 And you want to be in the drawing for some fabulous travel size door prizes. You can only imagine what's in these puppies. Please make sure that you give your name tag to Fuji, who's walking around with a box. So if you're coming in through the main door, please turn in your name badges. We like to recycle. We're a nonprofit, so we'd like to recycle. But if you did not, or you forgot your name tag and you don't have it, don't worry, just go ahead and speak to someone from our team and they're gonna give you a little paper to write your name down. This is how we're gonna do the prizes today. There are plenty of snacks outside for you. We still have some cookies and some sweets to get our energy going. Sorry, Dr. Ferrer, we have to give them a little bit of snack tonight. So, and then Brittany, do we have more people still coming in? Okay. Now, all of you guys also stopped by the Ryan White table and you would have gotten a little white ticket for that. That's a separate drawing for that Weber barbecue pit. So everybody's been asking about that and we will do that drawing separate from the gifts that we're having from the health literacy group. So, thank you. I hope everyone enjoyed the sessions. Did everybody enjoy? Great. I know some, I know one particular session was a little loud and having all sorts of fun. Woo! But we were all pretty loud out here too. So, as long as everyone was having fun, that's all that matters. So, we're gonna go ahead and get started. I know some people are still walking in but we're gonna go ahead and get started and I'm very excited to present to you again my board leader, Dr. Robert Ferrer. He's gonna give us an overview of needs assessment or needs of our community and lots of really other cool stuff. All right. Thanks, Liz. Is the microphone, microphoneing? Okay, good. I like to, oh, the clicker. Maybe clicker. Aha, okay. All right, so the presentation is gonna be on the theme of some of the things I was alluding to this morning. It's gonna be about health literacy in so, as kind of a wraparound of health literacy is probably the best way to talk about it. To say that we need to think of health literacy not just in terms of the people but in terms of the systems that they're in, the communities they're in. And so, we think of it as a system where we have people's abilities and the demands. So, I'm gonna spend maybe a little bit more time talking on the demand side during this presentation. And I hope it'll be a good compliment to a lot of the things that you heard today. So, that's why I took my little Magritte painting there. It's a health literacy is a pursuit but also a mirror, a mirror of ourselves who provide the services for patients. So, this is one piece of data from the community health needs assessment that we presented in late September, sorry, late August, August 23rd to be exact, at tri-point. And it was also, you may have seen this in the San Antonio Express News that appeared there. This is a life expectancy map for San Antonio showing some of the very deep disparities from north to south and east to west in life expectancy in our city. A lot of city's maps looks like this, the differences in life expectancy between the most affluent areas of town and the least affluent areas of town are quite large, 20 years. If you wanted to get on a plane and go somewhere where the life expectancy was 70 years, you could get on a plane to Azerbaijan or Turkmenistan or you could just drive to the south side of San Antonio. So, these are pretty profound disparities from north to south. And so, why do these things exist? Well, it's your neighborhood, sort of depends on where you can afford to live and that depends on your socioeconomic status. And so, that in turn is associated with a whole bunch of things, the kind of food you can afford, the kind of neighborhood, safe or unsafe you can afford to live in, the kind of work that you do, the kind of vacations you can afford to take or not take, the good schools or less good schools that your kids go to in those neighborhoods and set their own trajectory of health or poor health for their lives. And so, and obviously, we don't have any health literacy maps in the United States because no one has gone ahead and done that research yet. I'm lying just a little because there are health literacy maps for the United States but they don't measure health literacy. They're predicting people's health literacy based on their educational status, based on census data, on their educational status and their income levels. But we don't have any primary health literacy data yet. I hope somebody's working on it. So, I just wanna talk about a little bit about the context for health literacy and I alluded to this this morning. This is the task that we ask of people in terms of one tiny slice of health literacy which is understanding what they eat. This is actually a health literacy test that was developed by one of my old bosses in family medicine here at the Health Science Center. And this asks people to do an everyday routine task we hope for people which is to read a food label and then interpret it to make it meaningful for them and it asks them several questions. So this comes from an ice cream container and so it asks questions like, okay, if you ate the whole container of ice cream which we all have done right at one point or another, let's admit it. How many calories would you have? So, if you can understand such a thing and do a tiny bit of math, you can say four times 250 is 1,000 calories. And let's say you're a diabetic and you're allowed a 60 gram carbohydrate snack, how many servings of ice cream can you eat and so on. So, the test is actually six items and it just asks people those questions you see on the left side of the slide and we score them based on how many out of six they get right. So a few years back, I did two studies. I did one in our own clinic again at the Robert B. Green where we gave this to patients in English or Spanish, we had a Spanish version and then I went ahead and did kind of a statewide version where I went to seven different primary care clinics in Texas and seven different cities and I had people fill it out. And the results were not so encouraging. You can see that the two most common scores were either zero right out of seven or one right out of seven. And then there's the extremes of the distribution have the most people. There are people who are more literate, health literate at the top end and score high but the two most common scores are to be able to do almost nothing with that label in terms of interpreting it. So, the other thing I can tell you about this and I'm a family doctor but I'm also a health services, public health researcher and when we give these questionnaires to people and ask them to do it, one of the common responses is that they cry. They cry because they know they're supposed to be able to do it. These seem like simple questions and yet they're humiliated and embarrassed to show in front of someone who's scoring the test that they're unable to do it. So that's sort of the real life background for a lot of the skills and tasks that we're asking people to do in conjunction with their abilities. So I wanna say that health literacy is extremely important and it's where we wanna get everybody but there are a lot of things that come before health literacy and that's what I'm gonna concentrate on in the next few minutes. And sometimes we can misdiagnose people as either having health literacy problems or as having willpower problems when the issues actually go much deeper than that. So this is a social risk factor framework and I'm, actually this has a lot of, I didn't make this slide, this comes from the feds, a