National Jewish Health: Caring for Respiratory Health & Your Community

Good afternoon and welcome and thank you all for joining us at our community health benefits discussion.

If you just a few housekeeping details at the front, your microphone is muted to just keep the noise down.

You can type your questions in the Q&A box that you may see at the bottom of your screen.

And I just want to let you know that the session is being recorded and it will be made available for those who couldn't attend or want to look at it again beginning the 1st of July.

Today we have a number of really excellent speakers for you to go through this report.

Dr. Michael Salem is our president and CEO.

Chris Forkner over here to my left is our executive vice president of corporate affairs.

And then across the table for me, we have Steve Frankel, who's our executive vice president for clinical affairs, and Kerry Horne, who is our chief medical officer.

And we'll go through this agenda that you see on your screen and with that I'll turn it over to Dr. Salem.

Thank you Lauren and thank you all for attending this important session where we get to, you know, talk a little bit with great pride about national Jewish health and what we've been able to achieve in partnership with the Colorado community for over 123 years.

You take a look at this set of photos, which are very important to us, and tell you a little bit about really a summary of what you need to know about why national Jewish has developed the collegial collaborative nature and partnership with the community that you all have seen for many years.

So national Jewish health opened in 1899, and board of directors make various decisions. And what the board said for national Jewish health was that they were going to be a completely free hospital.

And the only patients that could be admitted to the hospital were those that were homeless.

And for us, we were taking care of what at the time was the last respiratory pandemic for which there were no cures, and those were tuberculosis patients. So if you look in the upper right hand corner of this particular photo, you see one of our buildings with our motto on it. And at the time it was none may enter who can pay, none can pay who enter. So national Jewish is national Jewish health.

Its charitable mission is something that has been inculcated in the institution from the beginning of its foundings, humble beginnings back in 1899.

In fact, the first hospital building was built in 1892, but they had no money, so the hospital didn't open until 1899.

The second thing you want to know about national Jewish health is that it had to be a very innovative place.

In other words, if you are taking on a respiratory pandemic for which there were no cures. At the time, there were no antibiotics either.

Antibiotics for tuberculosis weren't really starting to be used until 1950. So if you look at the other series of pictures on the right hand side of the slide, you'll see what they had on campus was a dairy, they had nutrition for the kids, and in the lower right hand corner, they were doing very novel things like taking out parts of people's lungs for tuberculosis and doing other things.

So a charitable mission for the institution and an innovative institution were very important parts of what went on. In the lower left hand corner, you see a building that was from 1915.

And that was the first research building because you had to do research if you were going to try to find out some treatments for untreatable diseases.

And so that research building was the first research building built in 1915 outside of a university campus built in the United States.

So really the three things that you want to know about National Jewish Health, which sets up how we perform today, are that we're headed to have a charitable mission, we're an innovative place and research and care are very important and central to what we do.

And there have been a lot of scientific breakthroughs that have occurred at National Jewish Health.

And all of those are essential to helping our community.

And it's something that we invest heavily in in National Jewish Health.

And these are just a few of the scientific discoveries that have been made here through the many years of our history.

So for those of you that suffered from allergies, the molecule responsible for that, which tends to get made in increasing amount or activated by certain allergens, was discovered at National Jewish Health.

We did a lot of work early on for antibiotics for tuberculosis and other diseases.

Part of what you've heard so much about over the last couple of years with respect to this now respiratory pandemic, for which there are no cures, is what is our immune system do?

Well, part of our immune system and our own bodies, which is made up of a number of components, are T cells and B cells and other components.

The receptors, which recognizes what is our cell versus what is a bacteria, what is a virus that was discovered here at National Jewish Health.

We have done a lot of work in terms of how our body fights off cancerous tumors.

And we do a lot of work with respect to asthma and COPD or emphysema, where we're in the 10th year now of leading many other institutions around the country to study those patients over time.

We have also done multiple diagnostic platforms in order to diagnose the COVID virus and many clinical trials related to that, and you'll hear more about that.

