Funding Health, Wellness, & Disease Prevention

good morning everyone my name is Shira Erte and I'm the program manager for member education at the Jewish funders Network thank you so much for joining this important webinar funding health wellness and disease prevention I'm so pleased that we'll be joined by two scholars today jfn member dr. Norbert Oldfield and dr. Kate Lorig dr. Gould field deeply cares about health and healing issues and has been part of a small group of GFI members who want to start a peer network of funders who care about these issues many of them are on the call today he's the founder and executive director of healing across the divides a thirteen year old organization focusing on peace building throughout health in the palate the israeli-palestinian conflict healing across the device accomplishes its objective by seeking to improve health through community-based locally driven interventions aimed at marginalised Israelis and Palestinians he also works as the medical director for private health care research group developing tools linking payment for healthcare services to improve quality of care outcomes he's a board certified internist practicing at the community health center and edits a peer reviewed medical journal the Journal of ambulatory care management and has published more than 50 books and articles dr. Kate Lorig is professor emeritus Stanford University School of Medicine and is the developer of a number of community-based health promotion disease prevention programs for seniors and others she also serves as a spiritual care volunteer with the Jewish Stanford chaplaincy service first we're going to hear from dr. Laura lorig and she will define the terms associated with this field and give an overview of health and wellness as it relates to philanthropy and then Norbert will pose questions to Kate and we'll end with Q&A from everybody so I'd like to turn it over to Kate now good morning can we please have the first slide and the third slide yeah thank you I'm delighted to be with you all and since I don't know you the first part of this slide may be over simplistic and it may be new information it's just a little bit of an overview of what the burden is around the world and I can frankly my Centers for Disease Control but for the first part of the slides in this presentation so it used to be at least when I was growing up at first during international work that hunger and infectious diseases were the major killers in the world today this is not really true today although these data of the United States this is pretty true around the world that non-communication czar chronic conditions such as diabetes cancer respiratory diseases actually count account for two-thirds of the world's deaths today so our big problems have really changed a great deal over the last 50 years can we see the next slide please not only that but these these diseases are incredibly costly we know that in the United States if you're older than about 50 that your average number of chronic conditions is 2.2 chronic conditions so about a 50% of all US adults have chronic conditions and by the time you get to be 60 years old probably 70 to 80 percent of US population has chronic conditions ninety-three percent of all Medicare costs go for chronic conditions so not only are these a burden to individuals a huge burden to society because people live with these conditions for many many years the next slide please now there's a great deal that can be done to prolong the time of health and shorten the time of illness Jim Freeze called this the compression of morbidity or the compression of chronic illness we cannot totally prevent all chronic diseases I wish we could sometimes we kind of make over promise what we can do but we can certainly prolong the times of health and shorten the times of illness however all of these efforts and health promotion at the present time are only receiving about 3% of the total US health spending and it's probably about the same as that worldwide so we're not actually putting much money into this whole area of health promotion disease prevention and by the way this includes not only preventing the diseases but helping people live more healthfully with the diseases once they have them we'll talk about that a little bit later next slide please and you would think given that that may be people in the US government would be more interested in this whole area in fact if you look at the budget which we don't have for the coming year the proposed budget is actually cutting the amount of money that is going to this field it is not expanding it so we have in some a problem an expensive problem expensive problem it's not getting much attention and seems to be going to be getting less attention than we have now can we continue please so when we talk about chronic diseases we actually talk about and we talk about prevention we actually talk about three areas we talk about preventing the disease and that's why we eat healthfully and we get enough sleep and we do exercise we talk about early detection mammograms colonoscopies these sorts of things and mitigation mitigation has to do with helping people live better lift fuller lives when they do have chronic illnesses and optimizing the quality of life and reducing the demands on the healthcare system another way of talking about these in public health terms is primary preventing secondary detecting and tertiary mitigating prevention primary secondary and tertiary prevention you'll sometimes hear these terms and next please so when we're talking about these these terms one of the things that we want is we want cost-effective programs and cost-effective programs there's going to be including the ones I'm going to talk about in a minute this is the diabetes prevention program these programs address key problems such as heart disease diabetes etc they help develop life-size interventions over periods ranging from weeks and months and they usually have standardized protocols that are then custom tailored to specific communities we have a number of these programs we have lots of these programs some of them we actually know or effective some of them we just think they're effective and next please I'm going to talk about one of those programs today the chronic disease self-management program these