EP.9 OPEN ACCESS, OPEN MIC WITH PHYLLIS KAUFMAN

Welcome along to the latest episode of Open Access Open Mic with the Apt Foundation. Now on today's episode, we are joined by our very special guest, Phyllis Kaufman. Now Phyllis has over 20 years of experience designing cross sector strategies that connect institutions and communities. Now transitioning from being a lawyer to working in public health, Phyllis has led and contributed to a large number of impactful projects.

Most recently as Director of Planning at the RISE Centre. RISE Centre is New York City Health and Hospitals innovative multidisciplinary clinical programme for pregnant and postpartum women and their children impacted by substance use disorder. I'm really looking forward to finding out more about your work. So Phyllis, welcome to Open Access Open Mic.

Well, thank you, Claire, for that lovely introduction. Thank you, Lynn Madden, and APT Foundation for inviting me to participate in this month's Open Access Open Mic podcast.

We are delighted to have you.

thank you. So to answer your question, Claire, in terms of my transition from an active law practice to working in public health, bit of a circuitous route.

After advising several clients who are founders, I decided to try the role for myself. And so I am the co-founder and former producing director of Theater of War Productions, a social impact company that uses theater and other media to address public health, social justice issues. And with Theater of War, I traveled around the world to military sites, medical conferences, post-natural disaster communities.

And these community-specific visits highlighted the importance of hearing in community members' voices what they viewed as barriers to seeking healthcare and what they viewed as healthcare being essential for them to go ahead and come into care. And that really engaged me in terms of trying to understand these barriers.

and trying to work with other teams to address these barriers. So after a brief stint back to law school to do advanced work in human rights, I began to consult with organizations like Physicians for Human Rights, Center for Victims of Torture. Those were largely medical legal partnerships, which also gave me the opportunity to begin to understand the downstream impact of policy and legislation.

And then I moved into delivery of direct services. The two positions that I most recently held were with Massachusetts General Hospital Psychiatry Academy and New York State Office of Mental Health for Project TEACH. And then, as you mentioned, Claire, New York City Health and Hospitals Rise Center.

Well, you've not done much then really, have you? mean, you possibly could have done a little bit more, do you think, Phyllis? Joking aside.

And there's always a lot more to do, that's for sure. And that I think is going to be the focus of what we talk about today. What can we do? What models are out there that can address, in particular, women who are using drugs, but also pregnant and parenting women who are using drugs?

You're not wrong

And Claire, you know, I only introduce you to powerfully interesting people who care about vulnerability, right? And who care in ways that I think connect structural solutions to actual human beings, right? And that is not, I think, always the case for people who are in sort of structural or planning kinds of positions.

Absolutely.

Yes.

But in the case of Phyllis and some of the other guests that we've had on, her work, from my perspective, really spans this theoretical set of ideas about how you can improve care for vulnerable populations and why it actually matters. It spans that all the way to seeing that it actually takes place and taking in that perspective.

Well, thank you so much for that, Lynn. And you know, that is also part of this transition journey, right? Is after being a lawyer and working within the constructs of the law, looking beyond that and where are those solutions that live beyond those particular structures?

I can't wait to find out more. Tell me a little bit about the Rise Centre. Tell me more about that.

So the RISE Center is, Clara, as you mentioned, a multidisciplinary, fully integrated specialty clinical care model designed specifically for pregnant and postpartum women and their children impacted by substance use opioid use disorder. Co-located in one safe space, there is the full continuum of care. So we're talking about adult and child family medicine, women's health, OB-GYN.

adult and child behavioral health and addiction medicine treatment. And this particular model, and there are several other models across the country, this particular model was designed to try to avoid as much as possible fractured care. Fractured care frequently results in

lack of short-term and long-term adherence to treatment protocols. And I want to talk more about this particular model perhaps later in our conversation if that works for both of you. Because I think, as I mentioned earlier, one of the reasons that I feel so passionate about this work is because there are so many barriers keeping people from seeking care.

and keeping people from seeking care sooner rather than later. So we're not talking about the ER versus a much more public health centered lens. So I'd like to come back to the RYCEN or other models a little bit later if that works for both of you.

Absolutely, without a doubt. You know, some of the work we've been doing certainly with the App Foundation is about smashing stigma. It's about breaking down barriers. It's about getting people into care as quickly as possible. You know, we want people to get better. So thinking about the work and the experiences you've had, what do you view as the most major barriers to bringing women using drugs into care?

