And talking about thought leaders, I want to make sure we put a little plug in here. For those of you who do not know about the San Antonio Literacy Initiative or don't know how to connect but have been dying to want to be a part of this elite group of ragtag volunteers that like to make trouble everywhere we go, please be sure to visit with us. We meet every second Thursday of the month from 9 to 10.30 at Texas Diabetes Institute right off of Sarasamora Street. If you can't leave your office, that's okay. We have go-to meetings so you can also log on and just listen and chat with us on the phone. We have a brand new redone website at sahealthliteracy.com where we've started to add a lot of resources. That's also where you're going to see the presentations from today. But we also have a list of other resources including some training, some training, the trainer workshops that we offer, and then just a lot of other really valuable local partners that are working in this issue. So if you want to learn more about joining the health literacy group, there's no cost. It's completely free. We're all volunteers. But more so if you want to start really learning more about what you can do within your organization and you're looking for some quick tools, definitely contact us. Go to the website, call us at the health collaborative. Our phone number and information is on your program so I encourage you to visit with us. And we also have health literacy committee members that are here today. I have Kate Martin right over there, Ms. Melanie Stone, Dr. Oralia Vasaldua, and who else is here from the health literacy group? Oh, there you go, Ellen Spitzen from San Antonio Metro Health Department. I'm missing someone maybe. Okay, well, me. That's me. So please visit with us maybe at lunch at the poster session and just ask them some questions about how much committee work do you really have to do and how many meetings do I really have to go to. I know sometimes that's the biggest question and really it's whatever your passion drives for you to give. So I'm going to do an introduction here for our next speaker, Ms. Andrea Guajardo. She is a PhD candidate. Can I say that? She is working on her. Please say that. Yes. She is working among so many other things in a community advocate, a leader, a Latina researcher. She also happens to be a board member of the health collaborative representing Krista Santa Rosa and she was actually part of our panel last night. So today you're actually participating in a deeper dive session of integrating health literacy into Krista Santa Rosa. And Andrea is going to talk to us today about their mission, the programming that they do, the use of their community health workers and what changes they've seen, not just in the healthcare aspect but also in the actual health aspect of our community. So today she's going to teach us so much more about that. So again Andrea Guajardo is a native of South Texas, is the director of community health for Krista Santa Rosa Health System, a doctoral candidate at the University of the Incarnate Ward, my school. And she is seeking a PhD in education. She's an adjunct professor at the University of Incarnate Ward in the Department of Health Promotion. And her research interests include Latinas in leadership, culturally competent models for population health, and public policy and program evaluation. She is also a voter registrar. Yes. And she is pushing for votes here with the Latina and Hispanic community. So welcome Andrea. Thank you. Thank you Liz. Okay, so I'm not a stand at the podium kind of presenter, so I know I'm short but can y'all see me? Okay, and just look at the slides, I'm not here to show off. Okay, so today Krista Santa Rosa, so thank you so much to all of you that were there for the health literacy conversation, community dialogue last night. I think we covered some really great topics. And so I appreciate Liz inviting me to come and give a deeper dive into what it is that Krista Santa Rosa does when it comes to health literacy and caring for our community. So Krista Santa Rosa Health System, we have an equity of care protocol process that is developing, has been developed for quite some time. And because Krista Santa Rosa is the sixth largest Catholic healthcare organization in the United States, we're very proud of that Catholic identity. And so we always sort of try to contextualize ourselves and our founders and how we came to be in this community. This is Bishop Claude de Buie, he was the first Bishop of Texas. And he came to Texas to minister to a wild frontier essentially. And so he put this call out to his, to the sisters of charity who were in France at the time and he told them, our Lord Jesus Christ suffering in the persons of a multitude, the sick and infirm of every kind seeks relief at your hands. And for us, this is true, as true today as it was when Bishop de Buie first made this call in the mid-1800s.  And when he made that call, the sisters came from France and these were teenagers, young women who spoke only French and they came to Texas, first to Galveston and then answering another call, came to San Antonio in the midst of a cholera epidemic. And created what became the San Rosa Health Ministry. And that ministry and the mission is to extend the healing ministry of Jesus Christ. So first and foremost, that's what grounds us and everything that means when we extend the healing ministry, which is how we get here to health literacy today. That's a very short history, if you really want to hear the whole thing. Let's sit and have, I can talk all day, I love the sisters history. So fast forward to 2010, how many of you have heard of the Affordable Care Act? Of two that, thank you very much. I would, if you haven't, get out, just kidding, just kidding, we love everyone. So the Affordable Care Act did several things, probably the most notable is that it created the health insurance marketplace, Obamacare, we're all very familiar with that, but also did lots of other things. And one of those was to create this provision for accountable care organizations. It gives hospitals, medical providers the opportunity to be more accountable for population health. Christa San Rosa has chosen to become an accountable care organization, has been since January of this year. And this is the definition, we can all read it, but that's exactly what the textbook definition of what it is. But instead of just limiting ourselves to Medicare beneficiaries, we also extend this commitment to our uninsured, underinsured Medicaid, basically anyone who comes through our doors. We're responsible for this, whether it's legally obligated or not. So we get to our equity of care three-year plan. Christa San Rosa's outlined very specific metrics for exactly how we're going to move towards being a fully accountable care organization. The first of these are this year, so we are in our fiscal year, starting July 1st, to develop this process for identifying our most vulnerable patients who come back to the ED within 30 days. So if you come, leave, come back within 30 days, right? Readmissions.  