committee I was on, but let me, okay. So you see people's health literacy comes from somewhere and it comes from a lot of their, here it's called social risk factors. They're not necessarily risk factors, they're just characteristics of people. They're socioeconomic position, they're race, ethnicity, cultural context, social relationships, where they live and so on. And all that adds up to someone's health literacy, their educational experiences, what they learn from their families, from people in their community and so on. And then health literacy has a lot of consequences down the road. It has a lot of consequences for people's behaviors. Do they eat right, do they get the right amount of exercise, do they go to the doctor's office and get all the checkups and preventive care that they need and so on. And then those things cascade into, do they need to use the hospital or not, do they need to use the ER or not? And then ultimately the outcomes. So do they develop diabetes or not? Do they develop a potentially preventable colorectal cancer or not because they didn't get their screening? And those things then cascade into money and financial costs for both the patient and the rest of us. So these are upstream things, things that come before choices. When we talk about people's behaviors, often we frame it in terms of personal responsibility and making good choices. And that's a very simplified and I would say impoverished model of how people, why people behave certain ways. This is another study I did, again from our clinic downtown. And we asked people who either had diabetes or were obese and needed to exercise more and eat better. But we asked them some questions about how in their daily life feasible it is to do some of those things. And these are all framed a certain way. So getting closer to 100% is good and getting closer to 0% is bad, even if the question sounds like it should be the other way. So this way it's easy to look at the slide and understand if something is good or bad. So we want people to be as close to 100 as possible. And there's some things actually people scored better on than I thought available, fruits and vegetables where I shop, they have fruits and vegetables at the local grocery, we're doing pretty well on that in San Antonio. Easy to get to the food store, we start to lose about 20% of people. Nearby outdoor physical activity, we lose more, feel safe outside, we're losing about 40% of people at that point. Have a place where I can get physical activity without needing to pay, that's about 50, 50. It's a hut in the summer in San Antonio, that's news to you, I know. Do you have a place for safe indoor activity? Again, that's less than a 50, 50 proposition, feel safe walking after dark. Again, these are patients who come to the Robert B. Green, they live in many of them in unsafe neighborhoods and 70% or more say they're not safe walking after dark. So in a medical practice, it's easy to talk to someone and say, you know, it's free to walk. So every night after dinner you go out and you take a 20 minute walk and that's a great way to get exercise. Unless you live in the neighborhood that that patient lives in and then that turns out to be actually very unsafe advice. So this is the background, this is the context for the decisions that we're asking people to make. Now, that's things about the environment. These are things about people themselves and it's called conversion factors because it's something that allows them to take a resource like a grocery store or like a park and turn it into actual action for themselves. So there are some things about gender relationships that we heard also when we talked to people about husbands who didn't want their wives walking out alone, exercising. There were family members who, when someone came home with a new meal plan and they started making salad, the people at the table would say, this is rabbit food. Don't serve this again, where are the chicken McNuggets? But that's real life where it's not just the person themselves, it's a person in a very specific context of community and family. And again, here are even more of them. People say they don't get respect when they go to different places because they're, because they look poor or because they come from a disadvantaged community. And you can see a lot of people are nowhere close to 100 on the things that might 100% or even 80% on the things that might help them do the things that we ask them to do all the time. This is a little comment on my own profession, the physicians, we went to those same patients and we asked them, we said, does the doctor, and again, these are all people with diabetes and so the obesity, the doctor should be talking to them about these things. And does the doctor encourage you to eat healthy and does the doctor encourage you to get physical activity? And almost all of them say yes. So from that perspective, we're doing very well, almost more than 90% of the time we're doing our job and telling people, telling people what they need to do, encouraging them. But when we ask the follow up question and we say, does your doctor understand how hard it is for you to be physically active or how hard it is for you to eat healthy? We lose half and two thirds of the people. So there's a big gap between advice giving and actual understanding of a human being who you're expecting to put that advice into action in their real world life. And so that gap is a huge problem and we need to find creative ways to address that so that we're not just being glib and giving the 10 minute or the five minute talk on do this, do that, but really trying to drill down and saying, this person right here in front of me, what will it take for her to do the things that I'm asking her to do today? And so about 10 years ago, I started thinking of my job actually in a much different way, not just practicing medicine, but there's a whole branch of economics called human development, which isn't about gross national product and it's not about money, it's about helping people flourish. It's about how you take, and it comes from very poor places. It comes from places like, third world countries where people live on $2 a day and you have to figure out how to move someone from $2 a day to flourishing. Well, even though very few people in the US are living on $2 a day, we have people living on $10 or $20 a day in a much more expensive setting and we still have to figure out how to help them flourish. And so this is a simplified model that I'm using as I think about it and talk about it and try to put into action in our own clinic. What I alluded to this morning with our community health workers where we go into people's homes and try to help them literally flourish with limited resources by increasing knowledge, by increasing relationships and by trying to try to have them envision a future for themselves in their own life, in their own neighborhood, in their own family. So at the very last step you have outcomes and what comes before outcomes for everybody is choices. You have to, that's the final step but often that's where we begin and end, right? Is talking to people about good choices, about just talking at them and telling them what they need to do. But upstream from choices are opportunities and that's the part that I've really been trying to concentrate on. So that all those dots that I showed you on the last three slides, those are all things that create opportunities for people. Family support, a safe neighborhood, a place to buy actually fruits and vegetables in your neighborhood. Not being so depressed that you come home from work and just wanna sit down in front of the TV and veg out rather than cooking a meal for yourself and