Respite Care

Medical respite care tries to bridge the gap for homeless men and women who are too sick to be on the street or be in the shelter, but not sick enough to need to be in the hospital.

Dr. David Munson, Boston Health Care for the Homeless Program, and Andy McMahon, Vice President, Health and Human Services Policy UnitedHealthcare Community & State, discuss how to implement successful respite programs in this episode of Caring As Communities.

Transcript

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Enrique Enguidanos: 

Let's jump right in. Dave, let me just ask you. Can you define respite care. I think it might mean different things to different people so give us kind of a basic concept of what is respite care.

David Munson

Yeah, that's great. And, again, thanks for having us here and then thanks to all the listeners who tuned in. Yeah, I mean medical respite care tries to sort of bridge the gap for

homeless men and women who are too sick to be on the street or be in the shelter but not sick enough to need to be in the hospital so you know practically speaking that that covers a really wide range of clinical presentations. But, you know, we can think about it in terms of, of, like, you know, serving serving the needs for patients that that really don't need to be in the hospital anymore but are just too sick to be outside that's kind of the way that we really distill it down in the most simplest terms.

EE:

That's great. Thanks, Andy, anything that you'd add to that.

Andy McMahon:

I think Dave captured we certainly look to him for all the kind of core programming elements I guess the only thing I want and we may touch on this later is that the National Healthcare for the Homeless Council has also set out a number of kind of standards for which medical respite care should meet which I encourage our listeners to check out just because, you know, you got to make sure you're providing all the right services to ensure effective respite care.

EE:

Thank you. And that you know I want to direct the next question to you, Andy. How did the concept evolve in the US? I know the Boston respite program is one of the earliest in the country but. How did it start, maybe a little historical perspective, and what's it evolved into. Dave, feel free to jump in as well because I think your program started in Boston. 

AM:

Yeah, so, you know, as you mentioned, our respite for us was part of our sort of founding ethics, about self care for the homeless program where, you know, from the very beginning of our program in 1985, the folks the advocates homeless advocates and homeless folks and clinicians who came together recognize that there was a need for this type of place, a place for people to get well and get better. 

When they had to leave the hospital, and so respite, you know, for us, starting at the very beginning, was part of our founding. We started with, you know, 20 or so beds that were tucked inside of a shelter. And over that time really as I would say as the result of some great partnerships with with state government, who was sort of, you know, ended up being the primary payer for US state government and then, you know, local, local broader health systems have grown over that time and in sort of phases where we left the shelter setting and moved into a standalone program as like, physical space that was just ours. And then about 1012 years ago moved into a larger physical space. And then four years ago, sort of birth, a smaller sort of step down program so now those 124 beds that you that you mentioned, is actually two programs a program that's 104 beds, that's a fairly clinically intensive model, and a program of 2020 beds, which is a little bit less clinically intensive. 

DM:

And I think just one point to make is that, you know, medical respite looks different in everyone and it's important. 

Andy mentioned the standards which we can totally talk about which are important sort of foundational aspects but, you know, every respite program looks a little bit different because the needs of the populations that the epic program serve are different than partnerships or different funding sources are different so so because of that all the programs look a little bit different, though we've tried to establish some core principles with the standards.

AM:

Yeah, and I would just add I think Dave hit the nail on the head for sure I think I'll say as we think about some of the evolution components. If you think back to the 80s prior to Boston healthcare, homeless programs existing in shelters were emerging as a thing, if you will. And I think it was just a recognition fairly quickly among hospital folks that folks needed to get out of hospital beds but didn't necessarily have a viable place to go. And I think homeless shelters were seeing people come to them and they were completely incapable of caring for their medical needs. 

And so I think, you know, and then if you pair kind of that, the, the pair's perspective of thinking about kind of how do we work to manage the best health outcomes, I think there's kind of a confluence of the healthcare players and in the homeless services community of cities we need to have this type of intervention that became medical respite.

EE:

Thank you, that's perfect and I'm gonna try to elaborate on that a little bit. I mean, the basic questions: what type of conditions are we seeing an interest by care—but I imagine that varies by community but are there some basic ones that perhaps—we'd start off with. What are some of the nuances that that different programs are bringing and how are they staffed, do we have medical personnel in these respite centers? Is it better care or worse care—or is it just a more timely care? How do you both see the care that's being provided in the respite centers as opposed to what folks are receiving in a hospital setting. 

