Here’s What Happened in May at the Center

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If you haven’t visited the Center for Total Health recently, May was a busy month with events covering a wide range of topics and initiatives. In addition to hosting robust discussions about preventing violence, preventing and treating cancer, and creating innovative, healthy workplaces, we also had the opportunity to celebrate National Nurses Week (May 6-12) with leaders from the American Nurses Foundation. We not only welcomed this organization to the Center, but also showcased onsite displays that bring to life nursing leadership and communicate our appreciation for the difference nurses make in patients’ lives.

  • We welcomed the National Health Collaborative on Violence and Abuse (NHCVA) – including representatives from more than 30 health professional organizations – to discuss ways to reduce and address the health consequences of intimate partner violence (IPV) and abuse. Our very own Brigid McCaw, MD, represented Kaiser Permanente’s Family Violence Prevention Program, highlighting the crucial role health care play in caring for victims.
  • DC’s Colorectal Cancer Roundtable Summit brought local and national providers, advocates and educators to the Center to discuss the prevention and early detection of colorectal cancer and ways to improve screening rates to 80% by 2018 – a lifesaving goal set by the National Colorectal Cancer Roundtable. Joseph Territo, MD, of the Mid-Atlantic Permanente Medical Group, shared how Kaiser Permanente consistently ranks in the top 10% of the National Committee for Quality Assurance (NCQA) HEDIS Measures, which assess the number of adults who have had appropriate screening for colorectal cancer. NCQA data is also featured throughout the Center’s onsite displays.
  • The Center hosted the third annual Better Together event, All Systems Go! Closing the Gaps in Cancer Care, with the American Cancer Society and the Council for Accountable Physician Practices. The event highlighted patient stories, representing how coverage and accountable healthcare systems can improve survival and reduce morbidity for people living with complex conditions like cancer.
  • We hosted the Network for Excellence in Health Innovation (NEHI) and challenged attendees to think about Health Care Without Walls, a mind-shift to caring for patients outside of conventional institutional settings. To help get the conversation started, the center’s staff presented “Imaging Care Anywhere,” an example of our own provocation used with staff to think about the next generation of care for Kaiser Permanente members.
  • CoreNet Global’s Mid-Atlantic Chapter turned to Center to host an educational event focused on The Healthy Workplace, highlighting the subtle nudges that can be built into our work environments to drive healthier behaviors. Architects, designers, facility managers and other professionals learned how improving the health and wellbeing of employees through facility design can improve an organization’s bottom line, and also toured the Center’s interactive space to see the learnings come to life.

During the month, the Center also hosted meetings on improving prenatal conversations, credentialing of community health workers, and increasing the quality of ambulatory services, and welcomed a wide range of students, health care leaders, government employees and medical professionals for tours of our interactive and educational facility.

Supporting Healthy Communities through Collaboration: The Healthcare Anchor Network

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Supporting Healthy Communities through Collaboration: The Healthcare Anchor Network

Last December, 40 health systems gathered at the Kaiser Permanente Center for Total Health in Washington DC, to explore together how we can advance thriving, inclusive economies in the communities we serve across the country. This week, we’ll gather again to officially launch the Healthcare Anchor Network.

This collaboration represents a critical milestone in mobilizing our sector towards action and collaboration, and we are so proud to be a founding member.

Other founders include Advocate Health Care, Catholic Health Initiatives, Dignity Health, Henry Ford Health System, ProMedica, Providence St. Joseph Health, RWJBarnabas Health, UMass Memorial Health Care, Rush University Medical Center and Trinity Health.

And the Network continues to grow – new members include Adventist Health System, Bon Secours Health System, Children’s Hospital of Philadelphia, Christiana Care Health System, Cleveland Clinic, Dartmouth-Hitchcock, Gundersen Health System, HealthEast Care System, Mercy Health, Northwell Health, Our Lady of the Lake Regional Medical Center, Partners Healthcare (Massachusetts General Hospital and Brigham and Women’s), Presbyterian Healthcare Services, Presence Health, Seattle Children’s Hospital, UC San Francisco and VCU Health.