pictures are peach pictures of participants all over the world of the Caribbean Canada India China the United States you can and we could add many more countries but I didn't want to show you pictures all day and let's talk a little bit about this program the next slide please so why should we care about chronic disease self-management we've always said that a huge number of people around the world have chronic diseases they're living with these diseases day in and day out and what these people do is they only spend about 1% or even less than 1% of their time within the healthcare system the rest of the time they're walking around in the community living their daily lives and how they live their daily lives during this time greatly affects their quality of life and also the use of the healthcare system unfortunately until very recently we've had very little in the way of formalized programs to help people learn with chronic diseases how to live their lives on a day to day basis the next slide please so the program that we developed at Stanford years ago and which is still being used around the world the chronic disease self-management program is its small groups of 10 to 16 people there are people with many different diseases and comorbidities in the same group and why can you do that you can do that because about 80% of the things that people need to do to manage product is illnesses are the same across illnesses it also allows people that would never get any chronic disease self-management to get these programs I have one of the Jewish hereditary diseases I have Gaucher disease there are less than 2,000 of us I can promise you that nobody is going to ever put together a program in chronic disease self-management of food O'Shea's disease and by putting people like me or people with cystic fibrosis or people with silk cell disease or people with colitis or people with people with diabetes and heart disease it means that we can reach all people with chronic illnesses plus which most of us have more than one chronic illness we have two or three and this means that we don't have to go to a heart disease prevention heart disease class one week and a lung class the next week in a diabetes class the next week we can basically get the basic content all together in one class the courses are two and a half hours a week for six weeks and they're facilitated by peers what do I mean by P I mean people from their own communities so if I'm in an african-american community the peers are probably going to be african-american if I'm at the Jewish Community Center the peers are probably going to be older Jews if I'm at the Stanford campus they're quite probably going to be the facilitators are probably going to be a retired faculty and staff from Stanford that's what I mean by peers next slide please what do we teach we teach managing symptoms because what people care about most your symptoms pain fatigue depression shortness of breath disability not being able to do the things we want to do we teach exercise and we help people tailor that exercise to their own conditions so exercise for some people may be a minute an hour while your weights and for other people it may be walking 10 minutes twice a day and for other people it may be a walking a mile or two a day we teach a variety of relaxation techniques we teach basic healthy eating communication skills communication with family and friends communication with the healthcare system and communication with healthcare professionals and those by the way are different sorts of things and different skills we talk about medication management not medications because we certainly couldn't talk about the medications of all people to come to our programs but we do talk about how do you manage your medications how do you remember to take them what is it that medications can do many people think that medications make you better well many medications do make you better but in chronic disease many medications also help you get worse more slowly that's a new concept to many people and finally we teach three very basic skills to self-management problem-solving how do you solve problems we teach a very formalized way to do this action planning how do you make a commitment each week and follow through on it and finally decision-making all of us have many decisions and what decision-making does is helps us make better and stronger decisions so these are the things that are taught over six weeks and now let's see the next slide please I'm going to show you one study there are probably at this point more than 40 studies about this program this was a study that was done about four or five years ago in 22 sites all across the United States the training while leaders in the program delivery was done at all the sites the sites went all the way from Maine to Southern California to Illinois Denver Ohio New Jersey Florida Texas we had more than a thousand participants 40% of those in this study were underserved minority populations and we were focused sitting on the outcomes being in the areas of the triple aims of self health care triple aims are better care for people better outcomes and lower costs in the next slide please at one year what did we see we saw that people had less depression depression is by the way one of the most common symptoms across chronic illnesses we know that about 30% of people with any chronic illness are actually clinically depressed they may not know they're clinically depressed but when we give them standardized tests we can see this and depression drives a great deal of the ank's and the problems of chronic disease people have less pain they were doing more exercise they were better they were better adhering to their medications they were taking them on time as they were supposed to they had fewer unhealthy mental health days and fewer unhealthy physical days they had less healthcare utilization and savings per individual by taking this program was about 350 dollars per person I might mention that we now have four or five cost effectiveness studies all of these studies show that the saving some less utilization is around this same thing you're around three hundred and fifty dollars per person and the next slide please so in ending because I really wanted to have lots and lots of time for you to ask questions here's some