 that's right and she is now 25 and she is 25 yesterday yesterday but over the years the San Antonio Health Literacy Initiative has really grown it started with a very small group of people five maybe four Dr. Basal Dua some of you guys may have stayed for or may have attended her Health Literacy 101 workshop earlier today has also been one of the founders Charlene Doria Ortiz Charlene will you stand so everyone can see you oh that's right Charlene is one of our founding members and we have Dr. Mica Virginia Mica which is with a university health system and she is over the care link department was also one of the founders and then we have the great honor the Health Collaborative has the great honor of having Mr. Charles Kite on our board who is actually the founder and itself is a former CEO of Community First Health Plans with us so this group has really done as I said a lot with so little but I will tell you that the volume of volunteers of the volume of partners that we've had the privilege of working with in collaboration to broaden this message of health literacy has really just grown over the years and so we're very privileged to have your support here tonight but the support of so many others as well as we advance and we continue to look for ways to share this message throughout our communities and definitely with our families Charlene Jackie Calak Jack Jackie Burant with University Health System is the other founder I'm so sorry I forgot to mention that to her I'm gonna be very selfish right now and I'm gonna actually ask my wonderful unique board members to stand Miss Bilal Oates who is our vice chair for the Health Collaborative Dr. Steven Blanchard with our Lady of the Lake University and of course Charlene Doria Ortiz who is also with our board of directors for the Health Collaborative we have Miss Christine Guzman here from the San Antonio I'm sorry the YMCA the Greater San Antonio Miss Andrea Guajardo who is on the board of directors representing Krista Santa Rosa and yes thank you so much so with our board of directors is delighted to have you president we're looking forward to a wonderful session tomorrow as well all day next I'd like to ask you to please help me welcome our co-chairs Dr. Bertha Flores and Dr. Lisette Leal Vasquez who are going to be providing us with some great information about our health literacy heroes I'm Lisette Vasquez and thank you so much for coming this evening it has been so informative I got to sit in with the health literacy 101 which was just amazing information and I saw a lot of good interaction in all the other breakouts that were being held and the food was amazing right we always have great great food so thanks thanks to Liz and her team so as this was mentioning we wanted to kind of share who got the outstanding award for health literacy this year if you didn't know we every year try to get some awards going out to all the people that are really you know doing a great job in this area and so this year we have three candidates that we are going to give awards to this evening and I just kind of wanted to share with you very quickly what are the categories so you'll know and kind of what what they're doing so the three categories one is the champion for change so in this category the health literacy area is in advocacy outreach and education in the community and then our second category is innovative programs and we're looking at different activities initiatives that demonstrate innovation and effective solutions and in category three we're looking at people that have really worked on published materials that are really written for for bringing effective communication change within their community so those are the three categories that we have selected from and Dr. Lopez will be sharing the names of the candidates for all three thank you again thank you everybody for coming today we would like to honor today our health literacy hero awards our first award goes to the champion of change and that is Miss Mary Kate Martin from the UT School of Public Health San Antonio regional campus Miss Kate is recognized for being engaged in the community member that is helping bridge more conversations on the importance of health literacy please help me welcome Miss Mary Kate Martin if you can say a few words Miss Martin thank you very much for this award I'm usually very talkative but this is the first kind of big award I've had so I appreciate all of the work that the people out in the audience have done today and do every day to help people understand our health system and understand their own health please keep up the good work thank you congratulations to Miss Kate Martin for all her hard work and dedication to health literacy our second award goes to innovative programs and that award goes to Catherine Belmont is she here today oh please come on in she's a patient navigator and she has developed a chemotherapy symptoms symptom tracker which is a checklist that has been given to clients to voice the bridge of the gap between themselves and their medical providers during their chemotherapy she's now presently working on translating into Spanish please help me congratulate her on her hero award I would just like to take this time to say thank you and thank you for my co-workers for nominating me as well and I hope that everyone keeps up the good work and this health literacy program thanks again and our final award is for Miss Lucy Maria Castillo and Miss David Correa for published materials are they here today Miss Lucy Maria Castillo and Mr. David Correa are employed at the University Health System in San Antonio and they have co-authored scenarios for success in patient communication thank you to the health collaborative for this award we're very very honored you know it takes a team to do what we do and it a lot of healthcare professionals that donated their time with all the interviews that we did and it just all the support that we get to improve communication between the healthcare provider and the patient thank you so much it's an honor thank you thanks to the San Antonio Health Literacy Initiative and the health collaborative for recognizing our efforts and everyone that has won and been recognized this evening we are very grateful as you all know most of you have probably experienced growing up as a child many examples where individuals walked into healthcare organizations and journeyed through a complex system that doesn't mean to be that way but is that way and through our experience during these past years I've teamed up with a great knowledgeable woman who has experienced the same thing so I would say that we come with passion and we've turned this negative situation into a positive situation by using what we are experienced when we grew up as a child because I can honestly tell you that both Luis Maria and I when we started talking when we first teamed up in 2012 we talked about how our experiences were so similar when we would go to to the clinics with our grandparents and then my grandmother had limited English abilities and many times as a young child I was the person that was served as the interpreter and obviously that was not the ideal situation Lord knows what I said back in the days because I don't recall but evidently I guess grandma got better because she she she lived to be 80 something years old and you know and and and but you know what there was a reason for that there was a reason for that and that purpose was for this particular award tonight so thank you so much on behalf of us thank you so much thank you guys congratulations to everybody and welcome again I hope everybody enjoys the conference thank you well thank you so much again and another one of applause for the the recipients tonight thank you so much for all of your efforts this is actually our fifth year that we are able to present a health literacy hero award and in the past we've honored our founding board members or our founding members of the San Antonio health literacy initiative to include community first to include our founding members to include Bear County for being a huge source of support for being able to put this conference on every year and Methodist health care ministries and other agencies like that that are really looking for different ways innovative solutions to be able to help in this area so again thank you so much for the honorees today for being with us but more so for sharing your innovation and sharing your passion for this for this specific topic of health literacy and advancing that in our community so thank you very much next we'd like to move on into the program we are going to have a great conversation we are just honored to have Miss Wendy Rigby here today Wendy if you just want to come on up we are delighted to have her here today many of you already know that she's with Texas Public Radio but she has actually been in a voice for community and for health for a number of years and so today she has a great we're honored to have her here as our moderator for our community panel and our panelists tonight include Miss Christine Guzman, Miss Andrea Guajardo and Officer Velazquez if you guys will go ahead and come on up and so I want so the way we're going to do this panel tonight just so that you know Miss Rigby has some preset questions that she has provided in in your conference packet today in your booklet you actually have some quick biographies of each of our of our panelists tonight the reason we chose or we asked these leaders to come to the to to this evening's reception is because many of us in the community are doing health literacy many of us are working in this effort we may not be calling our programs health literacy or putting bold titles with that terminology in it but the