What is their race, their ethnicity, their language spoken at home, their religion, their country of origin? These are all things that in the past I think we collect them. We say, look at our demographics and like every other report and plan, it goes on a shelf and we kind of really don't look at it anymore until it's time to look at demographics again. So we're really going to be very intentional about collecting this data and then moving forward. So by year two, we'll have strategic partnerships with community organizations. Those already exist, but these community organizations and partnerships would be more formal. And also to participate and invest in culturally appropriate programs that address the identified needs and we'll get to sort of what the identified needs are in here in a second. And then long term, year three and beyond to ensure an equitable 30-day revisit rate by race and ethnicity at our region level. And to decrease the ED visit rates within 30 days by 5% as a system.  But really, we want to know that if you're coming back, it's not because we have in some way not addressed the particular issues that are associated with your race, ethnicity, language, religion, or country of origin or age. So we want to ensure that if you're coming back, it's equitable across all of those criteria. So our metrics, how are we going to do this? I'm an evaluator, so of course we have metrics, logic models, all kinds of stuff like that to make sure that what we say we're going to do is measurable, there's a time limit, and that we're holding ourselves accountable to those targets. So these are our thresholds. We're measuring right now and have measured our 30-day revisit baseline. We've identified our top ten diagnoses and we're doing geographic mapping to see where those patients are coming from. Which zip codes they're coming to us from within our primary service area of our facility. So our target, once we've established that threshold in year one, the target is to develop the plan that addresses how we're going to mitigate these factors. Once we know who's coming from where they're coming and how many there are. Selecting the target population, looking at the social determinants and the chronic conditions that we're going to address. And identifying all of the community resources that might be able to address those particular populations. And then, as always, and really that's at the heart of all of this, is that anything that we do is going to be culturally responsive. And I say culturally responsive and I don't say culturally competent. Because in my brain, in the way that I work, competence implies a finality. I'm competent, I'm done. Took a test, I'm competent, check the box. Responsiveness means that we're able to respond to a community and all of its fluidity and all of the things that changes with it. And so I would suggest to you that maybe we start changing our ways and maybe our vocabulary around how we respond to the community. And it's difficult to take a whole concept like cultural confidence out of our vocabulary completely. But think about that in your work. Am I considering myself competent today? I've met you, I know who you are, I'm helping you address your needs. I'm competent, we're done. But then when I meet you, do I do the same thing? No, because your needs are different. And to be responsive is to change as we interact with our community. And then when we say we have exceeded all of our goals, that is when we implement an evidence-based program. We're publishing, we're saying, great, look, we solved all the world's problems. Chris DeSanderos is the most amazing place ever. But that's our maximum. That's really saying that we've achieved something that we set out to do. And we've changed the face of population health within our facilities and with our populations. So this is our model, and it just represented a little bit different way. And it's the triple aim, sort of, I don't know what you call that cone. What do you call that shape? But the triple aim is that we are looking to increase population health. So decreasing our 30-day revisit rates, and improving the utilization of our primary care services. Because we're seeing people go with their primary care position. There's a less likelihood that they're going to come to the emergency room for their primary care. The second is the care experience. And that's around the people. How are people being cared for in a culturally responsive way? And what is their patient, oh, I just bit my tongue. What is their patient satisfaction, really bad? And patient satisfaction, and patient satisfaction that goes across the board. It's standard in every single healthcare organization. We measure that all the time. But really taking patient satisfaction with a special emphasis on these cultural aspects and the data that we're collecting.  We look at the cost avoidance. And so this is not really a savings. This is not necessarily how much money we are saving, like a reduction in the amount of money. But it's really how many times are our patients not coming back to us. So that's kind of a little bit of a different thing. How many times are we helping Mrs. Garcia with her chronic illness, based on how many times she's been to the emergency room in the last year? How many times is she not coming this year? So that's more of a cost avoidance rather than a cost savings. But measuring that and comparing it to our baseline data. So this is some actual hospital data. This is what we're collecting. And this is at our West Over Hills facility from the ED. This is our revisits and just a snapshot from FY16. So this would have been July 1 of 15 to June 30, 16. And this is total ED visits here. So you see 49,000. It's our busiest ED. And everybody know where West Over Hills is? Far west side near SeaWorld. Okay, and of those ED visits, 16% were revisits. So within 30 days. So this is our target. This is our baseline where we're saying, these are how many people are coming to us, but this is something that we need to take a deeper look at to see why are they coming back? Who is coming back? And how can we mitigate this effect? These are zip codes, and I'll show you a map in a second. But we're also, we said that we're targeting a specific geographic area. So we're looking at the most common zip codes. Oh, shoot. The most common zip codes, operate this in our service area, which are 78245, 227, 251. And these are tied for fourth. But this is where we can make the biggest impact here within those specific, so of that 7,000 number, these are our top targets. And an even deeper dive of those 7,000 from those specific zip codes, these are our top diagnoses in terms of who's coming into us. We have hypertension, type two diabetes. This is no surprise, right? You all could have predicted this. And this is Westover, but this data is pretty similar for almost all of our EDs. So high cholesterol, coronary artery disease, and then sort of on down the line. And all of them are pretty consistent across all of our facilities. So you'll see, oh, my pie chart didn't come over. So you'll see that for the top diagnoses, that's all of these right here. And then that's the rest of it. So really this is