 I was just trying to do it, but how do I do it? Just because I don't read all of that. Okay, we're gonna get started with our lunch session. So this is the moment that you have all been waiting for. I know I have. I was trying to put into context how amazing and incredible this is, this conversation, this Doctor's Lounge Room Talk Shop here. That's what this is staged as. So it's the Doctor's Lounge. And we have three incredibly esteemed individuals who are going to have a conversation with us in front of us and then with us. And so I was trying to put into context how exciting this moment is. And I don't know how many of you have had a chance to meet some famous person in your life. Yes, run into somebody famous. So I was in Rockport at Tackle Town and I was buying some fishing gear. And George Strait was standing right in front of me. So cool, just ultimately cool. And you know that feeling you get when you meet that really famous person and you're thinking yourself, should I say something? Should I not? Do I talk? How do I look? So as we was putting this together and started to think of the incredible work that you all are about to do and have done and are about to undertake, I thought this really deserved a rock star panel. Just completely a rock star panel. And so in thinking about that, I don't know how many of you have had a chance to read Code Red. Yeah, so the data nerds of us out there, okay, I saw that. Thank you. It is an incredible piece of work. And if you look at that, not only does it set the tone to lay out what the critical healthcare needs of South Texas are, but very thoughtfully it lays out recommendations on how we as a community begin to address those issues. And if you haven't read it, I suggest you read it because as you look through there and you look at the recommendations, I want you all to know that the proposals that you have put forth for C-Texas, the initiatives, the innovation that you have proposed are very much aligned to the recommendations and solutions that will solve healthcare crisis in South Texas. And so I thought with that in mind, it would be an honor to have the champion, the leader, key author of Code Red to present to us all as well as bring in some key visionaries who are part of the current and existing systems and structures that will ultimately work and integrate with the results of what you were gonna do for C-Texas. And so I'm gonna read their bios, but by no means does it capture everything that they've done and or the continuous contribution they are making to this community. So we're gonna have a presentation and he is also gonna serve as our moderator, Dr. Ken Shine, and he is the special advisor to the executive vice chancellor for health affairs university of Texas system. He is currently overseeing the development of a new medical school in South Texas as well as the one in Austin. Prior to his role as special advisor, Dr. Shine served as executive vice chancellor of health affairs. In that capacity, he was responsible for the six UT system health initiatives and their aggregate opening and their operating budgets of 8.4 billion dollars. He's led system wide initiatives in clinical effectiveness, patient safety, and public health, as well as efforts to transform medical education. He was president of the Institute of Medicine from 1992 to 2002. Under Dr. Shine's leadership, the IOM played an important and visible role in addressing key issues in medicine and healthcare. Dr. Shine has served as president of the American Heart Association in 1985 to 1986. Next, we'll have on our panel the inaugural dean and vice president for medical affairs at University of Texas Rio Grande Valley School of Medicine as well as the professor and department of psychiatry at the University of Texas Health Science Center. Dr. Francisco Fernandez, the national leader in academic medicine, and he is the inaugural dean of the new Texas Rio Grande Valley School of Medicine. Prior to his selection, and by the way, Dr. Shine was part of the recruitment team for Dean Fernandez, he spent the last 12 years of his career as a professor and chair of the Department of Psychiatry and Behavioral Neurosciences at the College of Medicine and a professor in the Department of Community and Family Health in the College of Public Health at the University of South Florida in Tampa, Florida. Prior to his post, he served as the chair of the Department of Psychiatry at Loyola University, Strict School of Medicine in Chicago from 1997 to 2002. Dr. Fernandez is no stranger to Texas. He's having served from 1986 to 1997 as chief psychiatrist at the St. Luke Episcopal Hospital in Houston, he was chief of psychiatry. He also served as director of the HIV Psychiatry Clinic before joining the Baylor faculty, and he was also the director of the psychology clinic and assistant consultation liaison psychiatry to MD Anderson Hospital. Dr. Fernandez is known nationally for his scholarly work in psychiatric aspects of medical illness and having offered 131 peer-reviewed publications and one book on psychiatric aspects of AIDS. Third is Justin Rock, who if you all have had the opportunity to work with Justin here in the Valley, Justin is by far one of the upcoming premier leaders in this community with a true passion, true knowledge and a vision for population health and the integration of that in our systems, our delivery systems. So Justin is the director of Clinical Integration Network at Valley Baptist Health System in Harlingen, Texas. He received an MBA specializing in healthcare administration from Baylor University and a BBA in economics from UT Arlington. Justin served as an administrative resident at Valley Baptist and he was instrumental in the development of the customer service department. Again, having been part of conversations and working with Justin, patient-centered focus is such a core and key for him in all of his work. And from there, he's taken on leadership positions in data analysis, process improvement and diabetes intervention programming. So with that said, I'm going to invite Dr. Scheinde to please come up and begin the presentation. Thank you. Thank you so much for Rebecca. Appreciate that very nice introduction. It's been my pleasure to be able to sit in from time to time at this meeting of the C. Texas Project Subgrantee Spotlight. And it is my conclusion that in fact, you are lighting the way to health. And that what you're doing is extremely important. Congratulations to the Methodist Healthcare Ministries for their leadership and putting all this activity together to see and the funders of this program who recognize what can be offered. But most of all, congratulations to each of you for the programs you currently operate, for the programs that you will operate in the future. This is a very exciting venture because it not only involves improving healthcare and health and wellness, but it also provides the opportunity to test a variety of hypotheses about how to do it. To have evaluation as an integral part of the process is extraordinarily important. And there is a real potential here for the lessons learned to become important not only throughout the valley, but throughout the state of Texas and throughout the nation. And I would hope that publications arising from your activities will provide insights and directions that can be valuable across healthcare in the United States. So again, congratulations to all of you on what you've accomplished, what you're doing at the present time, and what you will do in the future. I do have to indicate that I'm a member of the Board of Directors of the United Health Group which includes an insurance company. And although I won't talk a lot about insurance, there are references to it that could be relevant in the conversation. What I'd like to do is to give you a little bit of an overview of the considerations that went into Code Red and try to relate them as Rebecca has suggested to the kinds of activities that you have underway. I don't have to tell you that our healthcare system is extraordinarily expensive. And although the cost of healthcare is mitigated for about three years, it now begins to be beginning to rise again. And we spend substantially more than any other developed nation. Anywhere between one and a half to two times what is spent in other developed countries on healthcare. And as a result, we get very uneven quality. American healthcare is best superb, but in many ways it's inadequate with unequal coverage. It's a fragmented system. And as you know, it's a disease system, a disease oriented system rather than a health system. Code Red was established as a way to look at some of these issues in Texas and make some recommendations that might be helpful here. And here you see the website where if you're interested, you can see this report as well as our reports from 2006, 2008 and 2012. Code Red is operated by a group of volunteers from across the state from a variety of expertise and they operate individually providing their wisdom. We had four hearings across the country, including one, which Dean Fernandez, among others, participated, actually Manny Vela from, and Israel Rocha from Doctors Hospital and Valley Baptist participated. Some brief background and I'm not going to go through all the details on all of these slides. I just want to hit a few high points, but I think you're aware that we have the highest rate of uninsured adults between 18 and 64 in the country. And