Going to change, or are they going to be modified . And how soon will you be establishing those . Are they in the same priority that was mentioned in terms of which ones are going to be focused on first . I would say it is in the same priority. So backing into it, our goal is, by the start of the next fiscal year, july 1st, to have established what those metrics are so we can begin to collect that data right away and report on it. In order for us to do that, getting back to january, we need to have some sense of which ones are looking like they are going to be doable and validated so that we can come back to the table as a network and say, okay , here is the potential universe of data that has been validated. Of this, how much of this support are true north pillars and particularly some of the metrics we have already identified . We feel the metrics we have now are appropriate and has been a 1 1 match within epic in our pre epic sources, we would be continuing along that journey anyway. So it is not as if were looking to change the metrics we have, it is just a matter of can we keep them and reliably get the data for the ones that we have. Thank you. And i understand that there are going to be some that lend themselves to this later, but with regard to quality and Care Experience, i know some of those are going to be based and others are not necessarily. Im just concerned that you were not just developing metric measures that are just about the regulations because, again, given the population that we have in San Francisco and some of the uniqueness around our Delivery System, and the needs and the way things are structured, that we are looking at quality and Care Experience measures that are really getting at what we need with regard to the kind of care we want to provide to our patients and our residents, and then how thats related to the needs with the workforce, some that have been expressed today, but that also are going to really need to be modified in relationship to those other measures. Right. That is a good question. I answered that by thinking about the investments weve made with our workforce over the last few years, particularly in terms of training and trauma informed care, training and racial ability, and the focus we have had the last two years in terms of Behavioral Health and homelessness, i think because of all these efforts, those will help inform the metrics that we choose, so i take your point very clear that we have to go beyond just baseline of whats required, but as i talked about true north being the head and the heart, particularly here in San Francisco, knowing that we have two choose metrics that also tear at our heart and our sense of the populations that we take care of. And really so were not just focused on process, that we are really looking at outcomes across a range of environmental conditions, both in consideration of the workforce, as well as in consideration of patients. I agree. Dr. Colfax . Thank you. I really want to acknowledge roland and his team. It is a huge amount of work and oversight. And we see we are making progress. We are not where we need to be yet. I also just want to acknowledge the commissioners comments about not just process. Some of these metrics are really important because it gets you to the outcomes and also we needed to expand our work in terms of the populationbased approach. So what we are doing the clinics in doing the hospitals is really key, and when we look at health equity, when he to make sure we are bending the curve of the population model. Having the population work within the network side, and we are strengthening other data systems, we can focus on the data science as one of our key areas going forward. We will continue to move in a good direction. Wall where we are compliant with the compliance requirements, but we are also meeting the needs of the community and our metrics are driven by what we need to do in those areas. I appreciate that. Thank you. Dr. Sung . [indiscernible] good afternoon, commissioners my name is irene sung and im the acting director of Behavioral Health for San Francisco health network. Today i will present an overview of our services, a followup on the action items presented by the previous director to the board of supervisors performance audit in 2018, and then finally touched on some significant changes that are coming down from the department of Healthcare Services as they propose changes to the medical Delivery System program and payment. I will be followed by another doctor to talk about changes with Mental Health reform. That will happen after my presentation. San Francisco Health network, Behavioral Health services is the largest provider of Mental Health and Substance Use prevention, Early Intervention, and Treatment Services in the city and county of San Francisco our total budget sits at about 384 million last fiscal year. 800 budgeted civilservice f. T. E. , but that includes not just clinical programs, but also i. T. , building, compliance, quality management, contractor facilities, all the infrastructures that keeps our system running. Over 80 c. B. O. Contractors will also provide a bulk of the Behavioral Health services. I do want to say we did receive your questions, by the way, and i tried to incorporate them into the presentation, so if you dont get them, ask me again. Thank you. We do hope we do hold two concepts. Many of our clients suffer from longterm chronic conditions such as schizophrenia or complex trauma that can span generations these are not unlike other chronic illnesses such as diabetes. Like diabetes, theres often no cure, what treatment can help to manage the onus and prevent complications and negative outcomes. It is important to remember that change is hard. It takes an understanding that theres even a problem in the first place and then times to build enough of trust in a relationship with someone to accept that changes needed or even possible, wherever they are in our continuum of care, whether it be voluntary or involuntary, we work with each