The lessons from the December meeting, and the vision of the Healthcare Anchor Network are presented in a report produced in partnership with the Democracy Collaborative and the founding members of the Network. The report reflects our collective voice calling our sector to action. It also provides useful examples and tools, to help health systems across the country become familiar with the policies and practices they might adopt to more intentionally support inclusive economic development in their communities. The examples and tools (produced with support from the Robert Wood Johnson Foundation) focus in particular on how healthcare providers can hire, buy goods and services, and invest capital in ways which benefit communities and residents most effectively.

These efforts are not easy—at Kaiser Permanente, we are working day-by-day to overcome the obstacles to adopting an anchor approach cross-functionally across our organization. We believe that our individual and collective journey in this important work will be greatly improved and our positive impacts amplified, if we work together.

The new Healthcare Anchor Network will convene health systems in order to share best practices, address common challenges, and identify areas where collaborative efforts may be possible. Our initial efforts will focus around:

1.     Making the case for adopting an anchor strategy;

2.     Effective collaboration with community stakeholders in these efforts;

3.     Shifting incentives to reward upstream health investments;

4.     Aligning approaches for scale;

5.     Building evidence of impact; and,

6.     Developing a shared policy agenda around addressing upstream determinants of health.

The Center for Total Health—an interactive learning destination committed to supporting innovation in how healthcare is delivered and experienced—provides the perfect venue for these conversations. We’re looking forward to gathering again at the Center this week to continue advancing healthcare sector innovation and collaboration for inclusive, thriving communities. We hope you and your health system will join us!

To learn more about the Healthcare Anchor Network, including how to join, contact David Zuckerman at the Democracy Collaborative, dave@democracycollaborative.org.

The Future of Care Delivery

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You walk in, verify at a kiosk that you’ve already checked in and paid, plug in your laptop at the charging station, and soon get a text that it’s your turn. No — you’re not at Starbucks — you’re at Kaiser Permanente’s new Signal Hill Medical Office in Southern California for your medical appointment.

Signal HillSignal Hill exemplifies Kaiser Permanente’s most recent effort of evolving its care model to better integrate into members’ lives.

“Granddad’s medical office building doesn’t cut it anymore,” said Don Orndoff, senior vice president, National Facilities Services.  “We’ve all now become accustomed to the Amazon and Uber experience and that’s our new expectation.”

The medical office of the future at Kaiser Permanente means harnessing design, technology and workflow to create an intuitive and convenient experience for members and care teams. It also means developing a much more agile and flexible environment that meets the evolving technology and service needs of those increasingly tech-savvy members and care teams.

Convenience and care under one roof

Signal Hill opened to Kaiser Permanente members on June 29, 2016, and its sleek architectural design doesn’t disappoint. But it’s the convenient technology features and efficient spaces inside that really impress. When you walk inside the building, you enter into the “public square.”

Since members have the option of checking in and handling their copayments at home, a quick visit to the kiosk allows them to take advantage of a number of options available to them in the public square. They can engage with others at the community table or use computers at the docking station. Or, they can decompress in a quiet spot on the upstairs “porch.” In fact, members can use their time wherever they wish because once the provider is ready, the member will receive a text message.

At the pharmacy, there is also no need to wait around. You’ll receive a text when your medication is ready.

signalhill2The exam rooms don’t look traditional either. Instead of the long, awkward exam table and steel chairs, there’s a comfortable reclining chair and a couch for family seating. The care team also uses hand-held tablets, which is not only easier for them, but avoids having the member stare at the back of a big computer monitor. On the wall, there’s a large monitor for virtual visits or patient education programs.

Read more of this story here. 

What Exactly IS the Trail Modeling & Assessment Platform, and Why Do We Care?

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Our guest blogger today is Tracy Hadden Loh with the Rails to Trails Conservancy.

Tracy Hadden Loh (right) and colleague with the pedestrian counter outside the CTH.

Tracy Hadden Loh (right) and colleague with the pedestrian counter outside the CTH. The counter was installed on one of the coldest days of this winter (high of 10 degrees!).

The Rails-to-Trails Conservancy is a national membership-based nonprofit dedicated to creating a nationwide network of trails from former rail lines and connecting corridors to build healthier places for healthier people. We serve as the national voice for more than 160,000 members/supporters, 30,000 miles of rail and multi-use trails, and over 8,000 miles of potential trail. When RTC was founded in 1986, there were less than 250 miles of rail-trail in the United States. Today, there are more than 21,000 miles of trails of serving some tens of millions of people each year.