fact of the matter is is that they are truly connecting with families one-on-one and ensuring that they are understanding on different levels the information that is being given to them they are in understanding or helping to understand the health issues that are that they're being affected with but more so that they're also looking at much larger solutions as well what is it that they are doing within their systems what is it that the YMCA is doing that Krista Santa Rosa is doing that our fire department is doing and then connecting them back over to some social services tomorrow we're gonna have a presentation by dr. Robert for air the community excuse me the bear county health collaborative produces a needs assessment every three years and so tomorrow we're gonna get a highlight of some of those findings but what you'll note today throughout the conversation is how each one of these organizations and these different leaders are really stepping outside of just their institutions and really providing an umbrella of support for many of the families that they're seeing here today so again we are thankful to miss wigby for being here today and moderating this discussion and we encourage you to participate in this in this panel as well good evening I see some friendly faces out there I spent about 20 years working at Ken's TV and that's how I knew some of you then but now I'm honored to work at Texas Public Radio where they were smart enough to gather a grant to fund a position that is dedicated to bioscience and medical reporting so that's good I've worked there about three months now and they really believe in local journalism and they believe in you know spreading the word about what's happening here in San Antonio because at its heart all news is local so thank you for being here tonight this is gonna be a very quick and informative hour and it's just gonna wet your appetite for everything that you're gonna learn tomorrow while you're here when I was reading about this conference I was shocked to learn that only about 12% of adults in this country are considered proficient in their health literacy skills those are the skills that you absolutely need to navigate this incredibly complicated healthcare system and when you add to that the fact that 25% of Medicare and Medicaid patients in Bear County don't have basic literacy skills and up to 30% of residents in Bear County over the age of 16 don't even have basic prose literary skills that that's not a very good equation and the outcome can be very very bad and that means that your jobs are even more crucial to the people you serve you're sometimes the interpreter you're sometimes the tour guide you're sometimes the cheerleader and you're often the advocate you may be the one face in the whole system that understands these people's needs and then points them in the right direction sometimes one person makes all the difference in the outcome words matter actions matter and decisions about how to increase health literacy matter and that's why I'm here tonight so let me introduce these three panelists to you when I say your name please stand they'll be answering my questions and then there'll be about 10 minutes at the end where they will answer your questions each of these panelists will also be taking a deeper dive tomorrow during the integrating health literacy concurrent breakout sessions say that five times from 1040 to 1140 and we are honored to have with us this evening Andrea Guajardo Andreas stand up yes they need to see you the regional director of community health for Christus Santa Rosa health system her work is so vital to communities in San Antonio I see you send them her research focus is on Latinas in leadership culturally competent models for population health and public policy and program evaluation she's a San Antonio native like me she's a doctoral candidate at the University of the Incarnate words seeking a PhD in education and she's also an adjunct professor at the UIW department of health promotion next on our panel Christine Guzman Christine not quite as shy she is the director of the Y living center on San Antonio's south side the programs at that center focus on the holistic balance of the big three you know mind body and spirit and that means providing wellness education and promoting physical activity obviously at the same time and the Y is trying to eliminate any barriers that exist in helping people down the road on their you know wellness journey and that includes financial barriers during tomorrow's deeper dive Christine will be explaining how the YMCA's behavior change programs are led by passionate and professional staff dedicated to helping people and the idea is that greater interaction helps when you're in a group learning environment so that should be very interesting and our final panelist this evening is Christopher Velasquez of the San Antonio fire department you couldn't tell by his attire could you he's a paramedic with the mobile integrated health care program and beyond that Christopher is also a trainer for the crisis intervention team of the police department he's been at the fire department for 20 years and he's also an instructor in emergency health sciences at the UT health science center and during tomorrow's deeper dive Christopher will be sharing stories from the field you'll learn how the mobile integrated health care program got its start and how it is impacting San Antonio and Bear County's most vulnerable populations I'm told that the San Antonio program is so good that it's become sort of a model for other communities around the country who are interested in setting something similar up in their own communities so with that interests you consider that at 1040 tomorrow but now it's time to focus on tonight's questions and I will tell the panelists you know we have these nine questions we want to get through in 50 minutes so be informative but keep it snappy all right first of all we'll just we'll just go down the line this way first of all so Christine for your organization how do you define health literacy put it pretty close to your mouth I think for the why we've always believed in being that community connector and when it comes to the health field we've actually really looked at that now and centered around it but then the last three to four years where we've really focused on being that community connector so that the patients our participants your patients can learn more about their diagnosis through programs that are actually hands-on so they get to know a lot more about what it is to be pre-diabetic what it is to be diabetic and what that looks like for their life and in the way that they live their life that community connector that we've become is is more to have them improve their health as well as understand their health and so I think that's where the why has really looked at health literacy Andrea so health literacy the capacity the capacity or degree to which one can take care of themselves right we all know this definition we can all recite it by heart but I think the philosophy that Krista Sanderosa takes is that none of our patients is alone especially when we discharge them and we give them a stack of papers and say go home and take care of yourself good luck with that so to us health literacy encompasses not just the degree to which that person can care for themselves but the degree to which we have worked to equip them with the tool that they need whether it's explaining their prescriptions whether it's helping them to read their doctor's instructions finding a primary care provider all of those things that come into to play when someone is discharged from their from the hospital and you know disarray they've just undergone a surgery that you know you know how it feels to be discharged from the hospital you're not a hundred percent so until we call them non-compliant and non-literate we make sure that we've done everything that we can in our power to make sure that we've given them the tools that they need to become literate and to increase the capacity to take care of themselves so that's number one the second piece of health literacy I think for Sanderosa is that it's it's never a finite quantity health literacy is much like cultural competence I don't like that word I'm just literate just means like okay we're literate and we're done we're competent and we're done it's much more fluid process and what I mean by that is that literacy is ongoing I mean you didn't you didn't stop reading at high school and say I'm literate I'm done I read all the classics I'm done you still read books right and so for our patients literacy is an ongoing process just like cultural competency I like cultural responsiveness better we're responding to the needs of the cultural needs of our of our community and so competence like literacy is an ongoing and fluid process so I think the philosophy Chris's health is that we're a partner in literacy we help our patients achieve that and then it's an ongoing process and Christopher how does your organization define health literacy so we define the health literacy based off the community needs and that can be anything from just connecting them to available resources in the community existing resources actually create help creating a resource in the community that's not for a need that's not being met by the citizen it could be it's again we have a lot of resources in the community that the people just aren't connecting with and it's it's I guess health care literacy is so it encompasses so much it's kind of hard to quantify exactly what literacy is for individual I think it that that just you know it's custom to each individual for whatever their need may be whether it's medical mental health or