4 Tuesday plenary

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4 Tuesday plenary

Astril: Good morning everyone, we are about to begin We do apologize for the late start but we know it’s raining a little bit outside But despite that you are all here so thank you very much for coming So I want to first of all welcome our distinguished plenary panelists this morning We want to welcome all of you, our HRSA grantees, our HRSA personal who are here today, invited guests, and friends of the National Center for Health and Public Housing I do want to recognize also our public housing authorities and our residents in public housing We welcome all of you today to the 2012 National Primary Care Conference for Health and Public Housing This year our theme is “Raising the Bar for Health Care for Residents in Public Housing.” So we are truly delighted for all the work that you do You have done tremendous work over the past year, and we want to continue to make sure that you continue to be successful and raise the quality of care that you provide for residents I do want to say a special thank you to HRSA the Human Service and Resources Administration, I’m sorry I’m sure I said that incorrectly, let’s try again, HRSA the Health Resources and Services Administration for funding our national-corporate agreement The National center for Health and Public Housing is a project of North American Management and we are funding by HRSA to provide training and technical assistance for all of our public housing health center grantees who are serving residents in public housing This has been a remarkable program especially for so many hundreds of thousands of residents in public housing, so we do recognize that this is a valuable program in many of the communities that you serve We have grown tremendously over the past year, last year this time we had about 55 public housing primary care health centers, this year HRSA has actually funded 8 additional ones so we are seeing some growth in the public housing primary care program and we are really proud of that and we will continue to see… yes I’m sorry forgive me my voice is giving me a little problems, but we welcome this type of growth We know it’s a needed program and hats off to HRSA for recognizing that and continuing to support the special populations So today we want to also recognize our H Jack Geiger awardees these are grantees who have done a tremendous job in accomplishing HRSA’s priority goals of program management, performance development, and analysis and performance improvement So at some point today please reach out, connect with them, congratulate them and find out what they are doing in their communities because each one of these programs is doing something remarkable and different so we want to congratulate all of our awardees I do also want to thank all of our sponsors and our exhibitors who have also added to the success of this conference so feel free to visit their various booths outside, they have tremendous resources and services to continue to strengthen your programs and support you And last but not least I must recognize our hard working and dedicated staff I want all of our staff members to please raise their hands, these are the folks who have worked tirelessly to put this conference together and I really appreciate the staff and all the hard work they have done many of you have gotten tireless calls but this is what do we are here to assist you and please interact with them over the course of the next two and a half days, you are going to be hearing from some phenomenal plenary speakers, you are going to learn a lot through these amazing workshops, and remember that there are CEUs attached to them so you will be able to get your credits And we look forward and we want you to have fun, enjoy, and feel free to ask anyone questions OK, so thank you again for joining us and I’m now going to turn it over to this morning’s moderator Mr. David Vincent who knows almost all of the grantees in this room over the past years Thank you David Vincent: Thank you Dr. Webb So nice to be with you guys this morning so many wonderful old friends that I see and

look forward to meeting some new friends today So I have the pleasure of introducing each of our wonderful plenary speakers today and I get to start with Dr. Brand So Dr. Brand is the Deputy Administrator of Health Resource Services Administration which we fondly call HRSA From 2001 to 2007 Dr. Brand was the director and associate administrator of HRSA’s Office of Rural Health Policy In that position she was responsible for health policy, research, and grant activities that promote better health care services in rural America From 2007 to 2008 Dr. Brand was the Associate Administrator of HRSA’s Bureau of Health Care Professionals where she provided national leadership in the development, distribution, and retention of a diverse culturally competent health work force that provided health care It’s my pleasure to introduce Dr. Brand Dr. Brand: Thank you, David Can I shut this? David: Yeah go ahead Dr. Brand: Great, and good morning Thank you David, and Thank you Astril And I want to thank you for this invitation and I also want to thank you, thank you, for not scheduling my presentation for immediately after Congressman Davis’s presentation this year He is arguably the most articulate, engaging, and passionate, speaker about issues you care about and we care about Blissfully, I am before congress women Edwards and I’m sure she is equally as good so I lucked out today Uhm I think it’s really important to know your audience and frankly I have been wondering about you This is the third time you have invited me back and I look around this room and I see lots of the same folks and I’m just curious about what keeps you so engaged Because arguably you have the most challenging work of any of HRSAs stake holders HRSAs mission is to serve the medically underserved, the most vulnerable among this nation, of the people in this nation And in 2012 HRSA will invest about 8.2 billion dollars in 80 different really great grant programs including you we have about 3,000 or so partner organizations So here is what I think I know about you, I may be wrong, but I think you are not afraid of a difficult challenge, you look at the 8.7 million residents who are in public housing and instead of hopelessness, you see the opportunities to make life better for the people you care about you look at the disparities data about the differences in health status between the residents of public housing and the general public and you don’t think these things just can’t be changed you think how can I change them You look at poor nutrition and the unavailability of healthy food options in these communities, you look at the higher rates of obesity and diabetes among residents, you don’t think people choose that lifestyle, you think OK we need a safe place to walk, we need a farmers market, and we need to rethink the potluck with this unlimited fried chicken, mac and cheese and desert tables You look at the 23% of the residents who are missing 6 or more permanent teeth and you don’t go Mmm Mmm Mmm, just like that I don’t know about you all but where I grew up that was the ultimate sort of condemnation those three notes Mmm Mmm Mmm that sort of meant what a shame So you look at these folks with missing teeth and dental pain and you think how could anyone get a job looking like that? Or how could anyone be a good student or a productive worker with that pain And you set up dental clinics or take the neighbors to the university dental clinics or badger local dental providers to see these folks You look at the higher rates of smoking, 28% of residents compared to 17% of residents of the population and you find a way to offer smoking cessation clinics and you look at the grinding poverty, 82.5% of your residents are below 100% of the poverty level and 96.7% are below 200% of the poverty level and you don’t say something biblical like well you know the poor will always be with us, you say these kids are going to graduate from high school or this guy is going to stay sober, and keep that job, and you work with the schools and the addiction counselors So what I think I know about you and I could be wrong, I think you are incredibly resourceful, tenacious, committed, and maybe just a little bit crazy because you are still here and you