where we're looking at making an impact. This is where we're going to focus most of our resources and most of our effort. Anybody? Putting you on the spot? Okay. Okay, so are you just embarrassed and you don't want to admit it? Okay, okay, never getting to look around. Was it your neighbor? Okay, so we're looking at, so we've gone from how many patients we have, that's 7,000, a little over 7,000. We know where they're coming from, where they're living. We know what conditions they're coming into us for. And now we're taking an even deeper dive and looking at race and ethnicity. So you'll see here, boom, no surprise, right? According to these diagnostic codes up here, 48% of our patients that are coming to us, and this is total, this is among all payer groups, 48%, so nearly half are coming in and reporting self-identifying as Hispanic. And Anglo-White is not that far behind. So I mean, given the demographic of that part of town, this is what we expected to see. Now this is our payer mix. So of those patients that are coming in, we know where they're coming from, we know who they are, we know how many, we know what the race and ethnicity are, and this is their payer mix. And this is the financial piece that we're looking at. How are they being managed? And most of them are coming to us from Medicare. So Medicaid, some managed care, and 11% are the self-pay, so are uninsured here. And this is important because we are an accountable care organization. And by saying yes, we are going to be accountable, what does that mean? If we're not managing these patients, we get danged. It affects our reimbursement rates, and it affects the way that we do business. So even though it is the right thing to do as a Catholic healthcare organization caring for our community, we've also obligated ourselves to it legally because of the Affordable Care Act. And a lot of other health systems are moving towards this model as well. So that was the overarching sort of view of every patient that come into our hospital. But because we have a special emphasis on care of those living in poverty and for vulnerable populations, we take a different look, and we want to look specifically at that 11% that was there on the side of the graph. And so as a healthcare system, our strategy is called Compass 2020. It's where we want to be in the year 2020. And one of the major, there's four of them, business literacy, quality, community benefit, that's my stuff. And there's one more, and I can't believe I'm blinking out on it right now. But community benefit, community healthcare of the community is one of those four top priorities for our hospital system. And so because of that, it's my job to make sure that we do take a look at that 11%. And so for, and this is part of our strategic plan and nothing happens unless it's on the strategic plan and everything that we do has to roll up to our strategic plan. But our goal is to really improve our disproportionate ED visits by race and ethnicity, especially among the uninsured. And so you'll see our financial indicator, of course our mission, to extend the healing ministry of Jesus Christ, strengthen the financial base to fulfill our mission. And we're looking at a two to 2.5% minimum on our net operating revenue, or I'm sorry, income. Our quality, zero harm. So all of these are linked together. Oh sorry, you have financial quality and then our community-based metrics are all linked together and all roll up to the strategic plan which is driven by the mission. The strategies that we are employing, and a lot of these have been ongoing for a long time. We've had community health worker program in some form or fashion since 1994. Kind of ramped it up to a little bit more formal program in 2002. And then the current program, the way that exists now has been in place since 2010. So this has always been a priority for us and so all of these strategies have always been employed. It's just now they are being employed and quantified system-wide. When I say system-wide, I mean all of Christa's health, not just San Antonio. And so facilitating follow-up appointments for primary care, leveraging community health clinic relationships by formalizing MOUs. We currently have relationship with Central Med where we fund obstetricians in their prenatal clinics so that we're supporting community clinics and infant outcomes in the community, developing prescription pricing grids by drug category, making sure that the people that we see when we're prescribing drugs that they can actually afford them or that the coverage that they have, the formularies are consistent with their coverage, examining these top diagnoses, determining which areas are for greatest impact and then also looking to where we're going to invest our community benefit dollars because they're very limited. We don't have that much money to invest in community benefit but the less money that we can spend on charity care in the hospital, the more money that is available for us to do proactive stuff. Charity care is an indicator for non-profit hospitals and we're required to do at least 5% every net patient revenue every year in order to maintain your non-profit status. And Santa Rosa consistently does 10 to 12% every year and people say, look what a great job we're doing in the community. We're doing $50 million in charity care and that just makes me cringe because all that means is that we're taking care of sick people for free in the hospital. We don't get reimbursed for that and so we say, oh, our costs were $50 million last year in charity care. If you could just give me one million of that so that I could spend that on proactive community health programming on upstream indicators. Social determinants way upstream, I think we could make such a bigger difference than just taking care of people once they get sick. So it's really about prevention and population health. So our community benefit investments are really targeted for those upstream indicators. So this is the same graph that you saw earlier but instead of just having this is our total ED visits and these are uninsured here so that 11% that we said that we're coming in.  