physical need mobility and we you know we started this journey in 2012 beginning to implement a program that was basically we found a need in the community that wasn't being met and that need that need being again hospital discharge read mittens the most vulnerable medically fragile population that wasn't just connecting with the available resources and we found that it was they just didn't know they didn't know what existed out there what they were what they were entitled to as far as benefits with their insured with the payer or just what are you know people who serve our country's veterans and again it just it's so it's so encompassing to just say what is health care literacy for organization I think it's it's a collaboration of efforts throughout the community to for literacy so you already answered my next question why did you why did you integrate health literacy but who supported you in the process and why is health literacy important again so our administration our leadership in the city of San Antonio they really had the foresight to look forward and they said rather than we had some individuals in our city that we were taken to the hospital 80 times a year and they said what do we do then just take him to the hospital and pick him back up next week so without the leadership's vision and foresight to say let's do something different let's step outside of the box and let's respond in a different way let's look at our 911 responses in a in a proactive manner rather than reactive without the leadership of you know a skull city manager Scully and show Scully and Eric Walsh and my chief hood and our fire department administration because you know you're taking a time when money's tight and we say we went to the council it's okay we need another 1.5 million because we have this idea and I really thought when we went to the council they were gonna say yeah right good luck they didn't I was kind of surprised to be honest with you and because you know it's a lot of money to say we have an idea and it's based off theory and then that proof is what really sold it to a math past the pilot phase so from your point of view for the patients you work with it's important because it helps keep people from going back and back to the hospital getting sicker costing them more money all it be above yes and it we initially I guess our endeavor initially it seemed maybe a little selfish right we said well we have a problem let's solve it but as we got really deep into the data I mean data it really is data drives everything right it drives it drives a funding more than anything but when we started looking at the effects the community was like this huge ripple effects that we didn't realize that it affected so many people it created availability for our first line EMS units it decreased response times it decreased increased unit availability for just the fire engines and the EMS units it increased hospital beds we found that average on our mental health piece of it the average psychiatric patient was consuming 15 to 17 hours per hospital bed and we were taking these folks I mean we took one lady Southwest General over 80 times to that one facility so that's a lot of time yeah and Andrea who who supported you in this process and and why is health literacy important well just to speak to his point just a little bit when they when they first started this program I found it so unique and so refreshing because as hospitals we're sort of the passive recipients of patients right that you know because you're you're moving a patient 80 times but we're receiving a patient you know and I mean in the early beginnings of some of our community health worker programs we were having patients that were coming to the emergency room more than once a day so more than 365 times per year annual visits for community health worker programs so and I think that I mean personally for me when you guys started your program I thought wow they're paying attention you know I never thought that you guys would be sort of part of that continuum of care and so when you started your program so excited because I thought well those guys are paying attention just like we are we're not just sort of taking these patients and you're just trucking them back and forth without thinking about it so I applaud you for that and I'm so proud that you're that you're your program but in terms of hospital leadership and our support for our program you know we started our community health worker program program model probably for Santa Rosa in its infancy probably as early as like maybe 1994 kind of really got ramped up around 2002 this team that you see right here started in about 2010 with the CMS grant that was just looking at primary care usage among Medicaid and CHIP patients and then our leadership through that grant sort of saw the benefits and had the foresight to think this could be something this is working know it did the original grant didn't exactly have the exact outcomes that we were looking for partly because our customer service in the ER was that good I'm just saying so they said our data was skewed people came back because they just loved our ER so much so it kind of like it created some invalid data but the the lesson learned was that community health workers in the emergency department are valuable and they can create a conversation and a trust relationship with patients that does not happen at the bedside it does not happen in a five-minute conversation in a discharge process and so we had some leadership CEO CFO that said this could be something so when this grant ends let's just hire everybody full time which hardly ever happens most of the time people like we don't want to apply for that grant because we don't know what's gonna happen afterwards that happens all the time right let's not even try because we can't sustain it right and so we so we did and so we had some hospital leadership that had some really like far seeing insight about how this could work and it's been going for six years that's wonderful and Christine how about you who supported you in this process and why do you think health literacy is important in your setting so it's funny because I think we all kind of build on each other because the promodores is really where we we got our ideas of going out and doing things within the community and so it's all kind of built on each other and we realized and when I say we I mean the why at a national level realize the importance of getting out into the community getting away from our walls we stop that whole we will build it they will come into our walls theory and thought and started realizing just how much we needed to be out in the community whether it's at churches community centers wherever we have to be and then to get a partner like Metro Health District to come along and say we believe in your program so much that we want to try funding them finding and securing that funding for multiple years and the why coming in right beside them and saying it is important that we're out there doing diabetes prevention it is important that we're doing cancer survivorship programs and arthritis management programs and that they're not just happening at the wise and it doesn't just haven't to happen with YMCA members it needs to be out in the community and I really think that support it's always been there I mean the wise in San Antonio is 130 years old but it was yeah we just celebrated but it's always been an important role that we play in the community and with the health crisis there is just not a more important role at this point that we should be playing than being that community outreach and you know I look and I say yeah how are we sitting on this panel with a hospital and with our fire department and I just think it's because we have gone and really broken down those barriers and broken down those walls and and looked at their programming said this will work we have more feet on the ground let us help and really become that partner with hospitals and physicians and doctors to be out and really be grassroots with our programs alright this next question I will open it up to whoever feels called to answer it first we'll get a little more specific now so people can understand how did you integrate health literacy into your organizational mission and your vision and your your operation so does it become part of the planning process you want to speak to that so it was difficult because with the fire department it was how do you change a culture we ran it we met initially from our a lot of the resistance we met was from our internal fellow firefighters and paramedics they were pretty much this is not going to work this is the worst idea ever you know so that was kind of you know the resistance we had out there from the community as well as the primary care physicians and even some of the the hospitals were like no it's it's not gonna it's not gonna I'm sorry I lost my train of thought this is question number three windy okay so the mission again okay integrate the mission so our mission is of course you know to serve and help the public protect public safety and integrating that mission is kind of it would sound in on the surface you think it'd be easy it really wasn't with a lot of work in the last two years we did integrate and now we're kind of the go-to folks for the program for the fire department actually for EMS when they have a problem that when our paramedics our problem out in the field they can't solve because they have no idea what to do APS is hit a wall we've hit a wall or our paramedics in a wall they call us and we're the next call so again integrating it's kind of a new mission you know looking instead of being reactive being proactive so the mission statement has changed