questions that I thought as a funder have to admit I've never been a funder but I certainly SAP on review committees the questions that you might ask is people come to you approaching for programs number one is there a need almost always there's a need but then the next question is is this a local need and if it is and you want to fund locally that's terrific maybe you don't have to do anything more than locally or is this a broader need and does whatever your funding have to do have effects on a broader audience excuse me I have a cold today number two is the intervention evidence-based and this is becoming more and more important not only here but I'm doing work with the World Health Organization and it's also very important for them an evidence-based program means that the program has been published somewhere usually and was usually conducted a randomized trial it was published in a peer-reviewed journal usually by a randomized trial usually more than one publication second are there tools for dissemination we have many many wonderful health promotion disease prevention programs they seem to be really really effective but in fact of nobody can do them except the people to put them together there's no manuals there's no way of doing this there's no training so for folks in mentioned to be evidence-based there must be tools for a dissemination these include training manuals administrative manuals and fidelity manuals other standards by which you can judge is this program being done the way it was originally intended oh is it not I should mention that in the United States there is the evidence-based Leadership Council and this council has been working very hard to see that evidence-based programs get to adults and especially senior citizens if you want to know more about it just look up evidence-based Leadership Council on the web and by the way you can also find a program map there and you will find programs that are evidence-based in your geographic area and the final question that I'd probably ask as a funder is are these efforts being coordinated with other efforts or are they a standalone effort that doesn't impact other organizations other systems I think as we're doing this more and more we're working more and more to see that there are systems and coordinated efforts across the world across the country as I said I'm working both with w-h-o now and with a number of organizations in the United States to set up networks of these programs to make them available as widely as possible I think that I have probably reached the end of my slides unless I'm wrong is that correct yes so I think we're at a point that I think Norbit might have some questions for me and then you can be thinking of questions you have for me and we'll have plenty of time to do both okay I want to thank you very much it's really a pleasure and in fact it's an honor to to be part of this effort that jfn is leading I would just make two or three very brief introductory comments then ask a couple questions and hopefully that'll stimulate a whole bunch of other questions as I've indicated to my colleagues at Jaffa and decayed everything that we do at healing cross the divides is informed by the fact that I'm Jewish and that's my primary identity we fund ten different initiatives in both Israel and the West Bank and in fact we have implemented catalogs work the chronic disease self-management program primarily because it's not just evidence base which is absolutely critical for people like myself but in addition there's a manual been translated and validated in Arabic and so there's a potential for it to be carried forward and over a thousand individuals with diabetes osteoarthritis and hypertension you know are participating in this in a variety of different villages between Ramallah and Nablus we're doing other interventions working with Israeli community based groups on one that's in that starting right now in karmiel and that's working with Israeli marginalised Jews and another one in eurocom and this other negative that is working on issues pertaining to healthy eating so I think the points you know that last slide bye-bye Kate really highlights the importance of evidence-based that there's you know a possibility of replicability because as Kate said there's many different ways and many different tools that have been developed that are completely reliant on the on the developer so with that in his background I'd like to just start off with a couple questions and again like I said hopefully there'll be lots of other questions we have plenty of time for questions so why don't we start out Kate considering that the GFN is very well established in the United States expect that what is the current climate in the United States around the integration of lifestyle based interventions as a means of dealing with chronic conditions such as multiple sclerosis and other conditions that are chronic I think the climate is very good good I think that we have a network of community organizations that are working together that has grown over the last many years we don't have time to really talk about it all now but this initiative was actually started by Lancet Atlantic Philanthropies about ten years ago so philanthropies had a very very important role in this ah well I say this assignment is good and the need is there the major problem today is funding as I say the federal funding is diminishing the entire federal budget for community-based chronic disease programs for older people is twelve million dollars not much money an entire nation so it means that if these programs are to exist because even if they went by volunteers at some level they need staff they need for nation they need oversight it means that funding is going to have to come from other places and right now we have a hodgepodge of funding nationally although networks are beginning to be a forum so climate is good funding clean not so good thank you my next question is then I'll make a brief comment before you respond is as follows to what extent have different stakeholders this question applies throughout the world and certainly includes Israeli participants not just American participants and you anybody from the UK etc to what extent have different stakeholders health Nationals policymakers insurance companies medical researchers