And so I just wanted to give you a flavor of how important research is for this institution and for what it does for both the Colorado community and for people around the world.

So where does National Jewish Health stand today?

For as long as they've been doing a U.S. News and World Report rankings, National Jewish Health is really the top respiratory hospital in our nation.

We have been open for over 123 years now, and our main focus, and you'll see we have a number of other foci has been as it relates to being the top respiratory hospital in the nation.

And unfortunately, 123 years later, we now have another respiratory pandemic for which there have no cures yet, but the massive effort of our physicians, our scientists, all of our employees here at National Jewish Health to help the community during this time is going to be outlined by Dr. Frankel, but it's obviously been a massive effort.

We get very high scores from patients relative to the care that they receive at National Jewish Health, and we're fortunate in that we gain a lot of funding for the science and the research that is done here and for a relatively small institution.

We're in the top 6% of those institutions that perform research.

So that's where National Jewish Health stands today.

We are rooted in the Colorado community, but we are a national organization in that about 30% of our patient revenues, and you recall that National Jewish never charged a patient for the first 70 years of our existence, come from outside of Colorado.

So the vast majority of our patients are from in-state, but we do have a broad referral base from around the country and really around the world who have seen multiple physicians and have really challenging problems, whether it be them, children or adults, and National Jewish Health reaches out and those patients come here to Colorado to be cared for.

We are a very mission-driven organization, right?

I've talked to you about the discoveries we do, the education that we do, and it's also a preeminent healthcare institution. We provide integrated and innovative care for patients and their families. We couldn't be a place that was founded in a pandemic for which there were no cures where one doc wasn't talking to the other one, and that's something that we have absolutely continued to do.

Our vision is to really strengthen our role continuously as the leader in respiratory, cardiovascular and immune-related diseases, and we have built here precision medicine programs that embrace sort of the shift from being more reactive medicine to being more proactive and to have preventive healthcare delivery, and we have done everything we can to help patients in Colorado as well as worldwide. So we have a number of specialty areas of care, both in children and adults. We're not just a respiratory shop, though we do have more pulmonary physicians in any place on the planet, but we also have very large programs in asthma and allergy and sleep-related disorders, rheumatology and the whole immune system.

We have a very large cardiology group because, you know, the heart is close to the lungs and many of the patients that come here are short of breath and they might have been told by their cardiologist that it was their lungs or by their pulmonologist that it was their heart, and so bringing that together is very important. We have a large gastroenterology group. Cancer care is very important here. We take care a lot of the sickest patients in critical care, intensive care units, which you may have heard of so much in the last several years by our physicians managing hospitals every night, five different hospitals on the front range in Colorado, and then electronically through tele-ICU in five states every night in collaboration with the Banner Health System, and we have the largest adult cystic fibrosis program in the country. We have similar programs for children and allergy and asthma and atopic dermatitis. We do a lot of behavioral health services, particularly as it relates to sleep and child psychiatry consultation, a very big food allergy program, which is something that National Jewish has been known for for a very long time in addition to immune deficiency and exercise tolerance and neuropsychology services, so we have a lot of those psychosocial and other severe asthma programs for children as well as adults through our National Jewish Health for Kids programs.

We have a number of strong collaborations throughout Colorado and really throughout the country. Our view has been in as many ways as we can elevate respiratory care and research around the country. We've developed strong relationships with St. Joseph Hospital and now the Intermountain Health Care Group. We've had a long-time academic research and other relationship with Colorado University School of Medicine, and we've developed now over the last five to seven years a number of collaborative respiratory institutes in the country, one with the Mount Sinai, the Icahn School of Medicine at Mount Sinai in New York, and also with Jefferson Health in Philadelphia, so we really develop strong partnerships that can advance both research and care and education in all of those areas where we have expertise and something to offer.