just a bit not a lot I mean you know we quantitate that with you know well with numbers of course with our success we've seen over 75% reduction somewhere a freaking callers we you know sometime it's 60% sometimes high 75% again the mission is the same and you know increase the health for the community Andrea how do you evaluate the success of health literacy because it's a little bit esoteric there's a couple different ways I mean obviously you know just an evaluation just basic evaluation there's qualitative and quantitative evaluation but in the hospital setting and and I always like to sort of describe my location in in this equation is right on the midline between you know I have one foot in the community and one foot in hospital operations in that what we do for our community and our community health workers for the most part manage a lot of our uninsured patients who are completely unfunded and would have almost no access to health care without their help and so what we do is essential in a life-or-death situation for some of our patients so their health outcomes are primary and and and a priority and so that lends to population health on the whole now then I go to our some of our administrative meetings and while our mission and our vision as a health care organization has been the same since we started in 1869 to extend the healing ministry of Jesus Christ we still our business a non-profit business but we still have to maintain a certain margin in order to keep our doors open so that we can serve the most vulnerable of our community so that that's the that's sort of the midline he disappeared and so that's that's that's the territory that that I navigate as in my position now that being said evaluation it's sort of too pronged how are we caring for our community and what are the health outcomes in population health of each individual patient which are going to be different with each diagnosis our primary diagnoses are probably what you see hypertension diabetes cardiovascular high cholesterol those are our top four for any of our eds but also there he is we were worried about you but then when I speak to my CFO and to my hospital leadership not that they are not concerned with all of our health outcomes but they want how are we affecting our business and how how are we caring for our hospital system so that we can better care for our community it goes hand in hand so in that way we do we measure financial outcomes average cost per patient we measure repeat ed visits read missions within 30 days as well as our a one C's and our hypertension and all of those things and the number of patients that make and keep an appointment that speaks to health literacy and so so those types of things so so really it's a too pronged approach it's not just the qualitative and quantitative but it's also health outcomes versus financial outcomes great great Christine can you tell us more some of the strategies that you have in place to meet the various levels the various health literacy skills of your clients I think one one of the things that we've done and I feel like we've done well is make sure that the people that are actually doing the programs they're not necessarily health care professionals some have that background but a lot of them have gone through the program or have met head on some of these diseases and have won or are still in the fight and so they're able to lead these groups a lot stronger obviously we've done the things like making sure everything's bilingual all of our programs being bilingual we've started doing a lot more social media making sure that that's done both in English and Spanish and looking towards the future what other languages are we gonna be tasked on on making sure that our programs are offered in we have a why living for health text messaging campaign where we send out healthy messages every week what's a healthy message I just want to know what that would be have you had your water today just simple reminders of of little things are hey Cicluvias this week or whatever it is did you get your flu shot so those are all things that we like to to remind easy reminders and in language that we all understand you know if we start using the big language that they hear from their doctors again we're just competing with that that health literacy barrier and so we like to make sure that everything is in a language that they can understand and yes we even do some of those text messages in Spanish so although I am not bilingual our staff is very bilingual I make sure that I have at least somebody who can at health fairs go out into the community and we started working with UTSA health screening mobile that is at flea markets that and to me that it was so outside the box because we're used to setting up health fairs and that's where they are well no they go out into actual where the community is and sitting right beside them and doing these health screenings and then sitting down with them and explaining what does this mean for them and then what is what programs or what resources are available and it's not just YMCA programs that we are showing them so so meeting people where they are how important do you think that is in raising the health literacy rate of a place like San Antonio it's huge I think when we talk about meeting people where they are we don't just mean location we mean journey we mean everything because if a person's not ready to do a commitment of 16 weeks to do a program they might be ready to do a health chat once a month you know and so I think that that meeting them where they are both in the community is big because it takes off that social deterrent of I have to find a ride over there or I can't leave my kiddos and actually going to the churches and talking to them are going to their community center and talking to them is a huge part of what makes the programs and what makes health literacy successful so social media fill us in how do you use social media oh we Facebook like crazy we Twitter like crazy like I said text messaging but we also have to remember that not everybody is on social right and that's a huge part as well and so do you tailor it then to a younger audience yes and no I have a lot of grandparents that are on Facebook and I can say that old people have taken over Facebook and everybody else has moved on but we do have to but we do have to realize that a lot of a lot of our older generation is not in a lot of our areas that don't have the ability to find a computer or have a cell phone in everybody's hand also need to be reached and so we maybe more and that's the truth because those are the people that may not be able to afford health care or have not thought of it you know if I have to pay for food or if I have to go see a doctor guess who's going to win my children being fed is going to win and so we try to make sure that we really do span out to social media we look at the the the different community newspapers because that's what they picked up right so that's where we're going to be right that even even though we do have a segment of the population that is not going to be online with their smartphone or by internet that the Pew Research Center put out a study I think it was last year maybe a year and a half ago that those who do have a smartphone the top two sort of sectors or segments that they that they research are health and financial information their banking and their health information those are the top two most utilized sectors that they use their smartphone for so raise your hand if you have not googled the symptom of your own yeah everything it's true it's true Christopher what what steps can your organization take to become more health literate I think the multi-lingual aspect of the communications here in San Antonio it wasn't we really got into really looking at the problematic areas and you know we can look at it a map you can look at it's not just English and Spanish it's a lot more like what can you name some other C and I'm trying to think of it what else French now we haven't run to that one yet not French not yet there's another it's not far see it's it they speak it in Somalia I forget the name of it so it might make the communication aspect is is something that we're kind of struggling with when is that because there are more refugees here I don't know I we you know we we have a population it's not a huge yeah but he said yes yeah and we don't see a huge as far as you know our target demographic we don't see a lot of them but they're you know the calls are there I mean just definitely they're there because when they don't know what to do they know they can pick up the phone and call 911 well that's good because you know they deserve the same level of quality but he also lives here so it's encouraging to know that that you know you're on their radar I mean that makes me as a citizen feel good so what else would be beneficial in your organization do you think to enhance health literacy no Andrea okay so we've all heard of a little thing called the Affordable Care Act right of 2010 and it created a lot of things like the health like healthcare.gov so that people can get an affordable health care coverage but another thing that it did was provide an opportunity for health care organizations like Christus and others to become accountable care organizations which means we're going to step up to the plate and assume some responsibility not that that we weren't before but formal declaration that we're going to make inroads into creating population health in the service areas in which we operate and so for Christus we became an accountable care organization in January so almost we're coming up on a year almost and even though we've had these population health based community