should be so proud of the mission that you have chosen and there are folks who want to partner with you and sort of share that madness And so I want to talk a little bit about support for the health centers and your program HRSA funds the health centers and grantees to work with you to provide vision services and all health care, they create outreach, took kits for residents Another example of working with you in the madness is the award to the community health partners for sustainability which provides assistance to new public health primary care sites, monthly newsletters, actual alerts about funding opportunities or policy issues and seasoned veteran peer counselors We are also trying to work and collaborate across the department with other federal partners like the AOA to improve health outcomes of seniors living in public housing So HRSA has strengthened its collaboration at the federal level to increase access to quality care and improve outcomes of residents in public housing, including our work with the AOA And in 2011 we led a cooperative agreement to the North American Management association Health and the Aging project and they are working with the administration on aging to deliver information in the form of training, webinars, and yesterday’s first annual conference, its convene to address the health care needs of the elderly across the US with a focus on health centers as a safety net provider So we are hoping that you will be able to work directly with AOA and the agencies that help you monitor and provide care through the health centers to seniors We also think it’s important not to reach across just HHS with our other sister agencies, but also to work with other cabinet level departments And so I am very pleased to be able to share with you the fact that secretary Sebelius, HHS’s secretary Sebelius and HUD secretary Shaun, have discussed this association between housing and health and frankly released a joint commentary entitled Poverty and Opportunity, posted in December of 2011 They talked about the connection between people’s homes, people’s health The New England Journal of Medicine recently published the results of Moving to Opportunity studies, showing connections between health and housing at the neighborhood scale We looked at 4,500 very low income families living in public housing projects in high poverty neighborhoods in five cities and the study found that very low income women who have the opportunity to move from high to lower poverty areas are significantly less likely to be extremely obese or have diabetes So what that means to you is that you get to help these folks bridge their movement from public housing to a lower poverty level kind of housing We have I think over the past couple of years, almost since 2009 made incredible investments in health centers And so between the recovery act which seems like so long ago but was so much work and the affordable care act we have really made enormous investments in the safety net expanding access to primary care and preventive care And since the president took office the number of patients getting care at health centers has grown by 2.4 million, that’s 19.5 million patients getting care in more than 8,500 sites and I want to get specific about some of those investments and then also talk with you about what you can anticipate going forward So since 2011 HRSA has funded 40 million dollars to establish 67 new health center sites Of these 67 total awards, 11 went to public housing grantees, we’ve also released about 32 million dollars to 904 community health centers and these provide assistance to existing health centers as they try to achieve recognition as patient centered medical homes In a medical home you plan, support team based models of service delivery and systems upgrades, and recipients of these awards included 42 public housing grantees and they got the dollars for the patient centered medical home and in some ways you all had already figured that out That chronic disease management needed to be done to improve health outcomes another 8 of the public health grantees received health center capital developmental awards and in all we spent about 732 million for 144 such awards for construction and renovation projects and we’ve spent about 50 million dollars last year for school based health center capital grants And so as you know we’ve made a lot of investment between the ORA and the ACA given the challenges

that you’ve faced I think you might be interested in what’s coming next in terms of resources So let me talk a little bit more about the investments that the ACA makes in you and in health centers We will have about 150 million dollars to establish 220 new health center access points and we anticipate the awards will be made this summer and that we will be able to see about a million more patients We anticipate awarding another 20 million dollars more to support the adoption of electronic health records and other health HIT and that funding announcement in imminent, so you watch your calendar and not your clock, OK Expanded services, there will be about 15 million dollars more to support the expansion of services particularly for HIV and AIDS which I know is a population that you all work closely with This is the announcement for which you can watch your clock, your watch and not the calendar, 600 million dollars in health center capital development, building capacity for the program will provide approximately, will be made to about 125 to 150 health centers to improve their capacity to provide primary and preventive health services Another 100 million dollars with be made in health center capital development for immediate facility improvements and since I really enjoy this job and have no intention of scoping the administrator or the secretary that is as much as I’m going to say but you get my drift so this could be a good day So I want to close on a fairly positive remark obviously we will be successful in doing our work as you are successful in doing yours and so I want to encourage you to share with us your ideas about how we can do our work better and how we can help you do yours better, because I think we have a tremendous opportunity to address the challenges here and frankly we know that you are not afraid of a challenge and you are incredibly resourceful, tenacious, committed, and just my kind of crazy, so thank you very much David: Dr. Brand thank you so much It’s always a pleasure to see you and we so appreciate you coming here on your busy day and helping lead this effort, thank you so much Our next plenary speaker is congress women Donna Edwards, who is with Fort Washington, she represents Maryland’s fourth congressional district comprising portions of Prince George and Montgomery Counties I actually have family in there so thank you for representing them, and she was sworn in as a member of the US House of Representatives in the 110th congress in 2008 and she began her first full term in the 111th congress in 2009 Representative Edwards has enjoyed a diverse career, as a non-profit public interest advocate and in the private sector on NASA’s space land project Prior to serving in congress she was the Executive Director of the ARCA foundation in Washington DC and was also the co-founder and Executive Director of the National Network to End Domestic Violence where she led the effort to pass the Violence Against Women’s Act of 1994 that was signed into law by President Clinton So it’s my pleasure to introduce Congresswoman Edwards, Please Edwards: Thank you very much You know Dr. Brand and I had a little bit of a conversion beforehand and I shared with her that she got to give all of the good information and get people very excited about the details of health reform and what that means and all of the work that HRSA is doing, and I get to get up here and I have the easy part I give the Ra Ra speech And so in that my first Ra Ra though, has to be to HRSA and HHS It has been amazing to see that since the passage of the Affordable Care Act, prior to that the American Recovery and Reinvestment Act the stimulus package that this administration really from Day 1 has been focused on how to reinvent government services and provide care to the most needy and underserved communities and population, and it’s just amazing to the amount of progress