individual to support the change that will help them move forward with their lives. Change does not happen in a straight line. You think about any time that someone you know or you, yourself, is determined to change something, maybe start exercising regularly, i have done that. And even when we are committed to make the change, it doesnt always happen quickly. We take two steps forward and one step back. There are relapses, and we work to support each individual or family wherever they are in their stage of change. And with this we know wellness and recovery is possible. We have seen people progress in their lives, build relationships with family, friends and community, and continue to support their wellness. So it is with these key concepts in mind we align our mission and vision. Our mission is to maximize the coverage and wellness and potential for healthy and meaningful lives and our clients communities. Our vision is a Behavioral Health system of care that is welcoming, culturally and linguistically competent, gender responsive, integrative and comprehensive. We value time and access to treatment where any door is the right door. One thing i did want to say is we are rethinking this idea of doors. Much of our Behavioral Health services in ambulatory care are set out by individuals and families. At the same time, we know that there are individuals who we believe would benefit from our services who dont walk through our doors. So while any door is the right door, we are really rethinking this and how to expand our services to treatment and outreach beyond doors. Our overarching goal is still supplying for clients to be thriving in their natural environment. So what does it look like in San Francisco . We have probably seen this before, the upside down triangle , im sure. Our i will go through this quickly because you have seen it in two systems of care, there is the adult and older system of care, the children, youth, and family, Mental Health system of care and the Substance Abuse order of care. There are services that actually bridge these Service Lines like translation, for example, is a good example where children were not able to move into adult hood easel easily and they needed Specialized Services to move them to make sure they can actually retain services. Within each service, within each system of care, there are levels of care from prevention, Early Intervention, to outpatient treatment, to residential, crisis, and you move more into the involuntary services on hospitalization or locked facilities. We really try, most of the people that served at the top are voluntary services and we really try to actually serve more people at the top rather than where it is involuntary. Fuhr for fewer clients and it is much more expensive. The intensive Case Management sits within our Outpatient Service delivery. And entry into our services, most of the entry comes in through Outpatient Services. You have heard of the Behavioral Health active centre which they are trying to expand. They move into outpatient and they are are also people who enter through our crisis programs. They do come in that direction and we hope that we can move more into the voluntary section as possible. This includes Specialized Services, which i talked about, like transitional age youth services. It is growing and becoming its own system of care. We serve nearly 25,000 lives, 25,000 people in our systems of care. I know that the number 30,000 has been brought up in various places. The 25,000 here are really people that we are serving in our specialty Mental Health system of care that we can capture. There are other Behavioral HealthServices Provided in primary care, in jail health, which arent captured in this number because they just dont use the same Electronic Health record system. As you can see, theres a lot of attention to homelessness. I have the homeless numbers up there as well. We provide more services to adults then kids, but it is important to remember the kids are not just the kids of the families, too, that we serve and their numbers are not reflected there. Most of our Substance Use services are provided to adults, and you can see the homeless percentages on the far righthand side, and the 59 are Substance Use clients who are homeless. An important number is the overlap, and that overlap number are the people who are being served by both our Mental Health system and the Substance Use system, almost 2,000, 71 of those clients are homeless. In addition to the Treatment Services, there are other prevention, Early Intervention fronted services, schoolbased services, where we dont actually open up charts on each of them and that is a large number. The last number i saw was about 50,000 people. Our demographics. I dont know if you need me to go through them. Children services, the latin next population is probably the largest served in our system, and then the next is africanamerican, asian, and caucasian, and it is smaller for native american and other groups and there are substantive services that more caucasians are provided in our systems of care then africanamerican. We pay very close attention to demographics and we know the disparities that exist in the system. For example, we know certain groups are overrepresented and others are underrepresented relative to the census. So in december of 2018, we created a new office of equity and social justice and multicultural education to really focus on equity, diversity, and inclusion. We worked with our systems of Care Development equity work plan to address gaps across services and develop an equity improvement work group to look at root causes of identified disparities. Our equity director works very closely with dr. Bennett at the department level. You know our director who is leaving us to another county, unfortunately, but he has built a system that will be able to continue on after he goes. Our gender numbers, we can go through them. 1 transgender patients, and then more males than females in the system. And our budget. These are our total expenditures