DM:

Yeah, I can sort of take a first stab at that i think you know to the first part of your question about, you know what, what are the clinical presentations that we see, I think, you know, we sort of think about it in buckets, I think because there are you know, I tell when I have residents and students that come through here I tell them it's like 10,000, different emitting presentations that we have, you know, but in buckets that you know is, is chronic diseases that have that are out of control for some reason, you know, diabetes and hypertension or heart failure and cirrhosis that, you know, for whatever reason, you know, or for the reason of the you know the stressors of homelessness or trying to manage your blood sugar in the shelter are out of control and we can use respite to sort of get those, those folks under control, or as a step down from hospital if the problem has required hospitalization. It's, you know sequelae from substance use disorder. So, whether that's you know continuing six weeks of IV antibiotic treatment for endocarditis or wound care from an abscess, that kind of thing and that bucket. We also were a little unique again because we're pretty clinically intensive but we do do alcohol opioid and sedative detox here in our program so we can kind of offer that service and link people to care through there. I will say linkage to substance use disorder care is something that most restaurant programs can do in terms of initiating buprenorphine or connecting the methadone tracks is a nice continuum that can be started in respite. And then kind of another big bucket is like cancer care and supporting people through cancer care chemotherapy. And then we add some other programs do you know circle the city in Phoenix does some end of life care to as we do end of life care for homeless folks so you know for people that can't access hospice or just don't, or just are well known to a respite program can sort of can sort of access and do that so sort of in terms of big buckets that you know and then, and then things overlap in between there's a high comorbidity of coordinate comorbidity of substance use, amongst the population and a high amount of comorbid mental illness amongst the population too so it tends to be a pretty complicated patient population.

EE:

Yeah, and I think, I mean I think they've you know that i think one thing I would add is actually just what you were just talking about Dave I think also thinking about that lens of, you know, how can we use this these services these course services that Dave and his team are providing to kind of stabilize folks, and then help them get connected to other systems of care they need. 

AM:

Whether it's addiction counseling or mental health treatment or other things, respite care is such a critical kind of stabilizing force for folks, and others who run respite can provide for these kind of critical care needs that then also enable people to access some of the other cares and support they need. And some of those underlying issues around behavioral health that are probably exacerbating their conditions.

In terms of, you know, caring that's better or worse or it's it's different, you know, and I think, you know, maybe in one tangible way it's different is maybe it's a little bit more patient centered interest with her and then a hospital based care would be you know and you might have clinicians and providers, of which, and you know, and again, some restaurant programs are very heavy on clinical folks, and some respite programs are less heavy on clinical this sort of spans the gamut. But, you know, they might be, namely, you know, we, you know, they're made up of folks who take care of homeless people as a, as a career. And so there may be a little bit more attuned to the needs of that population and the patient's, you know, might sort of settle in and have a more successful stay than in the respite program than they would in a hospital per se just, you know, just because we know that, you know, our folks sometimes struggle to stay in hospital they sometimes struggle in interactions with emergency rooms and things like that but you know maybe they'll settle out in the interest of its day. So it's just different. It's not better or worse, per se. What do you think, yeah, Ithink I'm glad you said that he's in a little bit of irony here and we gave it I actually started my early on in my career really, many moons ago, working with Boston in city city bossier homeless services and and Dave, I think you're exactly ready and I also worked at a group called align to the streets here in Minneapolis which is basically a drop in center and advocacy for homeless folks. And I think you're right that there's, you know, candidly there's a huge part of the hospital system that is not well, skilled and isn't necessarily positioned and doesn't necessarily have kind of the right kind of bedside manner, perhaps, or whatever to to work with. You can certainly can be be challenging and so I think Dave's point about kind of, you know, thinking about kind of the non medical part of this work, and then just as human beings, I think that a lot of them end up getting better care and better connections to people through respite programs.

EE:

Dave, I love that you highlighted that and so it's fair to think of perhaps risk by being an environment where once a severely acute hospital stays situation is somewhat stabilized that might be a transition, particularly for the high risk individuals that wouldn't be able to to to really complete that course in a home environment or in a safe environment instead of fair.

It's perfect. That's a perfect, perfect. You know, and then the other sort of building off that a little bit just knows that the high risk folks are using respite to link with emergency departments sometimes in terms of the folks that are cycling through their high utilizers and using respite as kind of an offering.

And I imagine you must. It really must be critical to have those community connections, because at some point they're going to leave. And so the issues you're struggling with, or the patients are struggling at homelessness mental health, substance. Is it fair to think that the rest of our programs around the country are really kind of leading that charge as far as developing some of those community connections we need to continue long term care for from my perspective, I think. 