that has been made over the last almost four years And so that’s about as political as this speech is going to get because I think it’s important to value where we were and where we are right now And Dr. Brand has laid out over the course of these next several months and years where we’re going and that’s why we’re all here today, because we know that the populations that we serve are sometimes overlooked, I think about the district that I represent which frankly is not all that different from a lot of districts across the country where we have and we are fortunate in Maryland I will say this because our governor wouldn’t let me get out without saying it, Maryland has the number 1 schools in the country for the fourth year in a row, Maryland’s unemployment has remained significantly below the national unemployment levels across this country even through a very difficult economy and even though there are Marylanders who are suffering We just found out that Maryland has a higher per capita number of millionaires than any place else in the country and we are a small state OK, so what that means though is that in districts like the one that I represent, populations that are really in need can sometimes be masked behind that kind of wealth that it becomes easy to be behind our gates and our gated communities and in our fancy jobs and shopping at great places where we can buy yellow shoes, and we forget sometimes that there are populations that have tremendous need and communities and people who work hard every day but still live below the poverty line and still need services and still need healthcare And so I want to thank the administration for not allowing districts like mine, states like mine, not and all across this country not allowing us to forget that we still have a lot of work to do And that goes to you as well and so let’s think about that, I also come from I live in a county where a young boy several years ago his name was Deamonte Driver, many of you know his name because he was a poor child living with a mom who couldn’t afford to take care of him or find dental services and I believe at 12 years old he lost his life because he has an abscess and couldn’t get care That is in a county that has some of the highest per capita incomes in the country and so we have to remind ourselves over and over again about what the need is and where our work is So, I think about where we want to go and Dr. Brand has laid that out and she said to us the challenges making sure that we have this sort of robust development of community health centers across the country that are providing health care services to people where they are Those of you who have been community health providers in public housing, what you know and what you’ve always known is the importance of being in a community and providing services in that community This is something actually rather new for us on the national stage that all of a sudden we have an orientation in health care that’s about community based health care and that means wherever those communities are and if those communities are in public housing and improving the day to day living of those who live in public housing because it’s that kind of foundation that gives people a leg up It’s that kind of foundation that enables people to see their prospects in a different kind of way But if you are in public housing and are both worried about the housing that you have, now you’re not homeless you do have some place to live, Dr. Webb and I talked about this, you know that we have plenty of people who have some place to live but they are still poor, they have need of health care, they still work, they have need of food services but they still work, they have need of being able to buy fresh fruits and vegetables on a corner in their community and not just leave it to all of us who live in fancy neighborhoods to have farmers markets We just work with some groups over in our community over in Prince George’s county just across the river, and I want to thank Major Julie for allowing us to be here in Alexandria, but across the Wilson bridge and the Potomac river our communities we are inside of the beltway perimeter here in the metropolitan area are deep pockets of poverty and it took

a community coming together to say you know what, we actually do want fresh fruits and vegetables that are affordable in our community for people who live there because we want to improve our health prospects And we may live in public housing but we don’t want it to have mold, we live in public housing but we still want the trash off of our streets and we don’t want just fast food restaurants and liquor stores in our neighborhood These are the things that it takes really to build a community and I think part of the reason that we are here today is to say what is it that we can do at the federal level that really empowers states, empowers local communities, empowers advocates to serve their populations And we recognize just as in my district we have many diverse populations to serve when I look at your agenda, your agenda actually recognizes the diversity of the population that you serve whether you’re talking about seniors and children, and those who speak different languages, and come from different cultures, and are new immigrants, and some are not people who maybe for generations have found their families for lots of different reasons living in public housing and being served by the services in those communities and so we have a whole range of different populations Well our services have to begin to reflect that and have to be sensitive to those needs I was working recently, and I’m not going to give a pitch, but there’s a group, you say I’m not going to give a pitch, but there’s a group over in Prince George’s county Maryland they serve the, a Latino’s Hispanic community and they want in their community to provide community based health care right there in their neighborhood, language sensitive services, culturally sensitive services, we ought to be able to find a way to deliver those kinds of services in all of our communities And these are in neighborhoods that are incredibly distressed in a whole range of different ways but I also know I think that there are things that we can do at the federal level we can actually expand not everybody who needs services and is in an underserved population is homeless, some people have homes but they still do need the benefit of those services So it’s not going to be up to Dr. Brand but it is certainly going to be up to people like me, members of congress to expand the availability of the resources that we do have even in a constrained economic environment to provide those services where people are and I don’t know, I think around this country, I’m one of these and I hope I share this in this room I’m actually really excited about the Affordable Care Act I mean I am so excited that I could jump up and down about the Affordable Care Act because, it was the right thing to do in this administration is implementing it in just the right way and saying where are folks, who needs health care, how can we get that to them Some of you know because I’ve shared this before I remember when I was working every day and didn’t have health care and I had some place to live but I didn’t have health care and I got really sick and I went into an emergency room and it was really expensive and it almost sent me under there are families like that all across the country And although we’ve expanded Medicaid eligibility to 133% of the poverty level Astril, has shared with me and I know that you recognize that the populations that you are working with are two-hundred percent below the poverty level So there are deep needs out there for the public housing serving the community In Montgomery County which is one of our wealthier counties in the country and one that I represent currently, we have new immigrant populations there and there’s a real need for some of our local municipalities our community governments and our states to recognize that these are also communities that need more access to housing Especially in an area where median incomes are like 93 thousand dollars but these families are not making anywhere near the median income of $93,000 dollars and what that means for them in terms of housing is that they need access to public housing they need access to jobs and opportunity, but they also need access to health care that’s delivered in an appropriate way in those places So I want to close by just sharing with you that I understand as a member of congress

that there’s work for me to do, but you represent 25 states, many different agencies, there’s work for you to do as well To talk to people like me about the work that we need to do and as we go into these budget debates and appropriations debates a lot of the things that we care do deeply about and I know that Dr. Brand knows this are in great jeopardy in this process And so we can’t sacrifice and allow to be sacrificed, those communities that are the most underserved that are the most in need because we are protecting the interest of those at the top and again not something that Dr. Brand can say but you know what, I’m a politician that’s something I can say And so I know the challenge that we have, that we face in the congress when it comes to figuring out budgets and there are alot of needs all across the federal government but if we can’t do right by the community of really great people who live in public housing who need health care and who need services, then we shouldn’t be allowed to go home and sleep at night I’ll just leave you with that Thank you very much So since I’ve actually in my life before congress, I ran the national network in domestic violence and I had Dr. Webb’s job of getting everybody together and organizing programs and sometimes figuring out what the script should be about when you don’t always plan it So I’m actually used to taking the mike and just rolling with the program so I came here today to roll with the program I have the great pleasure on behalf of the national center for health and public housing to present the second annual H. Jack Geiger awards at this year’s conference and I just want to read you, and it’s in your program but it’s definitely worth repeating Dr. Geiger’s legacy has been devoted to problems of health, poverty and human rights, combining community oriented primary care, public health intervention, civil rights, community development initiates, and research interests focused on racial and ethnic disparities in medical care Dr. Geiger made significant contributions in advocating for quality health care for the less fortunate through work of community health centers and in his words, these are great words, the real honor is in having such an award created in name for me to stimulate and reward the work of others in the future in the ongoing struggle for equity and health care, most particularly for such vulnerable populations as public housing residents So this year we are all and Dr. Brand is going to join us in presenting the second annual H. Jack Geiger awards to the following emerging leaders in the public housing primary care programs The first recipient is the Houston Area Community Services H. Jack Geiger award recipient recognized for excellence in performance improvement (applause) (Congratulations) The next award recipient is recognized for significant impact in the areas of program development and analysis and this award goes to the floating hospital (Congratulations) And then lastly but not leastly the H. Jack Geiger award recipient is recognized for outstanding leadership and program management goes to