for your 1819. These two pie charts depict our budget from two different perspectives. On the lefthand side our expenditures by systems of care. This is all levels of care from prevention, Early Intervention, all the way up to facilities. You can see the bulk of the expenditures are within the adult and older adult services. The second pie chart is really reflecting the Funding Resources , and most of these funding trends are subject to regulation for guiding who can be served and what services can be provided. For example, medical does not pay for outreach. It doesnt pay for integrated care. And integrated Behavioral Health homes. And another example is even things like these lockouts. If you are a case manager and have a client to get hospitalized, if you visit that client, that is unfunded. You have to maintain a connection with that client. Our general fund is used to cover these services that are unfounded or Cover Services for clients that are not eligible, for example, immigrants who are not eligible for medical. So the next portion i would like to address the board of supervisors from 2018. Our previous director has presented the Behavioral HealthServices Plan for addressing some of these key issues that were identified in the audit. I will not repeat his presentation, but i will provide updates to where we are with each of the plans. As a reminder, there are four key areas that he addressed. One was around provider performance, second was around access to intensive Case Management, third is on transitions really focusing on psychiatric Emergency Services, and the fourth was around adults who do not stabilize. Those are the focuses and the folks that we are having troubles reaching. [indiscernible] the red is [indiscernible] and the black is [indiscernible] it was presented the last time we came here. So the recommendation is having to do with the performance and one of one thing he implemented was an annual Program Review and random audits that was something that was implemented last year in 2018. We had hoped to put in realtime Performance Analysis using a Business Intelligence system, however, with implementation and a lot of new requirements coming down, we have really had to divert a lot of that attention and resources to meeting those requirements. I really appreciate what you have said about outcomes versus regulation because much of the reporting requirements is really process reporting, timely access , recidivism. [indiscernible] we have 60 process measures that have to track from a monthly or annual basis. It takes a lot of staff time. That is really where the majority of our resources have been devoted. The only outcome data which is required is Substance Use. [indiscernible] even those, we are not required to report the outcome data, which is required to report that we did. So its interesting that this is where all our resources is going just to keep our funding going. We actually did make a choice to do the [indiscernible] we do report that out quarterly on our website. That is it right now for what we do if you look at the outcome data. We are moving this year towards true north metric and to define our work and helped drive the improvement. An example of this is we are trying to move forward on and have some data, but it is not presentable yet. We would look at the percentage of people who are leaving and engaging in outpatient treatment , county people have left. These are new kinds of measures for us in different from what we have been required to do. We have also built in a tracking of people from the civilservice clinics. We have seen improvements improvements since the board of supervisors audit. We have seen a steady increase over the years, an increase of productivity by about 38 . Right now productivity, our current target is 60 of scheduled work time to be in direct, patient billable services. With regard to documentation, to improve documentation, we have seen a lot of challenges. We did create a document online. Our specialist did provide Technical Assistance in clinics and more broadly for the entire system. Unfortunately, there were times in january of this year where we havent been able to continue that. Their position is prioritized to fill it. One thing i did want to say is though we have completed many of these action items, we really do continue to have compliance issues. We are going to get a formal report from the compliance auditor in a few weeks, but i have also heard that there are continued problems that continue , particularly in the areas of missing documentation, incorrect service codes, incomplete plans of care, and d. P. H. Is working with a consultant to help us with some plans across the department and thinking about services to really work on how we can work with the provided documentation report to come back to us. We have to figure out how to get it out to the provider and have it move back. We will be working with the new director on implementing tools to improve his documentation issues moving forward. So we have not been able to implement [indiscernible] the other sections have used it very successfully. They make improvement work more visible and accountability. That will be under the strategic director of the new director coming in. This intensive Case Management as a reminder, it is not just Case Management. Case management is any Service Provided by social workers or Health Workers that accesses resources and navigates complex systems, helps obtain benefits. The service exists at Clinical Base levels as well. Intensive Case Management is a higher level of Outpatient Care that provides services outside the walls of a clinic. They might go to the street to find the client and they provide medication, take them to vocational training, or wellness centres, or even medical appointments. These are the clients who, without our support, could lose their housing. The audit identified a problem with our capacity. We had a wait list waitlist of about 200 people. The first thing that we did and we work with consultants on this