 Mike made the comment about trying to get concordance on what translational research is. And that's, I mean, there's just such a variety of stuff going on from the full beginning of T1, T2, and now we talk about T3, T4. And it's actually been, I'll preface it by saying it's been a huge actually growth experience for me to work with CTSI over the past five years being sort of in my own world far at the T2N. And I must say it's probably the experience that I have when I listen to Jeff give his talks is probably about what you're going to experience now, Jeff, with my talk, which is just, but that's part of this is it's a whole different language. It's a, you know, where I'm attacking health problems from and, you know, it's all I can do to get to a worm, but much back to the actual, you know, underlying cellular intricate dynamics. So I think what it calls us all of us to sort of think, are there common commonalities and parallels and language we can use about that? So that's one of the things I'm going to try to talk about with this is sort of a framework that maybe can draw on a whole host of translational research to try to put some of this work we're doing on community health and perspective. So this is going to be this update on SFHIP. And the first question you may rightfully ask is, what is HIP? Oh, see, this thing, all right. See, I was going to get clever, but you'll have to just imagine Tower of Power playing in the background. So SFHIP is the San Francisco Health Improvement Partnerships. It's gone through a few iterations of name changes. And this is, so this is a cross-cutting initiative that we've launched into as part of the renewal grant and we really started to move towards this the year leading up to the sixth year of our CTSI program. And this was the, this is what we put out as a challenge. And it's right, the reviewers as I think Laura Schmidt commented earlier said that this was overambitious and it probably is, but if you don't reach far, then you are suffer from poverty of ambitions, which is not a good thing. So we are trying to say, can we make a measurable impact on the health of our local community and eliminate disparities through better connectivity between all the research assets we have at UCSF and their tremendous needs out there in our own local communities to actually make a difference in health. So this is a structure. What we've tried to do is build a collaborative network among key stakeholders in San Francisco. So it's the government agencies, the mayor's office, other agencies, it's Department of Public Health, the school district, hospitals and health systems, the hospital council and a whole bunch of groups. And UCSF is one player, but UCSF is not frankly at the center. I mean, we are trying to articulate with this whole network of people out there working on these health issues. And so I think of this when Keith Yamamoto talks about networks and transdisciplinary science and the web of connectivity. This is sort of our version at the further out on the T2 end with what I think Keith is thinking about at the sort of T1 in the beginning of translational science, but it's how do you bring disparate elements together to work collaboratively on translational science? And what holds us all together is a coordinating council that has representatives from each of these constituent bodies. So we have people from community-based organizations, UCSF, the health department and so forth at the table helping to guide this project. We have selected the following eight priority areas for our work. These are based on looking carefully at what's been done in San Francisco over the past decade on needs assessment about the health problems, talking to leadership at the Department of Public Health, Mitch Katz, and then Barbara Garcia, who's a new director, sort of doing an assessment of what are the problems that account for a large amount of premature morbidity and mortality in this city and health disparities? And then where are our assets aligned at UCSF where we can plug in with some efforts in these particular areas, particularly thinking about moving upstream more on prevention rather than just acute treatment. So the first three that we're launching into, wow, that really sort of disappears, doesn't it? So I'm just gonna, so physical activity and healthy eating, hepatitis B and alcohol related issue of the first three, the next two teed up and just getting off the ground or around violence and youth and mental health issues and then also early childhood dental carries the number one completely preventable chronic condition of children. So for each of these areas, we're sort of facilitating and working with partnership working groups and the goal for each of these groups, let's say in physical activity and nutrition is define a target population, specify the outcomes that you wanna change for that population, whether it's behavioral intermediaries or ultimate outcomes, so whether it's eat more consumption of fruit in a week or it's a lowered BMI or less prevalence of the onset incidence of diabetes, outcome metrics to measure your outcomes, prioritize interventions, look at what the evidence says, look at what experience says from the wisdom out there in the community of people who've been working on these issues for a long time in real world