La Maestra Community Health Center (applause) Congratulations again to all of this year’s recipients David: We are so grateful to Dr. Brand and Congress women, they are going back to fight the cause, going back to work so thank you for taking time out of your day (applause) Continuing with our plenary session, I’m happy to introduce my friend Henry Lopez, Captain Lopez fellow social worker Henry Lopez is with the U.S. Health Service Commission Core, and is the director of the Office of Special Populations Health in HRSA In this capacity he has the responsibility for overseeing numerous special programs which provide primary and preventive health services including behavioral health to vulnerable populations He works with our Migrant Seasonal Farmworker Program, the Homeless Program, Residents of Public Housing Program, Asian Pacific Islander Program, as well as programs for school age children All of these programs provide health care to over 2 million individuals in the United States Ladies and gentlemen Henry Lopez Captain Lopez: Thank you, David When I was younger I would take the risk and jump down now I have to step down Well, good morning, how many were here yesterday? Ok, you can be excused No, I’m just kidding, I’m just kidding, I’m just kidding I’ve been accused of having adult ADD because I’m always moving around and my old philosophy is that you can’t hit a moving target that’s why I don’t stay in my office too long And talk about pressure, yesterday we had Dr. Wakefield our Administrator for HRSA and this morning we had the Deputy Administrator for HRSA, no pressure for Henry you know So if you all talk to them please tell them I did ok, please and the other thing is because I have a mortgage to pay and I wanna keep my job, Dr. Wakefield I mean Dr. Brand eluded to you some good news to look at your clock today Now I will say, I can’t say nothing either, but please take that to heart, look at your Blackberry from time to time for those who have an interest in doing that, hopefully it’s an exciting day for each and every one of you I know in this room, I’m not going to tell them to raise their hands it’s already been an exciting day for them Is this being recorded? Please don’t I cannot except any drinks from anybody just off the record, ok well I’m not going to bore you I’m going to skip through some slides I have, I’m a fed and I have 36 slides, I’m only going to show you part of them so don’t… shew ok we got a break time Is it working, ok I was having this conversation with one of my colleagues yesterday about how things are changing and the technology and all this stuff and as we get older we’re lucky we’ve been raised with computers now But I can only imagine, like my father, I try to buy him a computer and I have a conversation with my son my youngest boy, I said you can teach grandpa how to do this so I said go ahead try it, so he tried for about half an hour got it all down and I said go ahead take a break have some coffee come back and tell him to turn it on, he couldn’t do it No disrespect to my father who I love dearly but it scares him So we’re talking about senior citizens, we’re talking about aging, we’re talking about residents of public housing, same thing Change scares him, trying to help them, this is a partnership, so my job is to ensure that you have funding in an effort to keep providing the services that you are providing and one of the things that I want to do is expand that partnership that we have going on already with the housing authorities Why is that important? Because there’s a lot of people that don’t realize that they can receive care at some of our community health centers, they don’t know that they can do that They don’t recognize that now that they are homeless and their families are living in public housing they can go to a community health center that’s made available to them It’s always great to hear an elected official like Congresswoman Edwards who is supportive of these programs we can’t do it as federal employees, we can’t go to the hill but what we can do is tell you folks that the responsibility for you is to educate those on the hill to let them know what you are doing If you don’t let people know what you are doing then they don’t know what to do So I’ll leave that commercial aside

Now we all know, everybody has a mission but case in point, I always like to say assuring access to comprehensive culturally competent quality primary health care, some of our facilities you know that are brand new have the latest equipment have the best health professionals You know, I had the pleasure of meeting … from Colorado from the homeless program Where is he? There he is, educated at the Health Science Center in San Antonio Texas loan repair and has stayed there with us that’s fantastic, that’s the kind of folks we have working with us You heard this morning Dr. Brand say we have nineteen and a half million patients we know the special populations we oversee, we see close to two million patients, actually right at two million patients just about but 173,000 patients that we see are from public housing, those that identify themselves as from public housing I have news too, David doesn’t know but I also have a VA program we started to take accountability about the VA program we see over 265,000 veterans that have self-identified themselves as a veteran coming to our community health centers, I have been meeting with the VA in an effort to partner with them and collaborate with them to ensure that we give services to ensure that health centers can work and get you know, somehow work together with the VA Administration in an effort to make sure that these folks are seen, you know why they’re there I’ll tell you Cause while they were deployed, in Theater Operations, in Afghanistan their families came to the health centers They came back they go to the VA and say well we can’t see you for another 2-3 weeks and you have to drive down to our VA hospital 50 miles down the road, and the wife says gee the health center is two blocks down why don’t we just go there they’ll see you and we have a sliding fee scale So what happens they start going up and those are just the ones that have identified because I’ve learned something, and this is why I put emphasis we have to learn to say have you ever served in the military not if you are a vet, some folks see themselves as veterans only if they went to Theater Operation out there during the war and don’t see themselves entitled to any veterans benefits, but that’s not true so just a little something I’ve learned here You heard me say yesterday 77 million patients that’s a lot that’s a wow factor come on guys give me a wow 77 million patients, visits Ah come on, here we go 1 2 3.. wow… We’re spread out all over the country and there’s more money to come—I’ll get to that Here’s the thing I’m gonna go really fast through it, it’s going to be made available to you on the web by the way, and if you don’t have access and if you want a hard copy I’ll see what I can do for you it won’t be in color because we are trying to save money, it might be double sided but that’s ok, times are hard right now folks ok, if you see news print on there, disregard it, just teasing you Just so you know 33% is the U.S. population We see 92% of poverty You can see that oh it’s only on one side, OK, you can see that, here’s the thing that I wanted to emphasize Dr. Brand made mention to this, this is the increase in patients from 2008 to 2010 now see what about 2010, 2011? Governments always behind a year in the UDS we’re going to come out with the numbers here in a month for 2011 and then next year we have to wait until 2012 We’re always behind because we have to collect all the numbers that are fine, and all these good things in reporting It’s kind of like the IRS they collect the money in April but you don’t know what the budget is until heavens knows when But the sites, we’ve increased the number of site to over 8,100 as I mentioned yesterday Here’s the thing that’s important, jobs because of the grow, we increased 18,000 jobs Any of my friends from Puerto Rico “Ponce?” So 18,600 jobs have been created We have a focus like you do but our focus should be somewhat similar: primary health care, public health leadership, performance improvement, outreach, quality of care, health outcomes disparities But the program requirements are what’s really key here-we have a need, we have services, management and finance, and governance We try to make sure that we are partnering with a community to make sure that they can provide access and govern the health centers so it adapts to whatever the needs may be In case you don’t know we have strategic priorities, the grantee satisfaction, can you tell me how I’m doing on time because I can talk for an hour and a half (laughter), the external technical assistance training strategy, we have employee satisfaction, timeless quality impact We take surveys folks, we take surveys of the patients that come to our health centers, we make them simple, because we want to know if the health center is doing the right thing and we also want to hear from the health centers if we are providing the right kind of technical