to provide a metric. This was to see whether or not the focus could be to create space by moving people from intensive Case Management to outpatient. So we pulled criteria from avatar. How many people werent using Emergency Services . How many people were not hospitalized . And to get this list for programs to look at who could be moved on to the next level of care to create space. And it didnt result in the discharges that we were hoping for, but it did help to identify the need to create clarity about who needs intensive Case Management to progress, and identified the need for more linkage services. Clients who might refer to be referred to icm by providers, when we meet with them based say im really not interested. Linkage services are different. High touch services. It takes time to engage and build that relationship, but slowly to move to a higher level to intensive Case Management. I will shift a little bit because i do want to talk about the pay group because pay was a system where they increase capacity. They create 40 new intensive Case Management slots and when they did that, they were able to decompress their Linkage Program because they have intensive linkage as well and that has resulted in complete elimination of the waitlist. So they have none. The last piece of the recommendation was around centralizing the tracking. We worked with a system of care on a level of care review and waitlist management to improve client flow. The hope is we can actually start implementing utilization management, but that got challenged around union issues. We can wait for those things to work itself out. [please stand by] the Performance Improvement plan to increase flow reduces by 13 happened last fiscal year during 1819 to reduce it by 14 prior to my coming to the position. The last thing created was pier navigators to help with warm handoffs from intensive Case Management to outpatient. One of the issues that continue is the work force challenge of 20 vacancy rate of an intensive Case Management services. Transition to lower levels of care. We did get funding, and it is homeless mentally ill funding to support transition pes to outpatient, a social worker to reach out to make sure there was a warmish handoff to outpatient programs. There is a linkage to hummingbird where we hired peers to walk people. When we found we made the referral they would be lost in the system, and the mha is funding peer linkage to do more warm handoffs. The last piece around communication. We do know that communication will be enhanced through levels of care. Behavioral health is on wave three of epic implementation, but even so we continue to work to optimize data sharing for clinical share prior to implementation of wave three. Cohort of adults who do not stabilize. I will leave this to my colleague who will talk about whole person care and Mental Health reform about this section, but it is really around we are working in close collaboration to implement these strategies. Challenges. We still have a significant number of vacancies across the city and county of San Francisco in Behavioral Health in Civil Service and the cb o have challenges with retaining staff. They have high turnover, given the high cost of living when trying to hire bilingual staff. There is a nationwide shortages of psychiatrists and San Francisco is not immune. Working with finance and hr to improve hiring within Civil Service. During the time i have been acting director, we hired 62 Behavioral Health employees and lost 38. It is less at 24. I anticipate this number to increase as we only started the new process of meeting together to prioritize positions. We will need to hire clinicians to fill the priority positions to fill gaps in language outreach staff, expansion and intensive Case Management. Our Clinic Based Services are the bulk of the services and they work well. Homelessness makes it challenging to attend appointments, to remember to take medications and participate in other clinic base services. Linkage programs do the fieldbased services. The vacancy rate does not help. To be able to make up for the rate we increased caseloads and that doesnt help. We feel we need more. Lastly, data continues to be a challenge. We are moving forward. Much of it is manual. Some is electronic. We are moving forward to create Electronic Solutions to much of our tracking. Again, a lot of resources on reporting and outcomes. We look to shift that. This is the exciting part. This is really about transformation. Changes are on the horizon at the state level as well as San Francisco. There is a very innovative proposal called cal aim. California advancing and innovating medical. That looks to change the Behavioral Health delivery to be more plex i believe with paymentbased value and outcomes rather than service encounters. The proposal is 200 pages. It is public so anyone can read it. I havent yet. This is a brief overview. I recommend a more complete presentation. Wwe have three goals to identify apmanage member risk and need through whole person care and addressing social derm min nats of health. To move to a seamless system by reducing complexity and increasing flexibility and to improve quality outcomes and drive Delivery System transformation from modern systems and payment reform. We are going through the whole process and work groups to identify what the next step should be and how we make the transformation across the entire state. They are undertaking a robust cal aim to engage Key Stakeholders and cover key areas. The ones that are pertinent to us, one is about enhanced Care Management benefit and the set of services that i was describing that are not funded by medical. Those are services that could be funded in the future. Behavioral Health Payment reform and Delivery System trans formation. What they are looking at is integrating rather than having two substance delivery and Mental Health put them together under one plan. That is one. Another is how do you reform change payment to be more value and outcome base rather than compliance