ACA Outreach and Enrollment Challenges in AANHPI Communities: Some Findings

Coordinator: Good afternoon and thank you all for holding. The lines have been placed on a listen only mode until the question and answer portion of today’s conference I would like to remind all parties the call is now being recorded. If you have any objections, please disconnect at this time. And I would now like to turn the call over to Suhaila Khan. Thank you. You may begin Suhaila Khan: Hi everybody. Welcome to this webinar on ACA Outreach and Enrollment Challenges in Asian American, Native Hawaiian and Pacific Islander Communities: Some Findings I’m Suhaila Khan, your presenter. The information in this webinar is based on a needs assessment report that was prepared for by Domin Chan, Perry Chan, Charlene Kazner and myself. The needs assessment report and this webinar are sponsored by the Substance Abuse and Mental Health Services Administration, SAMHSA. Next So today we’ll be talking about four topics of these communities. So my presentation will be about 30 minutes. I will first talk about Asian American, Native Hawaiian and Pacific Islander communities, who they are and where they live Next I will talk about their mental health and substance abuse issues. And the first two topics are based on the literature and data that we reviewed for the needs assessment report The third and fourth topics, the Asian American, Native Hawaiian, Pacific Islander experiences with ACA outreach and enrollment and on the needs related to these are based on multiple discussions that we had for the needs assessment report with community-based organizations serving these communities So after the presentation we’ll open the lines for questions and answers. You have to press Star 1 to get into the queue. You must also use the conference line to hear the webinar So you’ll have to call 888-970-4177 and use passcode SAMHSA if you want to hear this webinar Next. So let’s begin with some demographics Who Asian American, Native Hawaiian, Pacific Islander communities are and where do they live? Next. So Asian American, Native Hawaiian and Pacific Islander communities are the fastest-growing and most diverse population in the United States They are projected to double in 50 years, going from 15.9 million in 2012 to 34.4 million in 2060. They comprise of 50 different race and ethnicities, speaking over 100 languages Asian Americans consist of East Asians, like Japanese Americans, Korean Americans. Southeast Asians consist of Filipino Americans, Vietnamese Americans. South Asians consist of Asian Indians, Bangladeshi Americans. And the Native Hawaiian Pacific Islander population includes groups like Native Hawaiians, Samoans, Tongans. Next So currently there are 18.9 million Asian Americans and 1.2 million Native Hawaiian and Pacific islanders. The five largest ethnic Asian American groups are Chinese, Filipino, Asian Indian, Vietnamese and Korean. And that the largest five Native Hawaiian, Pacific Islander ethnic group are Native Hawaiian, Samoan, Guamanian, Tongan and Fijian When you look at the numbers you see that the largest five groups make up almost 60% of the total Asian American, Native Hawaiian and Pacific Islander population. Next This slide shows the five states and counties with the highest number of Asian Americans, Native Hawaiians and Pacific Islanders. The three states in red — Hawaii, California and Texas have both high Asian Americans and Native Hawaiians and Pacific Islanders. New York and New Jersey have high Asian Americans And Washington and Florida have the highest number of Native Hawaiian and Pacific Islanders And if you look at the five counties that have the highest number of Asian Americans, it’s New York, Los Angeles, San Jose, San Francisco and San Diego. And for NHPI it is Honolulu, Hawaii, Los Angeles, Maui and San Diego So it’s not surprising that the highest number of Asian Americans or Pacific Islanders are in the counties that are in the state that also have the highest numbers. Next

So for the needs assessment report, we also looked at the socioeconomic status of this population group in terms of poverty and unemployment Asian American poor tend to be older. Native Hawaiian, Pacific Islanders poor tend to be younger Most people in poverty in terms of absolute numbers are Chinese, Asian Indian, Vietnamese, Korean and Filipino. However, when we look at poverty rates and unemployment rates, the poorest Asian Americans are Hmong, Bangladeshi, Cambodian, Pakistani, Vietnamese, Thai and Laotian And the poorest Native Hawaiian, Pacific Islanders are Marshallese, Tongan, Samoan, Palawan, Guamanian and Native Hawaiian We also look at the top five metropolitan areas with the most people in poverty because Asian American, Native Hawaiian and Pacific Islanders tend to live in clusters in metropolitan areas So for Asian Americans the top five metropolitan areas are New York, Los Angeles, San Francisco, Chicago and San Jose. And for Native Hawaiian, Pacific Islanders it is Honolulu, Los Angeles, Hilo, Seattle and San Francisco We also looked at limited English proficiency and linguistic isolation. Because language challenges leads to communication challenges And where there are communication difficulties, it impacts people’s abilities to access health or social services and systems Thirty two percent of Asian Americans are limited English proficient. Whereas in the general population, this rate is 9%. And when we