect to continue collaborating with our physician partners (as we always have) and are pleased that the Medical Society of Virginia does not oppose this effort.

To the honorable members of the Health , Welfare and Institutions Committee, As an Adult Gerontology Clinical Nurse Specialist, I would greatly appreciate the ability to practice to the fullest extent of my educational level in Virginia. This would include the ability to prescribe medications, durable medical equipment, oxygen, while also updating code statuses for those patients in need. Of course, this priveledge would be expected to occur in conjunction with the collaboration of a physician, should situations of which I am uncertain be encountered. By removing the barriers and work-arounds, we can streamline processes and further decrease the overall cost of healthcare. This not only benefits patients but the overall healthcare system. I am certain that at this time in our state's history, the Committee can appreciate what a good idea it is in having more qualified healthcare providers to help provide care. I urge you all to remove the barriers the Clinical Nurse Specialists are faced with in Virginia. This is not a novel concept and has been done in countless other states. Please support HB 1747. Most respectfully, F. Kay Butler, MSN APRN AGCNS-BC CCRN ACM-RN

I support these bills that will give nurse midwives, certified midwives and nurse practitioners autonomy and authority in their respective practice.

To the Chair and Distinguished Delegates Re: HB1747 - clinical nurse specialists I am Katie Page, Certified Nurse-Midwife and Fellow of the American College of Nurse-Midwives. I am the President of the Virginia Affiliate of the ACNM. We support HB 1747 which would grant our CNS colleagues prescriptive authority and bring their regulation with other APRNs under the Joint Board of Nursing and Medicine. As with other APRNs, midwives, physician assistants, and doctors, patients are best served by a team of clinicians who are practicing to the full extent of their education, training, and certification. This improves collaboration and team-based care which meets the care needs of patients, improves quality for all, and reduces cost to the health system - including medicaid which impacts the state budget. Thank you for your service and support.

The CNS practice and impact serve Virginians within specialty popations related to their illnesses and injuries such as stroke, oncology, palliative care, wound care, diabetes, mental health, heart failure, and pulmonary disorders. The CNS scope of practice is hindered due to lack of prescriptive authority. Prescriptive authority would reduce delay in disease management care to Virginians and prevent unnecessary suffering. Examples include: o Healing topical treatments for wound management, o Nausea relief for cancer patients receiving chemotherapy, o Rehabilitation therapies for stroke patients, o Medication to optimize patients with heart failure, or o Medications and treatment to optimize diabetes management • An estimated 47,550 Virginians will be newly diagnosed with cancer in 2020 • 14,861 Virginians die per year of heart disease (CDC data) • 631,194 Virginians have diabetes (1 out of every 11 people) Our impact could be even greater in the rural and urban parts of our state using telehealth. As Clinical Nurse Specialist working in a busy ED in Newport News, I am fully aware of the unmet healthcare needs and disparities of Virginians. Every day I am on the frontlines and I meet them face mask to face mask; some with N95s. With prescriptive authority and licensure, I can do so much more- 1. renew medications, 2. decrease their healthcare bills by reducing their readmissions to hospitals, 3. improve their mobility through prescribing durable medical equipment, and 4. provide virtual visits through telehealth. Please support HB 1747 to improve health outcomes for Virginians!!

Please support this bill increase access to healthcare for the citizens of the commonwealth

Addressing topics for perspective is a form of growth.

Along with the other Advanced Practice Registered Nurses (nurse practitioners, certified registered nurse anesthetists, certified nurse midwives) clinical nurse specialists (CNSs) are educated, experienced and ready to fill the gap of access to care for Virginia residents. Currently, CNSs do not have prescriptive authority in Virginia, although we receive the same education in pharmacology and applied pharmacology clinical training as the other advanced practice registered nurses. Our national certifications, renewed every 5 years, require continuing education in pharmacology. CNSs are registered instead of licensed like our advanced practice nurse colleagues. Additionally, there are advanced practice nurses who decline to move to Virginia or who move away from Virginia because of the restrictions to practice. With increasing chronic illnesses and need for healthcare in the Commonwealth we can’t afford to lose any providers. Clinical nurse specialists are asking for licensure and prescriptive authority in collaboration with physicians. Prescriptive authority will reduce delays in treatment and improve disease management to Virginians with chronic diseases such as diabetes and heart failure and help meet the needs of patients in both rural and urban areas.