assistance, guidance, and what not If we don’t work together as a team we cannot be successful to provide the services to those in need Policy updates-ooh this is what you want to hear Just so you know, recent released policies, please pay attention to these, we put them as soon as we develop them they get approved, they go on the web Go once in a while to the HRSA website and look at policies, you know some of the things we’re gonna change some of the things you may have questions about, don’t hesitate, let us know Say gee you know this is hurting me we’ve sometimes adapted some of these policies and make some corrections because we are trying to meet the needs of those and sometimes we miss something so we want to hear from you as well We have the size, the scope, the projects, the capital projects, process for becoming eligible for Medicare, re-imbursement, that’s a big one It’s coming more and more health center collaboration that’s key; collaboration, this is one of the positive things I think that really has come about in this administration They came to say you guys are working in silos meaning you guys working in government, you know which is true I can’t even find, I saw a person in my building five years ago that I met, didn’t see this person until 5 years later, in my own building, didn’t know what this person was doing Now this person works for me because I didn’t know during the whole process she was working in a department that I always didn’t know who was working in that department, to get an answer in my own building, so now we are trying to work together I know this sounds funny but it is a reality you know, and one of the things I want to do, I go to meetings to the VA because I want to contact the same guy or the person who can help me with the answer I want, it’s trying to go through a lot of phone calls FTCA health center policy The Patient Centered Medical Home you know that’s important, you know electronic health records are going to change, personalized medicine Interesting story for me I was able unfortunately, I got sick in San Diego because I get treated here at the Navy Medical Center, first of all I’m public health service and not Navy so just for the record, but the reality is they were able to tell in San Diego what medications I was taking so they wouldn’t give me the wrong prescription to try to fix what was going on with me at that particular time ok, and those things happen folks and it’s great and I’m in hopes that that’s what happens because our special populations that we deal with in public housing when we move from the inner city urban area to the suburbs, sometimes they leave the suburbs, and they come back because they don’t like it They don’t have public transportation, there’s not a grocery store nearby, their friends are gone so they want to go back and sometimes move in with their friends or their relatives and so we want to make sure they go see somebody, if they we get moved in the interim If they see somebody we have to make sure that we are in contact and make sure that we give them the right health care, CMS requires all permanent and seasonal sites within a health center approved scope of project be enrolled individually in Medicare Each site must also indicate its unique Medicare building number These are initiated and maintained Medicare reimbursement plans Ok, I wanna stop here Look at this if you have questions don’t hesitate, you’ll have my e-mail address, I’ll get you to the right person Pay attention to these kinds of things there’re a lot of changes coming about Please ensure that your health center has all the correct medical billing numbers enlisted, that’s key isn’t that right Mr. Hubbert, without that right number you don’t get paid, you get rejected, this happens folks Anticipated policy topics, draft of sliding fee discount program, sub-recipients, sub-contracts, draft quality improvement/assurance, and all these again are posted on our website, funding updates-I wasn’t kidding when I said I had a lot of slides-ok, we have a spending plan, ok, this is another one, this is what we are going to do another 150 million dollars more for new access points, that means 200 – 230 awards, does that excite you? I didn’t hear a wow… (wow) alright come on what is it? (wow) alright this group gets the money they clapped the loudest, now I’m just kidding, I’m just kidding, ok do I hear a wow? (wow) alright, 15 million dollars for expanded services including expanded HIV services Guess what, we’re gonna partner with HIV because it’s improvement Things have evolved to what it used to be with HIV I worked at a health center in the Army I’m not going to mention the name but they put us all the way across the installation because they didn’t want us to be with the general

population This was when I first started in the mid-80s and now it’s evolved to, its maintained, they can go to community health centers and get the medications so we are partnering with them So we are trying to expand HIV services important for health centers, recruitment and retention strategies including the health center for veterans hiring challenge We are doing all these things with this money because we are starting to expand what we do, we are being more visionary $20 million dollars for health center controlled networks we want everybody to talk together we can have a system but even if you have a system it doesn’t connect $600 million for capital development building capacity (wow) alright this table gets the money this table, don’t be surprised next year, we say who got money they raised their hands Ok, don’t get disappointed, it’s a $100 million for capital development, immediate facility improvements $75 million for school-based health center This money is going out folks be ready (it’s already on the website) again please you can’t buy me drinks today OK, congratulations to those As I’m speaking here, messages are going out, OK you’re gonna see some people jump up, my staff here is sitting before me and I’m going to introduce them before I close, cause they’re here to protect me in case somebody didn’t get any funding, no I’m just kidding Continuing funding opportunities 2012 budget period progress report technical assistance, here’s the thing, I mentioned this yesterday and for those who’ve heard me speak I’m always preaching this don’t be afraid to ask for help Our job believe it or not, trust me I’m with the government, my job and the team that works with me the guys that really do all of the work and make me look good, where’s my photographer today no pictures oh there he is he’s sitting down ok, their job is to make sure that they ensure that your job is successful because we want you to be successful so we can get the money out there to those in need we didn’t get this money because there’s not a need for it there’s a tremendous need You hear this all the time as the economy changed a few years back, it changed a whole demographics of residents, I mean of homeless people, their neighborhoods have changed everything is changing around the neighborhood You heard Congresswoman Edwards mention some of her neighborhoods now are different That’s reality folks so we’ve got to make sure that we’ve got health care available to these folks We have 20 service area competition cooperative agreements-this is where North American comes in as others-we have state and regional primary care associations We work in partnership these PCAs as we call them they’re there to take a phone call if you’re in the community and say you know we really need a health center here and the plant closed down, we have people here, we have the poultry industry built a band here, have people coming in they need health care, how do we get a health center built how do we qualify for something like that Contact Jim Hunt you know I’ll give you his cell number and a home phone number in a minute (laughter) but you contact them because the PCAs across the country are there to help you as well, and they work with us and you know and their job is to make you successful and their job is to work sometimes with the local state legislations, legislators in an effort to make things happen, quality and data updates Do I have time, two minutes ok, Patient Centered Medical Home, health home that’s the N word you know that I want to bypass that because we know what we have to do We all have to have a home so we can make sure we’re being taken care of, my father has a home, I’ve used my father as an example because he only goes to one doctor and when doctor Gonzalez retired and he says I’m going to take you, so he met him at the new doctor’s office because he wanted to make sure that this person is going to take care of him now and he’s OK so Dr. Gonzalez passed him to Dr. Torino and Dr. Torino speaks Spanish and that’s ok for my dad, ok fine he must be ok because my other doctor said you’re ok because the other doctor retired because doctors do retire FTCA policy just so you know, again I apologize I got two minutes here I don’t want to take Jim’s time UDS reporting, you gotta do that folks we need those numbers, treated like a business as you do even though you are dealing with the government, proof is in the pudding, they need numbers without the numbers we don’t justify our existence sometimes and its getting more and more, and these computers boy they really say how come you don’t have a system