etc mainstream lifestyle based interventions for individuals with either chronic conditions or people who are well before you answer the question I just want to comment from a healing cross the divides perspective that our grants our three-year grants we presume that we as a funder that we're going to take a risk on issues that may not be completely well-established but by the second year of the third year of the three-year grant we demand and ask and require that the community-based group develop a plan by which they start involving stakeholders so again my question is to what extent okay to have different stakeholders mainstream these interventions um it's very interesting it seems to change over time and stakeholders seem to come and go and then come again today we have at least two countries of national programs Ireland in Denmark we have the English National Health Service which was a stakeholder for whatever reason decided just to to the spin off its programmes to a not-for-profit company and strangely enough is looking at becoming a stakeholder again now so it's it's a little unclear what's happening in England actually it's clearer but I won't go into the details the World Health Organization especially for Latin America has been a major stakeholder with programs growing in many countries in Latin America at this point in this country the National Council on Aging has been a technical Resource Center for many years and kind of the go-to point not so much for funding but for knowledge about these probes about programs but as I say the stakeholders changed there are indeed some third-party payers and insured as I know Tess helps plan in your state Norbert isn't involved with this and some others but but they come and go and we the first time we'll have a survey of stakeholders which was just done by the National Association of the area Agencies on Aging I've not seen that yet but we'll have a better idea of exactly who the stakeholders are in this country once that is published thank you and another way of asking for questions is I've been to several of the jfn annual meetings I co-chaired the healthcare track of the first effort the first year and annual media was in Israel and I've never met to my knowledge any jfn member was shy so I would like to encourage you all to start either writing questions or emailing them to Shira I don't see any questions just yet but I'm now going to go to my third question and then after Kate's answer I might make a comment how can funders move the needle locally and or globally around the adoption of different lifestyle practices pertain to exercise diet mindfulness some of the issues that Kate brought up as a way to promote their health and wellness I think they can do a couple of different things I think the first thing I would do as a community fan or a national scan and see what's what what's out there already and what's an interest to you I'm not saying that the definitive programs are there already but I see all too often funders creating kind of wonderful new initiatives go on for a couple of years then go away because they really had no infrastructure or movement into the mainstream and there's all kinds of spaces out there were thunders could make a real difference by taking a small piece of something and saying this is what we want to do or we want to move this program to this population you certainly did that there was no way that anybody else in the world that I know of at this time could have seen that the program would have moved to Palestine that our program would have moved to Palestine and hopefully very soon to Israel actually isn't is real I shouldn't say that there's a very small very small necklace of the program in Israel at this point so it's taking that scan and I think that's the way they can most be involved um and then they mindfully deciding where is it that fits our Jewish values our foundations values to be involved whether it's locally globally or somewhere in between so good sense actually interesting so that's why I'm glad I came after you because in many ways that was exactly the calm that was going to say but just to put it differently within an Israeli context we're not interested in in programs and I'll give the example of either translation services for Ethiopian Jews or music therapy where the evidence is clear one way or another so we want to take a risk where the evidence is is clear but there may be a reluctance for any number of reasons for for something – or an effort such as ronzi self-management or an effort to decrease childhood accidents at home that word that we're beginning with so so I think the issue of looking at the evidence is very important the issue of looking at the scan is absolutely critical and if there's simply no acceptance of something it's evidence-based I think that there has to be some serious questioning as to you know you know what what is our role and so that's part of the way we as a funder look at these issues to try to make an assessment is there a possibility that this might work and if it can work locally then is there a chance and that's what we do in the second year of the third year grant to to try to encourage stakeholders and several of our efforts have been taken over nationally either by the private health insurance and or the government and so that's that's exactly right as far as I'm concerned as to how to look at the needle local ease is really doing a community scan of what's available I have one more question and then I'm hoping that there'll be questions that we can turn to and this is on some level I want to thank the people at jfn my colleague Shira and Samantha and others at jfn for putting forward the basis of this question because even though it may seem like a strange question it's absolutely a critical question as far as I know the question is as follows even though it may be counterintuitive do pharmaceutical device manufacturers and other companies whose Ernie is derived from healthcare encounters have a role in transforming the thinking around the use of lifestyle based interventions if yes how can it be advanced if no how can they still be engaged you probably asked the right person because this is kind of a double-edged sword today in the United States probably the organizations with the most money for health promotion