Arizona beats us to the bottom. They have more uninsured children percentage wise than we do, but we're just a little bit better than they are. We are 49th among the states in that regard. One of the things that I did want to emphasize is that people without health insurance indicate that they've not taken advantage of the health system because of that. And we know that that is the implications. We believe that there were a minimum of 2,500 deaths a year in Texas directly due to failure to obtain care because of lack of insurance. Our hospitals bear a big burden here and so don't the taxpayers of counties that take care of a lot of indigent patients. And these taxpayers are through their hospital districts paying a lot of money to take care of these individuals. South Texas is relatively unique along with Galveston not having a hospital district. As you know, that's a subject of much discussion in South Texas and I think there's every reason to believe that there will be a valid issue again in Hidalgo County now that it would be capped at 25 cents per $100 assessed value as opposed to 75. Incidentally, Houston, Dallas are in the range of 26 to 27 cents per $100 assessed value in terms of their healthcare systems but that's because they're taking care of uninsured patients from a wide swath of Texas. I do want to call your attention to the third bullet which is that people don't realize that they are paying for this care through their insurance. A family of four who has insurance through their employer or personally is paying about $1,800 a year extra to cross subsidize the care of those without insurance. And employers are aware of this and to a certain extent explains their position on expanding Medicaid coverage. We have a real shortage of health professionals. Just to quote you and I don't want to get into the figures but I'll show you in a moment about physicians but South Texas is lacking in almost all health professions. There's only one health profession in which the state is at or above the average and that's licensed vocational nurses. Otherwise, every single area we are well below the national average and Rio Grande Valley is quite there. For many of you, it's important to recognize that federally qualified health centers are extraordinarily important in the safety net in this state of seeing about 1.1 million patients in 2013 of whom half are uninsured and 25% are on Medicaid and many of you are involved in these federally qualified health centers and the Methodist Health Care Ministries is involved in supporting many of these. Texas has benefited enormously the last several years from the 1115 waiver. Many of you I think have had interactions with it. I do want to make a couple of points, however. First, that it expires in 2016 and as I'm sure you've read in the newspapers, the administration is threatening not to renew or extend waivers in states that don't expand Medicaid and they've sent a letter to Florida. Florida is going to court on it. I don't think they'll win for a variety of reasons. The waivers are not obligatory in any sense. They are just that waivers and I don't believe the courts will force the federal government to do waivers but it'll have to play out in court and as you know Texas is supporting that suit. What is important to notice is that there were 29 billion dollars involved in that waiver of which 17.6 billion is for uncompensated care and of that 10.3 billion is federal money the other 7 billion is state money. If there is no waiver then all of that support goes away. There were of course the district projects. One of the interesting questions is whether the feds would renew or extend the waiver on district projects but not on uncompensated care and that's going to involve a negotiation. Code Red has been asked to play a role after the legislative session is over in those conversations and we try to save as much of that as possible. As you know the district activity has been quite extensive with some 1,500 projects many of them here in the valley. Our ability to create residency programs new residency programs expand existing residency programs is based very much on the availability of this money. Fortunately once the programs are established in hospitals which had not previously had residency programs Medicare will continue to support those residencies so the residencies are not dependent on expansion or extension of the district. Obviously we'd like to see it but our residency programs will persist. I also would point out given your interest in health and behavioral health that some 400 of these projects are in behavioral health and at least one of the grants here involves telepsychiatry which has been enormously successful. I think if you had told me the telepsychiatry would flourish I would have been very skeptical about that. In fact it's flourished significantly. I mentioned the workforce issue and Dr. Fernandez is going to say more about this in the role of the medical school I want to point out that the state is short of positions overall this national average is 263 Texas is 205 what do you think the number of physicians per 100,000 is in South Texas? Anybody? Take a guess. 107 so it's half of the statewide average and the same thing as to a primary care it's even worse than psychiatry we hired a dean who's a psychiatrist we all expect to get therapy but it's true of a variety of these others and Code Red does have a whole section addressing behavioral health indicating the prevalence, the frequency the lack of health professionals one of the things we're pleased with is there is a bill going through the legislature which I think will get through which will provide loan repayments for individuals getting into mental health professions and we've been very supportive of this but the fact is that in spite of the increase in expenditures in the last session that Texas is 29th among the states and per capita spending for behavioral health many of you are aware of the Affordable Care Act and I just want to make a couple of points one is that this issue of the subsidized health exchange coverage will be addressed by the Supreme Court probably in June the odds are that the exchanges will be allowed to proceed but again predicting the Supreme Court is always a tricky business I am not all that pessimistic about the outcome however because we've already seen states looking to find some way to deal with this Pennsylvania for example which has not expanded Medicare has just indicated that it would have created a state exchange if the Supreme Court ruled against subsidization of the federal exchanges there are also some other ways to get around it which the feds are not talking about now because they don't want the Congress to interfere but I think the subsidized health exchanges will persist on the other hand Texas has opposed Medicaid expansion and as you well know this has caused a coverage gap the thing that's remarkable about it of course is that if we did expand Medicaid 100% of the cost through 2017 would be boomed by the feds it then decreases to 90% it's 90% thereafter the argument is made well if you expand and the feds decide to go below 90% the state will be left holding the bag well the reality is Arizona for example explicitly wrote into its agreement that if the feds lowered the rate they'd terminate the program and there are ways to do that the fact is in the history of Medicaid that only occurred once in 1980 in a very limited way but the point is that this means that a very substantial number of Texans continue to not have coverage now the interesting thing about this debate is that the strongest argument for Medicaid expansion or expansion of insurance coverage is coming from the business community because the business community recognizes that if you lose money as a result of not having the waiver for example phasing out payments to hospitals for what's called disproportionate share that was to be phased out because if everybody had insurance coverage for Medicaid they'd be able to pay for it the hospitals in this state would lose about 11 billion dollars the point is that we stand to lose over 20 billion dollars in federal support whereas if we expanded coverage we'd get about 66 billion in direct federal funding and it's been estimated another 35 to 40 billion dollars in indirect because if you have more Medicaid funding you can hire more people services, a variety of other things this is pretty good data so it's 100 million dollars that we're ignoring at a cost of 5.8 billion to cover that 10% when you go to 90% in 2017, 2018 so the task force made a number of recommendations and I'm only hitting the high spots of it because of time if you look at the material on the report on the web you'll see much more detail but we recommended that Texas negotiate with CMS to implement a plan which we call the Texas Prescription you can't talk about Medicaid expansion that's a dirty word you can't talk about Obamacare we've proposed the Texas Prescription that would use federal funds to provide premium assistance to Texans in the coverage gap so they could obtain private non-governmental health insurance again we can try to I'm glad to discuss that with you and defend it but what we're saying is we need a market approach that we need an insurance approach that we ought to be able to use federal funds to buy that coverage and that has a number of other advantages which again time doesn't allow me to go into