based programs in play for a long time I think they were always sort of seen as mission centered random acts of kindness the things that we do because we're a nonprofit we're a Catholic organization but now and the tide has changed and we're trending more towards this is our responsibility to take care of our community we live and work here and this is this is what we're supposed to do so the accountable part of that is really being manifested in Christus because of that we have created a senior level position for those of you who don't know Santa Rosa is a region of Christus health Christus health is the sixth largest Catholic organization Catholic health organization in the United States and we have hospitals in Texas Louisiana New Mexico Mexico Chile Peru so it's a big it's a big organization and and all of that is accountable care and so we've created a senior level position in Irving at our corporate headquarters for health equity diversity and inclusion and that includes division level regional level population health staff that are focused on collecting data about race country of origin language age so that we can start looking at who our population is because believe it or not you know there were some studies probably done maybe five or six years ago about health disparities in San Antonio and the data came back and they were like well there are no health disparities everyone's Hispanic there's no disparity between the race because everybody's Hispanic right everybody's sick no disparities we're done right so let's all go home of course it's not true and so when you start sort of disaggregating the data and looking at all of those different factors and categories of people there are some very significant disparities and we really are trying to address how to create a greater health in our population how to address health literacy by really benchmarking who our population is who's coming to us from which country which race how old are they what language do they speak because we know not all of us because you're from a Latin American country does not necessarily mean we all speak Spanish we're not a heterogeneous community all the time so Chris is has taken that step and basically created an entirely new division which in a hospital organization is a big deal yeah it wasn't just a little undertaking and so collecting that and creating a strategic plan around collecting that data and then in the second year creating strategic partnerships and all focused of course there's all indicators of decreased readmissions and ED visits and all of that stuff but really it starts with health literacy it starts with the care management piece because if we take care of our population we create the population health those ED visits and those financial indicators will follow so it's been a big undertaking within Christmas Christine what steps do you think your organization could take to be more health literate I think for us health literacy has is so new to us so we've always been unfortunately a gym and a pool maybe I hate saying Jim because we are not a gym we are a Y but you know we've always had the gym or we've always been the after-school care program or you know everybody can tell us stories about sports and the sports are kids play and we can all dance yes and we can all do the dance but actual health literacy is brand new to us and like I said we open the doors of the Y Living Center three and a half years ago to really make it a centralized point of what the Y is about here in San Antonio and and I think that some of the steps are internal first because we're having to change the thinking of our gyms you know going out to a personal trainer and saying it's not just about personal training but let's sit down with them and really find out about the person and what they need and how we can be of service to them not just the forty five dollar an hour personal training that you need to get done you know and that whole culture has been a big culture shop to the Y and so right now part of it is that it can't just be our one center so we're slowly integrating ourselves into all of the branches to make sure that we do have these health champions and making sure that we have somebody that will sit down and actually get to know what the needs are and not just I want to lose ten pounds by my you know my sister's wedding or whatever it is and then the second part is really communicating our message to the public and letting people know we're out there not just the health care but the communities as well I think that's been a huge part because all of our programs that we offer for our healthy living programs are free and so for people not to be you know knocking on our doors and breaking down those walls we can't understand it but part of that is on us we haven't been out there enough and that's what that shows me is that we need to get out there more and really share our story share our cause and share what we can do and help with in the community great this is for all three of you besides money take money out of the equation well what Christopher was the main challenge you faced in trying to make your organization more health literate the biggest challenge was getting all the data the aggregate data and the solo part okay sorry the biggest challenge was getting all the aggregate data and all the the response data and kind of quantifying and justifying our position with the council and the community it wasn't just council was our administration as well and you know hoping that they had the the foresight to see that there's something there the other the other piece that you know we had was getting the initial trust of the health care community you know I'm like I go to a primary care physician and I'm a paramedic I'm like hi I'm Chris I'm a paramedic and they're like great see you next week don't come here again you know so it's kind of like that a lot of doors shut on us some of the hospitals as well we we've got past that no not Christmas never the sharing the data all I heard was HIPAA we got HIPAA no no no don't even don't just say that word here it was a big the H word was bad so getting all the lawyer stuff out of the way we they made us address different they didn't want us they wanted us to look different the lawyer the legal team did and the game the trust of citizens was pretty easy actually they were now come on in you know grab a seat but that was some of the challenges again the health care community was kind of not so accepting of having a paramedic come into their office and talk about health care right okay no one's having a heart attack what are you doing here so it was kind of that you know mindset kind of changing the culture again Andrea what are some of the challenges you have faced besides money my team sitting in front of me could probably answer this question much better than I can but from what from what we see I think that health literacy is never a one-size-fits-all situation it's it's very unique to each individual person so when they come to work every day they never know what the literacy level is going to be of their clients from literally one minute to the next they could spend five minutes with one patient and three hours with the next she's shaking her head and so that makes for a very unpredictable workflow so when you know my my hospital systems very focused on productivity and and you know put throughput and all of those other lean processes which is important but at the same time it's a challenge to say that you know because it works in nursing or because it works in some other clinical discipline does not necessarily means it mean it works in community and so that the unpredictability of your population and the the variability that you have from one client to the next or one patient to the next is is a challenge so navigating that is is a is an extremely valuable tool I can't say that I have it but I know that at least these four people that I have in front of me have that and so it makes them an invaluable part of the clinical care team one that I'm not sure that the clinical care team itself recognizes just yet but they're working on it yeah they're working on it our social workers in case management people Christine challenges well I think being a community-based organization is probably its own challenge when it comes to help literacy because what do we know about health literacy and I think sometimes that's seen both at the hospital and health care level and then with the patients so it's winning over the trust having that data having that those evidence-based programs that have allowed us to kind of start moving in the right direction and being you know somebody that that doctors now are willing to partner with and in the continuation of care for their patients I think that that's been one of the main challenges and then the second one is really the community not taking their health personally enough for me anyway because a lot of times it is a decision that they're having to make over a family choice or themselves and a lot of times they take care of family before themselves and I think that's the other challenge that all of us have to think about is how many of the people that we serve or should I say we don't serve because they don't come in fast. Right so ideas on ways to change that Christine I mean that's an ongoing problem forever so any brilliant flashes you have please share them. To me it's a lot of education but again education where they're at a lot of times we do it on TV at two o'clock in the morning bless you because that's the cheapest time right and so we're saying get your flu shot at two o'clock in the morning and nobody's awake yes during the America's Diamond show and I love that show and a