look at subgroup data, the highest rates are seen in Vietnamese, as high as 51%. So that’s half the community were limited English proficient. So the highest rates for limited English proficiency is seen in Vietnamese, Bangladeshi, Cambodian, Hmong, Taiwanese, Chinese, Korean and Laotian Americans Twenty-one percent of Asian Americans are linguistically isolated. And the highest rates of isolation are seen in Vietnamese, Korean, Chinese, Bangladeshi and Laotian So linguistic isolation means all members of households over the age of 14 were limited English proficient. So it’s entire households who have language communication problems Nine Percent of Native Hawaiians and Pacific Islanders are limited English proficient Highest rates are seen in Marshallese, Fijian, Palawan, Tongan and Samoan. Next We also looked at health insurance coverage The highest five uninsured groups in Asian American population are Koreans, Hmong, Bangladeshi, Vietnamese and Asian Indians. And for Native Hawaiians it’s Tongan, Marshallese, Fijians, Guamanians and Samoans So the general un-insurance rate for the US population is 15%. And when you look at aggregate data, it’s the same for Asian Americans and Native Hawaiian, Pacific Islanders. But when we look at this aggregate data, you see how high the insurance coverage, or not coverage I should say, are quite as high as 35.5% in some communities. It’s 26% for Tongans in some communities Five states with the highest uninsured for Asian Americans are California, New York, Texas, New Jersey and Illinois. And for Native Hawaiian and Pacific Islanders it’s California, Hawaii, Washington, Texas and Utah There are new numbers available from ACA that there are 8 million new enrollees, 2.6 million through the state marketplaces and 5.4 million in the federal marketplaces. Of these 8 million, 7.9% are Asian Americans and .1% are Native Hawaiian and Pacific Islanders. Next So now we’re going to present some data on the mental health and substance abuse issues and Asian American and the Native Hawaiian, Pacific Islander communities. This section is also based on the literature and data that we reviewed from the needs assessment report

Next The general concerns — Asian American and to Native Hawaiian, Pacific Islanders are underrepresented in national studies. For example, the National Survey on Drug Use and Health, National Latino and Asian American Study, National Epidemiologic Survey on Alcohol and Related Conditions These national surveys also have methodological concerns. For example, they didn’t use culturally valid detection and diagnosis among Asian Americans, Native Hawaiians and Pacific Islanders Those studies that do have found that there are higher rates of mental health problems in these communities And these studies are usually done in English or Spanish. So if you are Asian American or a Native Hawaiian, Pacific Islander who has limited English proficiency or your household, you are linguistically isolated, you would not be represented in these surveys Sub-group data for Asian American, Native Hawaiian and Pacific Islanders are either not collected, analyzed or reported. Aggregate data is problematic because they usually report lowest rates in Asian Americans, Native Hawaiians and Pacific Islanders compared to other racial groups Aggregate data also masks sub-group differences For example, there are higher suicide risks in Asian elderly women. Higher rates of PTSD, or posttraumatic stress disorder and depression among Southeast Asian refugees, extremely high tobacco use among Pacific Islanders Next So this slide shows some mental health disorder rates. Any psychiatric disorder, lifetime prevalence for Chinese, Filipino, Vietnamese of 17.3%. Mental health disorder prevalence 15.8%, depression prevalence for Chinese 19.6%, posttraumatic stress disorder highest in refugees, for example Cambodians, Vietnamese. Next This slide shows some rates on suicide, suicidal ideation and attempts. For Asian Americans suicide rate of 6.24 per hundred thousand, suicidal ideation 8.6% and suicide attempts 2.5% Suicide is a problem for both Asian American and Native Hawaiian, Pacific Islander students Asian American high school students seriously considered attempting suicide, the rate is 18.9 to 21%. For NHPI high school students it is 16.7%. Next Substance abuse is also a problem in this community. As high as 64% Asian Americans, Native Hawaiian and Pacific Islanders reported alcohol as a problem when admitted for substance abuse treatment Smoking rates are incredibly high in Pacific Islanders. Forty-six percent Pacific Islanders, Samoans, Tongans smoke cigarettes, which is double the national average. Smoking rates are also very high in Vietnamese, Filipino and Chinese men Drugs like marijuana, cocaine, prescription drugs are also a problem. And the rates are the highest in Filipino men. Alcohol use and drugs are also a problem in the youth. Past month alcohol use in Filipinos are 9.7% and Asian Indians 5.1% And prescription drug use, foreign-borns have a higher use than US-borns. And it’s the opposite for alcohol use where US-borns have a higher – US-born youth have a higher alcohol use than foreign-borns. Next. Barriers to behavioral health problem. Reporting, detection and treatment