in a great deal of detail second recommendation recommends that we try very hard to get an extension or renewal of the waiver including continued funding and compensated care and that we identify the most successful district projects to scale up either regionally across the state again if you read the report you'll see a number of other recommendations with regard to the waiver particularly the importance of getting data that's comparable across projects and across regions third we recommend the continued development of proven healthcare delivery systems with an emphasis on preventive primary care and incorporating population health approaches to improve the health of all Texans resonated all with anybody in this room I mean that's what you're about and we've indicated that we think that this ought to be expanded we're particularly interested in the notion that health homes, accountable care organizations comparable approaches need to be implemented and the interesting thing of course is that Medicaid in Texas is now managed care but the managed care organizations are the ones who are responsible for implementing those new delivery models and we think a great deal of pressure if not legal support has to be done to get that to happen and we also believe that new funding mechanisms including gain sharing, capitation pay for performance and bundle services are required and we think those are going to happen some of you are aware that Medicare has just announced substantial expansion and ACO support for Medicare recipients they also are going to expand value-based purchasing and some of you are aware of the so-called DOCFIX which was the SGR in which physicians purportedly were going to have their compensation reduced over time if necessary and the Congress kept postponing that and so forth I started five minutes late I get my 20 minutes I'm watching the clock but the point is that those kinds of payment models are going to be implemented in part because the SGR requires it the settlement that allowed physicians to get more compensation the fourth recommendation again relevant to your interest is that we recommend the continuation of state support for behavioral health initiatives and particularly including behavioral and primary care teams and health homes, emergency care teams inpatient services community rehab services or whatever again any echoes to any of the things that you're thinking about or that you're doing and finally we recommended that there be an expansion of the culturally competent healthcare workforce with the use of community health workers health care navigators, pharmacists workers, social workers and others and that we enrich the environment in which healthcare professionals are taught in an interprofessional way so that they can provide team care and that they can work together to provide integrated care that we need to expand programs to train community health workers, primators health care navigators and health educators and finally that we grant health professionals practice plan authority with the fullest extent of their education and demonstrated competencies so in terms of your projects immediately as I look through that material it became clear that you do have population based models which we think is critical that you have examples of cutting edge delivery models and using a variety of health care providers and I had a chance last night to talk to a number of you about that about improving access including access to mental health as part of the primary care environment that you do have extendance in team care and improving quality again I think the fact that the project has careful evaluation is extremely important but that we also need to educate a 21st century workforce and that's a workforce that knows how to provide team care that knows about delivery models who knows about population care and that if you do the work that you're doing well and I expect you to do it that there will be important lessons for Texas and the nation so let me conclude with 40 seconds to go by saying that again I think you would enjoy looking through the Code Red report to see much more detail about what we're talking about but at the same time you have an opportunity to truly transform health care in America not just in the Valley, not just in the state but in health in America and I think to the extent that the kinds of things you're talking about can be proven to work you can set an example for everyone so let me conclude by saying congratulations to everyone concerned and I'm looking to follow your developments very closely over the next few years as examples for everyone thank you very much and my watch says 25 minutes of one I started at 12.15 I'm going to invite my co-panelists to come up and we'll sit down together we're actually getting some furniture a doctor's lounge can not awesome one thing I want my colleagues to remember is that the lounge is not a place for sleeping it's for relaxing you would be interested to know that we built a marvelous new pediatric research building in Austin opposite the pediatric hospital but we didn't put a cafeteria in or a lounge we did so because we wanted the scientists and the physicians and so forth to mix regularly and exchange ideas so that's what's happening this is the lounge for exchanging ideas let's start off with Dr. Fernandez and I'd like him to make some comments particularly about the role of the medical school in pursuing a number of the objectives of this project in terms of population delivery and the role of health professions before I do that I just want to follow on Rebecca's starting point in terms of her first time that she was with with somebody of import and it was a family thing it was the first time the whole family had that opportunity and we were in an Astros game and my wife told Lyle Lovett that he was in the wrong seats and so it wasn't a great it was great to be in front of Lyle Lovett and it was fantastic except we told them to move and my kids were horrified and so thematically I would say that I hope to be the medical school I hope to be the beneficiary of your good work so that we could say to fee for service you're in the wrong seats here okay and we could go to value-based or equity-based type of payment system so please do everything that you say you're going to do and do it well so that we can do that and I'll tell my wife that you followed suit in the same way that she did and I'll love it out there are some medical schools that have added departments of population health we're starting out with a department of population health and a strong collaborative relationship with the school of public health to be able to make a difference and make a difference not just in educating the students that are going to be coming through and hopefully not just within the school of medicine an interprofessional education initiative so that we can all work together and learn what team collaborative health really is about and so from the get-go we hope to be able to make a difference in the workforce of the future by taking all of these elements and putting them into the curriculum not just in the manner in which they normally would occur teaching medical students but we are creating threads so population health will be a thread throughout the curriculum so whether you're teaching molecular medicine or you're teaching behavioral health or something in between you will have to address those issues and make sure that the integrity of that particular area is well represented across all the curricular materials that are presented to the students that they're also made part of what they do in the real world some of you heard me this morning say that the medical students are going to be able to adopt a disease adopt a clinic, adopt a colonia they can adopt a family member who has I joke about the fact that I may not have been Mexican by birth I mean by birth but certainly by birth I would measure up to the task so they can adopt me if they would like to and try to get me before graduation to adopt more favorable habits but the point of it is they need to be in the field they need to be able to experience this from day one it's very difficult to sort of do it and I'd be curious to hear just in your experiences doing it from the other end you've got physicians how do you get them to embrace these concepts now to make a difference in the care of not just the individuals but the whole community and the whole population which is what it's about raising the outcomes of health for those individuals and we are committed obviously in the in the Rio Grande Valley to be a part of that solution so I'm going to stop there because I don't want to sound like Fidel Castro in the UN in the early 60's and go on so you should be aware that Dean Fernandez also happens to be an expert on pop music salsa and a variety of other things so I'm expecting him sometime in the course of his comments to use the title of some song to make his point but so far I've been disappointed Justin you've been very much interested in integrated care delivery models maybe you could tell us a little bit about that certainly and some of that's born of the fact that as Rebecca had mentioned the background I have in economics and when you get down to some of population health management a lot of it does relate to what are the economic needs not just of our patient population but also of our physician, hospital and services population