And of that, 4,600 are non-urgent. So they're coming in because usually they don't have access to a primary care provider and whatever access means and we know that, right. Not having access means lots of different things. Sometimes it's insurance, sometimes it's hours, sometimes it's the fact that my PCP's not open when I need him or her. Man, that was really bad of me, I shouldn't have said that. Him, oh, horrible. Okay, so we know there's lots of different reasons that people come in for non-urgent reasons and so that's another population that we know that we can have some impact on. Again, this is the same graph, so top 10 zip codes, but these are where our uninsured, non-urgent patients are coming from. So those are our top line right here and then this one down here because it's close in. And this is what they look like on the map. So if you look at, let's see, here's SeaWorld right over here, 151 right here. This is where our hospital is right here, 151 and 6204, right on that little line right there. And so you'll see our uninsured, non-urgent patients, for some reason, are coming from all of these zip codes to find their primary care at that emergency department. And I will guarantee you there are plenty of primary care providers in this area. So the deeper dive is asking the question, looking at who you are, what is your race, language, ethnicity, country of origin, and your age, and what is your barrier to accessing your PCP? Because it's not just because they feel like coming to the emergency room. I mean, we have a great hospital and all, but it's no fun sitting in the emergency room, I promise you. So really that's the question that we're getting at in terms of becoming more accountable to population health. Why? Asking the question why. So this is where we're focusing the top four zip codes here. Again, some diagnostic codes, these are the tops that come in, nicotine, hypertension, diabetes, anxiety. These are non-urgent conditions that people come into the hospital with that probably could have waited 10 to 12 hours until they could get to their PCP the next day, assuming that they had a PCP and assuming that they could access that through a number of barriers. These are things that we consider non-urgent. Nicotine, these are my community health workers. When somebody comes in and says nicotine, explain why that diagnosis comes up. Did everybody hear that? Right, right, so a COPD, asthma, like any kind of breathing lung kind of a thing, and so, but it's a non-urgent thing. It's like I feel bad today, worse than I usually do, but it's linked back to the root cause because I'm a nicotine user, but it's a, that's how they code it, that's how they code it. Now, I could call in some experts from our medical records department, but yeah, but those are, but really this is very, I think, telling indicator because if we just said COPD or asthma, the root cause of those could be very diverse, but nicotine gets to the heart of why that person's there. There's one reason why that person's there because I smoke, I make myself sick, but I continue to smoke, so it really sort of nails down the primary thing that we could make a difference in to reduce this number. Smoking, it's bad, stop it, right? Yeah, it makes sense to me, but yeah. So we continue to see this as a major reason for people coming for non-urgent stuff. And I can't believe my pie graphs, there were very pretty, there's percentages there. So you'll see, so these four make up, I think about 93% of the reasons for people coming for non-urgent reasons and the rest are that tiny little sliver right there. So where are we looking to make our impact right here in this blue area? Again, looking just at uninsured patients. These are our target, I mean, our race and ethnicity who we're looking at. Obviously again, Hispanic folks, people who self-identify, and this is them saying I am a Hispanic person. This is our major population and within these targeted diagnostic codes, hypertension, nicotine dependence, diabetes, anxiety, and then about the same percentage, Anglo and Hispanic as for the total population. So we're seeing a really nice subset that really mirrors the total population. So we look at all of this and we take it into account like who's coming and why and what do they look like? So that we can start to structure what our population health strategies are going to be, where we need to develop our health literacy vocabulary in order to communicate with our patients. We really need to come up with programs that are responsive to the Hispanic community, that target middle-aged people, so 26 to 54, so that middle demographic, those without a PCP, most of them are coming here with no primary care, and 36% of whom say they are Catholic. And that makes a difference because the way that I receive my health education might be impacted by my religion. I might have access to a parish nursing program. I might trust health information given to me by my priest or by some my deacon, or I might be more likely to use a program that is based at my parish if I am a Catholic and I identify as such. And so this is how we are working to structure our population health programs. So really these are our recommendations and this is what we're running with in terms of equity of care. And this is just for one facility. So this is happening over all of our facilities including New Bromples, anywhere we have an emergency department. So we have emergency departments in New Bromples at the hospital and a freestanding ED. We have the West Over Hills ED. We have a pediatric ED at West Over Hills. We have children's ED, ALON, and West Over, yeah. So that's it. So yeah, so anywhere we have an emergency department, we're looking at all of this data and tailoring specific strategies for each population. This is just one example because it's the biggest example at West Over. In terms of our market share, I think it's probably both. I mean, obviously like I said, we're a business and so in order to sustain our ability to care for our uninsured, we also have to have facilities that will generate revenue and it's a balance. And so yeah, the decisions that are made by our business development departments to put an ED here or there is really largely competition and market-based but also there's a huge piece that ties back to this and what does the community need? The next expansion will be to Bernie after this to put a facility there.  But at the same time, we're trying to take care of kids in Stone Oak. We also have a pediatric mobile van that partners with Harland Dillon Edgewood School Districts to provide free care to those students at school who most of them are the largest part of the document or population is undocumented. So we really try to structure our business that generates revenue so that we can do the things that we know is our responsibility and obligation as a healthcare system. So these are our target populations for equity of care. So the ones are total population here. And then down here, specific targets for our uninsured folks. And so that's the hospital piece. And if you attended or have looked at the health collaborative community health needs assessment that was just completed for 2016, it's an amazing document. It is astonishing in some respects because it does highlight the severe disparities that we have in San Antonio. You can literally draw a line through the city at Hildebrand and the things that occur south of that line generally don't occur north of that line. And then disparity between the two is pretty shocking. So if you haven't had a chance to look at that document, I would suggest it, especially if this is your passion and your line of work. But this is a logic model that comes out of that document. So this is not mine, but it comes from the health collaborative. And this is where we, as a community health department, so you saw the hospital data and all of that, but as a community health department, this is where we really try to locate ourselves in how we do our work and why we do our work.  