So how we serve, obviously from what Dr. Salem referred to, community benefit is something that we live every day and have lived every day for 123 years. So if you look at our numbers, we see 106,000 roughly outpatient visits a year.

We have just under 1,700 staff. We practice at 24 Colorado locations, so for those of you who have been in an ICU throughout the city, you may have encountered our physicians, and we have roughly 100 or 250 faculty members or physicians that practice here. So what is community benefit?

Community benefits are defined as areas where we improve access to health care, we enhance the public health, we advance increased general knowledge, or we relieve or reduce a health burden of government to improve health, and all of those are a focus that we pay a lot of attention to and ensure that we do that every day. From a community benefit by the numbers, so National Jewish has always scheduled based on who calls first, regardless of their insurance or lack thereof. So we don't limit our care to Medicaid clinics. We operate, if you call and you happen to not have insurance, you are scheduled on an equal basis with somebody who calls who is fully insured. But that does come as a cost, and that costs us roughly $10.9 million a year. The difference between our charity care revenues, frequently those are free care, and the cost of providing that service. We spend $3.2 million educating health professionals, so as the number one respiratory hospital in the country, we spend a lot of time educating future health care providers, and that is at a variety of levels. So that ranges from your medical assistance all the way up to physicians seeking specialty training. That costs us roughly $3.2 million a year. We spend about $1.6 million in 2021 on a variety of community outreach and benefit programs, and every manager here and every staff member is committed to our community, and that takes place in a variety of ways. We recycle. One of the first things we did with the pandemic was recycle masks.

We recycle. We do food banks. We have asthma management programs, some of them on Native American reservations and elsewhere. We do black lung clinics. We have a nurse advisory line that's free. If people have a question, they can call, and many more things throughout the community. We actually have one dedicated group of employees that does nothing but focus on our environment and how they can reduce national Jewish's economic or environmental footprint. We have the Mortgage Academy, which is something that we actually fund almost fully.

We get a little bit of state money for it. We do not get any property taxes, and it is our school for K through 8 students who are two grade levels behind in school because they have a chronic illness, and we don't care if it's a chronic illness that we treat. We have specialized nurses and spend a lot of time with very small class sizes with the goal of bringing these students back up to where they need to be, both managing their medical condition as well as actually at the grade level in school so that they can transition back to maybe their homeschools.

We spend 2.7 million on subsidized health services, so that's a whole host of things that we dedicate time to make sure that people can receive the care that they need, whether that is outreach lines, whether that is special programs for indigent patients, whether that is other things within that realm. Our faculty volunteer at some of the clinics around town that cater to the indigent, we really look at how we can best get into the community and make a difference. The other, as Dr. Salem said, biggest investment we make is in research, and it is a research program that we adapt to the needs of our community. We went from everyone else having nothing related to COVID research to quickly shifting so that we could study and hopefully help our immune-compromised patients deal with COVID and help others find, hopefully, what is someday a cure for it. So if you look at our total program, we invested 9.5 million of our unrestricted annual revenue towards these programs to benefit our community. Actually, it's closer to 12%, 12.5%, because some of our unrestricted revenue are very precise research grants that cannot be spent however we wish it to be. And that is netted out in our research net of 14.3 million.

So we are very dedicated to our community. We spend a lot of our bottom line, unlike a lot of health care across the country. We operate on very, very thin margins, and commitment to our community is top of our priority list. So as Dr. Salem introduced a little bit earlier, when the unprecedented global COVID-19 pandemic arrived here in Colorado, National News responded to that very urgent need for care as well as research. So given that it is a respiratory pandemic and we do bring that specialized expertise, we leveraged all of our resources to fight the camp, combat the pandemic in essentially every way that we could.

So early on that was bringing testing online, one of the first institutions west of Mississippi to be able to offer COVID-19 testing. And it continued to grow from there. So you can see in some of the photos down below some of our vaccination efforts. So for those of you that live in the neighborhood, you probably will remember over the winter that the faculty and staff standing out in the cold and in the snow doing drive-through vaccination for our friends, neighbors, community, and our larger Colorado community.