DM:

Absolutely Enrique i think you know, working in image tournament I think of a lot of the respite care programs is kind of great kind of connectors right and it's extremely difficult work right because the fortunate reality right is that we have such a lack of resources and housing and other things in the community so it's not, you know, it's not always simple to get people to do the things that they need, whether it's rental assistance or ongoing mental health treatment, etc. So there's a challenge on the resource side but I do think you know from our perspective, we see them as respite care providers as critical connectors and, and in in a big picture sense helping to kind of expand access to care for those folks, which is kind of a key tenant for for us within managed care.

EE:

You mentioned how you're working with the rest by programs around the country. What are some of the challenges and Andy, this is going to come to you as well. You know, financial challenges, administrative challenges clinical challenges that communities that want to set up respite care are our seeing we had the pleasure of having Rob McMahon on a couple of months ago who was speaking to a program they set up in Spokane he's CEO of Catholic Charities in Spokane, and their risk by program started small and evolved and eventually helped fund housing programs for the community so they really parlayed rest bite work into a much broader program if you would in the community. What are some of them, if a community is looking to start something. Where do they turn? What are some of the initial hurdles that some of the programs that you've helped bring along have to struggle with?

DM:

Yeah, I think the sort of the some ways the fundamental challenge that sort of is that there is no regular universal funding source for medical respite. You know we don't we can't sort of, you know, you know, not like a medical visit for diabetes which you know through a community health center kind of looks the same in Massachusetts for all intensive purposes as it does in Arizona, you know, with some, some cloud, you know, respite is is is not kind of funded in any so so that way, that means that when programs are looking to build. They sort of have to do it on their own in some ways in terms of finding partnerships for funding. And so then that dictates in many ways what the care models ended up being because the care models sort of them in some time. So for example, if our program is looking to start up, one of the things we often say, if they don't have a relationship with a managed care organization is to look to a hospital that sort of enter into a relationship with a hospital where you sort of say hey look, we can help you guys out and we can, you know, take some of these patients from from the impatient. But then you're kind of, you're gonna, you know, build your model and design your program around the needs of the hospital and that just brings you you know but the fundamental problem there is the fact that you know that the funding is not is not is not uniform across the country. And then there's all sorts of challenges that fall from that in terms of you know what sort of, do you want to have a model in a shelter, and then it for example which maybe is easier in some ways because you can use the shelter infrastructure, but then you have to kind of partner with the shelter and if the shelter looks at substance use disorder differently than your model does then you sort of had challenges with that versus if you want to have your own building which is lovely and wonderful because you can do whatever you want in your own building well then you got to run a building and then if the air conditioner goes out on the Fourth of July, which happens here it seems like. And then you got to come in on the Fourth of July and, you know, so, you know, there's kind of a couple of different rabbit holes you can go down to, but I think the fundamental challenge and the one we've sort of worked on with the, with the steering committee is to try to standardize things so that, you know, we can, at some point, get payers, like Andy's group to look and recognize respite as something that we can we can be reimbursed for so that programs don't have to kind of beg, borrow and steal the southern programs.

AM:

Yeah, you can get a better game and I think that's actually one of the couple of efforts that we have ongoing and reached out to speak to, probably more on kind of the financing challenges and defer to take on on getting the AC book back up, but um, but I think that, you know, from our perspective. So, we've done a couple of things because Dave's absolutely right. It's a patchwork when you think about Medicaid, which is, which is where I work space I work in. There are some states that allow for many of the services that are provided in respite care to be billable to Medicaid to be in the medical loss ratio quote unquote the MLR. But there are large amounts of states where those where those services are not included as billable to Medicaid, which creates a substantial challenge for us because it means that we and we do do this but we we do other things like kind of equivalent value added services and other things, and are able to pay for portions of respite care through the administrative side of our budget but fundamentally that's just you know probably 10 to 15% of the 100% and 85 to 87% of it fits into the Medicaid billable and so you know we're able to do it some around the edges but not not in a big way if it's not Medicaid billable and so to address that issue we're doing a couple of things that we are we are very actively engaged in right now and the first is we have worked with national health care for less to put out a we co authored a paper on how you leverage Medicaid to to finance medical respite care. So we have several examples there are a lot of places where you can do it and so we're trying to highlight those and replicate those and export the ways export to other communities the ways you can do it. And then we're also developing kind of an advocacy campaign and targeting in several states where we are really going to push the state Medicaid agency hard to say. You need to be able to finance. These findings need to be billable to Medicaid because they're critical for the care of the folks in your state and, and I think some of it is just making that case and using our microphone, quite honestly, from UnitedHealthcare. To do that, I think the other really key piece and I welcome it. Dave starts on. When we think about the financing challenges. I can make the case she dies, all day long, about why Medicaid should pay for room and board in medical respite care because it's just like long term care, and a whole host of other programs where we pay for this all day long. But for some not great reason a lot of states, then kind of balk at it as kind of a non medical service and so I think we have a particular highlight on ensuring that that the room and board portion of medical respite programs can be billable to medical.