The bar to seeking care has just been raised. But now, after two Trump presidencies, I have to say, well, the bar has been raised exponentially higher. So what we're looking at right now is a landscape that is much more punitive than looking at the landscape through a public health intervention lens.

So with that said, and Lynn, please jump in, what I see and what I'm hearing from this group of women and also from clinicians, hospitals working in this area is the barriers fall into a handful of big buckets. The first one I want to mention is legal. And so we're talking about the criminalization of the use of drugs during pregnancy.

Now the causes of action that are being brought across the country, state by state, quite variable, the list is quite long and growing. Probably the cause of action that you're gonna see the most or the causes of action that you're gonna see the most is negligence, child abuse, endangerment. Those causes of action are frequently coupled with many other causes of action and we are now seeing homicide as well.

So that is one big bucket. Another big bucket is the engagement of child services. So the engagement of child services frequently results in separation of families, frequently results in entanglements in family court, where judges, prosecutors, defense attorneys are not necessarily very well informed or educated.

about the use of drugs during pregnancy postpartum, including the gold standard buprenorphine and methadone. And that also, once you hit that place, can result in foster care. I just want to mention many of the women who come into care when they are pregnant already have children in their own households. So they may already be involved with family court at some.

at some point in time. Another bucket is psychosocial. So we're talking about co-occurring mental health issues, isolation, Claire, as you mentioned, stigma is huge, loneliness, lack of support from family members, lack of support from community members, sexual trauma, and trauma writ large. Then we're looking at a bucket of socioeconomic issues.

lack of health insurance, lack of ability to self-pay, cost of time. Many of these women are working more than one jobs, cost of childcare, cost of transportation to a treatment facility, many other issues that relate to the socioeconomic status of a woman. And then we're looking at some

systems level issues. So we're talking about healthcare institutions, provider level. And these issues are frequently top of mind along with family separation and criminalization. And they relate to things like lack of trust. had many of these women have had very negative experiences with healthcare, healthcare particular providers in the past. There is

toxicology issues, lack of toxicology testing without prior informed written consent, the culture of reporting to child services, particularly in the NICU and how to change that culture. Then we have, you know, on a provider level, the lack of education that providers have in terms of initiating MOUD.

and just the lack of, or hesitancy I should say, of many providers in treating pregnant women using drugs. So those system level issues are quite difficult. And Lynn, I think you might want to mention APT Foundation, Low Barrier Coming Into Care, because that wait time, once,

a woman waves us her hand and says, I'm coming into care, can really, really be a deterrent to following through with initiation of treatment. So maybe you want to say a little bit about APT's really important work in that area.

Yeah,

thank you so much, Phyllis, and I thank you for that really thoughtful answer. I will amplify that by saying, listen, it's already really hard to get into treatment for a drug use disorder. Period. End of statement. No matter who you are. And the reality is, part of the reason that that is so difficult, is a person has to be able to internalize that they need help.

And that's a hard thing to do in our culture, right? Because it carries with it this stigma that somehow you're less than a good person for everyone. As with almost all services in our country and indeed across most of the world, if you are a woman, that is amplified further, right? If you are a parenting woman, that's amplified even further.

Right? So you have this kind of scaffolding of difficulties or stigmas that are just attached to who you are. And the systems are in fact organized around that. So as Phyllis mentioned, a woman who is pregnant and perhaps is already a parent has other children in her home is going to be doubly judged for the fact that she's a mom and a female who

who needs help with a drug use problem, right? And our laws actually support that level of judgment in the guise of saying that it's better for your child or your unborn child if we do things on your behalf, excluding you from the care of your own family, right? There is not very much data to support that separating mom and child is helpful for either of them.

and we don't do it with other chronic illnesses that in fact may also have behavioral components such as, for example, tobacco use, right? So when it, which is really hard on the body and hard on a child living in a home where tobacco is used, but yet that isn't a reason for separating parents and children. So in the case of drug use disorders, the crime of having an illness is at the heart.

of actually the stigma and the structural problems that people have accessing treatment. And I would just simply say that is completely exacerbated by being female and by being a person who is female, a person of color, a person who's parenting or about to become a parent or all of the above. You know, that kind of stigma gets very much amplified.