so one question I have from an economic point of view for this group or for our panel economics is a study of the allocation of scarce resource what's the most scarce resource that we have people but for an individual what's the most scarce resource that you have time exactly and so when you're talking about integrated health you're talking about coordinating care at a population level that requires a tremendous amount of time it requires a tremendous amount of coordination and I think right now with the fee for service environment people are incentivized to do what gives them the most benefit in the shortest amount of time so of course it's all about how many patients can I see how many patients can I get admitted in discharge the number one thing that a lot of hospital administrators look at is what's the length of stay of my patient versus what's the quality of the length of stay while they're in my hospital for a physician and there's actually an article that was published recently that we had talked about this morning about how service in McAllen has improved quite a bit and it details a physician interaction with a patient about previously in the fee for service world it'd be in and out with a diabetic patient and they wouldn't really get a whole lot of care because they're not incentivized to do that it's not because a physician is doing a bad job it's because they get paid by how many patients that they see and they don't get paid for managing that patient's diabetes when they get changed to a different incentive program where they're getting paid to spend a little more time with that patient you get to see improved outcomes for our whole population and I think that's part of this conversation is how do we allow ourselves and create those incentives in an integrated care delivery world where we have the time to spend with our patients and actually address the needs that they have Justin, just to follow up on that I've indicated that Texas is already short of docs medical schools have in fact between new schools and existing schools increased their productivity by about 30% that would still leave us way short of docs an aging population again the population is relatively young in south Texas but as we look forward goodness it will age and we've certainly got plenty of chronic illness so it becomes pretty hard to see how a traditional physician operated healthcare systems going to succeed how are you dealing with that how do you think about that and it's something that I think the program that we're working on for chronic diabetes management with UTL Science Center has really shined the light on where some of the opportunities would be so in traditional sense we're a diabetic patient and I use diabetes a lot because that's definitely the chronic disease I'm most familiar with the traditional sense would be I'm diabetic my A1C is out of control I go to the ER because my doctor's office isn't open I get treated there my doctor may be two weeks later because they don't have an opening for me in the Saludivita model we've switched that a little bit because we have transitional case managers and promotores who can address those immediate patient needs teach them how to properly manage their diabetes get them connected to resources if they can't afford their medications or what have you the physician doesn't really need to be involved in that conversation unless there's something that needs to be escalated to that physician at that time to make care you still make sure they're informed of what's going on but we can address what a patient's needs are in a non-traditional healthcare setting and I think that's what we're going to increasingly see in the population health management world is let's treat the patient where they get the most healthcare which is at home and we're trying to get lunch about the question of where the patients would accept care from the non-physician to amplify that for a minute and tell you what to do and that's something I actually used kind of a live example I saw in a physician office where a patient had come in to visit their physician and the office manager and the person at the desk had informed that well you can either see the mid-level now or you can wait and see the physician in an hour but in either case the patient's going to get for their condition because it's not a high comorbidity it's not a high resource case it's something that, you know, a case of the sniffles but some of the struggle I think we're going to have in the valley or in some other areas of the country is making sure that patients know that if you're being treated by a mid-level practitioner it's going to be at times as good as, or if not and studies kind of back this up experience and I say experience because customer service rates of customer service satisfaction tend to be higher with mid-levels than with physicians don't blame me for that but um and so the that's I think something that we're going to eventually have to get through some of what we also saw with this LuthiVida program is it depends on who's actually having the conversation with that patient how many of y'all have gone to your doctor for your annual checkup and when they ask you are you eating healthy and exercising you say yes and are you? I know I'm not but the physician and the nurse that we're dealing with is an authority figure versus a promotora or community health worker someone who goes to that patient's home the patient has control of what's happening when it's in their own home and so those conversations tend to be a little bit more honest they're going to open up a little bit more about what their social issues open up a little bit more about what their barriers to care are and so you know tying into that conversation I think it depends on the setting and it depends on the individual who's having that conversation well in the discussion period we ought to see what our audience has to say about that frankly we're going to make a comment I have one he actually used the word once and the discussion that has been going on between my co-partners up here has excluded what? one of the things you're all looking at is social determinants right and you use the word social once and what's missing is the behavioral psychosocial piece in the discussion whether you're talking about diabetes management hypertension or anything else and it's always takes a backseat even when you're talking about integrated care it is the more difficult one and you add to that the piece that has to do with your little your beer or if I were to ask you if you knew the definition of the NIAAA of problem drinking I would venture to say that 70% of everybody in this room may qualify because it's do people know what the definition is of problem drinking more than one glass of anything or shot of anything for women and two for men so there's I've had that question asked by the patients well what if I just accumulate them all on Saturday Dr. Fernandez can I have my 10 on Saturday night the answer is you're a problem drinker you have so the fact remains is that we have a great deal of work to do and I hope that when you start developing these programs that you think about it we just went through an example here locally at not too far from here in Edinburgh thanks to the generosity of the Methodist Ministries in the sense that we opened up a clinic for triply diagnosed adolescents so it's adolescents that have a medical problem diabetes usually with either behavioral or formal psychiatric problem mental disorder and an addictions problem any repetitive drug disorder doesn't have to be drugs it could be gambling it could be sex it could be anything and everybody came in from their respective discipline each with an assessment instrument and I said no you have to make one assessment instrument we all are going to communicate in the same manner we're all going to document in the same manner but we don't do that and you go to an integrated care facility particularly in collaborative care and you have ten notes you have to review you have the pharmacist you have the social work you have psychology you name them they're all in the chart we have to try and find a way if we're going to be successful of being able to get it all we all need to be on the same page and that's going to take quite a bit of work as you saw the number you can't count my number of words I use because I'm Cuban so I'm allowed to use more than anybody else but in the discussion you heard the word social once before we leave this subject talk to us about your thoughts about the integration of behavioral care into primary care outside of this kind of special situation you've defined a very special environment with these triply challenged young people but in terms of the kinds of things that need to go on in the overall health care delivery system how do you see behavioral health being best integrated into the delivery models well you're going to have one of the projects that's going to deal with that actually and so you'll be hearing more about that as you all share your good work with each other at present it's not quite integrated it's collaborative at best and coordinated at best we're hoping to make a difference one of the things that of course we're considering it's not something that's hard and firm put into our application for accreditation for the LCME but one of the things that we're considering as part of the medical student experience maybe