We Support the Bill

We support this bill.

I am for nurse practitioner to be able to practice without a doctor being there

As interim executive director of Virginia Pride, one of the Commonwealth's leading LGBTQ organizations, I am writing in support of HB 1805 to ensure that older LGBTQ Virginians are considered a group with the greatest social need and are able to access and benefit from services provided by the Older Americans Act (OAA). Older LGBTQ adults are the backbone of the LGBTQ civil rights movement. Their history forms the foundation on which marriage equality, anti-discrimination laws and so much more are built. They are the generation that risked everything, including their families and jobs when they came out to fight for equality. This is the generation that literally built a community-based healthcare system to care for those impacted by AIDS in the early days of the epidemic. They are our heroes. Unfortunately, they are also more likely than any other elder group to experience isolation, to feel separated from family and friends and to feel anxious about accessing services designed for mainstream populations. They often do not have children to care for them and many LGBTQ organizations do not have the resources or experience to create and maintain culturally appropriate and accessible programming. We can and must do better. Virginia must recognize that older LGBTQ Virginians qualify as having the greatest social need in order to not just survive, but to thrive. We must ensure that targeted and culturally relevant services and programs are available to this vulnerable sub-population. To those of us in the LGBTQ community, these elders are OUR greatest generation. They deserve to be treated as such by our community and under the law. Thank you. James Millner Interim Executive Director Virginia Pride

I am the President of a Gay and Bi Men's group with 75 Chapters around the world and 130 members in Central Virginia. LGBT Seniors are more prone to be isolated. Many of them have outlived their family and partners. Loneliness and depression are very real issues. Many are still afraid for anyone to know that they are LGBT. Unfortunately they did not grow up in the era of gay marriage and recognition. Years of cultural isolation and discrimination contribute to distress and fear that prevent LGBTQ older adults from seeking or accessing needed services. Your support of this legislation will go a long ways to meeting the needs of this underserved population.

We write to support this legislation. LGBT seniors are very often people who live alone and also live isolated lives. They need to be included in the outreach of social service agencies. Senior LGBTQ people often fear reaching out to organizations for fear of mistreatment. They are often not as bold as the younger generation. Thank you for considering this bill

As a member of the LGBT community I have great fear of what will happen when I can no longer care for myself. I have great fear of not being treated fairly as a human being because I am 'not like the others'. This isn't right and the discrimination and taught hatred needs to be unlearned. I fear I will not receive the care I need and may be treated as a lower form of human being, which may contribute to an earlier death.

Addressing topics for perspective is a form of growth.

I am for nurse practitioner to be able to practice without a doctor being there

Representative of DBHDS, available to respond to any questions for the Dept. about the bill.

Addressing topics for perspective is a form of growth.

The disAbility Law Center of Virginia supports this bill as the Commonwealth's designated Protection and Advocacy system for individuals with disabilities. Full and complete access to the CHRIS system will better enable us to identify and serve individuals with disabilities who may have been abused, neglected or exploited.

As a person of Faith it is my calling to support these areas of concern and I ask you to consider how important these issues are and to vote to approve them!

I was asked to be available for the meeting.

Thanks very much for allowing me to speak with you. As a Virginia educator for the past 30 years, all of which have been spent in small, rural localities across the state, I have seen clear disparity in how our school divisions are able to access resources. I have never seen a disparity as glaring, or harmful, as the current inequality in access to broadband. As more and more essential services are made accessible via the internet, this inequity across the commonwealth is being highlighted. Today, almost 40% of the families in the community I serve do not have internet capability due to a lack of broadband. Aside from the impact given that so many healthcare and government services are being delivered online, student learning is suffering dramatically. Rural localities have suffered for years because of the lack of broadband. For decades divisions with broadband capability have employed learning management systems to streamline delivery of instruction, communication with families, and reduce consumption of paper. Many of us who lack broadband have been unable to justify the cost when so many families wouldn't be able to access it, so we’ve been stuck in dated systems that don’t serve our communities as well as suburban and urban localities with broadband can. The disparity became even more pronounced when schools were forced to close last March, and have continued to operate with significant remote, at-home learning. Imagine your doctor trying to assess your blood cholesterol level remotely, without the ability to connect with you online. Impossible. Similarly, our teachers aren’t able to assess the impact of regressed literacy and numeracy, developments that are absolutely essential building blocks to the learning Virginia will need students to have accomplished to contribute to the future economy, let alone lead productive and rewarding lives. The academic gaps that concerned us before the pandemic are growing at an alarming rate. Hotspots have enabled some to connect, but in localities where cell service is sparse, even those solutions come very short of providing the necessary access. My own home is located in an area without access to broadband. The estimate to bring cable internet to my home was just under $7,000. Our families cannot bear this burden. The impact of students’ inability to access learning because of inadequate access to broadband will be astounding. Addressing this disparity will have direct and lasting impact on the inequity among Virginia’s families. We simply cannot continue to allow it to be unresolved. Thank you for your consideration. Peter M. Gretz, Division Superintendent, Middlesex County Public Schools.