These are the social inequities that we're all born into. And then you've got the institutional power systems, like bureaucracies, like social security, government agencies, schools, all of those institutions of power that remain in power and are sometimes not always the most fair to those who have been born into social inequality. And so this has an effect on how unhealthy or how unhealthy our community is. And then we have our living conditions. This is our built environment, social environment, and all of the things that some people might say, well, those are choices, but really are they? Dr. Ferrer, our chair for the health collaborative, says, you know, people make the best choices from the choices that they're given. Just because you might have some choices based on your living conditions, sometimes they're just the best choice that you can make. So not necessarily lots of choice there. When we get to risk behaviors, as a hospital system, this is where we really feel like we can make the biggest impact by learning about the people that are coming to our emergency departments, where they're coming from, what illnesses they have, why they're coming there, and then what are the demographics around those people based on race, ethnicity, country of origin, language, and age? How can we best help them mitigate or improve some of these risk behaviors here?  So it's a lot easier to, you know, go to the, well, they got next door and buy whatever you can buy. So that's why we want to know where people are coming from and what the individual circumstances of that person are so that we can tailor our care management programs specifically to each one of those persons that we're identifying in that data. Because graphs and charts are really pretty and they look great and I love data, I'm a huge nerd, but each one of those percentage points represents a person who's a mom or a dad or a sister with a life, you know, one of our core values at Christus is dignity, the dignity of the human person. And so first and foremost, we have to recognize what is going on with that specific person and tailoring our strategies around that. Because what we don't want to happen is to increase the disease and injury piece of this, of this logic model, if we can, you know, which will naturally lead to mortality. We see that every day. People dying for preventable conditions. And so if we can make a difference here, this is where we sit, this is where we are located and why do I say we, I mean my department, community health workers, community health, all of us in this room, you wouldn't be here if this isn't where you sit. Now a lot of us, you know, participate in policy development, we go to meetings, we are advocates, we go to Austin, we testify, we talk to our elected officials, so we can all be doing the policy piece. But for today's discussion, we're really looking at these risk behaviors and how we do that. And so at Christus, like I said, we've had community health workers for some time. You know, and we use the social determinants model. It's tried and true, you know, I know a lot of people, oh, that's social determinants. But really, it's worked the best for us. And when I say social determinants, I mean that these are all the things that we are collecting. Who are the people coming to us? But then once they get here, we're looking at whether or not they're using nicotine, whether or not they have a poor diet. So what are these individual lifestyle factors? These are our risk behaviors, right? The choices that we make that impact our health. But then what about our social community networks? Am I living with domestic violence? Am I really gonna take care of my diabetes if I'm worried about whether or not I'm going to be beaten tonight by my husband? So we have some social and community networks that are very important. The grandparents raising grandchildren for the first time this year were included in the stakeholder group for the community health needs assessment. And this has been an issue that's been very prevalent for a long time. And I was listening to some of the grandmothers talk and she said, you know, she's talking about her experience and taking care of her grandchildren and how they came to her.  It's really difficult. And I thought, wow, I've never heard of that.  I'm a single grandmother. I was like, okay. So that's a completely different set of social and community networks that they've been able to develop to lean on each other because that's a whole other. I mean, we could do an whole hour on grandparents raising grandchildren. But in terms of how well she can create a social and community network is going to determine her own health and the health of her children. And then once we get further into these concentric circles, living and working conditions, do I have access to education, water and sanitation, healthcare services, housing, am I living in old housing with lead pipes and asbestos and lead paint? Do I have street lights? You know, I took my daughter to school yesterday and I was thinking about this conference and I live like North Central and they just built a brand new beautiful sidewalk coming from the elementary school all the way down the street, took a long time, built nice curbs up in front of everybody's houses. And there's already a sidewalk on the other side of the street, but they built two. And I'm looking at the new sidewalk and I think, wow, that's really nice. You know, we should come take a walk. We can walk to school very easily. And then I pull into the parking lot and on the corner, there's a crossing guard. Pull into the parking lot to drop my daughter off and the school has a program where students can be crossing guards or can be safety officers. So every time a child pulls up, a safety officer opens the door and lets that child out. And there's teachers standing behind them giving them high fives. Good morning, hello, hi, how are you? And I wait until the crossing guard blows his whistle, tweet, tweet, you can leave now. And I pull out of the parking lot and there's a police officer, school district police officer sitting there in his car, just chilling. And I thought, look at all of these wonderful social determinants. My kids are lucky. I'm lucky. I wonder how many elementary schools don't have all of these social determinants. My kids automatically, just by virtue of having a sidewalk and a crossing guard and a police officer and a high five every morning are already set up for success. And those kids that don't have that still have a shot, but not the same shot. And that's where the inequity comes in. So that's why looking at all of these other conditions that we don't think about every day. A high five in the morning? I would love somebody to give me a high five every morning, quite frankly. Yes, you're doing a good job. I try to pat myself on the back, but it gets tiring. So it's things like that that really make a difference to a child and would make a difference to an adult. So this social determinants model is at the heart of what we do at Christus. We ask all of these questions when someone comes to us. And this is an adult. We have children's, community health workers at children, but for the most part, most of our patients are adults. But you have to ask all of these questions. Who's giving you a high five today? Have you had a high five in the last six weeks? Why are you here? I'm here because my diabetes. Diabetes is not the thing. Diabetes is why you're here today.  