The Rural Health Revolution, Part 2: Bridging Gaps, Empowering Communities

Episode Topic: Bridging Gaps, Empowering Communities

AI holds immense promise, yet Ketan Paranjape warns the “last mile” remains a formidable barrier. From rural Indiana to India, infrastructure gaps and cultural nuances challenge the scalability of digital health. Explore how we can bridge this divide by prioritizing human kinship and ethical innovation over mere algorithmic speed. 

Featured Speakers:

• Dr. Ketan Paranjape, Bioscope AI
• Bukata Hayes, Blue Cross and Blue Shield of Minnesota
• Emily Ho, Northwestern
• Erwin Tan, AARP
• Shelley Kendrick '10 MNA, Ecumen

Read this episode's recap over on the University of Notre Dame's open online learning community platform, ThinkND: https://go.nd.edu/418575.

This podcast is a part of the ThinkND Series titled The Rural Health Revolution. 

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Transcript

Introduction

Speaker 10 0:06

It is my privilege to actually introduce you to your first speaker, Dr. Katon Paranjape. He is the Chief Operating Officer of the Enterprise Imaging at Optum, where he leads global operations for diagnostic imaging platforms that impact patients around the world. His career spans leadership at Roche, Intel and Health 2 0 4 7 always focused on transforming healthcare through data and innovation. He also serves as the digital health expert for the World Health Organization. So please join me in giving a warm welcome to Dr. Kean Perrin Jape.

Speaker 2 0:44

Yes, thank you. Good morning. Morning everybody. And I guess after the panel that you guys were part of just now, I dunno if we can keep up. But, what I'm gonna share with you all today is just experience that have had. Outside Optum. So this is all personal and nothing to do with Optum. So just wanna put that, uh, sort of disclaimer out there. What I'll do today is talk about, um, rural health and ai. And I think as part of the panel this morning, one of the big learnings was do you need ai? Right? In rural health? And my take is gonna be not yet.'cause we still have to fix a lot of problems internally before we get there. I have done a lot of, uh, rural health literally across the world. So I'll share those experiences and once you hear that, you'll realize that in a rural Indiana versus rural India are two different worlds, right? Even though both have rural in them, uh, you'll see the difference. So one size will not fit all right? So how do we sort of work with that? So the plan today is I'll just give some personal story of the health foundation, uh, that my wife and I run. And once you see how the last mile component works, hope you appreciate that getting AI then in that situation. Is a little difficult in that in terms of the infrastructure, getting people trained and actually deploying, you know, the solution in the market, not understanding what the true pain point it's you're trying to solve. Right? So we'll try to hopefully cover all that. Then we'll talk about the barriers into healthcare in rural communities, which of course, you know, I think all of us know that what AI troubles could they run into, wants to implement that. And then I'll show a whole bunch of examples and we'll get a good feel for, you know, where things are today. So starting with a personal story, uh, 2010, my wife and I started a little foundation back in India, and the intent was to do telemedicine services, right? It's a pretty broad concept. This is 2010, by the way, right? So no TikTok, no iPhones, none of that stuff. Well, there was iPhone, but not in India. and I was working for Intel at that time. So we had laptops. They gave me, um, you know, some whole bunch of laptops to go deploy the solution. They were no telemedicine solutions at that time, so you had to go build one. There was no zoom, so you had to use the camera on the. Anybody remember this thing called centrino on your laptops? I guess I'm dating myself. No.

Speaker 3 2:58

Okay.