Yes, absolutely, absolutely. And you know, from a policy perspective, which, you know, I'll just mention briefly and we can talk about that a little bit more later in the conversation. Current policy, I believe just on April 24th, I could be getting that date wrong. There were two letters issued by SAMHSA coming from the administration. One of them was about

the use of buprenorphine and methadone not being the road to recovery, that those gold standards should be viewed as something that is not a long-term use, but coupled with treatment, a behavioral health treatment, and other interventions. So now we're talking about the gold standard for substance use disorder, for MOUD.

no longer being described as the road to recovery and being able to be a helpful, stable parent. So that message, the downstream effect on women, pregnant women using drugs, is also another inhibiting factor to coming into care.

there's a very interesting ethnography, a book called Addicted, Pregnant, and Poor by Kelly Rae Knight, that if folks are really interested in this topic. And this ethnography really tells stories, if you will, or observations from the field regarding women who are pregnant and the challenges that they face that are truly, in fact, exacerbated by needing care or health.

for their drug use disorder. And as Phyllis just mentioned, the other real challenge that we have is that some of the well-researched, well-known science is being rolled back in the moment, right? So this idea that you're using a medicine for recovery being a negative thing is only attached really to drug use problems, right? When we use a medicine for recovery,

or stability when you're living with diabetes, for example, or living with COPD, that is not judged as somehow not being a good way to take care of yourself or not being the gold standard of care. In fact, it's judged in the opposite way. If you were a provider not providing your patient who's living with diabetes with the appropriate medication interventions, you would be liable for that. And what we're seeing is this

sort of turnaround in the field of addiction where there is this, medicines themselves, which actually save lives and work very, very well. They work better than almost any medicine for any other chronic illness. As a matter of fact, these medicines are being stigmatized even more strongly than they have been in the past. And healthcare providers are being encouraged at some level or

certainly not discouraged from saying, I don't take care of this kind of person. And that's really not okay from a medical perspective, a clinical perspective, a cultural perspective. And I would suggest as this conversation has been sort of thematically organized around that that kind of decision-making is more strongly endorsed among women.

and among parenting women.

I want to go back to Lynn's point for a moment to family court because what happens frequently in family court is that a woman is told that if you're using buprenorphine, if you're using methadone, you have to move to abstinence before your children are returned to you. So again,

The gold standard that allows someone to live a long and healthy life and be a really solid good parent is no longer viewed in that way.

Okay, thinking about your experience, Phyllis, how do you, sorry, how should we be moving forward as we try to bring more pregnant women and postpartum women impacted into care?

So that's a tough question to answer. But what I will do is talk about the Rye Center model, which when I left that position was moving towards implementation, as well as other similar models across the country. And I spoke to probably 12 to 15 of them to get some sense of what other cities and states were doing to address this issue.

So again, going to the RISE model, multidisciplinary, fully integrated specialty care model, specifically designed for pregnant postpartum women and their children. And, you know, I mentioned the co-location of the full continuum of care. And I think that word co-location is something very important to keep in mind.

Because again, the co-location of the full continuum of care for women and their children is structured to avoid fractured care and the lack of adherence to any kind of treatment protocol when fractured care is required. And all of those buckets that I mentioned before, psychosocial, socioeconomic, they all come into play.

if you can't go to one place, warm, friendly location and get the full continuum of care that you need for mother and child. Not all of the other models across the country have been able to do that for a variety of structural reasons, but all of them unanimously said that that is key to bringing women to care and keeping them in care.

The other aspect of the RISE model that I think is very important is the focus on the children living in these homes. And it's not just the newborn child or babies, but it's also taking a look at the older children living in these households because they are often frequently at most risk of developing

SUD and OUD later in life. Now, in terms of looking at all of the models, the age range that children can stay in these programs is frequently limited by funding restrictions as well as institutional structures. And I should mention, funding is another barrier to coming into care because the amount of federal state

and other support for programs like this right now is very limited. But in terms of that age range, some programs are limited to two-year-olds, some to five-year-olds, and some are really trying to extend the age of children in these programs. All of them across the country unanimously were, let's keep these kids in as long as we can. That also goes for the moms.

you know, sometimes there are restrictions for how long women can stay in these programs. Certainly all of the programs, I think, yeah, I can say that all of the programs are flexible to keep women in care for the first 12 months after delivery, those months being the months when women are most at risk for relapse. And that is another aspect of

the RISE model and some of the other models out there, which is advanced relapse planning. That is really, really important to have a plan in place, a written plan in place for other family members, other caregivers who can step in when a relapse occurs. No surprise if it does. And that also hopefully avoids family services jumping in at the first moment.

that there may be a relapse. That's also something that hopefully provides staff members with a culture beside immediately reflexing, reflexively reporting to child services. So those are some really important aspects. The other continuum of care that is offered at almost all of the programs is wraparound services on site.