However, that mileage number is about all we’ve measured with any precision. We don’t actually know how many people in the United States use trails each year. We know that these miles of trail are a great way to create healthier places and healthier people – for example, a recent meta-analysis of published research on the cost-effectiveness of population-level interventions to promote physical activity found that a rail-trail was the #1 most effective intervention. On the basis of similar evidence, the Centers for Disease Control and Prevention recognize trails as a proven strategy that works to increase physical activity, reduce risk of chronic disease, and improve mental health and wellness. So we know we’re on to something good – but how good? When it comes time to make room for trails in the budget, can we show a dollars-and-cents return on investment?

To that end, RTC has launched the Trail Modeling and Assessment Platform (T-MAP), a three-year research initiative to measure, model, and value trail use in the United States. The first phase of this project involves establishing a national network of trail traffic monitoring stations, so that we can continuously measure trail use across the different climactic zones of the US. We’ll use these data to develop two tools: a trail use demand forecasting model to estimate traffic volumes on existing trails or predict volumes on future trails; and a health impact assessment calculator for estimating health care costs avoided due to physical activity on trails.

Taken literally, RTC’s focus on “health” means that there are times when our mission overlaps with that of hospitals and health care systems. Under the Affordable Care Act, non-profit hospitals are now faced with a requirement to assess the health needs of the community, and based on that assessment draw up an implementation plan. We see that as an opportunity to make the case for trails!

Our partners at the Kaiser Permanante Center for Total Health already get it. Located in the heart of downtown Washington, DC right on the Metropolitan Branch Trail, the CTH is helping us implement T-MAP through the installation and maintenance of their very own trail traffic monitoring station, contributing critical data to the project from a unique trail location that is co-located with an urban sidewalk, and dominated by pedestrians. As they learn about how the trail relates to their facility, we’re learning about the trail and collecting the data necessary to accurately estimate the true magnitude of trail use in the United States, and what it’s worth.

 

Data from the CTH Pedestrian Counter

Data from the CTH Pedestrian Counter | February 15, 2015

A Q&A with FoodCorps DC

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FoodCorps DC Service Sites

FoodCorps DC Service Sites

On Monday, the Center for Total Health was delighted to host a meeting for FoodCorps DC.

FoodCorps is a national nonprofit organization that has nearly 200 AmeriCorps leaders throughout the country who are connecting kids to real food so they can grow up healthy.

These service members help schools in communities with limited resources, where they educate kids on how to make smart choices around food and nutrition.  They also lead hands-on activities like gardening and cooking that foster skills and pride around healthy food.  They even help make it possible for nutritious meals from local farms to make it onto school lunch trays. FoodCorps recently expanded into Washington, D.C., where they work in partnership with OSSE and many of D.C.’s wonderful food organizations such as D.C. Greens and City Blossoms.

After Monday’s “supervisor summit” at the CTH, we asked FoodCorps DC Supervisor Maddie Morales to answer a few questions for us.

Q: What is the mission or goal of FoodCorps? 

A: Together with communities, FoodCorps serves to connect kids to healthy food in school.

Q: What are some of the FoodCorps programs in DC? 

A: FoodCorps works with community partners to place service members into DC schools. We have 13 service members serving in 17 schools across the city. Our service members have been placed at schools through our service sites which are DC Greens, City Blossoms, FreshFarm Markets, Capital Area Food Bank, Marie Reed Elementary, Washington Youth Garden, Metz Culinary, and SEED Public Charter.

Q: Where should someone go to see your work in action in DC?

A: One of our 17 partner schools! Cleveland Elementary, Eastern High School, Kimball Elementary, or Hart Middle School, to name a few.

Q: If FoodCorps could change one thing, what would it be? 

A: We would create a future in which all of our nation’s children––regardless of class, race, or geography––know what healthy food is, care where it comes from, and eat it every day.

Q: What attracted you to working with FoodCorps? 

A: I originally applied to be a service member, because I saw this as a position that aligned my goals and personal values with tangible work. After a year of service, I wanted to continue my journey with FoodCorps as a fellow to further support the amazing work this organization has been able to accomplish.

Q: How can others get involved? 