settings, figure out what's feasible to try to implement, what's scalable to be more than 25 people in an experiment about a whole population that you can affect and how's it gonna be sustainable? So it just doesn't end when you have a grant and the grant ends and then the whole project ends and then implement those interventions and evaluate them. It's not quite as linear as that when you actually get down to it. So it sounds good on paper, but the experience you find, it's a little bit like doing any research project. It looks good in the grant proposal, but you don't actually march through it quite in the same methodical way once you actually get to work on it. So the first project has been around alcohol and the initial problem that this is working around is on high users and multiple services that go by the acronym HUMS. And I don't know if any of you read a Tool Gawande's article in the New Yorker six months or so ago, but there's this whole hotspotters. These are individuals who consume huge amounts of resources through emergency medical services, ambulance transport, emergency services, social services, jail services. And so the Department of Health has been trying to get their hands around how to better understand this population and manage them along with a lot of community organizations and social service organizations. And one of the things they did, which has been to merge disparate datasets from community mental health, from health department, from emergency services, from jail services, and so forth from the welfare system into one integrated database with individual level data so you can identify an individual and track them across these different data sources. So they needed though expertise in how do we analyze this huge dataset with very complex accumulated data to make sense of it and to understand how this can inform our work. So what we have as an asset at UCSF is Laura Schmidt who's both a sociologist and social worker who has a lot of experience in both analytic work and understanding policies in these programs. So Laura's worked with the Department of Public Health and other partners to analyze this. So they've done a preliminary analysis to show that there's about 400 individuals that are in this high-utilizer group, most are homeless or chronic inebriates. The top 10 individuals on this list cost the city, us, our taxpayers $2.3 million a year. And about one of them die a month. So what they're working now is developing predictive models for HUMs to identify this and it made me think of Clay's project I was thinking back on with Kaiser and others was identifying patients with TIAs that are at high risk of having strokes. Wasn't that one of the project? So this is, it's very analogous to that in the clinical realm is how do you know which patients with risk factors are at the top of that list who need the most aggressive interventions to try to head up a cascade of worse outcomes following, the work isn't gonna expand more to primary prevention around much more policy level interventions that are related to adoption of alcohol in populations. The next project is Hepatitis B. There has been in San Francisco for several years the SFB Free Campaign. Let me just look at the, interesting, all right. It's funny when you look at your slide and it's not the slide you remember actually creating but that's a whole nother matter. All right, the Hepatitis B campaign advocates Asian Health Week, Asian community leaders along with the health department have targeted outreach to the Asian immigrant community in particular 30% of San Franciscans are of Asian ethnicity about half reborn outside the United States where there is endemic Hepatitis B infection, a lot of vertical transmission at or soon after birth with people then acquiring chronic Hepatitis B infection about one in 10 Asians has chronic Hepatitis B. Big outreach to get Asian immigrants particularly screened and then tracked into care if they test positive for chronic Hepatitis B. The problem has been tremendous lack of readiness on the clinical side to actually respond to people particularly if they test positive positive for Hepatitis B. It's a complicated chronic illness. You need structured programs to get people in for hepatocellular cancer surveillance for appropriate antiviral treatment on the subgroup that's appropriate for that. And what we looked, we looked at some initial data in San Francisco, there's inappropriate screening being done, people order the wrong screening tests in community settings. If they're susceptible and not already infected then people don't get their immunizations completed and there's inadequate follow up for people who test positive. So what we've done there is working is to assemble a quality improvement collaborative with all these different groups in San Francisco essentially to go at the health delivery system level and say can we get everybody in the room and agree how we're gonna tackle this citywide problem in a collaborative framework. What's remarkable about this is you just don't see these two names even on a slide next to each other. You just don't see the Hill Physicians Group, Brown-Tolen, I see Jeff Newman here, I mean CPMC and UCSF and San Francisco General and Chinese Hospital talking together. And that's what we've done. We're not too far along this