So we are trying to assist you to make sure that the numbers are complete and corrected you know and we added things, new clinical measures, coronary heart disease, colorectal cancer, the reason that we are added these things because there’s a need out there, we see the numbers rising so we’re going to make sure that we take credit for what we’re doing and for what you’re doing out there to provide the services to those in need OK, technical assistance resources you know national-cooperate agreements we have primary care association, primary care offices those individuals that work with the local state health development department in an effort to work and to work with the state we have federal TAs, we have project officers On that note we have Mr. Lieutenant Commander Mr. Kevin Bates stand up Kevin, he works in the office he’s a project officer, we have Mr. Chrisp Perry project officer for public housing, I have my senior advisor who’s been around for many years like myself … This is just part of the team of the 21 people I have now that make me look good you know and the nice thing about having Hubert he says Henry we wanna make you look good today I say ok So, primary care health money, I’m sorry about this but thank you, I always go over time so there’s no time for questions, (laughter) just kidding I’m easy to spot I’m here all day there’s my e-mail, there’s my office number, but more importantly again I always give out my cell number 703-861-0700 people say you’re crazy I say no I’m not, if it’s important to you to contact me it’s important for me to respond back or have somebody from my office respond back to you, immediately I may be in travel as I do a lot I’m out of the office I get these e-mails and I have people here in the office in the audience who I know I’ve called back raise your hands, on the weekends Dr. Page, Henry Tuttle, a hand reached out back there Michael they know I call on the weekends, you call me at night I’ll call you back it’s important That means you have something that really needs to be answered and times sometime is money folks and with that note thank you so much for your time, thank you for what you do, and for my dental friends as Dr. (inaudible) would say only brush the teeth you want to keep and thank you for not smoking (applause) 57:08 David: Henry it’s always a pleasure Thank you so much For those that haven’t met Henry please take a few moments out of your day to sit down and talk with him and tell him about your project tell him about what life is like there It’s really important that Henry understands the reality that you guys are facing so he can bring it to work every day So Henry thank you so so much I am pleased to introduce Jim Hunt who I believe is now Dr. Hunt, correct? Dr. Hunt, yea (applause) uhm and for those that don’t know Jim, Jim has been in the health center world really since the first day of community health centers He is a leader like you can’t even imagine and we are really really privileged to have him at our table and taking time out of his busy day to talk with us so I don’t need to read his bio it’s in there, he’s great, I wanna save the time so that he can actually talk Jim: Thanks David, Thank you Wow, thanks everyone, as you can see my presentation today is a historical overview of community health centers but I think I’ve renamed it after listening to these fabulous three speakers before me I think I’ll call it random thoughts from the podium because I’d like to comment more on what they said then on what I intended to say I’ll weave in a little history and I’ll try to get us back on schedule if I can So obviously Congressmen Edwards, Congresswomen Edwards spoke about the need for advocacy, secretary of state Sebelius, Doctors Wakefield, and Brand, and Jim McCray and our dear friend Henry Lopez are all there as part of the team supporting us and we need to support them Uhm both of us, Henry and I are celebrating, don’t we look younger to this week, we are both celebrating that both of our sons passed the bar so we basically (applause) are free, are free, and that prescription he was looking for my wife said in San Diego was for hair because Henry’s hair and my hair are styled the same but he joined the federal government and I stayed with the health centers, (laughter) He used to call me the follically impaired one not from that I just finished my doctorate and I did it on the history of the health center movement and the Reagan Block grants turning back activity to the states Isn’t that comical and Congressmen Davis was one my members of my committee and I must say the toughest member of all holding me to task and forcing me as he does do well to address the issues head on, but our movement has a rich history and that history is of