RE: Support for HB1822 – Cost-sharing payments for prescription asthma inhalers Dear Members of the Virginia House Labor and Commerce Subcommittee, Allergy & Asthma Network, a leading national nonprofit dedicated to protecting and improving the health of people with allergies, asthma and related conditions, supports bill HB1822, which aims to limit patient cost sharing for asthma medications to $50. With more than 22 million Americans living with asthma, including 6 million children, asthma remains one of the most serious chronic diseases, especially among low-income populations and certain racial and ethnic groups. Approximately 3,600 Americans die each year from asthma and this chronic condition costs the U.S. healthcare system $80 billion annually in direct healthcare expenditures (emergency department visits and hospitalizations) and indirect costs from lost productivity (missed school days and work days). We appreciate your consideration, and we hope you will support HB1822. Please contact me or our Director of Advocacy Charmayne Anderson at 703-641-9595 if you have any questions. To learn more about Allergy & Asthma Network, visit AllergyAsthmaNetwork.org. Thank you. Sincerely, Tonya A. Winders President and CEO

RE: Support for HB1822 – Cost-sharing payments for prescription asthma inhalers Dear Members of the Virginia House Labor and Commerce Subcommittee, Allergy & Asthma Network, a leading national nonprofit dedicated to protecting and improving the health of people with allergies, asthma and related conditions, supports bill HB1822, which aims to limit patient cost sharing for asthma medications to $50. With more than 22 million Americans living with asthma, including 6 million children, asthma remains one of the most serious chronic diseases, especially among low-income populations and certain racial and ethnic groups. Approximately 3,600 Americans die each year from asthma and this chronic condition costs the U.S. healthcare system $80 billion annually in direct healthcare expenditures (emergency department visits and hospitalizations) and indirect costs from lost productivity (missed school days and work days). We appreciate your consideration, and we hope you will support HB 342. Please contact me or our Director of Advocacy Charmayne Anderson at 703-641-9595 if you have any questions. To learn more about Allergy & Asthma Network, visit AllergyAsthmaNetwork.org. Thank you. Sincerely, Tonya A. Winders President and CEO

The VA College of Emergency Physicians supports Delegate Askew's HB 1822 that limits cost sharing payments for asthma inhalers. Our ER physicians across the Commonwealth see patients who return often to the emergency department because they cannot afford to regularly fill their asthma inhalers. The more we can do on the front end to get patients the medications they need, the less likely they are to end up in our emergency departments and able to lead healthy lives. We hope you will pass this bill.

I am for nurse practitioner to be able to practice without a doctor being there

Addressing topics for perspective is a form of growth.

I am for nurse practitioner to be able to practice without a doctor being there

The disAbility Law Center of Virginia, the Commonwealth’s designated protection and advocacy system for individuals with disabilities, including those with brain injury, supports this bill. Modifying the Code definition of “traumatic brain injury” to reflect that these injuries occur prior to age 65 simply reflects the reality that thousands of Virginians with brain injury experience each day.

Addressing topics for perspective is a form of growth.

The Brain Injury Association of Virginia requested and supports the bill. This is the only definition of brain injury that appears in the Code of Virginia and we frequently reference it when we are providing education, most recently to magistrates throughout the state. According to the CDC, falls are the most common cause of traumatic brain injuries. The statement that brain injury occurs before the age of 65 is a no longer relevant attempt to limit eligibility for a non-existent, never appropriated brain injury waiver, and the definition should be modified to make it accurate, because it isn’t. More than 3 million older people are treated in emergency departments for fall injuries and over 800,000 patients a year are hospitalized because of a brain injury or hip fracture. BIAV has spoken with DBHDS and DARS stakeholders who are supportive of our effort.