You can see some of the other photos there. There's some vaccination events we did in partnership with the University of Denver. I believe that's in their field house right there.

You can see us using our conference rooms and office space to do vaccines. Again, for anyone that needed a vaccine was welcomed and vaccinated. And then you can see we also did a National Guard unit and really have continued to vaccinate throughout the pandemic, over 60,000 to date. In addition, we offered clinical care for folks throughout the pandemic, essentially at every stage. So here what we're highlighting is our Center for Post-COVID Care and Recovery. And what this really refers to is providing care for those folks that are characterized as long haulers. So for many, many people who get COVID, fortunately it's an acute self-limited illness and they get better and resume their lives. But there are some folks that are less fortunate and have persistent symptoms and sequelae of their illness, whether that's respiratory or neurologic or constitutional or what have you. And those folks do need specialized care and specialized expertise. So we've seen over 2,000 patients in our Center for Post-COVID

Recovery since it opened and continue to provide that care until the present. And then in terms of research and moving the field forward and better understanding the disease and being better able to combat the disease, we have taken a leadership role in research as well.

So national judges participated in key clinical trials, both for therapeutics as well as to better understand the underlying disease as well as ways to utilize and develop novel testing. We've engaged in more than 80 separate studies that are either funded or underway or completed.

And for example, if you're sort of wondering what kind of studies beyond let's say drug trials, one study is looking at coronavirus infections in children's and the family to better understand the role that children play in the pandemic itself.

But again, I mean, the scope of the studies really range from novel testing to therapeutics to transmission to understanding the basic science and pathophysiology behind the disease.

And then another addition of clinical programs was the immediate care. So our faculty have provided critical care for the care of patients with COVID-19 throughout the pandemic here in five major hospitals in Colorado. We actually also send faculty to New York, to California to help those communities when they were overwhelmed as well.

But one thing we did that was kind of a novel offering to our community was to bring on the immediate care clinic. So very early in the pandemic, you may remember people were a little bit reluctant to go to emergency rooms that were afraid to seek care in emergency rooms or the emergency room would be overwhelmed. And so we opened up a seven day a week acute respiratory clinic where we would see patients that maybe were pretty sick, but maybe didn't quite need emergency care that needed to get evaluated for signs and symptoms that may or may not be COVID-19.

This was so well received. And the members of our community were so happy to have availability to the national Jewish expertise after kind of normal clinic hours and on the weekends that we made that permanent and also extended that which our immediate care folks could see.

So that's now staffed by emergency medicine physicians. And we now see a full spectrum of acute and urgent problems seven days a week. So not only things necessarily related to COVID or respiratory, but really the full scope of urgent needs. And that program has now seen over 1,500 patients since transitioning from acute respiratory clinic to immediate care.

And then critical care, which I already alluded to, national Jewish covers over 800 critical care beds in five states through the telecritical care program, as well as five major metro hospitals right here in metropolitan Denver. And we staff those essentially around the clock, 24-7-365. At the height of the pandemic, when New York was overwhelmed, a bunch of our critical care faculty got on the plane and went to New York and cared for patients until those communities were doing a little better and could help support themselves a little better. And when that same wave of illness happened in Los Angeles, our docs again got on the plane and when provided service and care to the citizens of California to make sure they could get through their most dire days. And we continue to provide critical care leadership given our particular expertise nationally. So the hospital transformation program is a specific program that's aimed at showing our commitment to both the state and the community. So this is a new program that the state has put on with the specific goal of trying to improve the quality of care for our health first Colorado members. So the goal is that every hospital has a unique patient population and was allowed to pick specific quality metrics that mattered to us and to our patient population. This is a five-year program where we implement changes in these specific areas and then do continuous monitoring improvement over that time. So we chose the eight measures that are shown on the slide. Two of them are very specific to pediatrics, which is an important population for us. These are around making sure that we are screening all of our pediatric patients for depression while they're in the hospital and making sure that all of our asthma patients are being discharged with a home care plan to ensure that they have quick and easy and effective treatments ready when they get home. There are two other metrics that are specific to the high-risk transition point for when patients are leaving the hospital and that's making sure that we're communicating with their primary care physicians and sending electronic versions of their care record to their primary care doc as well as making sure they're raised, the regional accountability entities are monitoring those patients once they leave. We're also making sure that every patient has a follow-up appointment with their primary care doctor so that they're getting that continuity of care quickly at a time that they can make that appointment.