So we're talking about trained childcare. We're talking about food pantry. We're talking about baby infant supplies, sometimes pregnancy clothing, everything that's going to make it easier and also, you know, friendly in terms of there's a lot going on beside getting health care. These are all important supports. And that brings us to the other issue, which is having a really strong case management aspect to your program.

so that referrals out to trusted community organizations are not only provided with a warm handoff, but also followed up. Did these families actually go for these supports? So supports for other aspects of recovery. We're talking about food security, employment opportunities, educational opportunities.

income stability. All of those wraparound services are particularly important. And then I want to talk a little bit about community and involving the community in these programs. So the Rye Center, with the exception of a few of the programs that I spoke with, are all outpatient for MOUD.

So in some cases, residential treatment is going to be appropriate. So referrals out to trusted residential facilities, very important. And to the extent that there are residential facilities that will take women and their children up to usually preschool or kindergarten in some cases, very important. And then to get...

those referrals back from the residential treatment facility when women complete their stint in residential treatment. But we're also talking about the support of trusted community harm reduction organizations. We're also talking about houses of worship. Frequently, know, houses of worship are the first stop for

women in their communities to discuss what their options are to discuss. And I should mention in terms of psychosocial barriers to coming into care, frequently there are religious and other cultural concerns that women are addressing in terms of coming into care. So houses of worship, very important. I mean, I was quite lucky. I worked with a very activist chaplain.

when I was with the Rye Center, who would really go out to her house of worship and others talking about de-stigmatization of women using drugs generally and certainly pregnant women using drugs. So I think that's very, very important. Working with the community at the outset of implementing one of these programs, you gotta get the community on board. And that brings me to another point, which is

Not all of the programs did this, but all of them recommended that this be done is that internally you form some nature of advisory group, advisory board, which includes the voices of the women who have been and are currently in the program, as well as other community members. So again, bringing in the harm reduction community members.

And also just neighbors surrounding you. There could be schools close by or other community members who you really want to be supportive. So again, and this goes back to my sort of journey into public health from law, which is hearing community members in their own voices express what's keeping me from coming into care and what is the care that I really need? Not what you think I need.

but what I really need.

I couldn't agree with you more there, Phyllis. I think that at some level we have to make this simple for people to digest this idea. And the idea is, for me, as straightforward as this. If you have a drug use disorder, then by definition you have a chronic illness and you need all of the support that goes into managing and living

Yeah.

with

any kind of chronic illness. And the first and most important piece of all of that is access. You have to have access to evidence-based care and someone has to ask you and listen to you, tell them what it is that you actually need. And then work with you to provide within the constructs of what is actually

evidence-based to provide that. Right? So if you need a medication, you need a medication and you need it today, not a month from now or three weeks from now. And if you need a place to live, you need to find a way to do that in real time. If your child needs diapers, you need them now. Right? So a way of thinking about how we understand what the

needs of a person might be as important to the constellation of interventions or assistance that might actually help them be on a path to recovery and maintain in that space. And when it comes to relapse, we so often consider relapse or return to drug use as a failure, as a failure of the individual or potential

a failure of the healthcare system or both, when in fact what it is is normal. Everyone relapses, right? These are chronic, reoccurring conditions. And by nature, that's the definition of them. And if we move away from drug use for a moment and into another kind of chronic illness, such as diabetes, what you see is that there really are no people who 100 % manage

their

diabetes every minute of every day perfectly well, right? They're not judged for that per se. What they are in fact taught is when to take care of themselves, how to take care of themselves, when to touch the healthcare system, and what to expect from touching the healthcare system. This is not the kind of approach that we use with the chronicity of drug use disorders. We in fact kind of dismiss people

who return to use and put them at the end of the line, right? Because they're not worthy in the moment or they don't, they're not motivated, whatever that actually means. When in fact, what we should be doing is encouraging them, look, that you know what the best indicator of doing well in the future is? It's having done well in the past. So you did it, you made it, you did it for a month or you did it for a year. You can do that again. Yeah.

as soon as you can come into the organization as soon as you can reach out to us call us use our app whatever it may be as soon as you feel like you're in difficulty because that's true support and that's how you really center a person in their own lives right is putting them in the middle and giving them the tools and the language to advocate for themselves and to be heard and responded to in real time.