The professional organizations preparing Advanced Practice Registered Nurses and Certified Midwives unwaveringly teach consultation and collaboration with MD's and other professionals as a standard of client care. NP, CNM, and CM's are all certified professionals who take an oath to do no harm. Malpractice insurance for a physician is steep and coverage of an additional provider (said professional currently required to have a written agreement with) is care-prohibitive.

I am in favor of licensed certified nurse midwives to have full scope of practice. I am a Professor Emerita from Shenandoah University in Winchester. I was a graduate faculty member who taught foundation courses to the student nurse midwives and found each of them to be exceptionally smart and genuinely caring nurses seeking to aid women and their families through this course of study and calling. The breadth and depth of their education and certification and licensure process is among the highest for the professionals - they are capable and competent to practice without supervision and collaboration. Please support this bill. We need every licensed health professional practicing at the top of their education to meet the needs of Virginians during this healthcare crisis.

In favor of programs to better facilitate the development and progress of my community.

I write in full support of HB 1953. I was born and raised in Manassas, Virginia, and many of my family members continue to live in the Northern Virginia area. I currently live in New York, where I am employed as a Certified Midwife by a large federally qualified health center. I am not able to work in Virginia. I submit this letter in support of HB 1953 to license Certified Midwives in Virginia. As a Certified Midwife, I provide the full scope midwifery care that was my education and training, including routine gynecological care, primary care, and care during pregnancy through the postpartum period. I perform diagnostic biopsy procedures and refer patients for imaging and specialist care. I have full prescriptive authority, in keeping with my scope of practice, which allows me to provide timely, appropriate care for my patients. I have had privileges at 4 hospitals in the Hudson Valley region. My hospital privileges allow me to independently manage the care of low-risk women during labor, birth, and postpartum; I collaborate with a physician to co-manage high-risk patients, and I am a surgical first assist for cesarean deliveries. The high quality of my care has been recognized and awarded in the past by my employer. There is growing awareness and alarm over the poor maternal health outcomes and pronounced racial health disparities in the United States. Virginia’s maternal health record reflects these same outcomes and disparities. Virginia’s women need solutions. Increasing access to midwifery care, as noted by the March of Dimes, is an essential aspect of eliminating maternal health care deserts while providing high-quality care that is shown to reduce costly interventions and improve outcomes for mothers and babies (https://www.marchofdimes.org/materials/2020-Maternity-Care-Report.pdf). Thank you for your attention to the needs of women and their families in Virginia. Respectfully, Marian Seliquini, CM, MS President, NY Midwives, ACNM Affiliate

I write in full support of HB1953/SB1320 to authorize licensure of Certified Midwives (CM). At the Midwifery Institute at Thomas Jefferson University, we have been educating midwives since 1996. Beginning in 2010, we expanded our admission process to include all qualified applicants rather than limiting application to Registered Nurses. I am an author on a retrospective study demonstrating that prior work and educational experience are not associated with successful completion of a master's-level, distance education midwifery program. All graduate students completing education leading to board eligibility for the Certified Nurse-Midwife (CNM) or Certified Midwife (CM) credential demonstrate health, social, and basic science pre-requisites prior to beginning graduate studies in midwifery. Students are educated side-by-side using the same curriculum, standards, and outcome measures. Our program provides didactic courses using robust online teaching methods, on-campus simulation for skill acquisition and clinical reasoning, and clinical education under the supervision of qualified and licensed preceptors. Prior to graduation and board-eligibility, all students demonstrate the Core Competencies for Basic Midwifery Practice published by the American College of Nurse-Midwives and pass a comprehensive exam for the degree. In 2020, our program had a 100% board pass rate. Our graduates are successful and work in all settings where midwives practice. CM graduates go on to work in community hospitals, academic medical centers, internationally, in birth centers, and in communities, including Federally Qualified Community Health Centers. Our graduates have successfully worked with insurance companies to ensure equitable reimbursement with their CNM colleagues. One of my graduates lives in Lorton, Virginia. She is unable to be licensed despite having accredited graduate education in midwifery and national certification because she is not a Registered Nurse. I hope that the legislature will grant licensure to Certified Midwives consistent with the Core Competencies, Standards of Practice, Code of Ethics, and joint statement of practice relations between Certified Nurse-Midwives and Certified Midwives and Obstetrician-Gynecologists. By ensuring multiple pathways to accredited, graduate education in the full-scope of midwifery, more aspiring midwives can afford to attend school, take out fewer loans, and enter the workforce. Decades of research support midwifery as a key component of quality maternal-child and preventative healthcare. However, midwives are underutilized in the United States. I urge you to license Certified Midwives to help alleviate the provider shortage in over 50% of Virginia counties with no maternity care. Dana B. Perlman, DNP, CNM, FACNM Director, Midwifery Institute Associate Professor