A: Apply to be a service member! Applications are open until March 31st. Spread the word or volunteer at a service site.

Q: Who won during today’s pre-meeting warm up (physically active video) games? 

The FoodCorps team took an active meeting break on Monday morning with the help of an X-Box game.

The FoodCorps team took an active meeting break on Monday morning with the help of a physically active video game.

A: Rebecca Lemos. That girl has a mean uppercut punch. (Sorry Sam.)

Q: What healthy strategies does FoodCorps employ for its employees? 

A: FoodCorps supports an environment of wellness for employees. Through access to health care, support for eating healthy and reminders to take personal time, I know that my health is a priority for the entire organization. Also, potlucks and sharing delicious, healthy food is huge around here.

Q: Besides Kaiser Permanente, what other organizations does FoodCorps partner with to succeed? 

A: We are grateful to have support from a plethora of generous organizations, foundations and individuals who think kids deserve the chance to grow up healthy and happy. Take a look at our funders’ page for a complete list.

Q: What is your goal or personal mission at FoodCorps? What do you enjoy most? 

A: As a fellow with FoodCorps, I hope to support our service members and promote the amazing work being done in DC to support healthy lives for our students. I hope my passion for improving the food environment for children and families in DC is motivational to the service member cohort and our larger community! I most enjoy working alongside fantastic and dedicated people already doing this work and learning from the strong foundation that they have created. I also have a personal mission of learning how to cook like all of my colleagues…they are amazing!

You can read more about FoodCorps on their blog and follow their work on Twitter.

Learn more about Keith Montgomery and Alice Patty through their answers to our Total Health Questionnaire.

Supporting Communities to End an Epidemic

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In 2013, Kaiser Permanente announced an initiative to provide support to community organizations whose work it is to improve the health of individuals newly diagnosed with HIV in minority communities disproportionately affected by the HIV epidemic.

Seven organizations currently funded by Kaiser Permanente through this initiative are developing innovative approaches to prevent new HIV infections; identifying HIV positive patients sooner, getting them into high quality HIV care sooner and remain in such care.

In light of World AIDS Day, Kyra Nead, senior communications consultant at Kaiser Permanente, sits down with a few representatives of these organizations about the work they are involved in and speaks with Alexandra Caraballo, Manager of Charitable Contributions at Kaiser Permanente about why Kaiser Permanente was interested in creating this initiative.

Check it out below.  The transcript for this recording is available after the jump.

 

Read More

A Perfect Storm Brings Health Care, Government and Business Together for a More Sustainable DC

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There was a “perfect storm” of activity in the nation’s capital last week, and if you weren’t tuned in closely, you might have missed it.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

The Sustainable DC pledge awaits formal signatures from health care representatives signifying their commitment.

This perfect storm was not another Superstorm Sandy. In fact, one might argue that one of the aims of this perfect storm was to build resilience to any such storms in the future. This perfect storm brought together representatives from 21 different health care organizations and local government officials at Kaiser Permanente’s Center for Total Health pledging to make the District of Columbia “the most sustainable city in the United States.

So what makes this newsworthy? The health care sector is certainly no stranger to coming together under the umbrella of sustainability. Over the past 20 years, the sector has been leading its very own “green revolution,” with hospitals and health care systems of all sizes looking hard at their contributions to environmental waste and pollution and what they must do to flip the equation and support more environmentally sustainable health care approaches.

What makes the Sustainable DC effort special is its focus on a single urban community, on bringing together leaders from health care, government and business sectors in a particular place, concentrating their efforts across governance, jobs and the economy, equity and diversity with the goal that, “By 2032, the District will be the healthiest, greenest, most livable city in the nation by using sustainability solutions to address core challenges.” The Sustainable DC plan outlines specific goals, targets and actions to get there. And the plan makes it clear that health care organizations to be at the table to bring the mighty vision to fruition.

Hospitals in America contribute an estimated 8 percent of greenhouse gas emissions, generate more than 2 million tons of waste each year and draw upon natural resources like water in ways that often counteract efforts to support the health of individuals and communities. Recognizing this paradox, many health care leaders have joined efforts like the Healthier Hospitals Initiative, Practice Greenhealth and Health Care Without Harm to green their own health care systems.