not in the hospital because then every single attending might come after us and want to kill us for extending the amount of time that they have to round on the wards with patients is that the medical student has to actually present the case on the basis of the subjective history of present illness not the objective one that we all want to listen to to get into differential diagnostic consideration therapeutics but don't present it to me from the medical HMP presented to me from the subjective side of the patient and see what does the patient think is wrong with them what do they think the barriers are what are the challenges that they're going to face in trying to get the proper treatment for themselves or for that matter getting the lab work done it doesn't matter at which stage of the game it would be so it would have to start really from very early on making sure that the person knows to make those or ask those kinds of questions they have to be a thousand questions but eventually you call them out to what are the more key ones you know you're all familiar with instruments that start out like the symptom checklist from Johns Hopkins and then you're able to get it down to the brief symptom inventory and just use a hundred questions and then get down to 60 questions and then get down further you get to the ones that are key for you to know whether you should pursue psychosocial issues, finances transportation, family related issues and things of that nature but I think it will take a while to be able to address that in such a way that everybody whether you're in nursing, whether you're in pharmacy, whether you're in social work whether you're in psychology no matter what your communication disorders whichever area you're in including medicine really focuses and does that in a particular way that allows you to key into the essential features that will make a difference at the end thank you Justin there are all kinds of activities going on to create accountable care organizations similar kinds of activities in the private sector how do you see those kinds of organizational changes affecting the care of people who are not in the private sector that is medicaid patients, uninsured patients are there are there lessons to be learned from your experience in ACOs that could help us think about what might happen in other populations I think so, now one thing I can speak to as part of my role for the clinical integration network is effectively we create commercial ACO programs or commercial pay for performance or some type of quality incentive programs for our physicians but what's included in there is managed medicaid so managed medicaid is a group that we can work with, so there is commercial applications of creating ACOs for at risk medicaid populations now it doesn't cover traditional medicaid so you have a separate bucket of patients who potentially would be missing out on some type of ACO activity so I think there is opportunity either through the 11-15 waiver through disc rip or something like that to allow hospitals or clinical integration networks already existing medicare ACOs to participate in medicaid just as much as they are participating in whatever already existing ACO program they have in place now for the indigent population so those who have no access to care whatsoever and this is I think something that Valley Baptist is very proud of we have an organization led up by Pam McWhorke called Cameron Care which uses ACO type of principles to manage an indigent population so you go back about 6 months and they were only managing patients who qualified who only made up to 200% of the federal poverty level and had no more than $2000 in assets so that was actually something when you were showing where that gap is that is very much the patients that Cameron Care assist with and of course they use a lot of care coordination social work activities to ensure that patients one are getting the care that they need two aren't over utilizing care so of course that's part of the talent that we run into is if you have a patient who's chronic kidney disease who doesn't have access to dialysis and they miss 3 dialysis sessions where do they end up in the emergency room and now they cost probably you know 5 to 10 times what it would have cost to just get them those 3 dialysis sessions and it's criminally inefficient for the hospital it's providing terrible outcomes for the patients and it's kind of indicative of some of the challenges that we run into in healthcare as a whole well Cameron Care is able to work with these patients and make sure that they're going to the care settings that they need to get them connected to the care that they need and that type of care coordination and that type of intervention for our patients is something that I would say could be duplicated throughout the state of Texas and you go back to when Cameron County was strictly running this they would usually run out of funds fairly quickly they worked with an agreement with Valley Baptist we've been able to be solvent for the entire year and in fact are expanding the number of patients that we're able to take on so my understanding is this year they're increasing 200% of federal poverty level although up to 400% of federal poverty level so it's not just that they're managing these patients and can treat more patients to what do you attribute the improved financial situation if you were to name one thing Pam Pam McGwork and the work that she's done management and kind of the understanding that she has of what we're trying to do with that type of initiative I would say the success of an ACO is going to be contingent upon the passion and the understanding of the leaders who run it and I think Pam has that in spades I think the other component of is she has very good relationships with her doctors and they have good relationships with their patients where they set down and say if you're joining this program you're going to be one of our patients you're going to be participating in your own care you're going to be getting this preventive care and working with those patients to make sure that they understand this is why it's important that Cameron Care has done a wonderful job of doing that for their patients Right, could I just ask as an extension of what you said two things one is again we're talking about dialysis but I'm glad you use dialysis actually because there's some how many people are addictionologists or do you deal with addictions in the audience I know one person don't worry I'm not going to call him but everybody has everybody whether you're in medicine or behavioral health or addictions or whatever has theoretical frameworks they work on so let's take your patient that you just used in terms of dialysis let's say it's not a non-compliance issue that kept them from coming let's say it's not depression let's just say somebody who went to a Vipers game down the street here and had certain indiscretions up at the dialysis center 30 pounds over now that person whether or not there was care coordination or missed the dialysis because they didn't want to go that day because they felt terrible through care coordination you would hook them back into the system in some way yeah we would connect them and I think this is something where where for our Indian care population especially and and kind of what has been alluded to throughout this presentation is the significant shortage of behavioral health support and I will say this so of course the Vida program Tropical Texas is a big part of that been immensely immensely helpful but there's only so much that we can do with so many resources that we have available and I think that's it's we would like to get that patient connected back to someone who can help them with whatever addiction or behavioral health issues or what have you that they have but it's just a question of is there any can place these patients just because I think irrespective of what behavioral health institute we talk about that they're not given the resources either in terms of funds in terms of individuals in terms of physicians to be as successful as could be so in an ideal world if we did have the resources available to be able to make those connections you'd be able to work and function smoothly but let's look at it from a different perspective supposing that that individual was somebody who was addicted to alcohol and the difference between dialysis for example and cheating or not being compliant or whatever versus any repetitive drive that has to do with drugs or alcohol is what's the first thing you tell me when I show up and I have a positive screen that you don't have an addiction well no that I have a positive screen I would assume that the person would just say oh no that's not accurate well okay so you're taking it from the perspective of what I would say if Susan were quizzing me about what I actually ate but that's not where I'm getting at you are told unlike the dialysis care coordinator let's say you're told you broke your contract right nobody in a dialysis center would say to you hey you broke your contract go home and suffocate now because we're not going to dialize you today but yet we have to keep in mind that for integrated behavioral health and integrated addictions and integrated care the theoretical frameworks that we've all been functioning under have to change or else it's not going to work that addicted patient whether or not they have diabetes and