disease prevention a pharmaceutical company uh the use of that money is almost always tied to a product or a drug or advertising of some sort many healthcare organizations are more and more wary of accepting this money having said that one of the things that's happening in the United States is and many healthcare organizations are now forming their own foundations and maybe they've always had them I'm not sure these foundations have been very helpful in giving monies to determine mod questions I'm thinking specifically of a very large diabetes initiative that was run around the world by one of by one of the pharmaceutical foundations we recently have completed a study with another pharmaceutical foundation that included ourselves a major insurer and the pharmaceutical organization and the National Council on Aging so that I think that there really is a place for pharmaceutical and I'm from a pharmaceutical but this is also true of health care organizations most of the major third party insurers Aetna Kaiser etcetera have their own foundations so I think there's definitely a role that role has never been as far as I can see consolidated around a singular effort or civil efforts it's always been kind of what this foundation wants to do today or that but I think that there's real potential there and I'm not seeing links between pharmaceutical or other industry foundations and philanthropy but again I think there's a role for that to happen so as somebody who works in the private sector you know I would agree wholeheartedly but with the caveat as you've as you've outlined the reality is is that the private sector a pharmaceutical company or whatever device manufacturer you know expects something in return and I think as long as there's transparency then it you know the it can go forward in a positive way the reality is I mean just to make it simple those type of entities are the ones that have the funds you know the prevention organizations you know have you as you very well outlined at the very beginning of this conversation don't have the funds still hoping for some questions there's a number there's quite a few participants that are signed on but we're hoping I'm hoping for some questions I guess I have my own thoughts about this Kate do you have any sense Kate in particular with respect to insurance companies the reality is you know chronic disease self-management of of any strike is very hard to to engage with insurance companies and similarly as somebody as was kindly stated by sure at the very beginning of this that I'm a clinician I'm an internist I see patients two days a week you know I'm just I'm all so many ways baffled by the reluctance and it's it's definitely present in my practice on the part of medical professionals to chronic disease self-management of any sort so I'm just wondering if we could just sort of focus son what you think might be some approaches that might be worthwhile you know particularly with respect to insurance companies or pota in Israel or the National Health Service and the medical profession in general before I do that I just want to tell people whoops how to how to ask questions if you go to the very bottom of your screen in the black bar if you kind of swivel along that you'll see a thing called chat if you click on it then you'll see a chat box and you'll be able to type a message there so that will get it I not sure that we actually talked about how it was the jazz question so that's how you do it fine and find the chat box at the bottom of your screen write in something and so we're here to answer them so let's talk about why health professions and insurers and managing chronic illness or health promotion in general quite frankly health professionals do not have the time to do self-management we have 14 and a half hours to teach something a practitioner has maybe if they're lucky 15 minutes with a patient if it's a brand-new patient maybe 40 minutes they're seeing so many people in a day that other than give maybe one single message it's very very difficult for them to do much in the whole area of health promotion disease prevention and I think for us to feel that this is a burden that should be on the health professionals is an unfair burden to put on this secondly they are probably not well educated to do this behavioral science is a different science than medical science most physicians don't have much behavioral science or health behavior science in their backgrounds and that's true by the way of nurses and physical therapists than everyone else so while we talk about this thing of everyone in fact no one does it within Health Professions very well and so if we're going to really have this as a keystone of care we're going to have to build a system for doing it I happen to feel the community agencies and I've never found the community that doesn't have community agencies are in a very good position to do this why is that because people live in communities they don't live in health care systems and they're much more comfortable going to their local library their local bank their local church their local synagogue to take a program than they are to go to a health facility which is not usually terribly patient family so um I think the role of the Health Professions are to set up a referral system and encouragement system we're seeing a number of these happening in your own state in Massachusetts right now it's probably the most advanced state maybe in the country if not the world as far as getting people into programs and referral systems the state of Massachusetts can now guarantee a program to anyone in the state within about three or four weeks usually within a couple of weeks of referral and we'll working on that in different states and it's a it's a it's a systems problem between health care systems and community organizations ensures have been slow to fund these programs and they've been slow to fund this because basically ensures fund based on what employers want and with a few exceptions employers don't even know about the programs and so they don't know enough to even ask for them as part of their insurance package again we have an example of a difference here with unite here one of the unions in this country that serves from tell workers service workers and unite here actually went to their insurers and