based . Requiring ncq8 add accreditation for the programs. In Behavioral Health we are not familiar with it. That is new. That is something that will take time to understand and implement the cost care system. The last of the full integration plan is one plan for physical health, Mental Health, Substance Abuse and oral health allinone. We have people here in our system who are in these work groups. We have the director of adult and older adult Behavioral Health services on the Delivery SystemTransformation Work Group and holly is on the full integration plan work groups. We are very happy about that. The timeline is actually both conservative and aggressive at the same time. They go through it if you go to the website i can send you the link. The work groups have started and they will continue through february of 2020. After that, by april of 2020, they will publish an updated process for the monitoring and reporting of performance standards. Then in december 31st, a lot of the wavers end. This is transformation by january 2021 with a path toward the real reform and start making the requirements around Population Health management, maybe implement enhanced care and a lot of different possibilities then. This actually will go on within cremental changes through january 2024 with full integration plans going live. They will do pilots on the full integration plans. By 2025 they will have all managed plans to be required to be accredited. By 12026, the Behavioral Health managed plans will be implemented. There is a lot of work that is going to be going on both in sacramento and here to keep up. Finally, a Behavioral Health director today but soon, i hope. It has been quite an experience being the acting director during this period of real intense focus on Behavioral Health. When i first started i intended to make sure there was coverage to make things rolling. I have been running around the race track since i started in march. The changes at the state level look very exciting. There is increased flexibility of services, value based payments and to transform the way we improve care for our clients. With that i thank you and i can take questions or turn it over. Thank you. We can have doctor bland come up now. I just want to note there are two separate items. You can do whatever you want. I want you to know that the Public Comment request for the next item but not this item. If you get to discussion you are the owners of the meeting, i dont mean to take over. We will survive this one. I am going to invite doctor bland to come up. Would you stay with us, doctor sung . Sure. The team and doctor sung, thank you for your partnership on these efforts. Many of you may know that i am a Board Certified psychiatrist and addiction psychiatrist and mackulty member at faculty member at the university of San Francisco. As i have been an opportunity to survey the system of care and to listen to concerned community members, to meet without communitybased organizations and service staff. The people on the front lines that are the boots on the ground providing services to patients and the neighbors each day, i have been very impressed. This chamber is freezing cold, my heart is warmed. My heart is warmed by the level of passion and commitment from our team members. I must point out i hav have been disturbed. Similar to the mayor and members of the community, disturbed by the Health System progress Meeting Needs of individuals experiencing homelessness,anticly the public indifference that we see on the streets every day. I accepted this assignment with the charge to develop a coherent strategy for meeting the Behavioral Health needs of those in San Francisco experiencing homeless niece. In collaboration with the stakeholders we developed a twoprong vision for meeting the needs of individuals facing homelessness, Behavioral Health needs. For our clients we want a system of care that offers access to highquality healthcare to meet their needs. For the system of care to make sure we develop a system that is grounded in evidencebased practices to reduce harm, increase recovery and suited to deliver the services to those experiencing homelessness. To that end, we developed key roles. First is being able to communicate the vision to the homelessness from the perspective of Health Department, issues around equity and strategies to address those issues, identifying opportunities for innovation and further investment on the part of the healthcare system. Many of th of the programs neede scaled. Lastly, making sure we are grounded in evidencebased and evidenceinformed uses that do e decisions anal locations going forward. I would like to emphasize that this is a populationheld approach. We haveitedded a february h specific segment for whom we want to improve the delivery of our services. This depicteds, one, there are approximately 18,000 individuals in San Francisco experience goes homelessness at this time. This is records that we have available through dph and defendant of homelessness and housing. Some only access these and they are only registered within the department. When we look closely at the individuals we were able to clear the data to identify a target population for our affirms effort. There is a depiction of the group for the shared priority negative. It is the care approach around our most severely affected clients. That came to the month ago to the Health Department around that effort. Lou are we talks about . These are residents suffering with the disorders. Then demonstrate the highest levels of need and resultorable. 41 are cycling through the services. 95 of these thirds suffer with an alcohol abuse problem. First first we identified inequity in the population. 35 of the individuals are black and africanamericans. That group makes up 35 . There are data points uncovered. They are highly vulnerable. 74s have Severe Health failure and hyped per tension. In temples of thesersis provision. 