concurrent renal disease is not going to work in your system it's going to cost you money if you don't address that issue so all of you as you go back into your settings and you think about your theoretical frameworks and how you structure a three-pronged approach of addiction's behavioral health and medical care you're going to have to address those things that keep us from actually bringing the care in the most comprehensive way to that individual to where they needed at that point in time I want to do we have a mic for people to ask questions and so forth or make comments I'd like to throw things open in the last 25 minutes or so to the audience and encourage you to make comments I would like you to identify yourself before you before you make your comment or ask a question but please come forward we'd like to hear what your thoughts are I'm particularly interested in opening the conversation about the nature of the person who's delivering care what's your experience been with regard to the receptivity of your clients patients or whatever to diverse health professionals I hate the terms mid-level there are all kinds of terms for it but I am Natalie from Laredo as a nurse practitioner we get patients they come in with hemoglobin A1Cs of 13 and 14 and we work with them and we make them take ownership of the plan and if they do we see good results sometimes they fall off the wagon as doctor said but for the most part we put them back on track and they are pretty much agreeable we have started a new integration plan any integrating behavioral health and hopefully this is going to work as well but they have to buy into the plan and they are taking our patients are taking an active part in their plan so we are impressed with their response so far this is really a compact yes and we tell them you're not following they get off the track we tell them they're not following the plan and this is not the plan that we set up for you where did you see when did you fall off the plan what caused you to fall off the plan is there something we can do to help you and we work together to get them back on track and that's a key point in population health and that's a self management program that you need to include them in other comments or questions yes sir my name is Deepu George and I work with the UT Health Science UTRGV Family Medicine Residency just two points I wanted to make one of the things that I found in my behavioral health provider in a primary care setting is patients are more likely to follow up with one of us who is installed and sort of integrated into the team especially when they hear the fact that my office is right down the hall or that I can spend an extra 20 minutes with them there in traditional referral models usually the mental health facilities across town and they may not really make it there and never follow up so that's it reduces stigma to a great extent the other thing that I wanted to highlight within the integrated care experience is the role of relationships and so part of the team I think one of my theories is that the more cohesive you are as a team between the physicians the behavioral health providers and social workers and the more people are willing to see each other as a team versus the lead in the coordination of care the easier that whole process will be and I think that directly impacts the type of services patients get two very good points would you also comment or others may want to comment as well clearly there are good examples of where having a person with behavioral health experience on the premises working closely with everyone working with a team adds value in terms of the mental health side the question I have for you to comment on is what's your impact on the behavior of the primary care providers who are in the same environment but who may or may not have had a background in the behavioral health aspects one of the so we in the training I finished my training in North Carolina and so we did exit interviews with the residents who went through the integrated program and as part of their one month a year in their year one two and three they do an integrated care month and part of their role is to do X number of consoles and warm handouts with behavioral health providers one of the things that we found through the exit interviews is the fact that many of them said when we came into the setting of practicing we thought behavioral health issues were mainly defined metrics and symptoms mainly described in the DSM four or DSM five measures and whereas they started realizing that the psychosocial components and behavioral health is a much broader issue that directly impacts people's ability to manage their own health I think the other thing that we were able to see in some of the way they question the patients and when they do their assessments is they started broadening their assessment to find out more about the patient in context of their family and probably their social structure and so that was the other thing that we saw in some of the residents as they passed through the system. Thank you, I don't know if you wanted to comment. I've just finished writing the forward to a book that will be coming out by Weiner and Schwartz on what they call contextualization of care and they have articulated this what they have done is they have received permission from groups of physicians to audio tape interviews between patients and the physicians and they have developed a methodology for rigorously assessing those interactions and one of the things that was striking for example was the patient missed three appointments that was a red flag for contextualization. What was it about the patient's social situation emotional situation whatever that caused them it may turn out that the car broke down and they weren't able to get there or it may turn out that the job didn't allow them to get away at a particular time or a whole variety of those kinds of things and I think that finding ways to educate all of us on those contextual issues as you point out is really important I recommend this book to you I think it turns out that I can't tell you Frank the extraordinary kinds of interactions that patients have with their healthcare providers some of the things where the patient is regularly cut off in terms of trying to say something when the patient has never asked why did you come what are you here for I mean a whole variety of things that you would think any experience provider would do and yet they don't do it yes ma'am there's a lady down here Hi I'm Glenda Walker and I'm from Texas A&M and I'm a psychiatric nurse and there are a couple of things that have been said that really strike home to me one is the idea of asking medical students to look at the patient in terms of the subjective I always tell nursing students if you listen to the patients they will tell you what's going on and what's going wrong so I think that is so critical but there's the other part too that I don't believe that the behavioral and these elements can be an add-on and medical education and nursing education in any education that we do it has to be a rethinking of how we think about everything that we do when we walk in and start talking with someone we're thinking about the contextual we're thinking about the behavioral we're thinking about the possibility of a drug and alcohol and we're rethinking and we're bringing them to all together at the same time so I'm bringing all of that together from day one when you ask students whether it's a nursing student a medical student on a mid-level to present a case it's not just the physical symptoms in the bigger sense it's also clear that the mind-body distinction is not a relevant distinction I recently had the opportunity to chair a meeting on the Persian Gulf Syndrome and one of the interesting things there are the veterans being outraged by the notion that some people said the Persian Gulf Syndrome was psychiatric and others saying it was physical waiting for something to happen and so forth so it's a false dichotomy and I think we need to be able to address that two points that I want to make about this discussion to the point of contextualization if you go look or if you have anybody that has not any research in communications in the emergency rooms and you look at just even the sign-off between physicians nurses and everybody else caring for the patient that the same would be true they're wrong about the sign-off in a significant period of time we don't communicate well with each other as cues or anything else in such a way that you take it all in and you can make an impact the other thing is and Dr. Shine knows him Dr. Thomas Hackett and I used to have an argument all the time because Tom used to say and he was fond of the area that I trained in was consultation liaison psychiatry and Tom was always fond of all the consult service the psychiatric consultation service he did not like the liaison role and we would have an argument about the so-called biopsychosocial model and he would say the biopsychosocial model is flawed because it's outnumbered 12 to 3 in other words there's 12 psychosocials to 3 biological and he said that's the reason why people like Dr. Shine in cardiology would not pay attention to the psychosocial about folks and I would argue the other way around given that 70% of most of the things an emergency room or a doctor's office or whatever are really related to social determinants of health