There are two statewide measures that we're participating in and those are around screening all patients for gaps in their social needs, specifically around things like housing, food, instability, and transportation so that we can ensure they're getting the appropriate care they need that way and then monitoring procedural complications. Two of the metrics are very specific for us and that's looking at expanding our subspecialty consult access for patients and then also providing physician-to-physician or provider-to-provider electronic asynchronous consults to help those kind of rural physicians know that they have access to specialty care for their patients. Thank you Dr. Horn. So let's drill down a little bit more on what we do with respect to both research as well as some of these community programs that report to us. Now this slide may look a little complicated but that's what this picture shows is basically our entire research enterprise in one particular slide and so let me sort of break it down for you into more straightforward terms. So I had to say what we do in terms of research for national Jewish health is we focus on the environmental, the genomic or genetic, and the immunologic or immune system basis of respiratory and allergic diseases both in terms of discovery and science, how you practically implement those discoveries and finding and testing new and innovative treatments and so for us we look at specific diseases. Obviously the lungs are important to us and asthma and emphysema and COPD are really important. All the allergic and immunologic diseases. Dr. Frankel mentioned that we have a great interest in the sickest of the patients requiring intensive care medicine and when their lungs and other systems are out of damage we have looked at a lot of different areas in terms of those diseases. We look at a lot of occupational lung diseases and we have a very large lung cancer program. Well as important as looking at the diseases are in clinical trials and how they are looked at is we want to understand the underlying mechanisms. The reason for both basic and translational science is that you've heard so much about the genetic and other information that's available. Why do these things happen? Why do some people respond to certain medications and others don't? What are the underlying features that make something into the cancer?

So for us looking at the underlying immune system, lung injury, how the lung repair system works, cell biology and inflammation that's so important in asthma and other things.

So we look not only in a disease focused way but also what are the mechanisms that underline those things. In order to achieve that and with the level of technology and development that has gone on over the last 10 years or 20 years you have to have sort of cross-cutting programs that allow you to look at both mechanism as well as disease. And so having a program in genomics and precision medicine and regenerative medicine as well as what are people doing in epidemiology and outcomes. So having a center for genes environment and health and now a center for environment climate and health are both very important tools for us and allow for a lot of collaborations a lot of research and a lot of what ends up helping the community. So that looks like a complicated slide and there's a lot of work that goes into it by a lot of folks here at National Jewish and a lot of scientists and a lot of collaborations around Colorado and around the world but that what makes up our research enterprise. So what are we doing in terms of how it changes lives for you? So let me talk about just some of the few recent studies in the last few months that have come out of National Jewish Health. One with National Jewish Health as well as other colleagues. So a study published in March talked about how we can simple interventions to improve asthma outcomes for minorities. A published that we that Dr. Frankel mentioned revealed sort of a root cause of what's causing these long COVID symptoms. A study that confirmed that many patients here in National Jewish and around the country and around the world who have chronic illnesses why they have lower antibody levels after vaccination doses than others that don't have chronic illnesses. A recent study that we published that has become very important that shows that later middle and high school start times that are later help parents as well as teens avoid an important issue relative to sleep deprivation. And also another recent study that to understand the increased use of hand sanitizer and potential allergies that all of us went through over the last couple of years. So those are just a sample of recent works published out of what we do for research in the community. And some of the things that are on many year studies. One relates to National Jewish Health being an asthma net which is a national trial network of long standing duration around the country to study asthma in vulnerable populations. I mentioned the study on COPD gene before led by National Jewish Health the Brigham and Women's Hospital in Boston and 23 other centers that have been studying the largest group of Americans for 10 years now suffering from COPD. We do a lot of work with the war fighters in terms of a specific program to help us understand illnesses that are suffered by our soldiers returning home from southwest Asia.