Okay, once we take care of that, what's the next step? What are all the other things that you need? And some of the things that we see, and we can take some questions from our community health workers, but we see things like social security eligibility, diabetic shoes, wheelchairs, a ride here, there, you know, Medicaid for my kids, something like that. And so that's where our community health worker program sort of lives and breathes is making sure that we look, we take care of the diagnosis and what brought them to our door, but then we look beyond that to see how can we help you navigate a system once you leave here that's going to increase the likelihood that you're not gonna come back in crisis. Not because we don't love you, but because we want you to be well. And that is all I have. This is my contact information. Do we have time for a Q and A? Yeah, if you guys wanna come up here and sit. So guys, these are my amazing community health workers. They are all certified. Chris DeSanderosa is an internship site for Northwest Vista, so we host interns who are becoming certified for community health workers. Let's go left to right. This is Tracy, Laura, Imelda, and Rodrigo and they all work out of the Westover Hills facility. And so they're the ones that are actually talking and interacting with all of the numbers that you saw today. So I asked them up here because I want to acknowledge their expertise. I want to acknowledge their hard work. It's nice for me to be able to get up here and talk and say all these nice things, but these are the guys that are on the front lines doing the real work. And so I have a tremendous amount of respect for them. And so if you have any questions, these are your guys. For me or anybody else? Hi, I, ooh. I'm interested to find out more about your hypertension diagnosis. That's interesting that it's so high. So I'm just wondering where the patients come from. Are they coming from the primary care office because it's in the urgent phase? Or do the patients go to HB or Walgreens and check it and it's high and then they come in? Or do you have any insights in terms of how they get there? Well, I can answer that. While a lot of the patients that come in, they usually come into the ER, they don't know whether they're feeling sick, they're having headaches or throwing up or having symptoms. When they come in, they knew, they come in, they get their triage and they identify as having high blood pressure. And so we deal with all the ones that are on the stirrer. So we, you know, once they're identified, then we have either the ED navigators or the care partners group work with them. And then we can, you know, we take them from there. We planned to meet with them to do an assessment at home and then from there, I case managed them to into a medical home. Yes. Yes, we deal with all the patients that come in through the ER. But basically she's saying that they, they weren't sent there by a physician. They were, they're just coming. They don't feel right. There is a family history of hypertension. By the time we start the screening process with them and we go through the history their mothers had at their father, their grandparents and they've just never thought that all this time that they were feeling bad that that's something that it could have crossed their mind that that's ended up what most of the time does happen is when they're sick and they come in, they're almost like shock that they have this hypertension and what do I do? Where do I go? Now I have medication that I need to start taking and that's where we fill it, fill in. There's pathways set up that we can help them go over and navigate. And a lot of these programs that are available to patients outside of the hospital it's really, really important for us to establish relationships with these resources because they change all the time, patients. We need to make sure that we're informed to give the right information for them. I'm curious about when a patient comes in and is uninsured or maybe has a need for something like they have food insecurity and maybe they wanna know how to apply for food stamps or maybe their need of temporary housing, something like that. Do you guys have a system in place for how you connect them to those resources? I can answer that. I actually, the food bank is my best friend. We send referrals through the food bank and usually when we come in to, we'll make a home visit. We identify some of the needs. Sometimes they need food. We see the need at home. So we help them, we write referrals through them. If they need housing, there's an application through the Saha website that we use and we can assist them with that. We actually, our primary goal is to set them up in a medical home but then once we come into the home, we identify other needs and we do have lots of resources and we have done a lot other services besides just the medical home. So I'll give a quick plug. During lunchtime, you're gonna be given a special treat about a community health bridge that the Health Collaborative has. So we'll be talking specifically about organizing around a resource building. You had a question? I think one of the most important things to remember about this is that it's not just sort of we say, oh, you're food insecure. You should go to the food bank. Here's a pamphlet and a number to call. One of these community health workers would have already called ahead and said, I'm sending someone to you and so we can tell the client, you need to go to the food bank. These are the things that they can help you with. Here are the four pieces of paper that you're gonna need in your hand, your identification, your telephone bill, whatever it is that you need to qualify, not necessarily the food bank for, but for a lot of resources, you need particular documents to be eligible and then give all of that information to the person that we're referring and then we might send them over or these guys have been known to meet them there and literally walk in with them, particularly at primary care visits if we know that maybe a person is reluctant or just maybe not committed to making their appointment. It helps if you say, well, I'll meet you there and then they show up when they know that you're sort of making them accountable to themselves. So making and keeping that appointment is a thing, but really paving the way. A lot of these programs are eligibility based, first of all, and every program is so different that it's really, really important at the home visit to articulate and literally write down on sheets of paper sometimes that this documentation is for this program, because the last thing you want to do is send them in there with anxiety. When a patient is sick and they're not feeling well, especially chronic illness and you send them into these resources without being prepared, they'll leave, they'll walk out and that's it. We only have one chance, that first chance, that first meeting to get them to trust us, to listen to everything we have to say. And not only that, but a lot of the programs out there, we might only be able to get them help for three months, six months, or two a year. But if we really hold their hand at the beginning of that first process, when it's time for them to reapply for these programs, they've got it. They're like, okay, I can do this. And that's the empowering part of our program. That's what makes us feel good inside because we keep track of them for up to 18 months. We're gonna know how long they were able to receive carefully and if they were able to reapply. And if I have to call them back and go, well, how do you go? Oh, it was fine, yeah, it was fair, and I got it really good. And we feel good about that.  