Dear Chairman and Members of the Committee: The requirement of a nursing degree prior to formal midwifery education is not only unnecessary in terms of wasteful student expense and time; overall, it weakens the nursing workforce. Students who pursue nursing education as a stepping-stone to midwifery (when there is no other choice in the state) take up a seat in the classroom and clinical placement for another student that truly wants to be a bedside nurse. I am Certified Midwife (CM) that lives in New York State and works in Washington, DC at Georgetown University. I am the former Program Director of the Georgetown Nurse Midwifery/WHNP and the WHNP programs as well the former director for the NYU Midwifery Program. Currently, we have 239 midwifery students in the program. They are all nurses. I could double that number if I could accept applicants that were not nurses. We could educate the midwives that we need to provide midwifery and primary care in many of the places that need health providers. Nationally, at the American College of Nurse-Midwives, I have served in numerous leadership positions and my background is in birth, both out of the hospital and in the hospital setting which prepared me to understand the needs of the women I have served. I was the first CM in two hospital settings and worked alongside my CNM colleagues like every other midwife. In the hospital setting at both Bon Secours Hospital (Port Jervis, NY) and Nyack Hospital, I attended hundreds of births in a full scope capacity and I served as First Assist for any of my patients that needed a cesarean section in Nyack. Additionally, in Nyack, I was on call for and managed complicated gynecological cases in the Emergency Room. CMs have the same midwifery education and the same scope of practice as their CNM colleagues. CMs not only practice midwifery, but they can also excel in health leadership and systems management. I also practiced for many years without a written practice agreement (WPA). The studies show that midwifery care is just as safe with or without a WPA which often has to signed by someone who is in direct competition with you. The WPA actually discourages midwifery practice!!! As a private practice owner for five years, my flourishing practice had to close when my MD colleague who did sign my WPA moved out of state! The same happened in NYC when almost 20 midwifery practices had to close when St. Vincent’s Hospital went under, prior to the passage of full practice authority for CNMs and CMs. This left hundreds of pregnant patients without a provider! I whole-heartedly and without reservation support HB 1953 and trust that you will consider your constituents who deserve have a midwife, if they so desire. Thank you for your consideration. Feel free to contact me should you have any questions. Julia Lange Kessler  CM, DNP, FACNM Program Faculty: Nurse Midwifery/WHNP Program Course Coordinator: Primary Care Assistant Professor Georgetown University School of Nursing & Health Studies

I am the current president of the Virginia Association of Clinical Nurse Specialists. I am writing in support of HB1953 to license certified midwives in Virginia. The addition of certified midwives will improve access to primary and maternal health care for Virginia residents.