And because we study so much relative to the immune system the vaccine research a variety of studies that are continuing now over many years to help determine how vaccines work and how to make them more effective. This is just a photo on our campus a portion of our campus two acre portion of our campus that we have set aside for community garden. Looking out there today it serves a lot of people and it's doing well at least early in the season.

What other community outreach programs do we have? We talked a little bit about our clinical and translational research center which provides the entire infrastructure for community-based research for patients to come in here. Chris Fortner mentioned our long line service which is a free information service for health care consumers and staffed by nurses. We've done for a very very long time the minors clinics of Colorado providing medical screening diagnosis pulmonary rehabilitation and education through free screening programs. Our asthma and COPD toolkit program which is an outreach program to the entire state that provides training of health care centers school programs and outreach to low income areas and low access to care to teach those folks how to manage and best manage asthma as well as COPD. Then Dr. Frankel talked really about our massive COVID care and research effort for which everyone in national Jewish was really intimately involved in and are involved into this day.

Chris Fortner talked about the mortgage academy and certainly if there are miracles that occur on campus it is in that tuition-free kindergarten through eighth grade school for children with chronic illnesses anything from diabetes to HIV to severe asthma and allergies as well as and allergies as well as trans children that undergo transplants that really that they're from they're overwhelmingly underprivileged and have missed a lot of school. So what we do is we have three nurses there that help them manage their illness as well as the other folks on campus and then what we do is we catch them up in school and we understand the needs of the child as well as the entire family. In fact we had one child just graduate from eighth grade there who had undergone double lung transplantation as a very very young child and just graduated from the school. So we're enormously proud of that we've always done that I don't know of any other freestanding school on a medical campus in the country that performs that way for between 70 to 90 chronically ill children. We have been you know being the leading respiratory hospital in the country smoking cessation has been of enormous importance to national Jewish and we've had the quit line or quit smoking programs that we've been in in that since about the year 2000 and helped about two million Americans quit smoking which we do for 20 states including our proud partner in Colorado and we also focus on at-risk populations the American Indian communities the LGBTQ communities as well as others and we've really helped a lot of people quit and since we have noticed the vaping epidemic in children since 2019 we developed our own program My Life My Quit which we're very proud of in terms of working to help children and adults quit vaping because we've seen a tremendous rise 27 percent among teens and young adults it's a collaborative program which is developed and a number of states are adopting it so in terms of vaping that's something that we developed our My Life My Quit program which helps with that particular problem.

What are our sort of going forward areas of focus for the community? You know pediatric asthma has always been really of importance to this community and we've seen continuing high rates of asthma immediate care and emergency room visits by children in the local communities and if you add into that the effects of the pandemic you have a significant unmet need so we continue to focus on research diagnosis and treatment in that area. Education for doctors education for patients and community members through you know targeted programming our library for patient education and professional education programs is something that's been important to us from the beginning and we will continue to focus on going forward and access to specialty care which is a real issue so we want to expand and add programs to bring care and education to the underserved population tapping into our expertise from the mortgage academy plus our focus on the center for post-COVID care recovery and services provided as Dr. Frankel mentioned through immediate care.

So that those have been our what we've focused on over the last year what we plan to focus on going forward we're very proud of how the institution partners with the Colorado community and look forward to many more years of that and with that we'd be happy to answer any questions that you might have. And we'll just start that out with saying that when everyone registered to participate in this session we did have an opportunity for you to send in questions and we did get a number of questions in with those those sign-up forms and we wanted to go ahead and go through those quickly and answer the answer the questions and then if any more come in we will take care of those as well and just so that you know as we end this program we will have a way for you to submit additional questions so this isn't the only opportunity this is really how we're opening the door to gather and respond to your questions.