that's the reason why you needed to have 12 to 3 so we'd go around and around and around in a circle around this issue all the time but I think it's that's why I call this whole movement back to the future like the movie because the reality is that we're trying to sort of go back to time when we may not have had the technological or the molecular advances that we have and in reality we're going back to that side as it were and I think that's exactly it it's if we're talking about especially chronic diseases that are highly highly preventable it's getting back to kind of what are the basic items related to that well if I'm at risk of diabetes or hypertension or hyperlipidemia it's a fair chance that it's related to my diet and studies after studies have shown your diet is influenced by the people that you eat with and I think that's what we run into with the Valley is the family isn't always brought into the conversation about that patient's disease either because the patient doesn't want to admit they have a disease so they don't share it with their family or oh you're feeling bad here eat some more and I'm sure all of our clinicians in here have seen that and I think that's part of this conversation is not just seeing the psychosocial issues of the patient but what are the psychosocial issues for the family as well how are they dealing with disease progression do they understand how to treat that patient now do they understand when I make now something that's not so good for you for the rest of the family and put grilled chicken in front of you what that influence is going to have and I think it's something so basic but at the same time we don't really conceptualize it sometimes and I think that's what we've seen a lot with the Saluti Vida program is that patients need their family involvement not just for support but also so the family understands what the disease progress and what the disease instead of it being that the grilled chicken is being put in front of me think about the person that is doing that sometimes in the heart association we found that there were really very important social class differences when we were actively trying to reduce the prevalence of heart attacks particularly in middle aged men in the days when it was very common for men in their 40s 50s to drop dead we found that white collar workers very quickly caught on to the changes in diet and so forth and exercise in fact there was something called a type A personality back then which you notice has disappeared the reason most likely is that the type A's were the most type A about changing their diet exercising doing a variety of other things and they went home and they encouraged their wives to buy low fat low saturated fat food and so on things of this sort didn't work at Kimberley Clock for example didn't work where there were large numbers of non-white collar workers because they are the wife determined what was going to be eating and the wife needed to be educated that that was a critical part of their husbands health now again at that time the focus was particularly on heart attacks in men we know now that that was this and half the population from that point of view but it was a very striking example of who gets educated may make a huge difference in terms of the outcome other comments from anybody yes sir my name is Dr. Togli I'm a chiropractor here in McAllen this program that you're discussing and I think it's fantastic it's got great upside what I see would be going back to the fee for schedule it's still as you as a clinician as you as a medical practitioner is the stuff we're talking about is more and more comprehensive than just one person being there and so you're still limited by time like you discussed earlier and so we get rid of that fee for service type of time frame then we're going to keep on having this self-limiting factor of how many patients can I see and how much proper care can I give to the patient and I know you discussed potentially having more these medical students educated in the sense of being more inquisitive and finding out the root problem and helping manage these type of cases but the program in itself is going to be fantastic and what do you all see that we can continue to do forward going forward that will help make sure that we can help alleviate that fee for service or going forward and make sure we maximize our time of how much we can educate the patient and at the same time give proper care I want to speak to something real quick this is a small scale example but it can be extrapolated into other models so we were one of the early participants in the bundle payment for care improvement project under CMS specifically targeting hip and knee replacement patients and so as part of that program you're allowed to effectively gain share with your surgeons who are participating so if you see efficiencies in cost efficiencies in care while still meeting quality guidelines then that physician can participate in some of the shared savings well since we implemented that program and kind of working with our primary surgeon who is a part of that we've reduced length of stay by 25% we've reduced implant cost by 25% we're using less blood we're getting patients up earlier so that tied to that giving that physician more time to focus on the overall care of that patient kind of taking a step back and see okay where can we be a little bit more efficient seems like it'll take more time but overall saves you time in the long run and I think that's something that needs to be recognized as part of value based purchasing is in the long run we're actually saving a whole whole lot of time because if you have a patient who is on the verge of chronic kidney disease you get them back under control suddenly you've saved yourself all that future time of managing that patient when they did develop chronic kidney disease so I would say that the value based purchasing is going to encourage more efficient care in the long run that will ultimately allow physicians to spend even more time with their patients I would say three things one, payers are more interested in value based care including moving away from fee for service and you're seeing private insurance companies Medicare you're going to see haven't seen it yet in Medicaid but you will but they're insisting on it secondly if indeed physicians get involved in it it turns out they like it in San Antonio there was big resistance to doing this kind of program at Baptist the docs love it now because in fact they are now encumbered by much less paperwork and so forth because they're getting there's a flat rate and if they do it well they make money and they get a check quarterly or actually they now get it monthly the key to both of these is quality measurement because the whole key with regard to delivering care for less expenditures is the patient or the payer is suspicious that you're cutting corners to make money and so that was the concern about capitated care so you have to have quality measures bundled head and neck surgery at MD Anderson because we know what the incidence is of not just death which is a relatively minor complication but of inability to speak inability to eat persistent pain or whatever and the final point I'd make is that I told you that I'm on the board of United Health Group United Health Group currently owns practices that's delivering care to well over 3 million people by the end of this year it'll be 4 million people so you've got an insurance company that owns practices and you know what those practices are doing most invariably they go into capitation they love it that they don't have to get involved in all kinds of bills and so forth now to be sure it's slow in Texas I'm delighted to experience that Valley Baptist has had a very resistant to change in this regard but in Florida, Arizona California, Michigan New York you're seeing major movements in the direction and it'll come to Texas eventually other comments we've got just another 5 minutes I do have to tell you since everyone's throwing around stories of celebrities I do have to tell you one story Bill Clinton was the president of the United States he had just been impeached by the house it hadn't yet gone to the senate for a trial and I was in the White House at an event for Nobel laureates and I'm standing there talking to Bill Clinton and he's framed behind him by a picture of Abraham Lincoln in that very thoughtful pose where his hands on his hands and so forth you know there he is very honest Abe and we're talking about a report on research in children and I said to him you know according to the report we really need to do a much better job on the research we do in children and it raises a lot of ethical issues and I'll never forget Bill Clinton without cracking a smile saying yes it turns out there's ethical issues almost every way you look and it took all my self control not to laugh last question from the audience anything let me conclude I want to ask each of my colleagues for a very quick response because again Rebecca's got the hook here in about four minutes from your point of view as an educator do you think UTRGV is going to be properly educating medical students who can operate in this kind of new delivery model team based approach and so forth and what are the things that you feel are likely to produce that kind of result I think that it would involve I think it would involve people in the hospital systems to NACOs and