EE:

That's such great insight and I really commend United for, you know, being at the table at the cutting edge of this because I think it's, it's so important that we have that voice. And, you know, working in the nitty gritty to make make these types of programs happen sustainable and broaden, frankly, along that line Dave you, you know, is there an ideal way to approach this is it, starting small, and building a starting with a two bed facility in a community, versus, you know, let's see if it's a big problem let's just jump in with 50 beds I imagine it's going to vary in each community but what have you seen as far as successful approaches you know Is it is it looking at a particular condition and trying to start something with a condition. Is it more? Trying to find the hospitals that are looking for help to to get more beds than they have access to, is there a kind of a pattern you've seen in the programs that you feel that you've worked with.

DM:

Well I guess I would say yes and no I mean I think it really is true that each, each program is, is different because the needs in the communities are going to be different and so they have to, you know, in order to develop to be successful they have to sort of, you know, work within the the constraints or the or the needs of that those particular communities, but I have, I have long thought that that starting with hospital post hospital care is the is the most straightforward place. 

AM:

You know, whether it be, you know, emergency room but really more impatient in terms of, you know, whether you know sort of designing a model that helps in terms of post acute care and and showing I think usually pretty clearly that you can help the hospitals in terms of patients that are there, you know and have completed their acute needs but that you can sort of provide that service. And that to me has been the easiest place to start. And then, and then then then building off of there the other way to do it is to sort of start in the shell in the shelter space, and to, and to sort of step out from the shelter in terms of for folks that are, you know, sort of, in the shelter and medically frail for example or medically compromised in some way to design a model that you know sort of coordinates off a portion of the shelter and, and build some clinical services into that so that says that you know this group. We're going to look after them in a dedicated organized way. You know, but again it sort of depends on you know that that might be a little bit more difficult on the, on the funding side so those are kind of the two areas that I guess I would sort of say when you're looking to start are the spaces, it's hard I mean we, you know, we're a third where our program is like 35, years old, we're like, really, we're just we're like it just don't mature program we've been around for a long time so we have this big building with a lot of staff and can do a lot. And we're also reimbursed by Massachusetts Medicaid, in a really, we're lucky and and you know incredibly fortunate to be able to do that so we've built a lot of infrastructure around that it's not a realistic thing for other other programs but the smaller starts, I think, are, are easy, and I'm getting a spot on and I will do that and we can do from thinking about it through the Medicaid lens. You know what I would say is that I'm working in a couple of markets now we're actually where they don't have respite care we're looking to try to help be the convener and driver to help create respite care programs. And I'm working on that in a couple of markets and I think one of the, one of the potentially unique ways that we as managed care can be engaged is that more often than not right roof we probably have a contract with the hospital system or hospital that you would likely be working with there's a high probability that that kind of federally qualified health center or of care for homeless folks are the subset of that are are in our network as well and so we have some of those relationships and candidly and contracts in place and so it is then. Today's point is thinking about that third piece of the puzzle of the housing component and whether you go to a shelter or find, you know, unused nursing home beds somewhere else or I think Dave knows that. I think there's three or four kinds of Usual Suspects for where you end up locating medical respite programs but we are certainly trying to lean in on the managed care side where medical respite doesn't exist to say this makes sense for our community. Let's pull together hospitals, let's pull together our FQHC partners, and try to find other partners on the housing side to develop medical respite programs.

EE:

You might have just answered my next question there Andy but I was gonna parlay into what you just mentioned, you know, again I just commend UnitedHealthcare for driving this dialogue in so many markets. But for smaller markets or folks that, that, you know, want to try to start something like this, who's best suited to to really start or draw, is there a best suited entity that should be driving this dialogue? Is it something that falls on the insurance industry is it the hospitals. Is it the housing centers, have you seen a pattern, Dave, of the programs that you've seen evolve, how they start, who starts and and who continues to drive the dialogue

and Andy said about being a convener, because I think that is really, because it's usually in the community that it's it's all those groups, you know, plus maybe the shelter providers or whether that's, you know, a charity or a religious organization or they're all touching these patients together and they're probably all have recognized the need, and so I you know I don't, I'm certainly not an example coming to my easily I'm like just that where it's been just one group that's like we're just gonna do this, like it's, it's always just been it's, you know, recognizing the need right, Andy?