in Asian American, Native Hawaiian, Pacific Islanders is a big issue Treatment stigma — it is such a big problem that it leads to underreporting of mental health and substance abuse issues. There is lack of awareness of understanding of behavioral health problems or treatment options And that influences treatment seeking and coping mechanisms. For the longest time when I was a child I used to hear rumors that my grandmother was crazy. It turned out that she had mental health issues which were treatable And this is complicated by lack of access to care, which arises from high cost of services, low social economic status of the families, lack of health insurance Added to these barriers is the communication difficulties. If you are a limited English proficient patient, or your household that is linguistically antiquated, it’s going to be hard to communicate your problems And at last, there’s lack of culturally competent services and/or providers. Manifestation of psychological distress in Asians tend to be more somatic and emotional. And all these factors influence diagnosis. Next We also wanted to address some behavioral health service capacity issues. Factors that are associated with healthcare seeking behavior are acculturation, nativity, generation The Surgeon General’s report in 2001 reported that mental health services are underused across Asian American subgroups. And when we look at the rates of, you know, how Asian Americans use services versus the general population, we can see that 34% use services compared to 41% in the general US population Twenty-eight percent Asian Americans use specialty mental services compared to 54% in the general population. Sixteen percent Asian Americans use primary care services, 11% use alternative services Asian Americans seek mental health services more from general medical providers and other nonprofessional sources than mental health providers. Next There’s a shortage of bilingual, bicultural or culturally competent providers, that serve limited English proficient and low income Asian American, Native Hawaiians and Pacific Islander populations, for example doctors, psychologists, psychiatric, nurses, social workers, other paraprofessionals There is also a shortage of substance abuse treatment facilities providing services to this population group. A national survey found that that only 2% facilities provided services and Chinese, Korean, Tagalog, Vietnamese or Hmong So where do all these patients go? These patients go to the community health centers or CHCs and federally qualified health centers, FQHCs About 450,000 annually. CHCs and FQHCs provide preventative and treatment services that are affordable, linguistically accessible and culturally appropriate Asian American, Native Hawaiian and Pacific Islander-serving CHCs serve a high percentage of patients in a language other than English, as high as 52%. That’s half the patient population The ratio of patients to providers is very large in CHCs and FQHCs. There are also long wait list for patient mental health services Next So we can project what the behavioral health needs may be in Asian American, Native Hawaiian and Pacific Islanders. Eight million people are newly insured through ACA, 7.9% or about

632,000 are Asian American, Native Hawaiian and Pacific Islanders There will be an increase in the need, detection and treatment seeking for behavioral health services in both primary care and specialty mental health care. And uninsured and lower income Asian Americans, Native Hawaiian and Pacific Islanders have higher need for mental health treatment services than insured Asians Next So the next section I’ll be talking about what experiences of this population group has been with ACA outreach and enrollment And that these sections are based on multiple discussions that we’ve had with community-based organizations serving Asian American, Native Hawaiian and Pacific Islander communities across the country. Next So we collected information through group phone discussions, one-on-one phone calls and online surveys. We used standardized questionnaires for the group and one-on-one calls. There were 20 questions. And for the online survey there were eight questions And the information was collected during April and May this year. We sent email invitations multiple times to 69 Asian Americans, Native Hawaiian and Pacific Islanders, social service, health or mental health community-based organizations in 24 states Twenty-three organizations from nine states participated. For the group forum discussion we have two calls with 14 participants, one-on-one phone call with six participants and online survey with five participants. Next So the standard questionnaires that were used to collect information covered the following six areas. And these six areas were set by SAMHSA. Number 1, use and utility of existing outreach and enrollment resources. Number 2, general consumer attitudes toward healthcare and the ACA. Number 3, information seeking habits of consumers on healthcare and healthcare systems. Number 4, positive and negative experiences with ACA outreach and enrollment. Number 5, perceived barriers and challenges for ACA outreach and enrollment. And Number 6, needs for ACA outreach and enrollment efforts Next. So the community-based organizations talk about their positive experiences with ACA outreach and enrollment. The CBO said that from an organizational perspective it was very – it was a very rewarding experience to inform and educate the community on ACA and sign them up CBOs were very excited about the positive impact in the community. For example, people with behavioral conditions were