lot of times we're the ones awake at that time but they might not be or if they are it's because they're doing something else so I think a lot of it is again educating them through means that that they can relate to like showing up at the flea market like showing up at the flea market I thought that was a brilliant idea from them but you know again being involved in community grassroots education not just TV and not just social media although all of those are very important the grassroots education and those grassroots groups that can help us get these words out that that's what's okay. Andrea how does your organization incorporate different target populations into the development and design of health, literate information and services. Wow that's a mouthful and before I answer that question I'll just while I'm what's in my brain and we all think of social media like Facebook, Twitter but one of the most successful strategies that we learned from a different state in health insurance enrollment this last year because I'm part of that coalition to get people covered in the health insurance marketplace was a group that put an ad on Tinder how many are familiar with Tinder the dating app okay okay not everybody okay so so basically it's like a dating app you put your profile up if you like the person you swipe right right okay who raised your hand and what do you swipe you swipe right if right okay and if you don't like the person you swipe left right so it's like that's horrible yeah it's like the dating game yes no right okay but here's the innovative thing is you have this person like me like an Andrea in another state who put up an ad that said I'm not looking to date but if you're interested in health insurance enrollment contact me on this site and you would be surprised at the number of people that swiped right and said I she didn't get any dating office but she got plenty of people that said yeah I'm on Tinder and I'm not health I'm not I don't have insurance and here I'd like to hit some more information about it so these are the the out of out of the box innovative ways that we have to move with the times and think about social media for those who are on social media for those who do have a smartphone and we will always acknowledge the segment that doesn't I'm never forgetting those people but we have to acknowledge the ways that we can reach out to more people so the other question was the other question is these these different target populations English as a second language people with disabilities older adults what have you done to try to target those okay well okay so from the Chris's perspective perspective our patients come to us so we're sort of passive recipients of our patients so the patients that present in the emergency department and their triage accordingly whether they're an emergent case or whether they're not they could have waited to see their PCP and so they could be of any age race ethnicity and I would say that the way that we do that is that we develop a workforce who can handle all of those things Tracy is our resident expert on social security eligibility she can do everything and you know Rodrigo he's nuts and bolts I mean he's fixed somebody stove before I mean that's that's that's the depth of skill set that we have on some of our community health workers so I think and we've just developed a team and I don't know if that's the best practice but we really have we've really sort of developed a team and a skill set that says okay we need to make sure that at least someone can handle anything that comes at us so almost it's like triage you triage the patients and decide what their needs are and then match them up with the the the right professional right well and obviously we're part of the health collaborative which works on a social determinants model and and yeah that's that's really you know once we get past their immediate need whatever they're in the emergency room for and then we get into a deeper conversation about okay what what else is going on with you and whether they're a senior whether they're a child whether they're someone's mental illness whether they need diabetic shoes right you know close to go home in their homeless something like that and we've just created a team that has been able to cover all of those bases Christopher what are the top three lessons your organization has learned in its journey to make your organization health literate top three top three I didn't think we're gonna get that far but gotta do your homework Christopher I'm getting out the red pen now minus five Christine please go first one was that we reflect our community so whether it be staffing marketing place pieces whatever it is our programs that it's reflective of our community and who we're serving especially like I said in grassroots the second one was getting outside the box both in in thoughts and actually getting outside the box like our walls of the Y and getting into the community to serve them grassroots and the third one let's see you might have to know I'm just kidding but I think the third one was learning how to connect and collaborate and be in good partnerships I think those have been our three lessons in these last three and a half tornado years is what I call them because it's been a tornado of learning these programs and implementing these programs but I think that those are our three lessons is that our collaborations both with partners in the community with doctors and hospitals and health systems and those resources because like I said it can't be just about the resources that the Y has we have to be outside of our walls even on those resources because you know yes we we only do programs but you know we find out a lot of things when you meet with somebody for a year-long program and you get to know them very very well in a group of 10 people and so knowing how to help and serve them kind of that triage thought is you know when somebody comes and says I don't have enough food that's why I don't eat like I'm supposed to right we've got to be able to make those connections and be that resource Andrea top three top three and and the first is kind of what I alluded to just now about social determinants I think we're always as health care providers are focused on the diagnosis what's the primary diagnosis and what we've learned is like the diagnosis is not always the thing the diagnosis is just what brought them to our emergency department that day they're in crisis we have to mitigate that crisis calm that down whatever you know whether it's primary care or prescriptions which is our top two usually and you know they couldn't get to their doctor and they ran out of their medicines and so that's why they're here in this crisis right now but the diagnosis is not the thing once we get past that crisis there are a myriad of other issues that we can get at to help increase health literacy help increase population health and help them navigate a system and that's my second point is that we think about health literacy and I think what you know I listened to dr. balsadua presentation earlier today which is amazing and wonderful and sort of highlights and outrageous and astonishes those of us in health care about you know reading prescriptions and you know the whole the example of eating a hamburger every time you know the label says eating a hamburger you know and so so those are all very valid points but health literacy I think sometimes we get into our own heads about what that means and so it's not just about being able to read a label it's not just about being able to read instruction so I think we sometimes take the word literacy to literally and so we need to get out of that definition and think that health literacy is really about someone's ability to care for themselves and their family how can I navigate a system that is unfriendly and not just you know I maybe I'm completely literate but I don't know the four pieces of paper that I have to have when I walk into or who to call exactly or some government office that says you have to have a phone bill and your you know birth certificate and everything else that you have to have in order to get whatever thing that you need and so I think that that factors into health literacy quite a bit so I think just getting outside of our own definitions you know we're all we've all been working in this so long we all know it backwards and forwards so step away from that put ourselves in an empathetic place in the in the position of our patients and try to understand what it means from their perspective which leads me to my third point is that the third biggest lesson I think that we should all learn is that um literacy is our own definition of our own language we're asking them to speak our language and if you're if you're not literate then you're deficient and so when we look at our patients from a place of deficiency we automatically put ourselves in in a place of almost superiority like you need to learn what I'm saying and that goes back to meeting people where they are why did we make our language the language of medicine and healthcare the normative standard why did we do that it's not the vernacular it's not who our patients are and so I think that we really have to sort of strip away our degrees and our credentials and all this other stuff and I speak from a very critical perspective when I say this but it's it's not for us to decide whose language we get to speak maybe we shouldn't say you're not literate because you don't understand this pill bottle maybe I'm deficient and explaining it to you and put the responsibility back on ourselves we are we can never call someone we can never call someone non-compliant until we've gone above and beyond out of our