but what we have is people in the room together talking about how are we gonna come up with a common set of metrics to measure appropriate practices, to track it, to feedback to each of our systems, to learn best practices from each other and work together. These are some of the individuals from CTSI who are involved in working on this effort which I think is quite remarkable. Huge opportunities for bioinformatics to come in here. If ever there was a place to start something like a health information exchange where you could share data across all systems would be something like Hepatitis B screening and Hepatitis B followup. If you wanna talk about a clinical research service center what this is gonna create is unbelievable database for longitudinal research on the history of Hepatitis B. I mean you can just invent the number of research studies. Our goal is to set up a quality improvement framework but it would have tremendous synergistic opportunities with other research. Physical activity and healthy eating, these are the data on children in San Francisco in terms of various indicators. You can see problems and they're particularly prominent in the Latino and African-American community. I won't make you dance anymore. That is the First Ladies Let's Move program. About five years ago Mayor Newsom launched a campaign in San Francisco called Shape Up San Francisco again to try to encourage programs to support to help promotion and physical activity and healthier eating. We've gotten involved with again a lot of good stuff going out there. So it's not like we come in to CTII and say let's solve this problem, let's just take this on. What we try to do is figure out how can we plug in and accelerate existing efforts that are going on out in their community. So one of the major events we had was last October which was a convening of major stakeholders around physical activity, healthy eating that we did with the Shape Up people and the Department of Public Health. And so these are some of the folks. So we have, again, this is what you heard about in the video, we have Supervisor Maher there with, let me just go back up with, oh this is that tap one. You have, there's Laura Schmidt, this is Karina Guerta from the Health Department. This is Michael Huff from the Hospital Council. Here you have some researchers here. Hillary Seligman is doing food policy. Here we have folks from Bayview Hunters Point working on programs, Larry Green from UCSF. Here you have some other investigators. And what this is showing is, so these one group starts to say, let's talk about regulatory policies, tax policies. This is from the New York Times article that was just in the Sunday Times about taxing food as a way to actually decrease consumption of particularly sweetened beverages. This group here with Hillary and Larry Green and community folks realized they had a connection with the community groups in Bayview working on food production, community farming. Hillary has a project on WIC vouchers that can be used for farmers market produce. Well, can they be used for this group in the Bayview that's working on farming? Connect them with Hillary's K project to synergize. Down here we have folks, Chris Mattson from Pediatrics who's done a lot of research on physical activity in the schools. They're working on a project Safe Routes to Schools where Kim has been mapping out how to work on changing school assignments to emphasize local school assignment and how to then create safe crosswalks so kids can actually walk to school, can bike to school instead of having to drive to school. They have a whole bunch of projects there. This group was involved on breastfeeding as a way of again affecting weight gain and infant obesity. And then again, you have folks like Larry Green who's here at the Cancer Center in Epian Biostats who was on the Institute of Medicine Committee that came out with a report bridging the evidence gap on obesity prevention. Tremendous resource to have at the table talking with these folks locally about how do we apply those lessons from national committees right here in our neighborhoods to strategic interventions. What we then do is try to work on a problem analysis. These are multifactorial problems with causal factors at all sorts of levels. You have socioeconomic factors, policy, neighborhood factors, family and community policies, individual, and those all collide to create this complex problem of obesity. And you can't think if you're just gonna do one little thing and just a let's move, get up and do five minutes of exercise that's gonna do it or if you just do the community garden, you have to have a very comprehensive array of interventions with a clear conceptual model of how these are gonna work together to actually move the dial on something as complicated as obesity. We've honed in on now on the Bayview Hunters Point on what's being called the Heel Zone. And this was through our work again through this collaboration to get a grant from the Kaiser Community Benefits Program that's gone to the San Francisco Department of Public Health and the Shape Up Program to really narrow it down to this 10,000 population size quadrant and Bayview Hunters Point and to really work on then an articulated plan to make a difference on that. This was also factored into a big CDC proposal