So what I'll do is just read some of the ones that have come in and then our panel here will help us answer the questions that did come in so one question we had was how are you explicitly combating systemic racism and advancing health equity through your community health benefit work and I thought I would maybe start with Carrie to help us get an answer to that. So National Jewish Health was founded on the idea that we should be open to everyone and while that was specifically with the unhoused population we continue to follow that mission for all patients so that being said you know we're always intentional when we look at new programs and look for opportunities to make sure that we aren't unintentionally creating barriers to our patients so one of the things that we're doing is we created a new leadership role that we are actively recruiting for that will focus entirely on diversity equity and inclusion and that will be both for staff as well as looking at our processes for our patients. In the meantime we have an internal lecture series where we provide education both to our providers and to our staff highlighting different issues within the diversity equity and inclusion kind of realm. Our library is focused on providing those resources to our staff and to patients as well and we have a newsletter that highlights programs again for our patients and for our staff to make sure that we're identifying biases and working to approve it all the time.

Another question that came in was about the HTP process and the question was how will you keep the feedback loop for your CHNA which is our community health needs assessment that we're involved with right now and the hospital transformation program processes and I think that's carries also because she's very involved with that program. Yeah so there will be a follow-up survey as Lauren mentioned specific for this meeting and then the plan is to do quarterly surveys going forward to continue to provide that opportunity to give us feedback over time.

We're also planning a number of outreach opportunities with surveys to the Colorado healthcare community specifically looking at how we can improve access with access to that specialty care and those e-consults where we do provider to provider consults. So there's a lot of outreach planned as the HTP program grows we'll learn more about how we can get that information back over time.

Great thank you. Just a quick follow-on to that there was a question about how CBOs community benefit organizations other organizations how can they participate in crafting community solutions as we identify top needs and a follow-on to that is have we ever thought about reversing community members or CBOs for that kind of participation.

So we certainly hope that people will respond to the feedback survey both for this meeting and in the quarterly surveys going forward and we really hope to engage with the community providers around our surveys for specialty care and we our website actually has a great feedback mechanism so we can receive feedback at any time if people go to our main site.

Right now we do not have a plan to reimburse for participation however we're going to monitor the time commitment we're asking from our community providers and community team members to make adjustments over time if needed. Thank you good we had one other question come in and that was a question about what new classes or services might be offered virtually particularly for those who may be homebound in the community maybe Steve or Chris. So we have a number of support groups largely built around disease specific interests and needs over the pandemic those did go virtual and continue to be be provided in a hybrid format because there was a great deal of interest in still having access to it if you couldn't be present physically on the campus. It's an interesting idea to try to try to increase the amount of virtual content for folks that may not be able to get here. The National Jewish Health website is a wealth of resources and we are trying to to build more individualized content. We were thinking about it in an asynchronous fashion in terms of people labeling being able to get that on demand when it suited their needs but you know the class format certainly an interesting one that we will take under advisement and and put some thought into. You know we're also investing in a new program which we're building at the moment to allow us to have more electronic communication with our patients whether that's for the sickest of the sick to help manage their chronic disease or whether it's others that want more access to online classes things like that in that format so that will be rolling out over the next 12 months. Thank you. And I think that's all the questions. I've got someone that's been monitoring the online world and I don't see any of the questions that have come in so I think we're probably at the end. I will just say again we really appreciate you joining us and your attention today as you think about what we've shared we're happy to take more questions. Again there is a space on the website that you can send a question in or as you entered your information here you got an email from us that came from feedback at njhealth.org and you can send a question through that process as well. You will get a follow-up from us in the next couple of days and that will also offer a way that you can send questions in so we certainly welcome not only questions but feedback and information that you want to share with us and we'll try to keep those lines of communication open.

So thank you very much we appreciate your time. Thank you.