your family. And literally those four, five dozen other things that I showed you that are the ingredients, the ingredients for people flourishing in their own life not just about physical activity and exercise but doing well on the job, being active in the community, being good parents, being good family members, friends, these are the things that allow people to flourish. And then, so then upstream from opportunities are resources, okay? There are personal resources, having a good income, having a supportive family. But the community resources are just as important. And I want us to think about wealth in sort of a new way. Wealth is not just the money in your bank account. Wealth are the things that we provide for each other as a community. So a park is wealth, right? It's a physical activity resource that you couldn't buy a park for yourself but if there's one in your neighborhood, then that's a great place to go and walk. Clean water is wealth, right? Like the folks in Flint, Michigan now are all impoverished because what comes out of their tap is poison and they have to go and buy bottled water. Good schools are wealth, right? You free up good high quality public schools. Otherwise, what do you have to do? You have to move to a better neighborhood with better schools. You have to spend thousands of dollars a year on private schools. So all these things, all these communal resources, we should think about them as wealth that we hold in common. And then we would invest a lot more in them, I think. But it takes a different kind of community conversation to do that instead of the same old things about blaming victims and conversations that really we have for decades and don't seem to get us anywhere. So resources create opportunities. The choices you make depends on the choices you have, right? And those come from opportunities and those create good outcomes. We talk a lot about freedom in the United States. People write op-eds in the San Antonio Express News that I read and cry over my Bryce Krispies in the morning about how universal healthcare coverage is enslavement. We take away people's freedom if we try to enact universal healthcare. I don't think that's true. I mean, almost every developed country in the world has universal healthcare. And I don't think the people in any of those countries think of them as enslaved because they have health coverage. When they need it. I think of freedom in a practical sense as those opportunities. When you have opportunities to do the things that you think will help you flourish, will help your family flourish, will help your community flourish, that's real freedom, okay? Those are what we call positive freedoms. Negative freedoms is no one is stopping you from eating healthy food. Like, don't tread on me. That's the American freedom, right? Stay out of my way, stay out of my backyard, stay out of my business. No one is stopping you from eating healthy food, which is literally true. If you go to the HEB, no one comes up behind you with a gun and says, don't pick up that bunch of kale. You know, don't buy those chicken breasts, right? That's, but if you're from a, if you don't have the money or the resources to do it, that lack of no one is stopping you, that's very thin comfort, right? If you go and buy a few chicken breasts or a pound of salmon, let's say, because you're trying to eat healthy. Your doctor told you to eat more fish, more lean meat. Well, how much is that gonna cost you? As opposed to going to the frozen food section and getting hot pockets, which you'll fill your whole family's belly for probably $15, as opposed to, you know, getting one piece of fish for $15. So we need to think in terms of positive freedoms, and that's what helps people really be free and to flourish. So I wanna close with thinking about health literacy from a, in terms of a systems perspective, and you know, working from the top, from the bottom up. So when we think about the environments that we put people in, the very basic thing, the most basic thing is the materials, the way we talk, are they consistent, are they usable by people at different levels of literacy and education? So we spend a lot of time on that, but that's sort of the lowest level, I think, in terms of impact. The next level would be, are we asking for feedback from the people who use the system? You know, not just to say, okay, this should be readable by a person with a ninth grade education, but putting in front of them, doing some testing, and say, does this work for you? Tell me what you think this says. Is it meaningful? And then the next step up would be having the community members actually involved in creating those systems, right? So if we were to send you a bill or an explanation of benefits form, help us design it. What would help you understand this piece of paper and allow you to act on it in a meaningful way in your own life? And then, you know, again, I keep harping on this because I'm obsessed with it, is the demand environment. So not just do we measure patient's literacy, but do we look hard at everything we do, all the forms we have, all the things we ask of people, our phone system, our patient portal? Do we look at that very carefully from the point of view of demand and say, what is this asking of people and is it reasonable? Is this really usable or is this some engineers or some doctors, you know, someone who said, this has all the information we need in it, but it makes sense to me, but it's not gonna make sense to someone who's struggling with those questions and those systems. And finally, you know, at the top is the issue of where does the problem lie? Does it lie with the people who don't know enough and who don't do enough and who won't take responsibility and who insist on behaving the wrong way, you know, even though we're trying to help them? Or does it lie with a system that doesn't necessarily provide all the support and enabling that those people need to succeed? So I'll show you an example. These contrast the American, the US food guidelines with the Brazilian food guidelines that came out a year or two ago. How many people have seen these? No, okay, so look at the language and look at the way they talk about things. And it's very plain, you know, eat mostly natural or minimally processed food, do sugar in small amounts. Okay, now number four is what I want to show you and also something I talked about this morning is the forces of anti-literacy and who are trying to keep happy in the United States, avoid consumption of ultra-processed foods, packaged snacks, soft drinks, et cetera. Okay, they're telling people don't eat those things. This would never fly in the US guidelines. You would never see something that says don't eat Captain Crunch, right? Even though probably it's not a good idea for many people to eat Captain Crunch, but they come out and say that. Shop in places that offer a variety of natural or minimally processed foods, teach kids to cook, pretty basic, right? But if you go to European schools, the five-year-olds, the eight-year-olds, they're learning to prepare food. They have strong food cultures in those countries, but that's the basics for a life of eating well is learning how to feed yourself. Okay, avoid fast food. Again, they come right out and say that because the guidelines haven't been written by the people from McDonald's and Burger King. And then be wary of food advertising and marketing. And again, this is stuff we know, but we don't say. The purpose of advertising is to sell stuff, not to make you healthy. And they come out and they don't use the word lie, but claims about specific nutrients are often used to make unhealthy foods, seem healthier. So for example, on my favorite