On behalf of the American College of Nurse-Midwives (ACNM), I appreciate the opportunity to provide comments in strong support of H.B. 1953, legislation to license and regulate the practice of certified midwives (CM) in VA. If enacted, H.B. 1953 would increase access to evidence-based, high-value maternal health care and improve maternal and newborn health outcomes during a time in which the Commonwealth faces a shortage of high-quality maternal health providers and significant race-based disparities in maternal and infant outcomes. While there are many different types of midwives, each holding different certifications based on their education and/or experience, a majority of midwives in the US have a master’s degree and many are doctorally-prepared. Certified Nurse-Midwives (CNMs) & CMs attend approximately 93% of all midwife-attended births in the US and are required to have a master’s degree to practice. CMs and CNMs differ in how they entered their master’s level midwifery educational program, but they do not differ in how they leave their programs, and how they leave is what is important for their practice. Like CNMs, a CM is an individual educated in the discipline of midwifery. CMs earn graduate degrees, meet health and science education requirements, and complete a midwifery education program accredited by Accreditation Commission for Midwifery Education. CMs pass the same national certification examination given by the American Midwifery Certification Board (AMCB) as CNMs, who are already licensed to practice in Virginia and receive the professional designation of CNM. Both CNMs and CMs demonstrate the Knowledge, Skills and Behaviors Prerequisite to Midwifery Clinical Education prior to commencing midwifery clinical training. Both CNMs and CMs demonstrate the identical Core Competencies for Basic Midwifery Practice of the ACNM upon completion of their midwifery education programs. Both CNMs and CMs must practice in accordance with ACNM Standards for the Practice of Midwifery. ACNM competencies and standards are consistent with, or exceed, the global competencies and standards for the practice of midwifery as defined by the International Confederation of Midwives. To maintain the designation of CNM or CM, midwives must be recertified every 5 years through AMCB and must meet specific continuing education requirements. Licensed to practice in DE, HI, ME, NY, NJ, OK & RI, individuals choosing this career path are pioneers in the profession, much like the early CNMs who practiced in the U.S. 50 – 70 years ago. CNMs and CMs have the identical ACNM defined scope of practice and follow ACNMs standards and code of ethics for midwifery. Like CNMs, CMs provide a full range of primary health care services in all stages of life, from the teenage years through menopause, including general health check-ups, screenings and vaccinations; pregnancy, birth, and postpartum care; gynecologic care; treatment of sexually transmitted infections; and prescribing medications, including all forms of pain control medications and contraception. While a majority of CNM/CM attended births occur in the hospital setting, CMs work in a variety of settings, including hospitals, health clinics, OB/GYN practices. Recognition of the CM credential in VA will cultivate increased access to a wide range of primary and maternal health care services and will help combat the ever-growing maternity care provider shortage plaguing many regions throughout the Commonwealth.

I am for nurse practitioner to be able to practice without a doctor being there

I support the bill to license Certified Midwives (CMs) in Virginia, HB1953. Born and raised in Virginia, I am a certified nurse-midwife (CNM) in a home birth and birth center practice based in Alexandria. CNMs have been licensed in VA since the 1970s. Though the CM credential, an equally academically rigorous pathway to becoming an advanced practice midwife, emerged in the 1990s, VA has yet to update our legislative language to welcome these qualified practitioners into our workforce. To become a CM, one must complete the same graduate level midwifery coursework as a CNM and take the same national certification exam from the American Midwifery Certification Board. The difference between the two credentials is simply that CNMs are also registered nurses, usually with a bachelor’s in nursing, whereas CMs can have any undergraduate major. Just like CNMs, CMs graduate from midwifery programs equipped with the core competencies that make them ready to practice safely and autonomously from day one. Our Commonwealth faces a shortage of women’s health and primary care providers, and CMs could be part of the solution. According to March of Dimes, 47% of counties in Virginia are either maternity care deserts or have low access to maternity care (https://www.marchofdimes.org/materials/2020-Maternity-Care-Report.pdf). Recognizing the CM credential will help us respond to our maternal health provider shortage in three key ways i) the talented CMs already living in VA will be able to provide care to our citizens; ii) CMs for whom our restrictive practice laws were once a deterrent will now be able to live and work here; and iii) VA universities will be able to attract midwifery students with diverse non-nursing backgrounds. Shenandoah University, for example, is poised to start a CM program as soon as this legislation is adopted. In addition to increasing our workforce, this could also generate revenue in VA. This bill has personal significance to me, as I heard my calling to become a midwife after having already earned an undergraduate degree in a field other than nursing. I am eager to remove unnecessary barriers and pave the way for others like me to answer the call to take care of women and families in our community. For this and the many reasons above, I support this bill without reservation. Thank you for your time and consideration. Sincerely, Tana K. McCoull, MSN, CNM, FNP-C