that went out as part of the community transformation grant proposals that the health department took the lead on. So what we try to do is we bring the scientific evidence, the IOM reports, the CDC publications as what we contribute. Gosh, I hate the tap thing. Is that, am I the only one that's driven crazy by tapping on this thing which changes it? All right, you then have community wisdom. These are food guardians. These are youth, young people in Bayview Hunters Point that are hired through some of these programs to actually go out and we have doing interviews and asset mapping to understand more what's really happening in the community and you put together scientific evidence from rigorous research with the wisdom and the local understanding of the context to try to see how these fit together. Data has to be a key part of that work working with bioinformatics about what are the datasets to monitor BMI, physical activity, datasets that the schools collect, that are collected through various survey tools and so forth. The indispensable assets that actually really make this work are our staff, frankly. This is Ellen Goldstein, our manager, Roberta Vargas, Paula Fleischer, James Rousen-Negas. I mean, all this takes people like them, these are the coordinator version that came up earlier when we were talking about clinical research services and the need for coordination. These are our key coordinators who are out there engaging with the community on a regular basis and holding kind of this complex coalitions together to make it work. What have we learned from some of this initial advancing of the work of SFHIP? So what, I mean, it's all about what can we add that's a unique strategic value to these efforts? Again, the thing we've learned is we're not gonna solve these problems as UCSF alone. And we're probably not even gonna be the ones primarily driving the interventions, but we can sure help. So we can help with networking and convening. Even though you heard in the video some suspicious, suspicion about UCSF and some community attitudes that are not all completely positive, there is an ability of UCSF to convene people like we did with the physical activity and nutrition planning because of UCSF stature in the community, so we can do that. We can provide research evidence base, busy public health department workers, school district workers who know some of this but really can use help in people synthesizing the evidence. Theory actually helps. I mean, it can annoy people who wanna just get to work and move forward but actually sometimes stepping back and putting some theoretical constructs and conceptual models can help the work take shape in a more focused way. We can help with data collection and analysis. Laws work with HUMs being a great example. We provide human and material resources including things like seed grants and navigator services. We play a role clearly in investigation and evaluation of whatever interventions get rolled out through these types of projects we're working on. And the final thing that we can do is help build local capacity, build the capacity of the health department, the school district of community-based organizations of neighborhoods to be able to be more empowered to tackle and continue to solve these problems in partnership with us. So that's where we are with SFHIP. I mean, it's still early. I can't come to you and have a metric for our dashboard yet that says the BMI and the Heel Zone has gone down 5% because of this. We're early on in moving forward with these projects. We're looking forward to rolling out some now in a more dental focused area with oral health disparities projects and someone in the more the mental health field. But it's been very exciting, tremendous learning experience and I think is really helping us at CTSI to say we can at least be at the table working in partnership to try to make a difference in the most pervasive problems affecting health disparities in our own communities. Thanks very much for letting me share this information. Great, thanks Kevin. So wasn't this a year six post-renewal project? Yeah, right, yeah. So anyway, obviously when you come across something that you get excited about. We've had 20, 28 days to get this stuff. Then you get it started early and obviously this was something that all of us were really excited about. So it's great to see the progress that's been made already. So any questions or comments? So Kevin, my question relates to training people to be collaborative. What are you all doing to help communities and academia and whatever understand what the process of collaboration and cooperation means and how it works and how you organize it? I mean that is so fundamental. It's related to David's comment earlier. I mean this should be part of interprofessional education. I mean I think this whole consciousness, I would say it's part of how do you engage with communities but frankly it's about how do you do teamwork well, which we don't teach particularly in medicine where it's all about you're the boss and you're the leader and you're writing orders for everybody and I'm finding the same thing is true in our clinical work that every clinician needs to be actually better prepared to how to work in teams. There's a great, one of my favorite videos that I've seen from those TED Talks