food to pick on hot pockets on the front of the package, it says made from real cheese, which is true, there's real cheese in it, but only after you get through two or three kinds of artificial cheese. And it's about the 30th ingredient out of 70 ingredients that's in the hot pocket. All right, so, oh, okay, the pictures did not translate. Anyway, the pictures were pretty simple. Ability exceeds demand, okay, you have a happy face. That's what I had pasted in there. Demand exceeds ability, you have a frowny face. And again, we're always gotta be thinking in terms of the balance between people's abilities and people's demand. And obviously we can intervene on either direction. Okay, so just to close, these are some recommendations on creating high-performing health systems in terms of increasing equity, decreasing the disparities that I showed you in the first slide between the people at the very top of the social ladder and the very bottom. So we put community informed, patient-centered care at the middle, but the first thing we have to do is we have to care about equity. We have to keep track of who's doing well and who isn't. Is the system performing well only for the people who live in the dominion in Olmos Park? Or is the system also performing well for the people that live in the Near East Side or the West Side of San Antonio? We have to care enough about that to look at those numbers and understand the outcomes and not just lump everyone together because the outcomes are very, very different from the top to the bottom of the social ladder. So first of all, you care enough to measure, then you decide what you can measure and look at the outcomes. And then you say, okay, if the outcomes are bad, why is that? What's driving those outcomes? Is it lack of access? Is it people access, but don't get the same benefit out of the system as people who are better off? Where exactly are the soft spots in what we're doing? And so you have to anticipate what people need in order to help them. And then once you have a good idea about where the soft spots are and what's going wrong, then you need to create partnerships to address those things. So again, this is a healthcare-centric diagram, but we could use it in public health, too. So in healthcare, if we find that the people who are really getting hospitalized a lot are the people with housing instability, with food instability, well, then we need to build some connections with people who can address housing, with people who can address food insecurity in the clinic. Not that they live with us, but we have very easy referrals, connections, feedback also on how people are doing and those partnerships are what we need to succeed. We need to think carefully about continuity. So as people's, we need to think about people's trajectories through different parts of the system from, let's say, meeting healthcare or going to a community center and what happens next and what happens after that and how do people know if they're succeeding or not? What kind of feedback do we get? So those continuity functions are very important. And finally, we need to make sure that we're engaging patients. So talking to the consumers, listening to what's working for them and what's not learning from them, what the soft spots in our own systems are because we don't see them, we're blind to them because we're not consumers. We don't know what it looks like often to people on the outside. And then the circle starts again. Then you look at your outcomes and you consider, okay, did that lift up the people who seem to be failing now? Are we helping them flourish? And we keep that virtuous circle going round and round. So maybe we'll, I'll let Christine Janis though and then we will take some questions at the end between us. Is that, sound like a good plan or? Yes, so we can definitely take some. I wanted to just interject really quickly. I'd like, has anyone heard of the, well, I said it earlier, but does anyone know of the Community Health Improvement Plan? You can raise your hand and tell me if you guys know of the Community Health Improvement Plan or what it is. Okay, so a large majority of you do not know and this is a very specifically, one of the wheels that Dr. Farrell's talking about is doing the comprehensive needs assessment, but then collaborative and partnerships and collaborating across providers and teams to identify some solutions. So Mario Martinez is here, I believe. Mario, can you stand for me if you're still here? Maybe Mario's not here. Okay, I know Kathy and Jennifer and some of the Metro Health team. Kathy, can you stand for me? And I think Jennifer's gone, but Kathy is working with Metro Health and they have a team that is helping partner with the Health Collaborative to do this community-wide comprehensive health improvement plan. And over the next couple of weeks and the next month or so, we're gonna be asking you to participate in this community project. And really, it's more than just a project. It's actually building an action plan that gets us from what we know is happening in the community and how to and how we build more partnerships and how we look at other sectors. Right now, all of us, the majority of us are in community-based organizations in health or health care. And we're really trying to reach some of the other sectors going back to a partner wheel that was discussed earlier, but understanding that the conversation doesn't stop here, it can't stop here. We can't keep talking to each other about it, but really encouraging a conversation that goes beyond the walls of these usual circles. So if you haven't had an opportunity to connect with us on the community health improvement plan, we're gonna be sending you guys a request. All of you that joined us today are sending you a request and asking you if you'd like to participate in this community-wide plan and really give us your thoughts, give us your feedback, let us know, give us, represent that hidden voice. One of the things that Dr. Frear probably touched on and I know some of the other presenters touched on is how oftentimes when we collect data, we're collecting the voice of the people that know or can or will participate, but we have a huge missing voice and that's where we need you. Most of you are connecting with those patients one-on-one or those families one-on-one that oftentimes can't make a stakeholder meeting, can't make a town hall meeting, do not know what it is or how it is that they can communicate the challenges and the barriers that they're facing and without their voice, we're not really gonna get any farther. We're only gonna continue to do the things that we've been doing and we're gonna continue to miss the mark on serving those that are most marginalized, that are most underrepresented and those are the people that often don't come up on data. So your representation at these workgroup meetings, this engagement process with the Community Health Improvement Plan is absolutely valuable so we encourage you to be a part of that and with that I'm gonna transfer over to you. Christine, who again, another voice is on the advocacy and what we can do about that. My name is Chris Giannis. I am the Director of Governmental Affairs for Methods Health Care Ministries and just wanted to provide you with an update on what's gonna happen with our upcoming legislative session, so which starts in January of 2017. So what I wanted to do today was just really provide you an overview of who we are, the political environment in the state of Texas Health Care in Texas and then what are some of the initiatives that MHM will be offering this coming January. So we are MHM, we're 20 years old, we have a wonderful mission statement of serving humanity to honor God. Some of our objectives are to facilitate access of care, do appropriate health care education and of course my job influence health care policy through advocacy. We also diversify and expand revenue sources and we have a working relationship with the Methodist Health Care System as part of our charitable purpose. 