so on to partner with us to allow students and trainees to be a part of that process if you do not do that it's in isolation and so there has to be the collaborative networking that has to occur at this level and then I'll let you respond to it too but I don't want to disappoint you I do have a song in my head I'm very excited by the idea of universities being involved in the transition to population health management and accountable care and in fact part of my world now our clinical integration networks have only been in place about five months now so it's still very very early on but I've reached out to the local pharmacy school I've reached out to social work schools I've started reaching out to clinics to see if there are students who would like to be involved in this type of project one because I think it's a great learning opportunity for any student because you do get to see the future of where healthcare is heading two is because and of course this is the business person in me I don't have to pay for anything no that's not entirely true that's not entirely true and three I think it's going to give us a fresh view on what population health management can be and I think that historically we've had an idea of what this might look like and we've kind of had preconceived notions I do like the idea of students being involved in saying well why don't you do it this way instead and in fact you know part of my title also is administrative residency coordinator so I work with administrative residents and one of the first conversations I have with them is okay you're a student you're coming in understand you don't know anything and that's great because you get to ask stupid questions that we would never ask ourselves that turn out to be very smart questions and so that's what I like about having students involved in this type of program and and so I said we would adopt a disease a clinical only you could even adopt the Dean we're going to have adoption of an ACO added to the list fair enough but I don't want to disappoint Dr. Shine so you heard his summary comments at the end how many of you have seen Diabetes filled the you have okay so you know that the valley gets a bum wrap on this and many of the things including what goes on in the border and all I could say to Dr. Shine's closing comments and it may not be current pop but it is pop if we could make it here make it it's up to you RGV RGV how's that Dr. Shine I don't think anyone could say it more eloquently thank you very much for your attention Rebecca we finished on the minute thank you so very much now you guys can see why I've just been so elated and truly the three rock stars that are sitting here we are just so honored that you have taken the time to be here with us to share your insights and we have a small gift for you each of you I want to take the time though to read I think it's very appropriate and this goes back to Pastor Mickey saying so much of everything that we're doing this journey that we're about to embark on is grounded in our values and our faith and certainly rings true throughout this entire conversation so serving humanity to honor God by improving the physical mental and spiritual health of those left served in south Texas conference area of the United Methodist Church and so this is a memento for you to place on your desk and it also I hope is the first of many opportunities that this group will have to be able to tap into the incredible brain power that is sitting at the top of this and we pledge to keep you informed and keep the conversation going and and I want to say the reason I think this was so important is as we're about to do this work I realize we've just spent the most of the day talking about compliance issues and those are all so important so we're going to have to dive really deep into the details and I think sometimes as you go through that process you lose sight because that's what you're doing right but I think that these opportunities to fly high and to really know the work that you're doing is going to inform and transform change in South Texas and so this was a small gift back to you for the two days that you've invested to really to say to you that what you're about to do is truly going to inspire transform and change the communities that you live and you work in we, MHM is just very honored to be in partnership with you to do that so I have a before I ask Kevin Moriarty to come up I have just a few housekeeping and I'm going to cover these because I know if I give in the bullet points I don't know so the survey for feedback on the entire convening is in the back of your packets and please turn that in the registration table and it's a very critical because we are going to use these to tabulate and evaluate how we can improve as we convene more frequently we want to make sure that it's meeting your needs the other is we will be sharing all the presentations so if you missed a handout didn't have it specifically this as well you can drop box and you will have access if you want to get connected and misplace business cards or didn't get to follow up Santiago is your man he is our conduit he is our communication conduit and then again I know we are going to have to dive really deep in the weeds to do this work but remember to fly high as you do as you move along so now I'm going to introduce Kevin I know what it means to be the cleanup guy the last person before you get on the road so I won't keep you but I want to thank you I want to thank our honored guests for all of their comments and their direction and also their leadership throughout their lives I want to thank all of you for the journey we are going to be on together some of you new and some of us who have been on this journey with us for the last decade as we've been bringing health care into this area and the rest of the area of south Texas that were responsible for all 74 counties but I want to leave you with a different thought we're kind of a small group of folk we've talked about a lot of other people that need to be on board with us and I was sitting there thinking to myself that I've kind of had a whirlwind of a couple of weeks Becca's had me in Curveville and we had a similar conference and last week we were in Corpus Christi so Sunday I was at the New Star Corporation and I was in a room like this except there were about a thousand people in the room and they were raising money for the homeless, for the mental health services for the Haven for Hope and with a business community group completely different from you corporate leaders, salesmen structural steel guys oil and gas guys that's the whole group that was there they raised four million this year and they raised it in one day and so I want to say to you that the whole lot of other people out there who see this as the highest and the most important community problem that need to be working on they understand the comorbidities they understand the issues and they understand that they have a responsibility to do that and then Monday night I was emceeing the Mental Health Association of Texas meeting where we honored Tom Loos but he received the award, the butt award was named for Howard Butt's mother and Howard Butt was there and you guys have been talking about your HEBs and I will tell you that when we put the Meadows Mental Health Policy Institute together and they came to Methodist to ask for some money we agreed to be a co-founder of it they were attempting to raise 11 million of these issues for the state of Texas and we raised 22-23 million dollars in six months because we talked to a business community groups and they said yes we have to change the face of mental health in Texas and in this state and so there are a lot of other pieces of all this happening, they're happening because of all the good work that you're doing and others are doing, I'm grateful to the CIF grant for the ability to bring all this together and go to the outcomes that tell us how to guide the nation on successful strategies and outcomes and I know definitively that each one of you will be there as we celebrate in four or five years whatever those outcomes will be and we then get on to the policy side of the equation on the national level on the state level to kind of change the outcomes for so many other people out there in our nation and so I give you that thought that there's a lot of other people working on all of this stuff and they don't look like us but they're just as concerned from different perspectives because their communities are having similar impacts and so with that I pledge to you that we're going to continue at Methodist Healthcare Ministries to stay on it stay focused, keep on working on funding, keep on working on projects keep on working on policy, keep on working on lobbying which we're allowed to do and after some conversations with y'all I'm going to have to ask my lobbying team to talk about getting us re-engaged on the federal side we don't do a lot of federal lobbying because it's been a waste of time in the last eight or so years but we do a lot on the state level and so maybe we need to kind of think about some big asks and hits out there to kind of make it easier for all of us and so I want to thank you all we're going to be with you all this way as we have been for the twenty years that I've been around in this life and the forty years I've been around doing healthcare and services and so thank you I appreciate it and drive safe