AM:

Yeah I think you're right and I will say I feel this way about respite care but lots of other things that go on in communities. It ultimately takes a champion with the guts vision to pull people together right because to Dave's point is there's so many disparate components right so if you're thinking about going to the rest of the hospitals like we run our hospital you know we're not charging run a respite care and the homeless, the homeless shelters are like we're not medical care providers and the Sq folks are like we don't deal in housing and so I think ultimately today's point right you you're going to need to bring this together and in my experience at least, it usually takes a champion and executive director or a senior leader of one of those organizations that says we need this in our community. And I'm going to drive the convening and the creation of it.

EE:

Have you seen that champion come from, from governmental agencies, and is, as you've looked I mean certainly I think of hospitals have a vested interests, the best which sees are those serving at risk groups. Certainly, the substance abuse, and behavioral health centers. The housing centers, but I suppose you know if you have a governmental agency that can drive that that's an ideal.

DM:

We have actually met at work on JSON so we have seen that in at least one or two states that I'm aware of where. And I actually credit the state where they have said even as we've gone in to respond to RFPs for providing care to individuals that the state has asked us. What are you all going to do to help create more medical respite beds in our community so I do think, Enrique that there are in a very positive way, times when when government provides some of the leadership I think in my experience, it usually ends up being those local groups the person from the hospital or person from the Fq in the shelter they get together and actually make it happen but I think that the state government leadership is is really i mean if you if you have it, it certainly makes it easier.

EE: 

Is it fair to think that most medical rescue programs are going to save healthcare dollars in the long run is that there must be situations in which we continue our rescue program, even though it's it's costly and maybe in the long term isn't a financial driver but but it's bringing tremendous social benefits but there must, it must work economically. When it's done right.

AM:

So I think that I will tell you I'm working with a number of healthcare economists and researchers on this exact question so if I could come back to you and visit you find nearby listeners in the six or 12 months, because we are we're doing that exact analysis now, it's I don't need to bore you or your visitors but it gets really complicated and complex really quickly when you're trying to identify who went to respite care, which those services, and then tracking the throughput, to the health outcomes and when did they go back to where we are trying to crack that nut. And I've actually had some conversations with Bobby Watson national healthcare for the homeless as well about thinking about that but. So I think it's something that we all kind of feel like inherently, it has to be there and it's certainly inherently no matter what is the right thing to do. But actually kind of counting the nickels is complicated and trying to understand where you might actually quote unquote save money but we are. We're on the case and going to try to find out.

EE:

So many moving parts, you didn't realize that you just committed yourself to another podcast with us now! I'd like to go back to some clinical question. It's time to, you know, we've, we've completed our course of care. We've stabilized. Where individuals that are leaving arrest typically go. And how does that transition out of risk by, how do we maximize the transition out of breastplate?

DM:

Yeah, that's a great question in some ways if I feel like if I was gonna, I was thinking about this in terms of the cost effectiveness piece because, you know, I wish we knew least in Boston, we don't have housing for everyone who leaves respite. We don't have an affordable housing market in Boston at all. No, people sit for 18 months on a housing voucher. In Boston so discharge to housing is not a realistic goal from our program. Because we're sort of prioritized on access and things like that so that piece is a little different in every program some programs have a longer length of stay and you know in cities and communities where there is more access to housing. It certainly lets kids transition into housing as a plan and that sometimes is a stated goal of some programs where they put a lot of wraparound services in and are. But for programs like ours and others that have shorter lengths of stay on average and our length of stay is somewhere kind of bring you know around the two week. Average in general. You know we're transitioning folks back to shelter for the most part with support. We've benefited Boston by having kind of an integrated network where we've integrated our clinical outpatient services into the shelter. So we have, you know, five to seven days a week presence in all of the major adult shelters in Boston from our clinic. You know our boss doesn't care for homeless firms so we can kind of pass the clinical and case management piece back to back to, to, to that group. So, you know, and then so there's a spectrum in respite programs in terms of, you know, transitioning to shelter with support to transitioning to housing with a longer length of stay to like in between, you know, we certainly have folks in our program that are interested in substance use a certain treatment for example, and so they can use our program to sort of stabilize and then go on to further substance use disorder treatment so that's a pathway. So, so yeah i mean it's tricky when you're trying to balance access into your program. Because if you kept everybody for housing you would grind to a halt in a, in a week. And, and then, you know, you wouldn't be able to serve the hospital and the community in the way that you sort of are designed to in some way so that part of the fundamental challenge is that we don't have enough affordable housing for everybody.