20 years ago the Methodist Health Care System sold half of its interest to HCA. So we are 50% partners with HCA and we take 50% of our revenue and we turn around and we provide that for access to care. We have nine San Antonio hospitals, three surgery centers and 27 facilities in Bayer County. One of the things I didn't know about Methodist Health Care Ministries really was the wonderful work that they did but not their service areas. So it is amazing to me that we provide services to all of these counties, 74 counties all the way down to the valley, up to Amarillo, up to Travis and Corpus Christi. So where you see dots, we have clinics, we fund clinics, we fund programs and really try to take care of that whole to provide access to care. And these are our partners Methodist Health Care System. This is where we have our referral physicians, 175 physicians with 31 specialties and some specialties. And this is just some of the work that we do. My department, strategic planning, behavioral health and support services, community outreach, and our two clinics that we have here in San Antonio on the west side, I mean on the south side and east side we provide medical, dental, recreation, enrichment, nutrition and health education. So Community Grants is really how we get our funding out in the community. If I can just have a show of hands, how many have you received money from Methodist Health Care Ministry, anybody? So a lot of folks and y'all are wonderful folks who are doing part of what we do and we fund you to get that, to get those services to the young and short. In 2016, we have 143 grants, 85 partners, $26.9 million that we will share with our community partners. This is what I do, guided by the social principles of the church. We develop policy, we collaborate with other nonprofits and we try to influence how that policy is going to be implemented. These are some of the contracts that I have with folks in Austin, South Texas here in San Antonio and these come to about $700, $800,000 a year that we fund for these groups. These are our two clinics, Wesley and Dixon on the south side and east and then our two primary care services and schools at Shirts and Kruger. And then we also of course have wraparound services for licensed counselors and social workers. So the political environment really, we're looking at state revenue and what we've learned is sales taxes are down, oil prices are down, revenue is down and when money is down, we are going to be looking at short revenue for funding our healthcare services. These are the political players and these are our leadership that we'll be looking to for any of the education and healthcare services that are going to be coming through the session. This is what's happening in Medicaid. We know that Medicaid expansion has dead, but we're looking at other ways to fund it through the Medicaid waiver, through mental health, to child protective services and through Medicaid provider rates. These are some of the initiatives that MHM will be looking at for this coming session, support the development of a bipartisan statewide initiative to cover that 1.5 million folks who don't have insurance, support the Medicaid waiver to address some of those uninsured and try to increase provider rates really to increase the Medicaid provider network and increase access. For behavioral health, we're looking to replace the state's 10 mental health facilities, we're looking to update outpatient treatment programs, establish public-private partnerships and also look at new delivery systems. For the healthcare workforce shortage, we're looking to fund our graduate medical education, we're looking to continue funding for healthcare providers in all of the workforce shortage areas for nurses, for mid-levels and we're looking to fund those loan repayment programs as well. For women's health, we're looking to continue the work that was done last session by the family planning program, contain that $50 million base that we were able to get last session and also provide care for the 19-year-olds coming out of the chip in children's Medicaid and looking at Health Texas Women's Program. For child and maternal health, we're trying to increase outcomes for moms and babies, we also support immunizations and we're looking to cover some of that Medicaid-covered gap to improve child and maternal health and we're also trying to address the mental health needs of children in foster care. For healthcare literacy, we're looking to maybe go ahead and refile the bill that was filed last session by Greg Bonin, creating an advisory committee to study and recommendations to improve health literacy. That bill died in the Senate without a hearing. It did pass in the House, but it died in the Senate Human Services, Health and Human Services. These are some of the initiatives that are happening in other states that we'll be looking at. In Maryland, provide state health occupation boards with recommended courses. Another Maryland initiative, provide healthcare professionals with evidence and completion of courses to be part of healthcare literacy, health disparities and culture and linguistic competency. We're also looking at Massachusetts and Rhode Island for a couple of initiatives to have healthcare literacy in healthcare facilities, pharmacies and health centers. And then the last one in Rhode Island require peace officers to study health literacy and establish mandatory standards for police officers and trainees. So these are some of our initiatives that NHM will be looking at and we hope to have a successful session and of course, what Mark Twain said, no man's life, liberty or property are safe while the legislature is in session. So that we know. Okay, so we have a few questions. I'm sorry, I'm squeezed by here. Let me get this question and then if I could get, Caroline, can you get another mic? Who had a question over here? Sorry. Yes, well, concerning Medicaid expansion. I mean, there have been other states, other southern states, a few who have gotten that reverse, I think South Carolina, a few other states. But again, it all comes down to money. And with the hospital corporations, I mean, what is the lobbying are done at that level? Because it seems like what I've read, the reasons the states got them to reverse that was because they had a strong hospital lobby and they showed the data and how it would benefit financially. But I know we have a lot of other roadblocks in Texas, but at least as a start, I mean, as constituents, can't you at least have like a stakeholders meeting, town hall meeting to have the Department of State Health Services commissioner present, which it seems like that's one of their duties they should and even at the governor level. And so they could have at least, be responsible to say, okay, no, we're not gonna do this and to have a justification. So as you'll know, Texas is one of 19 states in the country that has not expanded Medicaid. And we have a leadership right now, the governor and the governor, both the House and the Senate, there will be no mention of trying to expand Medicaid through the Affordable Care Act. That doesn't mean that the message shouldn't stop. That doesn't mean that our advocacy efforts shouldn't stop. What we are hearing is that it is not enough to cover those 1.5 million people who would automatically have care, who would automatically be serviced and