able to discuss their issues and get coverage for preventive and treatment services The CBOs also talked about their consumer perspective. They said that the consumers had mixed responses toward healthcare and ACA. Communities were happy when they’re successfully involved and receive tax credits Consumers preferred online and paper applications The CBOs also said that Asian American, Native Hawaiian and Pacific Islanders communities needed in person and in language assistance regardless of the forms of enrollment. Next The community-based organizations identified four barriers and challenges. These were lack of culturally and linguistically competent resources, unreliable enrollment platforms, lack of funding and negative state policies They all said that these barriers and challenges negatively and directly affected ACA outreach and enrollment. Next So the first barrier, lack of culturally and linguistically competent resources. The CBO said that materials were available from the federal and state exchanges, but were not

used because they were lengthy or complex or vague Many materials did not target the Asian American, Native Hawaiian and Pacific Islander communities Materials were not culturally or linguistically competent. Materials not available in Asian American, Native Hawaiian and Pacific Islander languages, or if they were available had many translation errors So the community-based organizations did the following. They simplified and/or translated the government forms, created their own materials, outreach materials and translated them in different languages. They used word-of-mouth, in person, phone, webinar, email, Facebook, ethnic newspapers, radio to do their outreach And all the community-based organizations also said – actually can you go back to the last one. Thanks – said that they met community members, mostly face-to-face, in various settings like churches, town hall meetings, grocery stores. Next please Another barrier was the unreliable enrollment platform. Communities were disappointed when they didn’t qualify for Medicaid or receive tax credits. Income level forced people to enroll in the health plans that didn’t have good coverage When the enrollment website was down, consumers had to revisit and redo the application. And CBO stepped in here and help the call centers But were doing the enrollment application for those who needed some assistance, like the working class and LEP, it discouraged them from signing up. And put at risk the trust and relationship between the consumer and the CBOs Many limited English proficient and/or low income consumers approached the FQHCs. And FQHCs were overwhelmed with the response Some consumers were not able to keep their doctors who work in FQHCs or CHCs. Next Lack of funding was a big barrier. Most CBOs conducted outreach and enrollment with no or low funding. But the demand for their services was extremely high As several people said, cost for outreaching in LEP communities are much higher than in the mainstream communities in terms of time, money, staff, they have to hire outreach workers They have to hire certified counselors. And these all take more time and effort and money The CBOs were very concerned about the sustainability and quality of services. Many CBOs developed high quality materials for their limited English proficient communities. But they didn’t have technical or financial capacity to make them available on their websites. Government agencies can step in here, as this is a rich resource that is already developed. Next Negative state policies affected outreach and enrollment. Outreach and enrollment were discouraged in states where ACA was not fully supported by the state legislation. And this led to the navigators experiencing longer and more costly processes to be certified in those states. Next And so based on these discussions with the community-based organizations across the country and the literature and data we reviewed, we came up with some unmet needs of Asian American, Native Hawaiian and Pacific Islanders communities for successful ACA outreach and enrollment And some recommendations are made. Number 1, funding is needed for outreach efforts I already gave some examples where the funding is needed, for outreach workers, for certified counselors We need to develop outreach advisory committees with the different agencies that support ACA

outreach and enrollment, both government and private. We need to partner and collaborates with community organizations like CBOs, FQHCs, CHCs Why? Because these are the trusted sources of information. These are the gatekeepers in limited English proficient and low income communities. Support is needed for developing bilingual resources like workforce, simple pamphlets, simple one page pamphlets, videos And almost all the community-based organizations said that outreach efforts should be ongoing We should not wait until next November to start again. They also said outreach efforts should be directly relevant to enrollment goals. And if we say we want to target the young, we need to target the youth, the low income, the mom and pop stores We also should think about and work towards integrating behavioral healthcare with primary care. The limited English proficient and poor Asian American, Native Hawaiian and Pacific Islander consumers, they go to the safety net providers These safety net providers are primary care providers in solo, or small group practices or working