say if you want our insurance because you know here insures some workers as a union you'll do this programs and so unite here has been doing these programs in union halls in Los Angeles and in other areas so we do have some examples of that but and I say but insurance companies per se have been a little hesitant to do these mainly because they don't get the benefits this huge amount of churn people change their insurance companies all the time and so if they find somebody to go and take the program and they take a program and they utilize less by the time they utilizing less they're probably insured by somebody else um hopefully that will change I think there's some discussion about changes but has not happened yet two brief comments on that the small for my Israeli colleagues on the phone I like the idea very much of the community agencies I'm sure all my Israeli colleagues are familiar with the mut Nasim and we actually funded an effort to increase some amah grafite among Orthodox Jewish women using community health attacks Jewish community health workers women but within a might not seem framework so I think community agencies are absolutely very helpful I myself as I indicated I helped implement some of Kate's work also and actually do it locally for fun in Massachusetts where I live and became a master trainer but again the community agency idea is actually a very very good idea the with respect to the insurance companies I think the I think that that's an important issue I do believe that employers have to push it and in the absence of employers and I guess is my last comment before I go to the first question my last comment is that I have to believe and I have to hope because that's why I am both as a Jew and as a health professional is that people can make a difference and individual consumers can make a difference and I think there's a greater demand for this for this type of work that that those of you who are on the call are are interested in so within that framework let me ask the first question here to your cave considering chronic disease is a global problem and you please elaborate on the position of the NA the National Health Service in the UK that you mentioned previously sure I'd be happy to I wish I knew what it was but I can tell you a little bit of history the National Health Service number of years ran the program ran our programs internal to the National Health Service and they reached a fairly large number of people there are a number of studies that have been done a randomized trial will cost effectiveness study an online study and I can supply you with any of these about 10 years ago now or so the National Health Service spun off those programs to a oh I think they're called a special interest company but I'm not sure that's the exact right name and that company and and also gave the company money to run the programs I think that company actually still exists I'm not sure about them but in effect after a few years they stopped giving the programs the programs continued and today there's an organization and I'd be happy to put you in touch with it it's a fine organization called talking health in England talking health is in the business of contracting and helping to contract with local trusts to offer the programs because right now a lot a lot of the money in England is flowing through local government organisations not easy to the federal organizations that goes from the federal to the local and then contracting out for these services and I am certainly not an expert on England but I'm very happy to put you in touch with the people that are there very good people I also know that there's a slightly different scheme where the government is more involved in Wales and for those of you that want to get a hold of me it's very easy I'm just lorig lor IG at Stanford as in the university that edu will definitely be sending all that information out for short though all the participants actually I was in England last week and I met with a a colleague and I just want to echo one point that you said with respect to training and education I was with a colleague is the chairman of community medicine and one of the major universities in England and again the the point that you state kate is absolutely true the issue in part is issue of lack of training and what I'm again hopeful is that the consumer push that can be facilitated by foundations and that's certainly part of our role and healing across advise is to try to encourage and that's what we fund community-based groups and in part is to encourage that that consumer interest the other thing that I want to highlight is that I do believe that there has to be financial incentives for this type of effort and the last thing we want to do is have financial disincentives you know by charging money for these type of efforts and and so I think that it's absolutely important the financial incentives goes both ways that we should have financial incentives frankly that reward health professionals and I see there's another question and I'll go to it in a second that reward health professionals – emphasizing this type of chronic disease self-management doesn't have to be done by health professionals you know we work in large groups you know I work in a large Medical Group which has a lot of health professionals but there is a colleague who has a question and and I'm hoping that he or she will enunciate it – stated yes hi Norbert and Kate thank you so much this is Shira Jeff and this has been really a fabulous conversation so far my question is what can we tell funders that aren't yet engaged in this universe what can we tell them so they become engaged how do we convey to them that this is really a universal need and now is the moment to get to get involved okay I'm trying to think about how I think that you can show people the statistics like I showed you this morning I think the other way to do this is Society and I do this very often in a room full of people how many people in this room have a chronic condition or know somebody with a chronic condition every hand goes up how many people does this chronic condition impact their quality of life where you know somebody every hand goes up this is kind of a secret I walk through life and if you saw me and you can't clean you this morning because I don't