funded through the federal government. They're afraid that the government will renege on those deal. They're afraid that right now it's a 90-10 match. The fed's picking up the highest part of that. They're afraid that's gonna go away. So we need to look at it, I think, as a way to talk to CMS and say, how might Texas develop its own unique coverage of benefits that involves private partnerships, it involves HMOs, it involves, it can't just be a direct Medicaid program. But there's gotta be a way. Five million people uninsured. We cannot let them stop the dialogue because they don't wanna cover that easy 1.5. We have to say that you have a responsibility to cover the entire five million patients who deserve to have insurance. So whether that's something out of the box that's been done in another state, a waiver that's been passed in the other states that have really come up with some really innovative ways to cover people, we have to ask them, as our leaders, bring that to the table, let us talk about it. But don't shut down the discussion. We are the highest, we have the highest number of uninsured adults and children in the country. And we have, obviously, has not gone down as much because we did not expand. But yeah, that discussion has to keep going. I had a question, oh, excuse me. I had a question about what you mentioned, mandatory health literacy training for police officers. Is that something that is being considered in Texas? And the reason I ask is because we've noticed that as a big issue, we work in violence prevention out in the community and we help people fill out victims of crime compensation forms. And really, we do not, a lot of times people get rejected because they don't fill out the form correctly. And I don't know how anyone in your right mind expects a victim of violence or a survivor of homicide to a family member who was killed to be able to be in the right mind to even fill out that form correctly. So these initiatives here are being considered as best practices in other states. We did this research with the National Conference of State Legislatures looking to see what was being done to address health literacy. A few weeks ago, our Sally Committee met with officers, peace officers, firefighters who were having these programs taking care of the folks who are at risk and not able to get to a hospital, making that first responder visit. They really were doing health literacy, we think, but they didn't know it in the way that they were able to educate that patient, making sure that you, which door to go through, following back up with them. So I don't think it's a far-fetched idea. We certainly don't want to offer some kind of a mandate. Sometimes when you say something is required, you get pushed back. Oh, don't put one more restriction on us. But if it's something that we say will save you money, will help keep folks out of the wrong door, out of ER, you offer it to them as an incentive. And it's something certainly that's gonna increase, it's gonna provide better quality care. So we hope, I need to talk to our Sally committee, but we hope that we might be able to get a sponsor to carry some of these initiatives. I just wanted to ask you on the Medicare expansion, the lack of or the refusal to expand Medicare here in Texas, how do you think that may impact 1115 funding in the future? So how many books of y'all are aware of the 1115 waiver and what it does? It has been an awesome waiver. I was, in 2010, I was working for a lot of the CEOs of the public hospitals when this waiver idea was brought to them. And the reason that we have a waiver is because managed care, the state had decided to do managed care in Texas. And when you do manage care and move away from fee for service, you are going to stop that payment coming to the provider just for doing that service or that, you know, what they did for the patient. What you're gonna have is the HMO getting a capitated amount for that patient and for the year, and that's it. Whether they cost you more, whether they cost you less, whether you made any kind of profit, that is really the HMO's job. So when you go to a capitated system, you accept that payment and there's no way for you to draw down that additional dollar from the federal government to make up for that low reimbursement. So in order for that delta to be brought back down to Texas and to keep those hospitals open and those providers also willing to take Medicaid patients, we had the 1115 waiver, $29 million over five years to have that funding come in and really fill the gap that was gonna be of the capitated payment that was not gonna be paying as much. So over five years, our hospitals and providers were paid for uncompensated care. And then for those great desert projects that y'all heard about that are just really transforming the way mental health is being delivered, specialty services are being delivered, it's really a big win for Texas. We have to renegotiate that waiver in the next 17 months. It comes to expire, we received an extension, but it comes to expire December 2017. So in that time between now and then, the feds want to see, you didn't expand Medicaid, it doesn't look like you want Medicaid expansion. So how are you going to deliver care in that waiver that will take care of more Medicaid patients? And yet, because we're gonna stop paying you for that uncompensated care, because if Medicaid was available, you would have less uncompensated care dollars coming to you as a provider. So that is a challenge. How are you going to increase those patients and you know your UC dollars are gonna decrease and that is what they're working on now. And I think there's gonna be a solution, I do. We have a more general question here. I would like to thank everybody for the great speeches we have on the meeting. So this is a very general question and it's for everybody and we can answer it or just leave it. Actually, I feel the problem is a little bit complicated because the target population is people who don't have any interest to learn some of them or they don't have an intention or an initiative to know more about health. So how we increase our interest first or make them have this kind of interest from inside to learn about things. So I have been facing in different positions or jobs I have that people even don't listen. So how can we make them listen first? And especially for the target population that we have, most of these people have like so many jobs, they are poor, they just need to feed their children, things like that. So for them they feel this is something not very important that we are just talking about something that's not that much for them and just they need just for the treatment. The other very important part, to be honest with you, there is so much to know. Like myself, I'm very illiterate in social media. I don't know much about technology, how to use iPhone just to, I have iPhone. I don't know how to keep just updating myself with these all applications that it's on there. And there is so much to know. I mean, there is so much to know. I mean, I'm not sure how many people know about oral health. This is my area. But you have oral health, if you have general health, if you have a mental health, if you have so many just health only, this is too much for somebody who is not educated or she's not educated, who have like several jobs, so many kids to know. So basically maybe we have to have a priority for them and among these priority to see their individual interest. Once we know their individual interest and problem, we have to increase their intention for the interest to know about it. It's basically it's too much and too complicated to say. Thank you. Sure. Okay. So in a way you answered