Kathy Gerwig, chief environmental stewardship officer for Kaiser Permanente, chronicles this green movement in her recent book, Greening Health Care: How Hospitals Can Heal the Planet. In the book, she notes the reasoning behind why health care organizations would move to join forces with each other and government to move the needle on environmental health:

“In the final analysis, most health systems engage with their communities not because they are incented to do so by federal and state tax law, but because they are mission-driven organizations that care deeply about the health of their communities. They know that individuals’ health depends on the health of the communities in which they live, work, learn, and play, and that the health of those communities depends on a healthy environment—health-sustaining air, water, soil, and all natural resources. They strongly believe, on the basis of compelling evidence, that when they invest their dollars and their expertise in promoting healthy social and physical environments, they are benefiting their communities and contributing to the health of everyone.”

That mission-driven energy was palpable on October 23, 2014. The energy in the room was exciting, collegial and activated. There was much talk of the sustainability progress that is already converging in DC – from an extensive array of green roofs and LEED-certified buildings across DC to the build out of the Metropolitan Trail to provide safe, physical activity and active transportation options. And there was a clear conviction expressed by health care leaders who were gathered, as well as the Mayor’s office, that this coming together for a more sustainable DC was just setting the stage for a convergence of efforts that would echo progress even beyond DC limits.

We can only hope that, as DC leads the way in sustainability, so goes the rest of the country.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Representatives from DC area health care organizations gather with Mayor Vincent Gray at the Center for Total Health after the signing of the Sustainable DC pledge.

Kaiser Permanente applauds the Sustainable DC plan, and we are pleased to be among the pledge-signers and the hosts for this momentous step forward. We have pledged our support and look forward to working with fellow health care system leaders to advance the goals outlined in the plan.

Kaiser Permanente physician director for the Center for Total Health, Ted Eytan, along with Keith Montgomery, executive director for the Center, nicely set the stage for the day’s event in their welcome remarks. Ted offered his follow-up reflections in a blog post that summarized the vision for total health that everyone in the room intuitively if not concretely echoed that morning. He writes, the Sustainable DC plan is “not just about the environment, it’s about everything that goes into creating an ‘equitable, prosperous, society.’”

You can watch the full signing ceremony in this video.

More on Community Access to Healthy Foods with Elevation DC

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On Tuesday, June 24, an panel came together for a discussion about food in our neighborhoods – where it comes from, what barriers keep healthy foods from some communities, and solutions that are working. Kaiser Permanente and Elevation DC hosted the discussion right here at the Center for Total Health.

Food writer Mary Beth Albright moderated a lively conversation among Laine Cidlowski, an urban sustainability planner for the D.C. Office of Planning; JuJu Harris, culinary educator with the Arcadia Center for Sustainable Food and Agriculture; and Ted Eytan, MD, physician director at the Center for Total Health. Panelists shared different perspectives about D.C.’s food system and considered the economics of good health.

This discussion was a prime opportunity to consider the consequences as well as the opportunities related to food in neighborhoods. According to Cidlowski, communities of high poverty that are more than a 10-minute walk or one bus transfer away from a full-service grocery store are considered food deserts. D.C. liquor stores and fast food restaurants dominate some of the most vulnerable communities where grocery stores have gone out of business or have never existed. This condition leaves residents wanting – and to a large extent, vulnerable to chronic illness and low quality of life.

Organizations such as Arcadia farms, with its mobile market, are filling the gap by bringing fresh produce to people where they live and teaching residents about food selection and meal preparation. Harris, Arcadia’s culinary educator and SNAP outreach coordinator, hosts cooking demonstrations at the markets to help engage customers about what to do with the produce once they get home. She shared that even a 10-minute walk can sometimes be too much for people living in poverty.

Community gardens, gardening plots and urban farms are also part of the solution, however Cidlowski shared that with so much demand, there are now wait lists – some as long as three years – to use some green spaces. But with revitalization efforts in the city, much consideration is being given to food access in the District.

Eytan offered the physician perspective. He highlighted the connection between food and health and why this issue is integral to Kaiser Permanente’s total health mission. “We want to provide health care, not just sick care,” said Eytan, who encourages patients to make time for physical activity and healthy meal preparation, but acknowledges that healthy choices are difficult to make in many neighborhoods.

Enjoy more food for thought—read Elevation DC’s full story.