that people have ever seen the TED, it's a guy named Syvers on FirstFollower. Have you ever seen this? We have to post it, which is about the importance of not just being that first person out there but nothing happens unless people follow good leadership and that's a great thing to train people how to follow something good. So that's a lot of what we have to is unlearn how we always have to be driving everything and marching in and I must say that's a particular problem I have is how you actually sit back and listen and engage and see where you can join in and plug into that. So I would think this is a skill that is essential whether it's in community engaged research or frankly how to be a good clinician or how to be a good scientist or how to work in a lab and be a collab in team science. I think this whole thing of how we train people to work in teams to understand how to follow not just always think that they have to lead is something we should be doing. Now we are doing as people talked about. I mean, we're certainly treating participatory engagement skills 101 in our K programs, our CTST programs, health and society, but I would think this would be the core part of interprofessional education that David mentioned. I had one comment on a Robert Wood Johnson foundation project. I was involved in a Robert Wood Johnson project on asthma and before we did the project, Robert Wood Johnson went to all these communities and just said, well, here's how you collaborate. I mean, basically had this whole process about what it is because what happened was people would sit and people would say, well, I want to talk to you about something or I want to, and they would use the wrong words or say that to me. And it would be very touchy and things would fall apart before you could even get started. So it seemed like this pre-training of how to act together. So we don't know anybody out. I will say, Duke, at least the School of Medicine, I think it's true, Duke requires every student to go through a whole web-based training module before they can do anything in the community to go through this. Ellen, please chime in. I'm just saying that it's really important for all of you navigators because our theory is that nobody makes a cold call, nobody gets a cold call and all of these interactions have a navigator facilitating that discussion and facilitating that conversation and then stays with that conversation until folks can go off on their own. But we have everything very much partnered and facilitated by the navigators, which is a really different model from something that is a little bit more database driven where you just find somebody's name and then make a cold call to see if they want to partner. So, Kevin, I may have missed this. So that's fine. In this team effort, or maybe more importantly in this overall effort where obviously UCSF has limited resources ultimately in terms of great human beings and forget the money, where does sort of capacity building in the neighborhoods creating a core group of non-professional health providers and educators so that these things can be disseminated. People in the neighborhoods that are really trained in a way to disseminate some of this knowledge information. Jeff, we are going in so much with this consciousness, particularly in this budgetary environment. I don't mean just for UC, but I think for all programs. The failure a lot in this type of work is people say, we have this great idea. Let's train 20 community health workers and we'll get a $2 million Robert Wood Johnson grant and do that and then they'll train them to do health nutrition and physical activity and stuff and work in schools or senior centers and then the grant ends and those people lose their jobs because there was no thought about how does that get institutionalized. So we're going on with this thing. We want this to be sustained. We don't want this to be dependent on some grant and in some ways it's good to not have too much money right off the bat. So it's things like how would we work with the schools to get this integrated into routine curriculum in the schools that we can support teachers doing this as part of the basic curricular problem without having to think we're gonna have to hire this whole new cadre of health educators. How do we work with existing community-based organizations, those food guardians that are already out there and there's some infrastructure and a lot of times what you find is just there's so much parallel play going on out there and that nobody sort of consolidated this and sort of say how do we again maximize within the resources that are there the work that's being done. That's another reason for why policy is so important because taxes are the most cost-effective intervention because you actually make money on taxes. So that's a good thinking about or changing the structural environment. If you can do a one-time upfront capital improvement on neighborhood improvement, safe play spaces, building walking lanes to school and things like that, that doesn't take ongoing operating funds to sustain. So it's all about finding capacity that you can either support and then can be self-sustaining. Yeah, so I understand the self-sustaining part so you have to find, but I'll give you just one example that I'm very familiar with is this requirement