your own question, I think when you said people don't do what it seems like they should be doing. And it's because they're struggling in their life. And when people live under a condition of scarcity, that's all they think about is where's my next meal coming from, can I pay them rent next month or am I gonna be evicted? Who's gonna take care of the kids tonight as the two spouses maybe go to their second job. And there's a lot of actually interesting information coming now about how people think under scarcity. So psychologists will take people like us, put us in a lab and they'll say, imagine that your car is in the shop and you have a $1,500 repair bill. Okay, and you don't know how you're gonna pay for it. Just imagine that, even though it's not true. And then they give them tests to ask them questions about fact questions or decision making questions. And after they planted that seed in the head of an unpayable $1,500 bill, the same people are making worse decisions and answering the questions in less adaptive ways than they did ahead of time. So imagine you're not in a lab with a hypothetical question about an unpayable car repair bill that are actually someone who goes home with their, the way they get the car that they took to work is in the shop. They don't know how they're gonna get it back. They don't know how they're gonna get to work tomorrow without begging a different friend every day. So when you're living under those conditions, it's very hard then to think every day about, how am I gonna thrive today? What great decisions am I gonna make about my exercise plan or my eating habits or going to the doctor to get my checkup? A lot of them are uncovered. They don't know where their checkup's gonna come from. I'll just, I'll tell a little story which I told at the community health rollout. San Antonio has one of the highest rates of diabetic amputations in the country because we have a lot of diabetics, because we have a lot of uninsured people. If you're gonna build an amputations factory, you would bring those two things together. A lot of people with diabetes, a lot of people without insurance and amputations sort of flow out the other end. But it's sort of deeper than that. We decided we were gonna get to the bottom of it. So we pulled together six men who had had amputations and formed a little focus group and they came together and we fed them dinner one night and they just talked about different questions. And we said, how did you get to this place where you knew you had diabetes, you knew that it was risky for your health, you knew your foot was at risk and yet here you are today missing a limb. And the answer they gave us was essentially we worked. I mean, that was our priority was being the breadwinner for the family and going to the doctor and taking care of ourselves. A lot of them work in occupations, some of them informal economy occupations where if you don't show up for work one day, well there's somebody else who's gonna be doing your construction job tomorrow. So what they prioritized was making sure that their family had the resources and a roof over their head and food on the table and their own health was secondary. That's the story we heard over and over. So not that that's the explanation for everybody but for many people who are living under conditions of scarcity, the realities of their lives and their priorities are such that all the health creating things are at the bottom and all the survival things are at the top and the health creating things often are very long term. Right, if I don't exercise today, well I'll do it tomorrow, I'll do it next week. Do I want to eat better food? Well okay, today we don't have a lot of money, we're gonna go to McDonald's and feed everybody so the kids don't go to bed hungry and hopefully next week or next month or next year we'll be in a better situation but that's the reality of living under conditions of scarcity and so until we solve those problems at a more fundamental level, not that everyone's gonna be wealthy but that no matter what, and we're always gonna have poor people we're just empowering poor people so that the basics of people are there, the basics of a dignified and minimally flourishing life, you know, a job that pays a decent wage, a food system so that people who live in every neighborhood have access to healthy food, have access to say physical activity, these aren't utopian things, there are so many places in the world where people have these things, it's just that we don't invest in them because we have this ethos of don't tread on me and we don't create things in the community that it would be actually not so expensive to create as a community but we don't prioritize it. We have one more question for Melanie and then we're gonna wrap up for the next piece. Hi Chris, as you know I work at the DT House Science Center and we actually have medical students here in attendance. My question is what advice do you have for them and for other healthcare professional students in getting involved in advocacy in the upcoming legislative session? Good question. So what I see with the medical students and anyone in the healthcare field and you're the one providing that direct care to the patient, get involved with your associations, get involved with the nurse association, the Texas Medical Association, they love to bring you to the Capitol. They love for you to, first they'll educate you on how to do that, how to talk to your legislator, what issues are gonna be key for the session and then you make the visits. You go to your legislator, your senator, I am from your district, I vote in your district, this is what I do for a living, these are the people I care for and ask them what they will do, what they plan to do, what they will commit to do to take care of the uninsured. I mean you are the ones that see your patient, those patients every day, you've got stories to tell them. What sells most is not a governmental affairs hack like me going and make and testifying. They don't wanna hear from me. What they do wanna hear is the story of the folks who are really living it every day. That program, that local program that succeeded at the local level, something we've done in our community that seems to work and might be able to be some kind of an answer for the state or for the state agency. They wanna hear a story that changes their mind on the issue. They know it costs money, they'll push back and say we can't do it this session, maybe next session. But don't, your voice is so powerful, your story is very powerful, the younger you get involved the better. I was 23 years old with my first job at the state capitol. It is not the way they teach you in civics or it was so eye opening. I ended up staying there 16 years but you get hooked and you're thinking you can make a difference. And I certainly encourage the students, I encourage our young medical students to really engage and be a part of it. And I am happy to help them if, you know, send them to me. I could use them, I think that's great. Thank you Christine. Thank you to both Dr. Farron Christine for the presentation today. So we're gonna play a quick video and this kind of ties in. We hope that you will take this message. We've been sharing this message with all of the community and so Bear Audio is gonna do a quick demo. The health collaborative, as I mentioned earlier, is working with a lot of different partners and communities to build some solutions. And one of the other layers that we're working on is community messaging. And messaging and the support to really identify new areas of where we can be supportive. Dr. Farer talked a minute ago about the significance of data, the significance of