Again, I couldn't emphasize more that that is more difficult as a skill set for women in our culture than in general, than it is for men. And I think that has to be considered when we're talking about women's healthcare planning.

Absolutely. You know, I want to I want to emphasize what you just said, Lynn, which is to talk a little bit about harm reduction, because I think, you know, these programs also have to be able to meet women where they are when they raise their hands and say, want to come into care. Some of them may not be ready to initiate MOUD. They may need

Absolutely. Yeah, agree more.

to look at harm reduction initially. And so I think, you know, in terms of wherever a woman is, when she raises her hand, you need to hear what she's prepared to do and then work very carefully and patiently to move that person on a path to recovery. And harm reduction does not mean that you're not on a path to recovery. And again, I'm gonna go back to there was a second.

for women to come into care and also for the institutions providing that care, right? Because no one wants their federal funding cut off. No one wants their state funding cut off. So now what do you do with someone who says, I'm ready to come in, but I'm not ready to start MOUD? I want to wait until after delivery. I want to wait until after the first three months. I tried it before and I had these side effects. want to wait.

There we go again with the downstream impact of policy.

Do know that leads me on beautifully? I've got two more questions for you guys, but that leads me on beautifully to this one. Let's talk a little bit about what policy looks like now for women using drugs under the second term under a Trump administration.

Well, I just mentioned two very particular examples of what that means. Lynn, please correct me if I'm quoting you inaccurately, but I want to talk about the two words that you frequently use, which is don't die. And I would like to add to that, keep families together. But in terms of don't die, you touched briefly on this before, Lynn, which is

Why is substance use disorder writ large?

And then again, particularly for women and particularly for women who are pregnant using drugs, why is that treated as a chronic condition versus as an emergency life threatening condition like a heart attack would be? What are we talking about in terms of time to first dose? Why from a legislative policy perspective and a cultural perspective, have we not been able at this point in

particularly given the overdose deaths that we've seen over time in this country and the threat of these new substances that are on the street. Why? Why have we not been able to get to that place? And frankly, based on

two terms of the Trump administration. I don't see that movement happening at the moment, but Lynn, I'll turn that over to you in terms of, you know, don't die.

Yeah, think that, thank you first of all for bringing that up. That needs to be first and foremost in our minds. We have had decades of overdose deaths. In the last 10 years, more than 100,000 people a year have died from drug overdoses in the United States. 100,000 people a year, twice as many as the number of people who die in motor vehicle accidents. Yet,

We continue to restrict access to the interventions that would really prevent that death, even if they didn't do all of the other things. First and foremost, don't die. Then we can talk a bit about getting your life on track. Let's get you on a stable dose of medicine, which is the only known...

interrupter for opioid use disorder that has a high efficacy rate. And it's not particularly expensive compared to some of the other interventions, right? So from a public health point of view, your point is really well taken, Phyllis. People identified with opioid use disorder should be prescribed a medication. Whether they stay on it or not is a different issue altogether, but that should be the first response of the healthcare system is to

consider this medication. It should be doubly the first response for a woman who is expecting a child, right? Because untreated opioid use disorder in pregnancy leads to all kinds of negative outcomes, including death of the infant, prepartum or at birth, including low birth weight babies, et cetera. So there are all kinds of reasons to consider very safe alternative of offering

medication in real time to people who have that constellation of need. And you ask the question, you know, why don't we do this? And I do think that that is the big question, right? We've never done it well.

But right now in our political landscape, we are certainly more conservative when it comes to women's healthcare than we have been in decades. So that's what's been happening over the last 18 months or so is that there's been an erosion of healthcare access for women, reproductive health, but also other kinds of healthcare. When you focus on, for example, controlling bodies of women,

by

denying them access to healthcare that they actually need, that's a form of what we would call biopower. That's a form of power of the state over a person's body that is in fact negative in this particular case. And that is, I think, in the United States or has been growing in the United States over this past 18 months or so, as I've

and it does not bode well for women's health and then by extension for the health of young children in particular.

Do you know what? I've got one more question and it's for both of you. We're gonna finish up with this one. And I'd like, yeah, I'd like you both to answer it if possible. You know, just thinking about particularly that topic and the impact that it's having right now on families, right now. What keeps you motivated to work in such a challenging field? Both of you. I mean, it's...

It's hard, right? It's hard. You're seeing on the front lines the outcomes and the consequences of some really big decisions being made by people very far removed from some would say real life. What keeps you guys motivated?