in the public schools that only a nurse can work with a kid who's got diabetes on their insulin injections, right? That we can't have somebody else in the school but a nurse when you have a school that has 7,000 kids in it. I mean, that's a policy issue, but it's also a training issue because these people are there and I just still feel that there's some pretty darn good people out there in the community that we can train to do this and not have to build a big, expensive program. I think those comments are right on, Jeff. It's sort of like what we're encountering in our clinics at UCSF Medical Center, isn't it, Talmage, about what a medical assistant can't, our medical assistants can't give injections at UCSF Medical Center. It takes a nurse to do that. So we're tackling all these, and that's again there again, that's policy regulatory things and that would be, I don't know if we're working on that, but those are the kind of things that you need state intervention to kind of change some of the regulatory. Yeah, we would have a big P and a small P, that's where Claire Brindis often talks about it, policy and small P policy is whether a drug is on a formulary. It's whether a nurse is required to be there, right? And so that's exactly the kind of, once we can identify those issues, that's where we move. See, and Jeff, I think, I mean, I'm really glad you raised that example. That is such a classic example of where all the wonderful research in the world hits this wall. Because you can come with a diabetes center. Here's the best way to treat childhood diabetes, juvenile diabetes. It needs to have insulin monitored, our glucose monitored and injected at school. There needs to be some support for that, particularly with younger kids. And we figured out the right algorithm for that. We know the right injection schedule and the short acting, long acting and the metabolic max optimization of glucose control. And then you hit this stupid thing like, and there's this assistant there who could help with that or a teacher who'd be willing to be trained or be knowledgeable, but they can't do it because of a regulatory policy. And so I think, I mean, that's one of the big barriers with translational research is just these real world impediments to getting great discovery. And even, I mean, those are sort of the clinical arc of it which is about how to deliver services and then you read the reality out there in the community, whether it's regulatory, whether it's just people aren't trained and so forth. So this is the classic stuff we need to tackle. And I think this is also where the power and prestige of UCSF really comes in handy. Because when we come to Supervisor Maher or to the health department and say, you really ought to do this because there's a strong evidence base that we know about that supports it. It does help. You know, they do listen to us. And so I... Particularly get the Dean of the School of Nursing to go to those conversations. Yeah, that's it. We have plenty of time. That's for now. I got the money. Yeah, go for it, David, yeah. Well, you know, coming from New York, the, I mean, just to get to this specific one and then back to the broader conversation, the nurse in the schools was a nurse practitioner and it wasn't just giving insulin, you know, there was a broad range of services with referral into adolescent health clinics. So it was tied in. But it was a much broader range of services so that you could take care of a population of 7,000 people, many of whom didn't have regular access to care. So I think there are a number of different models and at UCSF, I think we really do have to have that conversation about what are the range of possibilities and what's best for the population that's being served. Now in the broader thing, we had talked and I had talked when I first got here about some different ideas, some different models. Some of it is we're learning from the community. We bring things to the community, but it's also how are we educating the community for research. So for example, having basic, very simple research design, what is IRB, community IRB, what does that mean for you? What are your rights as citizens sharing in the grant funding? So it is an, I get funded and we come see you, but actually, you know, 50, 50 splits where it creates jobs for the community, sharing about what grantsmanship is so that they understand that not every grant's gonna come through. And you find people in the community that actually become pretty savvy about that. And so those kinds of things create a partnership where you're working with each other. And I think that's what becomes sustaining because if a grant doesn't come through, it isn't like we disappeared. Everybody's managed each other's expectations. And I think that was a great thing that we were talking about. Great, well, we gotta wrap up, but that was a great discussion. I hate to close. Yeah, let me just, this is cross-cutting. So again, we mentioned it's bioinformatics, we're working with Bill and others, but for everybody at CTSI, please, if there's ways to plug in, and we'd like this to be as inclusive as possible. So it's an open invitation to everybody. Yeah, definitely. So this is a cross-cutting initiative that's supposed to cut across campus, all the CTSI programs. So please, everybody get involved.