partnerships and collaborations. And so in that, we have had the great support of Interlex Communications to develop a community messaging campaign called Grow Healthy Together, sorry. And so we're gonna play a quick video for you and then we're gonna go through some wrap ups. We have some prizes that we're gonna give away and we'll go through some evaluations. Open schools, for the first time in history, the population over 65 will equal that below age 17. The majority of Bear County residents are Hispanic, about 60% in fact, and are mostly young. However, in the coming years, the population pyramid will shift as Hispanic youth reach adulthood. Rapid population growth, changing demographics and environmental transformation can be challenging to our community. These same challenges also present opportunity. Local access to recreational facilities, parks and pathways have improved, but public transportation or air quality and neighborhood walkability have remained constant or gotten worse. A person's health is greatly affected by their physical and social surroundings and influences their ability to make healthy decisions. The health issues these adults will face are heavy burdens of high blood pressure, cardiovascular disease and diabetes, ultimately challenging their health and decision making as they join the workforce. Obesity in Bear County is among the highest in the US and as citizens of Bear County, we must instill proactive efforts in our government, local businesses and financial sectors to promote healthy opportunities. We cannot stop progress, but together we can shape it. That's why the Bear County Health Collaborative urges everyone to become part of the Grow Healthy Movement to thoughtfully consider its community health needs assessment and participate in its community health improvement plan. Together we can grow healthy. So this is the first of the community messaging pieces that we'll be putting out. The next one that we are going to be providing to community is at the Mental Health Awareness Day on October the 10th, so that's this Monday. There's a free community wide resource fair that's happening in recognition of mental health awareness. And so we're partnering with the Bear County Department of Mental Health and along with the 50 plus partners that are part of the Mental Health Consortium. So on Monday we'll be providing a new message with regards to the topic of mental health in our community and how all of us can really work together in partnership and really collectively look for ways, look for solutions, look for partnerships and bridging, really providing that network of support for our families. So we hope you enjoyed this presentation and we'll be releasing the Mental Health messaging piece on Monday. We anticipate probably another top, maybe another, I don't know, Bob, how many do we wanna do? 10, 15, 20? No. But we will be looking to you again. This is where we really come back to you and ask you for your feedback. Today's conversations were very important. One of the pieces that you guys have before you leave today, we're asking you to complete your general evaluation surveys. Anything that you think that you can think of is important will help us provide more learning opportunities in the community beyond the Health Literacy Conference that happens annually. There are so many other things that we have potential and opportunity to do in partnership and in collaboration with you. So please take time to fill out your evaluations, give those to Brittany or you can leave them at your table and we can pick those up. And we really appreciate you guys sticking with us. Charlene has said to me that they are going to draw their tickets. So Charlene, Caroline, will you give Charlene a, and those were the white little tickets that were at her table. So time has passed. Only those that have the ticket will be able to do that. Anyone did not get a ticket? Oh, you have a couple people. So if you did not get a ticket, we're going to do that super quick. And Dr. Zarkadoulis also wanted me to remind anyone that is interested in participating in the Child Healthcare Survey. Please, please, please connect with her. We will happily send that link out to you as well. But she is also looking for that feedback from you. And that was a survey she talked about earlier on children's health. And while Charlene is shuffling hers, I'm going to start asking Dr. Ferrer to pick out a couple of named badges. This is how we're doing our prizes. We have a total of 11, actually, plus Charlene's is 12 door prizes. So only people that stay to the end are eligible for this. And you must be present to win. So if I call your name and you're not here, don't pretend to be your best friend because she left early. All right, we're going to catch you. Someone's going to tell on you. So Dr. Ferrer, will you pull out 10 named badges from the bag? Yep, one at a time. And Charlene, you tell me when you're ready. Tell them this is an exercise in scarcity. Yeah, this is an exercise in scarcity, he says. OK, so the first one is Gwenda Stewart-Reyes. All right. Gwenda, you are going to have Starbucks on us because it's kind of chilly in here. We tried with the. Charlene, are you ready for yours? OK, so here's for the Weber grill. Yes, don't be mad. OK, did everybody turn in their tickets? Oh, she doesn't have a mic. OK, so pull out your white ticket because we're going to do this quickly. We want to get you out of here before 4 or 5. 797-150. There you go. All right. All right, Weber's gone. All right, Dr. Ferrer has picked out some more names for me. Rachel Kite or Rachelle Kite. Rachelle, you're having Starbucks on us. Thank you. Next winner is Renee Palafos. Renee Palafos, come on up, Renee. Come on up. You're having Starbucks on us. These are $20 gift cards to Starbucks so you can actually maybe have a couple of Starbucks on us. Ellen Spitzen. Where's Ellen? Ellen, you must be present to win. Is she gone? Sorry. OK, Bruce Hanks. Bruce Hanks? Bruce, come on down, Bruce. Bruce, you also have a Starbucks card for us. And like I told my class the other day, I was doing a women's group conversation. And so they all got these goodie bags. And of course, you always want your neighbor's prize. So if you feel like you must trade your prize, that's OK. Melissa Kaufman. Oh, there you go. Thank you, Melissa, Starbucks card. Next one, Ricky Gonzalez. Ricky, come on up. Ricky, you have a gift card for iTunes. Do you have an Apple phone? Oh, well, OK, y'all can trade. Somebody can trade him. OK, next one is Carol Schlesinger. Thank you, Carol. And Carol, you are the proud owner of A, of A Nothing. Carol, I apologize. I don't know what happened there. Oh, you know what? Brittany, the movie cards. OK, it's a movie card. You have a, oh, it's right here. I'm sorry. I lied. It's right here. I am sorry. It was inside. It tricked me. Juan Lopez. All right. I don't know. I think Metro Health rigged this event today. Too many Metro Health winners. OK, next winner is Anita Morones. Anita, come on down. It's an iTunes gift card. Oh, I think Jackie Casas. Jackie Casas, where's Jackie? Come on down, Jackie. OK, and then the last prize, probably the most, the one we've all won. So La Quinta gave us a hotel night stay. They do this for us every year. Here you go. All right, that's it. Here we go. Monica Huerta. Monica, are you here? We have to check your ID, Monica, because usually some people just like harass us about this. Congratulations, Monica. You can use this, I believe, up to a year from now. So make your reservation. It's very nice. OK, well, again, I think we just really want to say thank you to you guys. Please fill out your evaluations, your surveys. And thank you for coming.