way a hundred percent and and given that person every tool that it takes to care for themselves at home on their own follow that Christopher yeah so we'll take questions now no and I think we're I think it's what we're seeing is kind of resonance off of each other and you know we my number one is we never make assumptions about anyone or any organization leave all your judgments at the door I mean I could tell you that because I was guilty of that myself before I became a mobile integrated healthcare paramedic we judge a book by its cover we can say you shouldn't but we do right you can't judge a book by its cover do we you know yeah you can tell how much it costs right that cover gets you to that book you know so we leave the judgments at the door don't have any kind of preconceived notions about anyone or any organization I can't say oh I had one bad experience with Christus we're never going back there again you can't do that that's never happened especially downtown before it came in pediatric no so you know you got to keep an open mind sometimes these people are you know the citizens especially they're they're very frustrated they can't navigate the system and and it's not I do put it back on us because I think we have failed and doing a better job and explaining it and rather than just send them home with a pack of 50 papers and saying here follow up with your primary care doctor tomorrow so again the judgment leave them at home next data drives everything from funding to more personnel to equipment justification if I go to Chris Santa Rosa children's hospital I see look we transported 50 pediatric asthmatic patients here last month and they're gonna say well how do I know that and again data drive is that so let's partner up and target this population and we actually have very heavy yes so collaboration with the community resource is probably the most significant attribute for success you're not alone and you know we always thought we were honestly I know we're out there I mean we go we go through the door last year we we got 215,000 calls for EMS service we never really thought we could partner up with hospitals or payers or humana or community health first we have with central mad so again collaboration is everything if you don't think that you have partners out there with and you're not really doing a good job of getting out there making yourself a known you know entity you know I really wasn't part of the health care literacy and and I was approached by a couple of young ladies and they said hey why don't you talk about this like you know what yeah so I you know we were here and I want program awareness out here as well so you know again collaboration is everything before I open it up to questions from the audience I want to know if you all think that this is a health literacy issue I'm I'm struggling and I'm a college educated person who actually knows a lot about health care when do I go to my primary care doctor when do I go to a specialist when do I go to an urgent care when do I go to a freestanding ED when do I go to an ED that's connected to a hospital and then when do I go to the hospital that's a lot of choices and if I am bleeding or I've just broken a bone or if I have a sore throat that's so bad that I can't talk I literally don't know where I'm supposed to go anymore and I think those kinds of things we need to communicate better with our patients about our patients your patients about because I think people are driving up the cost of health care by going places they don't really need to go because they don't know where to go that that I think is a health literacy problem right there anybody in the audience have any questions stand up tell us who you are identify yourself and ask away stand up your name UHS okay this is Christina with UHS I was just going to say being a parent of five and having four of those five special needs this is a common issue they always say do what you can at home treat as much as you can and then bring them in but yet there's five million different places to take them it's not just one ER there's like 15 I believe and then you have your private ER's and your facility ER's and then you have your urgent care so that is a common problem not just for our community but also for our own health care workers because there's too many options and it's really hard to know where you can and cannot go right and so you know the more specific that you all can be as people who are helping folks navigate through the system the better the more we can train people about where to go when I think would would be a big help to average people in the community and and that's that's um that's becoming more of an emerging issue I think especially now with it with the advent of the health care or the health insurance marketplace to date in this county service area so Bear County and the surrounding counties we have enrolled about 121,000 new people in health insurance right and these are people who have never been insured before most of them correct and so it is it is a it is a sharp learning curve as to how to not just manage their health insurance but exactly what you're talking about where to go so you're probably someone who's been insured for most of their working correct right I still don't know where to go yeah and so so imagine that you've been in uninsured your entire life and now you have this health insurance and you have no idea how to use it right and then you do use it and okay now I have a deductible what exactly does that mean how I thought I was insured now you're telling me right and it's like sticker shop because they went to the wrong place and you know just a personal story you know I grew up as an uninsured person my entire life until I graduated from graduate school you know my son who's 21 now has been an injured person his entire life and you know he had a backache you know he injured his back playing basketball and he went to the emergency department was shocked that he got a bill you know he's like I didn't know that's how insurance worked and I was so ashamed because I'm like you're my son like you're supposed to know this stuff and so but you know we can never assume that anyone understands you know and there are guidelines and you know you can talk to all the stuff but your question is not unique and it's something that the health collaborative has taken on as a responsibility in helping to create a health literacy module and app that connects to the enroll essay website about how to use your insurance of a glossary of vocabulary terms and what all those things mean which you know even if you've had insurance for a long time are probably beneficial to some people but definitely and you know that's the thing you don't want to think about this stuff until you need it I don't ever want to go to the ER never and so I don't really want to educate myself about where I'm supposed to go but then I don't want to wait till I'm bleeding on the floor either so imagine Wendy with you you had a number you could call and someone would go to your house triage you cardiac workup 12 ADKG do some blood a little bit of blood work not major stuff and and then kind of tell you where you need to go right that's EMS mobile health that's what we do good answer stand up well actually it's more of a comment I really appreciate the panel you've been fantastic there's some great insights into what our current environment is especially and that I will have a little spoke to that Texas has been largely a state that has been uninsured a large percentage of uninsured and so for many of our uninsured population the ER was their primary care and and so this is a very difficult place as we enroll them and Andreas part of enroll SA to get them into a system where they're going to have issues and now they have to navigate that system whereas before they went to the ER and so now they actually have a bill where before they didn't and so how do we educate a population that has much to learn and it isn't because they're at fault it's because we as a society have created situations and opportunities or lack thereof here in the state of Texas that we need to now look at and our communities and our populations are people that we serve and people that we live with and we need to understand that they're not always going to be understanding of what happens now that you're insured and what happens now that you have to pay a deductible what happens now their comfort level is let me go to the ER where I didn't have to pay so that's the reality of today's world and we need to to really be honest if we're going to be talking about health literacy we need to be beyond literacy and more about community literate and what is in our social environment and so I think when we have a conference about health literacy I really appreciate all of you very much and your insights into your organizations and the efforts they make to reach out but we have to be far more than that we have to be about community literate and socially literate about what's going on in our environment and how we can reach out despite that thank you and to be very realistic about it can I add one thing to that Pilar you're absolutely 100% correct but I would challenge each one of you because you all work in places that have some leverage and that have some influence and in addition to be community and socially literate be politically literate as well because expansion of Medicaid is an issue that's been on the table for several years I've been in discussions with HHS and in the last couple of weeks where every single time I talked to the Secretary of Health and Human Services every person from California to Massachusetts brings it up and she says I can't do anything I don't know