struggle and success We continue to struggle but we continue to have success within those struggles, so as you struggle with lack of resources, and challenges on the home front Just know, that those before you had those same struggles and were able to be successful through them we were searching and in the search light looking for resources and recognition and respect for many years, today we are in the spotlight and that spotlight is in the growth through the ACA that’s already been talked about and also in the growth of our patients served, and I’ll get to that in a few minutes, but one of the things that I think that Congresswoman, Dr. Brand eluded too, Henry certainly does it well every day and that is that you and I and we need to tell the stories The data is extremely impressive really important for our quality and our access but when you get in front of those legislators or you get in front of that city council person, or that congressman or women it is the stories that count how we’ve changed lives How people have been assisted in their own growth through our work and over the years that’s what leads to the success, the data is important, the quality is important the stories are equally important How many of you have, and welcome to my Massachusetts colleagues that are here, have visited more than 10 community health centers? Excellent, five, and the one you’re in or the public housing? Well just remember that our colleagues throughout the nation all do different things reflecting their communities and I always like to say and it’s the first Jack Geigerism that I’ll bring to you today and that is if you’ve seen one community health center you’ve seen one community health center So as you try to reflect the essence of your communities understand that within states or within special population groups or within the nation we all stand together as a movement-but each one of you is separate and unique and very important Our movement is a family, it is different than a business although the business principles that we practice are extremely important As a primary care association director it is my duty to bring you the shameless commercial messages from Massachusetts, some of you may be suffering from Massachusettsitis that’s hearing too many times how Massachusetts is the example of the nation, but the first community health center started in Massachusetts Today our not for profit community health centers and the whole state 50 of them in total, and 800,000 people served, and we’ll get to them in a minute As Henry just told us 8,100 sites across our nation now practice community health almost 21 million people served in Massachusetts, 800,000 served through over 280 practice sites You all know about the broad array of services we provide and continue to provide but it’s really important that in the 21st century we begin to leverage those 17 of our health centers had electronic medical records 10 years ago 49 out of 50 have them today leverage, state resources, private resources a little bit of borrowing here and there, a tin cup banging, asking for resources from our hospital partners and others and a big stimulus from the federal government the reason I like to include this slide is not only to site that but on the bottom there you will see that in Massachusetts and across the nation we have become big it’s not good to be small these days, we have 14,000 people supported in jobs in Massachusetts and about one and a half billion dollars in economic engine driven resources in my states some of the mill cities you’ve cited in the health centers and all of a sudden the bank appeared, you sited the health center and the pharmacy appeared, the pharmacy and the bank followed by the super market and entire communities reenergized by the anchor of the community health center that’s happening in your communities too It’s really important that we describe how big of an economic engine we are so in Massachusetts we have all of our growth outside of the big cities, the big City of Boston, City of Springfield and Worcester are now being equaled or surpassed by those who travel to find housing, who traveled to find jobs, who are conclaves of cultural and ethnic groups The City of Lowell health center served 85 hundred people 20 years ago today it’s building

a 30 million dollar complex, the city of Lynn, the health center is the city’s largest employer the Cities of New Bedford and Quincy, Henry Tuttle is here from Quincy Health centers have become a focal point of jobs of creation of action and over the last 12 years all the growth in Massachusetts have come from outside, outside the city of Boston What’s interesting is not only have we become the largest primary care network in Massachusetts, but as Henry just told us with some 1300 sites across the country soon to be 1300 grantees across the country hopefully in the next couple of months We have become community health centers, the largest primary care network in the United States, the largest primary care network in the United States (applause) So you all know what we do and you know how effective we are and you know how much work there is to be done, you know that our collaborations in concert with public and private partners are important, hospitals and health centers working together can create an interoperability with that electronic health record can follow that patient regardless of insurance, regardless of site, returning the patient back to the medical home as Henry and Dr. Brand have all taught us Geiger and Gibson saw what was happening in an isolated peninsula over in Massachusetts, and decided that this was wrong Tuft’s medical school was using that peninsula as a medical research site and a training site for its residents and although services were being provided to the 1503 housing units that housed over 5000 people they saw that three hours of bus changes to get to our city hospital was not appropriate It also happened to be Columbia Point and the then Speaker of the House John McCormack’s district didn’t hurt, Geiger had gone to South Africa during the Apartheid and worked with Emily and Sidney Cock on developing health centers in South Africa they had developed 16 of them Geiger worked in the Lamontville Project which was a Zulu tribal nation and thought that his life work would be in community health centers and global health internationally probably stationed in Africa but then during the freedom marches of 1964 he, Gibson, and many other physician’s on the physicians organization for human rights went to the south, and he discovered that the poverty and the need was right here in America and that if we were going to be an example for the world, we had to focus on what was happening right here Meanwhile, President Kennedy was supporting the Civil Rights movement in its beginnings the great Dr. Martin Luther King was leading the marches Geiger, Gibson, and many other physicians were taking care of the wounded and he fell upon an isolated county, anybody from Mississippi? Anybody from Delta? Delta Health Center? Anybody? No? Mississippi? No? He found an isolated hamlet in North Barbour county about 90 miles south of Memphis Along the Mississippi Delta called Mount Bayou and at the time he knew he couldn’t propose to the incoming Johnson administration that was implementing many of the visions of President Kennedy he knew that it wouldn’t fly to propose a health center empowering poor people in Mt. Bayou North Barbour county, Mississippi and instead said well why don’t we go to speaker McCormick and to then Sargent Shriver the new head of the new office of economic opportunity and propose two sites, one in this isolated county in Boston along with one in North Barbour county, and rural isolated site in the south So those two pilots were the first two health centers funded- 1965 at Colombia point and one year later to the exact day in Mount Bayou, Mississippi Remember President Johnson stood, and as a symbol he said we will conduct a war on poverty

and many of you forget the second line of that, and by that create a great society and therefore many of us who skipped 10th grade and didn’t study civics missed it when they said the great society programs included, jobs, community empowerment, the creation of access to health care We forgot that in fact the war on poverty was not to eradicate poverty solely it was to take poverty and craft it into a great societal effort so that’s why I like to use the war on poverty as the symbol of what Geiger and Gibson felt Columbia point was in fact where he first saw it and right after the establishment of these first health centers, Geiger began to write extensively about what he called the Schweitzer bit which I think Albert Schweitzer wouldn’t be pleased we called it the Schweitzer bit of actually treating and streeting people when they were profoundly sick So people would wind up in Emergency Rooms, they and would get treated in a fragmented way and probably quite well frankly, they might wait 8 hours as they do today but they might be treated quite well and then they would exit that Emergency Room and you wouldn’t see them till the next acute episode, Geiger thought that was wrong he said we have to create an empowerment because the poor get sicker and the sick get poorer so if you’ve got a child with malnutrition, if you treat just that child then the rest of the family remains malnourished So you’ve got to create an avenue where that whole family is uplifted by the cure that you give so that’s why he dedicated his life’s work and now Jack is 88 years old of age He’s doing much better and he basically is able to get out and about although his eye sight is very challenging and he asked me to make special mention to you of his thrill of having these awards named in his honor and he urged me to urge you to interact with these awardees and to get their essence and get their story and some day he says I will join you at this conference if I am able and he continues to be the firing brimstone that he always was Just a few more so the key to this slide is that when the medical schools establish the health centers understand that the OEO the federal government were the ones that said you must create an avenue of maximum feasible consumer participation, maximum feasible consumer participation, ok what does mean amongst all these acronyms What it meant was that those that were to be served have a meaningful role in those programs, another program that started around the same time that shot like a rocket in 1965 was the head start program we had the United States Public health service core and the origin of head start was that they wanted to name it was “Kiddy Core” because we were establishing the jobs core and we have the United States public health service core let’s call this the Kiddy Core and Sergeant Schweitzer said no, no, no for maximum consumer participation of parents we should invite these parents in, not that these children are joining some military organization, but in fact they are going to get a start because our war on poverty to create a great society requires it So the hope was that the community based model of care would lead to structural reform of the United States medical system and I’m here to tell you that it has, that it has We have made a profound impact on the American health care delivery system and hopefully we will stop using the word health care in the future and we will be talking about the health of the Americans rather than the health that we bring to those who are residents of our country so founded in ’66 The Delta health center had this vision of a complete model of uplifting the community so for those of you have seen the documentary out in the rural and if you haven’t I would urge you to go to my website and it’s posted on my website it’s a 26 minute if you will advertorial for community empowerment done in 1968 featuring Dr. Geiger