AM:

I could not agree more. And I think, Enrique, David, I think you know it's a non medical economist, to tell you that I think that's one of the challenges that we see in some of the days. You're right, is that restful crimps provide incredible value and support to folks but because of on the backside to today's point Boston has several seats. You know experience. Hyper acutely but there's an affordable housing crisis in pretty much every community in this country. And so, without that access to housing if folks are returning to the shelters and they were certainly there's an enormous value, they benefited, but that doesn't mean that they're that they're not going to experience other things coming down the pike right so they're not they're not necessarily being able to go from respite to, you know, a supportive housing. Housing development you know where they have their own one red red one bedroom unit and there's a part time nurse there and, and they have a case manager and there's all these supports right so when you get that I think you see a ton of bang for your buck but that unfortunately right it's such short supply so I'm guessing what you've touched upon is partially impacts. When we're talking about kind of the cost savings if you will.

EE:

Well, that was great insight. And you know we've, we've done some, some sessions on homelessness certainly it's, you know, it's going to be bringing everything together with the work we do with complex current CBCS you know the rest bite availability is so critical to get an individual's through that acute or subacute phase it's, it's, we're completely supportive we try to advocate for programs. When we're in communities if they don't exist and support them when they do and I really appreciate both of your insight in the work you're doing. With this, we. Our time has wrapped up so quickly before we leave. I do want to ask two questions of each of you if you can give some, some insight with, you know, first of all for companies that are looking to the startup. Any final words of wisdom, and then we ask each of our guest speakers. If they have particular resources they want our listeners to be aware of. We will post those on our website but we definitely want to advocate for the work you are all doing so, Dave, do you want to start off for us.

DM:

Yeah, I guess, um, it was funny my answer to the two questions is gonna be kind of the same but I you know there's, so we have really tried to compile a lot of rich resources on the Healthcare for the Homeless Council website and that and under the respite area for that. So, you know, with the idea that you know Andy mentioned this at the beginning but this idea. We have thought a lot about trying to standardize some of the care that happens in medical respite and standardized some of the approach which is going to help eventually payers recognize programs as respite and not respite and therefore, so I would direct folks to the Council website to to look and read the standards, and to reach out to folks like Julia Dobbins at the Council, who are you know who are just masters of this and then any of us at the council that would be happy to sort of lend ta but to try to help folks, so that we can kind of, we're in this like chicken or the egg thing where like all the programs look different and so none of them are funded the same way and what we need to try to do is to get everybody under the same roof, or the same combat tent I don't know, it's a big building, but we need to get everybody in the same space, so that he and his colleagues can can, you know, recognize that so that you are both leading that chart so so again I commend you both any anything to add.

AM:

I think I concur with everything Dave said and absolutely check out NASA Healthcare for the Homeless and to the 1000s in that team we work really closely with them I actually got to start. I'm not that smart. I'm smart enough to get her under contract to help us figure this out in other places. And so, so I highly recommend that too and like I said I'll share the paper that we had co authored with them, and also the advocacy document that we are for we're trying to use kind of you know the the voice and kind of the microphone of UnitedHealthcare to help push this at various state agencies and I think, I think my last kind of piece of advice is, is because no one person knew he owns this, or nor one agency can drive it right, is, is in your interested is is figuring out your coalition of the willing. Among those key partners right like, who at the hospital is willing to put in a war in the water to help out, who at the Fq is willing to do that. What shelter providers willing, who's underwater all the time he's willing to say I'm willing to put some time in on this, I think, you know, I think he got to start with, with people who, who understand the need and are willing to kind of put in some work off the side of the desk to help get started. Thank you.

EE:

I love that and again I can't, can't commend you both enough for for driving this dialogue it's such an important issue and I really appreciate the work you're doing and then the time with us today to the highlight the issues and you both realize now you're committed to come back in those six to 12 months we'll revisit this.

DM/AM:

Wonderful.

EE:

Look. We look forward to having you. Thank you listeners for being with us so that's gonna be in until next month. See you then.