90 of these individuals do not have an intensive case manager. In collaboration with the university of california, San Francisco, we helped establish key measures for tracking our progress and the outcomes associated with our efforts. We were focused on reducing the service uttill ligation, increasing connected necessary to housings, services, making sure when epthey are placed in services they are able to maintain those placements and stay in those settings. We are looking for the im provement be which changer to honor that is the intent. Our team started with the thorough review of the past 10 years of Strategic Planning on homelessness and Behavioral Health. We listed the reports we reflected on here. I will hints out homelessness and Behavioral Health developed with Tipping Point community as well as university of california of San Francisco. With a deep survey of the system. Within the department and in the opportunity about the conditions on our streets. We also initiated a series of meetings and actions with stakeholders at the community level. Starting in september to address the framework and background for this work to address questions from the Community Organizations about the emphasis for the reform work and make clarifications. Lastly, to elicit their ideas around opportunities for further and deeper collaboration to make an impact on the population. We held the second session where we had a similar conversation. In november we will be in a shared meeting to develop a shared agenda around reform efforts. So as i said before, this is our first time really taking a Population Based approach to addressing the Behavioral Health clients needs. You understand the care coordination to make an impact on this and we are happy to have the partnerships to do where it takes to wraparound these individuals, particularly in the par get population. We are targeting the expansions at the bay world access. The mayor committed to adding an additional 212 beds since 2018. We are not alone. We have partnerships with the development of the second hummingbirds respite Navigation Center on the campus of San Francisco general. Another Key Development is the use of technology to advance our understanding when capacity and service needs. We are excited to develop simulation modeling, it is an approach that uses our own data to determine what the pressure points are in the system. We are developing transparency including the launch of the public facing wealth pain with a mock crop of that database available to the public and to care providelers to know when and where there are bids available. We will roll this out with our Substance Use system of cash. Lastly, we have made progress towards addressing Harm Reduction and opioid overdose. Would he support expansion of naloxone through out the community, exploring the development of a man aged alcohol use program as identified in the target population. In supportings the recommendations of our Methamphetamine Task force. As we continue in this work, we are continuing to make targeted investments in our system capacity including 1,000 new Behavioral Health beds. We are developing the Sobering Center and have a new service bite for individuals experiencing it from their parents. It is within the next three to six months. We are actively exploring the implementation a of overdose efforts. Black and africanamerican communities are less likely. We have made recommendations to the mayors office. Both mr. Pickens and doctor sunk described recruitment we must incentivize people we are continuing to stay in San Francisco and working with us. More opportunities for working gear to continue to advance education and skill set to keep them motivated to work with us. Our city is taking steps to address the crisis for Mental Illness and Substance Abuse. We are striking the right balance between the strategy and investing in new ways of doing things. I believe with this approach we will improve outreach, engagement, reduce barriers to care and expand service capacity. All while developing new opportunities so that every one of these individuals are able to access a highquality system of care. Equity is ahaum mark. We want an equitable shot at wellness and recovery. I will take questions. Before Public Comment, i want to give the director a chance to comment on these items then Public Comment. If i want to thank them for their work. I think you can see there is progress. We still have quite a bit more to do. It is really important given the focus on Behavioral Health that it is also a priority of us as policy mayors, including the mayor. With additional priorities coming forward and looking at the date to to where we need to go. Our Behavioral Health system as it sands now not only because of changes now but not what they look like a year from now. There are a lot of unknowns. We know it will be driven with key Stakeholder Input and equity focus to make evidence based the focus and innovating. Across the department the Behavioral Health system has been in the network with tremendous work of integrating Behavioral Health with primary care. We know that 30 in the care have that diagnosis. We need to modernize that keyword and we need to make it a priority across the network, 3078lation homes, and we need to see what state changes at thelogical level. The truck of structure how Behavioral Health is led within the department. Resources how they are allocated and thousand they are guided and developed and that is an opportunity to modernize our work so we not only continue to do the work that doctor sung pointed out but we himself also reach the people we arent reaching. We really have key identifie identifiedmetrics. That is aframe. This is where we are now. Going forward we have huge opportunities. The Health Department has done big things and i see this going forward. We have Public Comment. Some of the hand writing i cannot read. I will announce the first name and last letter. Jessica w. Doctor theresa palmer. Jennifer e. Dana k. I am jessica a student pharmacist from usf. First comment 85 12 passed the edge later and requires cultural training. I would encourage as part of