Washington Post Takes on Public Health Benefits of Built Environments

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Wondering just how much where we live, work and play affects our health — and what cities and community organizations are doing to improve that environment?  The Washington Post recently wrote a great piece on that topic, and in it, they reference the 11th Street Bridge Park project — highlighted on this very blog back in March in a post authored by the organization’s director, Scott Kratz, called, “Connecting Health with Place.

Kratz has promised us another update on the project in September, when the finalists will submit their final drawings for the competition.  Stay tuned.

How Community-Clinic Integration is Boosting Population Health — Part 2

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When community organizations collaborate, change happens. Earmarked as one of the next frontiers in public health, community-clinic integration strengthens the health of populations through inclusion, collaboration, and commitment.

Earlier this week, we brought you the first installment of a two-part interview between Kaiser Permanente leaders about the need for community-clinic integration. In this post, Holly Potter, vice president of Brand Communication for Kaiser Permanente, continues her conversation with Loel Solomon, vice president of Community Health for  and Jandel Allen-Davis, MD, vice president of Government and External Relations for Kaiser Permanente Colorado about the creation – and the successes – of community initiative-turned-nonprofit, LiveWell Colorado.

HP: In Colorado, LiveWell has been very successful. Can you talk about that work and what has been achieved?

Jandel: Our work with LiveWell Colorado often makes me think of that Margaret Mead quote: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” This is a program that was started in Kaiser Permanente and in order to scale it, we invited other funders to work with us to take this program to the entire community. The Colorado Health Foundation and The Colorado Department of Public Health and Environment and Kaiser Permanente are the founding funders of the organization.

One essential element of LiveWell programming is that we work with a diverse group of community members to decide on approaches to address the issue of obesity through deployment of healthy eating and active living assets. The outcome of using community based assets to eliminate or reduce obesity is that the community is deeply invested in the results, and we build tremendous capacity in its members.

Loel: A relevant proverb in this case says, “If you want to go fast, go alone. If you want to go far, go together.” In Colorado, Kaiser Permanente wanted to do a place-based initiative. The Colorado Health Foundation wanted to do something similar, and we realized that by combining our forces, we could create much more impact. Now, LiveWell has gone from three communities to 23 communities, some of which have been doing this change work for nearly eight years.

There’s an infrastructure for technical assistance and evaluation that serve all these communities, and there are these state-level policy changes that we’ve been able to generate because all of these communities are creating the public will to have healthy school breakfasts, active transportation, and other things. It’s been powerful.

HP: When you spoke of lowering barriers to food assistance and now with the work with LiveWell, you are addressing policy and systems change that address health behaviors. Why is that so important?

Loel: Policy has a huge influence on the choices people have. It influences their opportunities, and the biggest way we can impact people’s health right now is to create a policy and environmental changes that help make the healthy choice the easy choice. Whether we’re talking about policies and practices about smoking in the workplace, or we’re talking about school lunches and access to PE, or people’s ability to access food stamps, the decisions that elected officials make and the private policies that organizations adopt have such a huge impact on health.

Jandel: We need to recognize that there are no silver bullets available to solve these deeply rooted health and social issues. Addressing these will require multi-pronged approaches. Simply providing food for those who are food insecure may not solve the long-term problem, which is the reason that people don’t have food in the first place. It’s a really interesting choreography of many actions that hopefully begin to affect change on a large scale.

HP: This is the Center for Total Health blog and I know Total Health is central to what drives each of you. How does the concept of Total Health influence your work?

Loel: The way I often think about Total Health is that it requires us to identify and act on the levers of health that exist both inside and outside the walls of Kaiser Permanente. We are focusing on not only what we do as a delivery system, but also what we can influence outside our clinic walls – where our members spend most of their time. To the extent that we can, we work with community partners to address violence and access to healthy food; leverage our workforce to volunteer in schools; and our clinicians to advocate for healthy school lunches. That’s seizing the levers of health. Doing that is necessary to improve the health of the populations we serve.

Jandel: Total Health embraces the notion that Kaiser Permanente plays many of the positions that are important in addressing health. In addition to the care delivery system, we influence many of the upstream inputs related to health and wellness that solve longer-term problems. It differentiates us. If we continue this work, I think we’re unstoppable.

HP: Thank you both for your time.