what to you know there's nothing we can do she says it much more eloquently than that but basically I'm sorry you're out of luck until your governor changes his mind but each one of you represents an organization that has some form of advocacy that can speak to our legislators and know it hasn't done any good in the past but we can never stop working at it and so we each have a responsibility to be politically literate as well next I too am very very and I don't get impressed easily by the way I'm very impressed with this panel and the issues that you brought up the issues of everybody thinks that collaboration is easy and that it's not an action word and that it's not a journey and it is for you guys to have created the trust levels that you have in order to make your programs go is absolutely remarkable and the other thing is because most of you know I do sexual health my condom is around my neck and the one thing that I wanted to say is if you would look at all the kinds of things that you talked about but can you imagine what it's like for somebody that has a severe STD or has HIV and how the marginalized or try to be a transgender in this community and we have one of the largest transgender populations around and it's very very very marginalized but Andrea when you said advocacy works it does in San Antonio we were almost like a third world country we had we have such a very high rate of syphilis and I know most people don't like to sit around talking about sexual health but we had 18 cases of congenital syphilis where babies were born still born and that was when Dr. Schlingker came he said it was like a third world country well what it took was advocacy people doctors were only testing in the first trimester as if you never have intercourse after your first trimester pregnant women don't have relation sexual relations right everybody know it's like I don't have sexual relations I mean we have such these myths what we did is we the HIV syphilis task force and other partnerships including the health collaborative got together they got on the legislative agenda with both the city of San Antonio and the Bear County legislative agenda they went to the Texas legislature and they mandated syphilis testing in not in the not just in the first trimester but in the third trimester we have gone from having 18 congenital syphilis cases to seven this last year so progress can be made when number one we know the data when number two we do an action plan collectively and when very unusual partners get together and that's my hope for either continuing the 1115 waiver which is brought together some of these remarkable programs so we can continue that for the next five years if we don't expand Medicaid but it takes each one of us to get up and it's really really very different partnerships that we didn't even think about so I think you are a remarkable vision of that because you went everything from the medical model which some of us have a concern and a problem with to the social determinants of health and personally I'd like to given my age I'd like to take a point of personal privilege my husband had a massive heart attack several years ago and thank God he's still with us in E 75 and it was the EMS and he said like most Mexican Latinos he goes it's the flu it's the flu don't call the EMS don't call the EMS and you guys were right down the street on the month you've got a station there and so the next and he recovered it was in December around Christmas and the next couple weeks later for Christmas I took the menudo and the tamales that he's not supposed to eat I knocked on the door the Almonte fire station I said here guys it's rather you to eat them than my husband and I'm sure they were gone like in an hour yeah and there and I hope their cholesterol levels were less than his well thank you and thank you for your kind words with the fire department and we we in the sense when you fire department when it's stress we can't stress it's enough that we are your fire department that is your fire station our doors are always open to the community so you know don't ever feel like you know I can't go this is your your this is your fire department we're your fire department we work for you so don't think we have any kind of preconceived notions of what our mission is with the mobile and greater health or advanced care or advanced practice paramedics what we call we have we're all critical care paramedics we're community health care workers we went to Northwest Vista College and we also we also did some extra training that I won't bore you all with but what that said I just I just want you to know that you know what who we choose is very significant we want the well seasoned paramedics who don't get afraid of really anything so we're they're not afraid to go into the house you know what midnight on the west side on you know Caesar Chavez because it's kind of a you know they're not they're not comfortable with that neighborhood right so we take our all of our medics pretty much have close to 20 years each so they're very comfortable and they're very well trained so we're ready to react and respond so we do knock on that door if they're not doing so well we have the full equipment of an ambulance we just don't have a stretcher can you thank our panelists because our hour is up I told you it's going to be fast but it's just to wet your appetite for tomorrow so if you're interested in hearing more from either of these three people you can hear from them tomorrow and thank you so much what a great conversation thanks thank you thank you again Wendy for just being a moderator tonight so big up round of applause for Wendy Rigby Wow I want to moderate like her when I grow up well so I know we have a we had a couple more comments but definitely we'll have a lot more opportunity to discuss tomorrow if you have any burning questions you definitely please connect with our panelists there's going to be here for another 10 minutes or so but one thing I want to just make comment on with regards to our panel tonight the Senate to New Health Literacy Initiative committee members that are present here tonight I'd like for you to stand please if you can stand if you're part of the Senate to New Health Literacy Initiative Charlene, Luis Maria, me, Lisette, Dr. Flores, Penny these are the just this is just a small fraction of the people that are involved with this and I would call it a movement I'd call it a movement because I can tell you they get together every every second Thursday of the month from 9 to 10 30 at the Texas Diabetes Institute they have some tough conversations and sometimes the conversations we have is around really understanding what our mission and vision is for this community and there are so many different areas that are affected by health literacy I mean I think the whole community and every single sector is is affected and there's so many collaborative partners that are at the table that have a true passion and interest in trying to work in this specific area we have the full array of leadership in that group we have community health workers we have a law firm that you recently joined us we have health educators we have researchers we have laymen trainers and we just have some rag-tag community advocates like my friend and green over there who really keep us grounded and really try to help understand it while we can have good discussions about the who and the what and the tools and and where we get there it's usually by that engaging conversation that we come up with some of these great learning opportunities like we have at these health literacy conferences it's thanks to you that come every single year that we are able to provide such a rich I think learning opportunity as well that we invite some key leadership from all around the nation but we don't ever forget that we have some very very extraordinary partners here local champions that we can't neglect and we have a rich resource within San Antonio within our Bayer County little area that is eagerly trying to collaborate with you so in your so the problem of the program tomorrow is that we're gonna start introducing you to a lot of these different people we have a packed agenda but more so what we want to ensure you're what ask you is to come out of your walls and really start engaging in conversations with people who do you don't normally maybe talk to you sit at our front table today don't sit next to your best friend sit next to someone who you do not know chances are those people are looking for partners in this work maybe some of them are new to this conversation and you'll be the right person to lead them in that direction and so we ask you to really consider an opportunity to go outside of your walls like these different champions here tonight I really really appreciate the Senate and Fire Department being here and I think the biggest thing for me was understanding that we have a mental health community here that really needs that resource I think a lot of times we forget about that piece and that we look at the layers and social determinants that Andrea was talking about earlier are so very important I have those conversations tomorrow if you don't know what social determinants are like I didn't know social determinants many many moons ago I had great leaders in my board members and my advocates that said hey rethink about this and let's have an honest conversation of what you know and what I know and how do we partner together to really meet the needs of our of our families so I thank you for coming out tonight I thank you for being patient I really enjoyed having you here and I think all of us really learned quite a bit from our panelists tonight so thank you for joining have a safe night home