in FQHCs or CHCs. And we wanted to present the data that most consumers from these communities go to primary care providers and other professionals rather than mental health providers. And there is also evidence when the integration of behavior with primary care, there’s better diagnosis and that there’s a better outcome CBO also talked about more accountability of government staff that are needed. No passing And last, we need disaggregated enrollment data. We know 7.9% Asian American, Native Hawaiian and Pacific Islanders enrolled. So that’s 632,000. We need to know who they are So we know who enrolled, who didn’t enroll so we can target at the next stage of the ACA outreach and enrollment So that was the gist of the presentation There are some other SAMHSA and CMS Webinars coming up. On July 17 there will be a CMS Webinar on connecting kids to coverage, July 22 on health insurance, how to get it, pay for it and use it July 23 and August 6 there will be two more webinars that specifically target Asian American, Native Hawaiian and Pacific Islander communities The July 23 one will be on the promising practices And on the 6th will be next steps to a healthier you. Next I hope you guys join us for these future webinars If you have any questions that are not answered during today’s webinar session, please feel free to contact Juliet Bui at SAMHSA or Perry Chan or myself or Charlene Kazner and Domin Chan and we will do our best to answer your questions We will be sending a post webinar survey after this webinar. Please, please respond and let us know if this webinar was useful to you And if you want to hear about other topics, you are very welcome to let us know that too So next be will open this webinar for questions and answers. You have to press Star 1 to get in the queue. And we will answer your questions in the order they’re received. You can also raise your hands or stand up. Just kidding Coordinator: Once again if you would like to ask a question, please press Star 1. Our first question today is from Manju Manju: Okay I have a question. We are a designated certified applications counselor agency. However, we do not have any funding. How do we go about getting funding to help the community? Suhaila Khan: That’s a very good question That was one of the biggest barriers that

the participants for the needs assessment report also raised that where do we find the funding So I can say on behalf of this group that you have to look for local funding, state funding and federal funding. But it’s very limited at this point in time Manju: Okay. Is this presentation available on PowerPoint? Suhaila Khan: Will you please repeat yourself? Manju: Is this presentation available for us to review it again if I need to? Suhaila Khan: Yes. It was sent in an email reminder that was sent to you Manju: Okay Suhaila Khan: I think it was sent by half an hour before the webinar started. So it should be in an email Manju: Okay Suhaila Khan: And it will also be available I think in the future on the SAMHSA Web site Manju: All right, sounds good Suhaila Khan: And we can also include this when we send the post webinar survey to you if you’re interested Manju: That will be great Suhaila Khan: Thank you Coordinator: Thank you. Our next question is from (Pricilla) Priscilla: Hi. This is Priscilla from the Asian and Pacific Islander American Health Forum. Thank you for the presentation. I had two questions. One is you mentioned that, and you went over kind of the methodology for collecting the responses and conducting a needs assessment. So I was curious if that needs assessment is available? Suhaila Khan: At this point it is not public But we can make that request on your behalf to SAMHSA. You can also email SAMHSA directly You can email Juliet Bui is listed as a contact for this webinar Priscilla: Okay great. Thank you. And then my next question is in the overview of the barriers, I guess I was a little surprised that there was no mention of immigration status as an outreach and enrollment barrier. Did you – I was curious to hear if in your interviews and surveys if those issues came up at all? Suhaila Khan: Yes they did. I think the reason we didn’t include it in the presentation was because of the timeframe. That was definitely an issue. And immigration was a big issue And one of the concerns was that especially it was reported from the East Coast that if you are a US citizen then your application process was faster. But if you are not, it took longer and sometimes it didn’t happen So it is definitely an issue that came up And we have much more detail in the needs assessment report Priscilla: Great. Thank you Suhaila Khan: You’re welcome Coordinator: Thank you. Our next question is from Bonnie Quan Bonnie Quan: Hi there. Actually my question was also going to be if the needs assessment was going to be available Suhaila Khan: We can make that request on your behalf. And you can also request SAMHSA directly Bonnie Quan: Okay. Thank you very much Suhaila Khan: When you ask your questions, can you please introduce yourself and your organization so we know who we are talking to? Coordinator: And as a reminder, to ask a question, please press Star 1. Our next question is from Joy Yoo Joy Yoo: Hi, this is Joy Yoo from the Asian and Pacific Islander Scholarship Fund. And I am interested, you know, in terms of the bilingual resources, whether that’s on the video or print materials or website We, as a scholarship fund, have a translated some of our materials. But it can be costly And I’m just wondering what kind of resources you all might be aware of or have utilized in terms of translating materials and ensuring that they are fully translated and correctly translated Suhaila Khan: Thank you. So for the needs assessment report, we also did and environmental scan of many Asian American, Native Hawaiian and Pacific Islander organization web sites to see what kind of materials are available related to ACA And whether, you know, they’re in English or that they’re in, you know, other languages, et cetera. And there are some. And we have a list of these organizations and examples