have a camera on my computer but it's not about pretty normal you know there's nothing terribly one way or another about me and I required 12 hours of sleep a day and I always have this really compromises much my life when I travel the first thing I tell people is I will do anything you want between about 8:30 in the morning and 8:30 at night I do not do anything after 8:30 at night which is really very difficult because a lot and a lot of country socializing takes place at that time and if you really want me to do something after 8:30 at night then you have to see that I don't do anything until 10:00 or 11:00 the next day because I have to manage my life if I'm going to function and most people to chronic illness in one way or another have to do something similar and it's not something you can see sometimes sometimes it's the non hidden chronic illnesses that you know we see people with multiple sclerosis we see people in wheelchairs we see people that are blind but we don't see the day-to-day struggle and symptoms that most people have and I think the way you interest people in them is you make it personal because it's very not harder to make something global until it's personal I would agree with that and I would just say that the stories really are a thousand words because at the end of the day the reality is this type of work is not one where you get to put your name you know on a building this is the type of work that occurs in people's homes and community centers you know on the street but I think the stories the absolutely dramatic stories of people doing much better either with a chronic illness or as is you know tomorrow I'll be with patients all day I work with any number of my patients to try to prevent the diabetes from happening where they're at they're pre-diabetic stage that doesn't get any kudos I can tell you right now but believe me we can prevent the diabetes from happening we can prevent the complications of diabetes any of the other chronic illnesses that not only makes a dramatic difference in the lives of these individuals but just as importantly is it really saves money and these days with the dramatic explosion and healthcare costs which in part are driven by the wonderful good things that you know that pharmaceutical companies are coming up with we need to try to be aware of this so that's how I look at it thanks for the question it's a very good question other questions there's nothing stated that we have to do this till 1250 or 11:59 no absolutely not no if there aren't any other questions we can certainly wrap up a little bit early please you know I will circulate Norbert's information kate's information to everybody who participated in the call this morning I'm sure they would just like Kate said be willing to help in any way they can thank you so much to both of you there's there's actually one question that just came in oh okay great and this is a great question to end that actually so I appreciate this question in your experience how many people both funders and health professionals are interested in this space so why don't you go Kate and then I'll take a whack at it okay well we know let's let's talk about people with chronic illness first one thing she knows where we can study that is in any one point in time 25 percent of Medicare participants are interested that doesn't mean over the entire lifetime because it may be 50 100 percent over lifetime but at any one point in time 25 percent are interested health professionals are interested but don't have the time I think is widespread interest I have never heard opposition from health professionals of any kind they just don't have the time so I don't think there's a problem with health professionals funders funders have a hard time getting their hands around this field and why because it's not a building it's not bricks and mortar it's not a classroom of happy children it's um it tends to be older people it tends to be people that aren't quite so photogenic it tends to be sequence that we all carry around with us that we don't want to discuss so much and so there are some major funders that have been really interested in this space probably in this country the biggest funder has been Robert Wood Johnson Atlantic Philanthropies as I said was certainly interested in this space efficiently been a number of smaller are shown in California has always been interested in this space and I'm sure there's a number of others but it's a little bit harder it's as far as I know it's not in a space that is traditionally been funded by Jewish funders I know that Jewish funders do give a give some money to chaplaincy services which is very thankful because chaplaincy services are kind of another piece of this which we have discussed today which we'd be happy to discuss at some other point because there are Jewish chaplaincy services throughout the country but I don't think this has been a traditional space for Jewish funders as far as I know or at least I haven't been aware of it and I would hope it would become a broader space for them my response and I think everything you said is true my coupons very quickly in just a few seconds is that I think it's it's the responsibility frankly a funders like healing cross divides and other funders probably Johnson obviously being much much larger you really try to figure out how health professionals and the broader public as expressed in funders can combine their interests in chronic diseases in terms of viewers and realize frankly that health chronic disease self broadly defined is absolutely a front and center on this so I want to thank jfn for myself on behalf of healing across the divides for we're setting this up we are actually at the close of the hour and I'll hand its back I want to thank of course Kate who I've known for years and applauded all her work and now what I hand this back to my colleague is a jfn thank you thank you so much again I'll just say stay tuned everyone we really hope that this will be just the beginning of conversations around this issue and feel free to follow up with me if you have specific questions or ideas about how you'd like to see us further explore this space so thanks so much everyone have a great day thank you Norbert and Kate very very much thank you

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