Yeah, she was so grateful for the help that we were able to give them. And we all have great success stories of walking away from somebody knowing that we helped them. We have time for one more question, I think. I'm really interested in the causal relationship between your hypertension diagnosis and also the anxiety diagnosis. And I think you kind of partially answered it already, but it just seems like if you take care of some of the anxiety, some of the hypertension would also go away. And also about partnership in the community that would help to alleviate things like hunger or lack of access to healthcare, domestic violence, those kinds of things. That's why conferences, seminars, coalitions are so important for all of us to get to know each other, for all of us, because some people are based on grants, some people have funding, they lose it. We have to know who's out there and who's available. And I'm not ashamed, Google is my friend. Like if I don't have the answer for somebody, I'm gonna Google it and make phone calls until we find some sort of resolution. And I think that's been the particular skill set of this team of community health workers, but also the assets that are available in San Antonio. We have a lot of resources here.  For every Tracy, there is a counterpart that Tracy knows at CareLink or at the food bank where she can pick up the phone and dial someone directly and it makes the referral that much faster and that much easier. So I think that's just sort of like rounding out why we're successful. Perfect, so I'm gonna just, I have to honor two questions that came in. So I just wanted to make sure this is pretty quickly. We're gonna get ready for lunch, but I do wanna honor the two questions that we have left. Thank you. I'm interested in the strategic day-to-day. So you have the patient who comes in for the admin and they get their treatment and they're successfully treated and then they leave and you contact them or you're contacting them before they're... It's both. It's both. We have two processes. And do you go week by week? So you get like first week, this is what... Day by day, day by day. We have two processes. Okay, go ahead. We have two processes. These are our ED navigators and they will process people that have been categorized after triage, three, fours, and fives if they are just being assessed for earache, sore throat, things like that. Not urgent. Non-urgent conditions. And they will... Yes. And then we, Rodrigo and I help the admin patients, which the ones that have been admitted to the hospital.  And then the next step after that would be a home visit where we go into the home and... Once they're discharged. Once they're discharged, yes. And help them with everything they need after that. And that really speaks to the trust relationship that we have to establish with patients, especially with the uninsured. They don't always give the most reliable contact information because they might have an immigration status that they don't want to disclose. They might think that they don't want to expect a bill for whatever reason. And so they don't give correct phone numbers.  I'm not worried about whether... We don't even ask about immigration status. But these are the worries and the anxieties that they have. So if we can talk to someone face to face, we have a much higher likelihood of being able to see them at their home and then start this process. Just real quick, I just wanted to know what from the promotores perspective, community health workers perspective, was the medical home. What does that mean to you? How do you make it good? Well, we identify a medical home as your doctor, your primary doctor. Someone that you're gonna be involved with for the next six months. Because these are programs that we use, are programs that are six month programs. That's where the medical home comes from. Being involved with the same doctor. Right, right, right, right. Yes. Well, that's gonna be part of their education, of what, this is where you're gonna go as far as your medical home, this is where you're gonna go for your education. Sometimes a lot of people don't even, like they touched upon it last night, education is very important when you're diagnosed with a chronic illness. And we have the why, we have the San Antonio Food Bank. All of these places offer education on diabetes prevention, how to eat right, hypertension prevention. So a medical home is yes, the doctor you're gonna see, but there's a whole pathway plan to help with education and diagnosis and care management for that person. Okay. Yes, that all of that is included. Yes, because well, we're very lucky, okay? We're very lucky for people that can't afford to be in the Affordable Health Care Act. We have CareLink, and I know that we'll- Which way not Medicaid expansion?  But if you're lucky enough, because my understanding is Houston and I think Dallas have also tried to model the CareLink program with no success. So we are very lucky here in San Antonio to have a program where if I have a diabetic and it's not just diabetes he has, but he might have neuropathy in his legs, he needs a specialist and CareLink is gonna offer him the specialist that he needs or she needs. Right, but related to the medical home question though, the education that they try to provide is to sort of take them out of the way of thinking that I can just go from emergency to room to emergency room. And a lot of times a good deal of our patients come from CareLink because they've gotten a balance there and they're under the impression that they can't go back if they don't pay it in full. And so they also work as advocates to help them set up payment plans so they can go back. And in as much as CareLink is a medical home, it's a longer term solution for a person to be able to go back to the same clinic, to be able to go back and receive ongoing care instead of coming back to an emergency department. It's a baby step, but it's a step because the current, most of our patients are not even using urgent care, they're coming to the EDs and using that as their so-called primary care. Thank you so much, guys. I know we probably have more questions, but we do need to get the rooms prepared for your lunch this afternoon. So thank you again, and thank you to our presenters and our guests, Q and A. So we're gonna be setting up for lunch. If you guys don't mind bearing with us.