My name is Elle Schnetzler, I am a Certified Midwife (CM), a Fellow of the American College of Nurse-Midwives, a Board member of the American Midwifery Certification Board, and a Lieutenant Colonel in the US Army living in Virginia. I hold a Master of Science in Midwifery, from Philadelphia University, which I attended alongside student nurse-midwives and a doctorate in Midwifery from Thomas Jefferson University. I completed my clinical training at Womack Army Medical Center at Ft Bragg, North Carolina while living in Virginia. I would drive to Womack monthly to complete my clinical requirements. After graduation and becoming an AMCB board-certified midwife, I would fly to NY, where I am licensed, monthly to practice as a midwife. I chose the CM pathway because I needed to take the most direct path to accomplishing my goal of becoming a midwife due to military and family constraints. Though the travel was taxing it was important to stay the course because I believe in the vital impact of the profession and I wanted to maintain my valuable skills. More American women are dying of pregnancy-related complications than any other developed country and the rate continues to increase. This increase is greatest among African American women, who are 2 to 3 times more likely to die from pregnancy-related complications than Caucasian women. A recent study mapping integration of midwifery in the US demonstrated a correlation between high density in midwives/higher proportion of midwife-attended births and significantly higher rates of spontaneous vaginal delivery, VBAC, and breastfeeding at birth to six months. As important as full integration of midwives in the health care system is developing a means to produce more midwives overall and more specifically midwives of color. Licensing CMs provide this means. Many nursing schools have a waitlist for those who want to become a nurse. Requiring those who want to become midwives to become nurses first further compounds the waitlist when they have no intentions to practice as a nurse. Further, the nursing and midwifery professions have failed to keep pace with changing demographics in the US. Research has shown that quality of, and access to, health care for people of color has been improved by increasing racial diversity in the healthcare workforce. Licensing CMs provides a pathway to directly increase midwives without burdening the pathway to nursing, where a shortage already exists. Further, increasing pathways to midwifery can increase diversity thereby increasing access and decreasing disparities. Race-concordant care produces longer visits, increased provider participation, and communication, and produced higher ratings of client satisfaction and trust compared with race-discordant visits. Provider-client communication has been associated with commitment to care plans/medical instructions, client satisfaction, and health outcomes resulting in greater quality of care. As a multi-ethnic midwife of color, I understand the importance of race concordant care first-hand. I strongly urge you to support HB 1953 Licensure of CMs in Virginia not only because CMs are equivalent to CNMs in their midwifery preparation and national board certification but because women in Virginia deserve the benefits that expanding the midwifery workforce can offer.

Nurse practitioners are more qualified and more caring than most of the medical practitioners you deal with. They have the skills, the education and take time to hear their patients .

I appreciate the opportunity to submit testimony on this bill. My name is Maryann Long, and I am a midwife, now retired, with over 30 years of experience as a midwifery clinician and educator. I completed my midwifery education at Downstate Medical Center in Brooklyn, NY in 1981, I hold a master's degree in public health and a PhD in midwifery. I am a Fellow of the American College of Nurse-Midwives. Maternity care in this country is in a sorry state. Maternal mortality is higher here than in any other high-income country and higher than in quite a few middle-income countries, especially among mothers of color. Some mothers are over-treated, subjected to unnecessary and non-evidence based birth interventions, while others, many in rural areas, cannot even access basic prenatal care for lack of nearby providers, and have to travel for miles to a hospital that offers maternity care. Costs associated with US maternity care continue to increase. Increased utilization of midwives has been recommended as part of the solution to these problems. Virginia has licensed Certified Nurse-Midwives (CNMs) for practice since 1975. Virginia's CNMs have a record of excellent outcomes using fewer interventions, which lowers the cost of care. Ideally, there would be a midwife for every childbearing person. Virginia is failing so far to take advantage of another source of midwives to bring needed care to our population. I refer to Certified Midwives (CMs), who are equivalent in all ways to CNMs, but currently able to practice in only 6 states: Delaware, Hawaii, Maine, New Jersey, New York, and Rhode Island. I would like to see Virginia added to this list. Two university midwifery programs in the US educate midwives from both nursing and non-nursing backgrounds. Their students all take the same courses and are held to the same standards for success. Coming from a background other than nursing is not a disadvantage. Indeed, those students perform as well or better in their course and clinical work than their peers who are nurses. They all must demonstrate the same competencies, and upon graduation, they all must pass the same certification examination to be entitled to call themselves either CNMs or CMs. The only difference is whether or not they were nurses before their midwifery education. The bill before you would extend the same licensure that CNMs now enjoy to CMs. Given that their education, competencies, and professional standards are identical, and given the need to expand our maternity care workforce to improve our outcomes, I strongly urge you to support this bill. Thank you.