Yeah, I'm gonna start by saying one of the things that keeps me motivated, and I wanna give you a longer answer, but one of the things that keeps me motivated is meeting people and talking to people like Phyllis.

That's very kind, Lynn. I really appreciate it. And right back at you, same thing. I mean, there's some incredible, Lynn being one of them, people out there who've been doing this work for a very long time. And it is important that they continue to do this really important work for a very long time because the landscape right now has really become very punitive, very restrictive. And I think that just for me anyway,

makes me feel that I want to do more. want to stay in this area and I want to support women, but all people who are using drugs and then all people coming into care. And Lynn, I don't think you've done sufficient justice to the app foundation because I think one of the things that is so key right now is the cost of healthcare for everyone is so extraordinary, so extraordinary.

The App Foundation's low barrier to care, which isn't going to, and Lynn, you speak to this because you know the mechanics of it better than I do, but someone coming into care at the App Foundation is not going to have to go through as many hurdles as someone coming into another large medical institution in terms of payment, in terms of behavioral health therapy first.

in terms of all sorts of regulatory red tape. Certainly there is some, but I think, Lynn, doing that work, for me, that is so exciting, because there's a model out there that is going to address what we're all looking at, and particular, again, women, and particular women using drugs, and women who are pregnant using drugs. So maybe you wanna say a little bit about that foundation work, and...

Why that empowers me to stay in this area.

Yeah, thank you. I will say App Foundation has worked really hard for about 20 years now at identifying and reducing barriers to care. mean, first and foremost, I think we have to acknowledge that the treatment gap is very wide. Fewer than one in five people who need one of these medicines actually receives it. That motivates me, Claire, when in terms of thinking about, you know, what can we actually do? One of the things that is

associated with that is that if you don't receive care, your likelihood of death is about 50 % higher than a person who doesn't have an opioid use disorder. Right? So that's highly motivating for me from a public health point of view. Look, we have an intervention. We know it can work. We can actually keep you from dying. But you have to be able to get to the treatment.

Here at Apt, our census went over the last decade or so, a couple of decades, from around 1,200 people to more than 8,000 people. And we did all of that with walk-in access. You really can walk in six days a week. We will evaluate you. We have residential treatment. We have outpatient treatment. We have primary care. All of the things that Phyllis was talking about in terms of as much as we can gather under one roof. And we've made several roofs.

if you will, but all interrelated. And we've made the access to those services simple. Just show up.

And that for me is the basic bottom line. And we know how to do this in our medical system in the US. You can show up at an emergency department, they will let you in. You might wait a couple of hours, but you're not gonna wait three weeks. They're gonna let you in, they're gonna have a look at you. We took that set of ideas and said, okay, how can we apply this to the environment that we're in?

And then secondly, we began to really develop the idea amongst our staff, which is so critical and hopefully amongst the community as well. This kind of care is really urgent.

This is not something that you can put off, right? I mean, this is a kind of care that can save your life today because every single time a person uses drugs, they are at risk of dying from a drug overdose every single time. And so to the extent that you can interrupt their drug use,

then you interrupt that potential for a person actually dying. And I'm not sure that all medicine isn't organized in that way, right? And just really trying to conceive of addiction medicine or the treatment of people who have drug use problems in the same way that potentially we conceive of other kinds of chronicity is for me very motivating.

empowering, but it truly is meeting people like Phyllis, who are committed to what we're trying to do and committed to moving forward in a field that is structurally impeded in various ebbs and flows, right? The politics change.

And that almost always brings with it political change regarding people who use drugs to excess. And that is a symptom of stigma to a very, very large degree. It could not be illustrated more strongly. But I also see in the face of that, know, progress is made. And when you make progress, these are real people.

So when I talk about moving from 1,200 people that we care for in any given year to 8,000 people, these are real people. They live in the community that I live in. They live in your community. And you really can do things that make a difference. And I find that to be a challenge that keeps me moving.

Guys, I can't thank you enough. I can't think of a better way to end today's podcast. On Open Access, Open Mic with the App Foundation, Phyllis Kaufman and Lynn Madden, thank you so much. I'm gonna put as much as I can, the information that we've been talking about on the show today, in the show notes with some links out as best I possibly can. All I can say is let's keep up the good fight and keep doing the right thing for as many people as possible. Thank you, Phyllis.

Tell us, thank you so much.

Thank you, Lynn,

so much. Thank you, Claire. Pleasure.

As always Claire, you're a rock star.