My name is Robert Tassen. I specialize in benign hematology at the John Thorer Cancer Center.  Also we deal with bleeding disorders as well as blood clotting issues. It's quite a broad field with a number of different options and treatment protocols based on the specific need of the specific patient. Patients who've had thrombotic complications often will require an extended evaluation looking for genetic and or acquired reasons for the development of their thrombosis. This ultimately also will require treatment with various blood thinners for patients with issues with bleeding disorders like von Willebrand's disease or factor deficiencies. We often administer medications that will prevent them from having significant bleeding, most commonly in the setting of a surgical intervention. Patients who have overproduction syndromes like polycythemia vera, which is an overproduction of red blood cells, will be treated with phlebotomy, removing a unit of blood periodically so that their blood is not as viscous and the risk of having a blood clotting event from the overproduction of red blood cells will be reduced. Patients who have essential thrombocytosis and overproduction of platelets will often be treated with an oral medication called hydroxyurea that will help control the overproduction of platelets. For patients with sickle cell disease specifically it's traditionally been a disease that has not had a lot of fantastic treatment options. It has historically been hydroxyurea and transfusional support and pain control and it's made sickle cell disease a very unpleasant condition to have to deal with. In the last year there have been two new medicines that have been FDA approved. One to help decrease the frequency of painful crises and one to help improve hemoglobin values to decrease transfusion requirements. So that's been a tremendous help for many of the sickle cell patients for whom I manage. I think it's a responsibility of every physician to communicate effectively, being able to have that connection and then being able to specifically tailor the treatment for your individual patient not based necessarily on their diagnosis alone but on their specific needs as well.


High-mobility parafskite Biosn03 films can be successfully grown using a modified oxide molecular beam epitaxy, MBE, process. This process involves supplying pre-oxidized SN-Ox to address issues associated with volatile snow formation during MBE growth. As a result, epitaxial, stoichiometric Biosn03 films can be produced with room-temperature electron mobilities of 150 square centimeters v-1s-1. These findings open up a wide range of possibilities for future electronic devices. This article was authored by Santosh Raghavan, Timo Shuman, Hongyu Kim, and others.


Ever wondered how your favorite morning pick-me-up is made? It's quite an intriguing journey from farm to cup. It all starts with planting a tiny coffee seed. Then, diligent care and patience come into play as the seed grows into a lush tree over the span of several years. Once mature, the trees are adorned with ripe cherries that are meticulously hand-picked to ensure only the best quality. Next, these cherries are processed and dried, a step that requires a keen eye and a gentle hand. The dried cherries are then hulled to reveal the coffee beans within. These beans undergo roasting and grinding, a process that unlocks the unique flavors and aromas we all love. Every step of this journey, from the planting of the seed to the grinding of the beans, requires hard work, dedication, and meticulousness. So, that invigorating cup of coffee you enjoy every morning. It's a labor of love and precision that begins in the lush fields of coffee farms. Now, let's journey to the big island of Hawaii, a paradise not just for beachgoers, but also for coffee lovers. Imagine a place where nature conspires to create the perfect conditions for coffee farming. That's the big island of Hawaii, blessed with an ideal climate, the island's warm sunny days, cool nights, and abundant rainfall provide the perfect environment for coffee trees to thrive. But it's not just the weather that makes this island special, the island's volcanic soil, rich in minerals, adds a unique richness to the flavor of the coffee. Here on the big island, coffee farming is more than just a business, it's a tradition passed down through generations. This is the home of the famous Kona Coffee, grown predominantly on small family-run farms. These farms, nestled on the slopes of Mauna Loa, are a testament to the hard work and dedication of the local farmers. Growing Kona coffee is labor-intensive. Each coffee cherry is handpicked at its peak ripeness to ensure the highest quality. The cherries are then processed and dried under the Hawaiian sun before being milled, roasted, and packed. It's a process that requires precision, patience, and a whole lot of love. But coffee farming on the big island is not without its challenges. Farmers here constantly battle pests like the coffee borer beetle, unpredictable weather conditions, and labor shortages. Despite these obstacles, they persist, driven by their love for the land and the coffee it produces. Their resilience is a testament to their commitment to providing the world with some of the best coffee. It's a commitment that shines through in every cup of Kona coffee, with its smooth, full-bodied flavor and low acidity. So the next time you sip a cup of coffee, remember the beautiful landscapes of the big island, and the dedicated farmers who help bring this delightful brew to your table. Because every good day starts with coffee, and every coffee starts with them.