of what’s available in detail in the needs assessment report We didn’t present any of that information in this webinar because of the short timeframe But some of that information is available But the general consensus is that many Asian American, Native Hawaiian and Pacific Islander communities, they’ve developed their own materials and translated the materials But they’re not available on the web sites because of lack of, you know, funding or because, you know, they don’t have the technical capacity for that. But there are materials out there Coordinator: Thank you. Our next question is from Manju Manju: I’m sorry. I keep coming back. I just have one Suhaila Khan: Can you tell us which organization you work for? Manju: Okay. I’m from Ohio Asian American Health Coalition in Columbus, Ohio. I just wanted to tell you in our Great Lakes Regional Health Equity Council, we actually developed a survey to measure the knowledge that was gained during the enrollment process That was done on a limited basis in Ohio and Michigan. Somebody asked about the survey I just wanted to tell you it was developed and we did do some survey to measure the knowledge they gained during the enrollment process Suhaila Khan: Is that survey available on your website? Manju: Yes it is Suhaila Khan: Great Manju: It’s very brief, but it kind of tells you how much they learned from the first time to the completion. And also we had – we used some social media also on the Facebook Suhaila Khan: That’s fantastic. So I hope the speakers – the participants in this webinar can access that Manju: Definitely. If they have a problem with it, just they can call me or they can go to the web site, which is – they can just send me an email. Maybe that’s much easier It’s oaahc@oahcoalition.org. They can go to our web site which is oahcoalition.org Suhaila Khan: Thank you very much. That’s very helpful Manju: All right Coordinator: Thank you. And once again to ask a question, please press Star 1. Our next question is from Vattana Peong Vattana Peong: Hello? Coordinator: Go ahead. Your line is open Vattana Peong: Can you hear me? Suhaila Khan: Yes we can Vattana Peong: My name is Vattana. I am from the Cambodian Family Center in Santana, Orange County, California. I have a couple questions regarding the data and respondent So basically all the respondents that you collected the data from, were they CBOs? Suhaila Khan: Yes Vattana Peong: I see. And I have experience working with the population here. We also have a lot of people that have come and applied for the ACAs, but in California they have a name change, it’s called Covered California And they were really frustrated with the long waiting time. So I was wondering the barriers to getting the enrollment could be also the long waited time that people have to wait and get enrolled in that And also the second thing is that in some county, they have these, their own safety net program in which they provide to people who do not qualify for Medicare or Medicaid program. And then they qualify for the county safety net program And those that are in that program usually are low income people who usually, like 95% they enroll automatically to the Covered California or ACA. And I was thinking about why you do not include the county for the part of the respondents because they might be able to give you a lot of good insights about the enrollment challenges in that particular spectrum Suhaila Khan: Thank you. So I agree with you that the long wait time was also a factor, was a barrier in the successful ACA outreach and enrollment. And that’s included in the

more detailed needs assessment report The second part of your comment, why we didn’t include the counties and that people use that county health services as, you know, the safety net provider is because we didn’t have time to look at the data. But that’s also a very important resource for low income communities Vattana Peong: Thank you Suhaila Khan: You’re welcome Coordinator: Thank you. And ma’am I am showing no further questions at this time Suhaila Khan: Well if that there are no more questions, I guess then that we wrap up. And if you think of any further questions, please feel free to email Juliet Bui, Perry Chan, myself, Suhaila Khan, Charlene Kazner or Domin Chan The PowerPoints were sent in an email reminder a half an hour before this webinar. And they will also be included again in the post webinar survey that will be sent to you pretty soon And hopefully this will also be available soon on the SAMHSA webinar. We hope that you enjoyed our webinar and that you learned many things. And we hope to see you during the future webinars again. Thank you so much and have a very good evening Coordinator: Thank you. And that this does conclude today’s conference. You may disconnect at this time