It speaks to the need for the food co-op of job creation, of education, of making your own health care providers by sending people to nursing school and medical school by getting people GEDS to stop them from exiting to going up to Michigan to be in the plants and stay on the line This one person out in the rural that says my brother went to the line and in 27 years he never moved a single inch on the line Why can’t we create jobs in this county so that people can come back and uplift themselves out of poverty and create if you will that great society? So community empowerment was both a central theme and Boston and Mound Bayou Mississippi I believe it makes us different as community health centers, health care for the homeless programs health care in rural HIV programs, community health centers, and health care in public housing I believe it makes the difference for us I believe that we should continue to empower our boards and grow our boards just two Jack Geiger stories and then I think I’m almost out of time First, those community boards are critically important so in 1967 as Geiger and his team were being called on the carpet and he needed more money from Mount Bayou he was being called on the carpet by then Julius Richmond who was the head of the Health Care programs for OEO he became the surgeon general and Sergeant Schweitzer who many of you know who are at least the aging boomers like me was the brother in law of the President of the United States, John F. Kennedy’s brother in law, he was called in the carpet to answer as to why they were buying food for poor people with prescriptions and why they were buying farm equipment with the grant being given them by the Office of Economic Opportunity for Health Care So he decided to take his board, and his board was headed up by Reverend Biggs Reverend Biggs was a local minister in Mount Bayou, the board all assembled and they went down and got on the plane in Memphis and Reverend Biggs announced for the 16 board members who were on the plane, that’s the first time they had ever been on an aircraft and they were a little nervous so as the plane was taxing out to the run-way all 140 people aboard 16 of them were board members of Delta Reverend Biggs began to offer prayer, Reverend Biggs then broke into song, the gospel music landed in the Nation’s Capital, they headed up to the hill Sargent Schweitzer came in with Julie Richmond and his team and Sargent Schweitzer said let’s begin the meeting, and Reverend Big said excuse me we have a tradition where I come from that we begin meetings in prayer and so for the next 35 minutes Reverend Biggs prayed for forgiveness for the miss-use of the grant, prayed that Sargent Schweitzer would see the lite and further fund the health center to do the good work that it was doing and prayed that the federal auditors would not visit Mississippi soon (laughter), meeting over, case closed, do good work and prosper So the moral of the story is that our stories are critically important, John Hatch who is the social worker head of the Columbia point health task force was studying the impact of Colombia Point and asked Geiger if he could go to Mound Bayou and advance of the Geiger-Gibson arrival, they started with a trail of and so he was granted permission to go and flew down and disappeared for two and a half weeks they thought something had befallen him this African-American Giant man from Boston Massachusetts with a Yankee accent heading down to Mound Bayou but finally he surfaced and he said he spent those two weeks in indigenous embodiment in the population served I said what’s that, he said well I picked cotton during the day and I went to church at night and I went to every church where the empowerment was, where people had roles in the church, where there was gospel music and singing and uplifting and empowerment and that’s what I did and during the day I wanted to feel what the people felt So I did that for the two or three weeks where I was missing in action and the first day Mound Bayou opened it had 6 patients, on the second day 25, and by year end lines out the doors trying to get the care based upon the word of mouth of respect, integrity, access, and primary health care So today you know with all the health centers we’ve got it’s really important that we reflect on what happened in Boston and Mound Bayou, what happens in your local communities

and to tell those stories that are so important, that now nearly 2000 health centers serving 20 million patients So you’ve heard the stories about error in public health, you’ve heard the stories about capital development and workforce, you’ve understood that presidential and congressional elections are here this year, no one in the federal government can speak to these because these are partisan elections and you can’t speak to them from your health centers in a partisan way, but you can tell the stories and push back on what error has done for jobs, what error has done for access, what the ACA is doing today you can become a part of your primary care association Very important, I urge you to join NACHC, National Association of Community Health Centers that is telling those stories on the hill every single day fighting for HRSA colleagues and the programs that they and others support ACA being the number one target on the agenda this new word that we are all facing sequestration, is something that’s going to be coming to a city or a town near you and for those of us that say well we’re exempt from some of those cuts, if the congress has to cut, remember if everything else is cut we’re going to be cut too If that source that you have that’s bringing you resources, that leverage, what you do if that’s cut you’re cut too, so supporting the congressional efforts to find a settlement where the most important if you will entitlement programs are protected and the most important discretionary programs like the health center programs are protected And then finally, just very important that we protect ourselves, and that we learn about these 19 program requirements of HRSA and the Bureau of Primary Health Care that we educate our staffs big and small in these 19 program requirements where need and services and governance and equality become really really important and that we understand that we need to protect ourselves by doing so, so thanks very much, why don’t I just stop there Astril: I would first of all like to thank all of our plenary speakers, Congresswoman Dr. Brand, Henry Lopez, Jim Hunt, and our moderator for this morning David Vincent, I think they did an awesome job, didn’t they? (applause) Thank you And Jim Hunt’s presentation was really one that we thought was important for you to understand the work we had started The community health center is really the heart of most communities and there is so much that we have because of the work that you do the dedication, the tireless hours, there’s so much help and movement and job creation and education, there’s so much done through the work that you do so thank you for that As Jim mentioned the 19 program requirements, that’s one of our biggest charges from HRSA to make sure that you have to make sure that you meet them and we are going to successfully do that and so as we break now for the next couple of minutes, we ask you to meet in the various workshops, uhm rooms that are scheduled for workshops I think we have something that addresses each of those 19 program requirements over the next two and a half days so we really encourage you to go to the workshops and receive the information that you need to take you to the next level, so again thank you all for coming today and we will convene for the workshops at 10:45 Thank you (applause) �