Ethics, Privacy, and Rural Health Barriers

AI Use Cases: Chatbots, Predictive Health, and Rehab

COVID Telehealth Lessons and Mobile Diagnostics

Connectivity, Trust, and Low-Bandwidth AI Solutions

Funding, Training, and Pilot Wins

Q&A

Speaker 2 2:58

Oh, you do? Well, perfect. so that's the wifi thing that these laptops had, right? So naturally you go to the village, you say, okay, let's go set up a telemedicine service. You need to find a solid structure where you can host these things in, right? So, temples, schools, post offices, these spaces didn't have clinics. And all you see is just thatched roof houses, right? So no power supply. So you've gotta think solar energy to sort of run these machines. You need to start thinking who's gonna use these machines, right? So naturally you look at people like post people, right? Postal workers.'cause in India, two things happen every morning, right? The mail gets to you and someone delivers milk. Okay? So now you know that individuals were actually getting to a point every single day. What if I trained them to take a, use a small ultrasound machine or capture virals. Heart rate conditions, whatever those things are. So you now have a constant connection into that end last mile, right? So that could be a house with some patient in it. So you do that, then you look at how do you, what diseases do you go after, right? This is not an emergency room situation. This is maternal care, right? Pregnancy tracking, looking at anemia, right? And, and those women childcare, right? Someone who's just had a surgery in the city, like a, let's say an open heart surgery. They've come all the way back home. How do you monitor them, right? You don't want these people traveling, you know, five, six hours in a bus on literally dirt roads back to the city every two weeks to get a checkup. And they've just had a traumatic surgery, right? So now if you start building up on this concept, you realize those are the true pain points. So now start thinking, how does AI help with that? Right? Can it help with infrastructure? Can it help with training? Can it help with deploying the last mile? So that's learning that hopefully through the talk you sort of appreciate that. We can have all the great ideas in the world, but if you can't get to that last mile and truly deploy something, you'll never succeed. Right? So that's the idea. And so, the other point I wanna make is rural Indiana versus rural India, right? So I just drove up from Indianapolis, um, you know, on Highway 31, Kokomo, which kind of sits in the middle. It's kind of rural Indiana, right? I mean, nothing, nothing against the folks of Kokomo, but, but a Kokomo infrastructure in 2010 was way different than what was in India in 2010, right? My wife, um, you know, is from Zambia, but Indian origin with born and brought up in Zambia. So we went, did a whole bunch of things there as well. But now you start seeing the difference, right? If we tried to build a solution in India, language and all that jazz wasn't gonna work in Zambia, right? We did stuff in Laos, Cambodia, Vietnam, Brazil, Portuguese, and Spanish, and even Spanish like mentioned Spanish in itself has a different take when you go to, you know, so language becomes an important can AI work with that, with language translation when build a solution? There's hope there, right? One size doesn't fit all. Hopefully that you're getting that message by now, and I'll be the first one to say, are we there yet? The answer is no. Right?'cause fundamentally, there are so many challenges you have to solve before we can get AI into that place, right? And so that's how I would like you folks to start thinking is how do you get to that last mile? Might sound cliched after a while, but that's what it's all about. So agenda wise, as I mentioned, we'll talk about the challenges first and then we'll break down, into some true solutions that exist. And we've built a few, and I'll share those. And then of course, we're at the RISE Conference, tip of the hat to the rise folks. And so how do we build ethical frameworks to actually make this happen? Because what happens a lot of times in these kind of situations, working with NGOs and the Gates Foundation and all the Robert Johnson Wood Foundations and stuff like that, it's a tough balance between innovation, stifling innovation and regulation, stifling innovation and privacy, right? Does a patient who is 600 kilometers from Bombay care about privacy when you're giving them care in their house with the closest clinic being a hundred miles away. So you just have to sort of balance that and see, you know, what works and what doesn't work. But of course, you has to be ethical, right? There's no two ways about it. So starting off with the challenges, I think you folks know this as well, geographic isolation. So we did some work in Queensland, Australia, and then through that connection we said, let's go up to Papua New Guinea, port Mepe area, all those islands in South Pacific, right? How do you deploy stuff? There's a scarcity of clinicians in all those populations, right? So again, you're now a lot of the work. We started 20 10, 20 11, 20 12. These were the challenges. Now, of course, times have changed. Things are much different now. But then you're looking at these isolations, you're flying from one place to the other. In Africa, when we flew, you had to take like three planes to get to a certain place. If anybody's done those safaris in Africa, you know, you're to take those two or three flights before you get there. so that's important. And then of course, you're talking about aging population comes into play. Now that's a problem universally, but because of just isolation, because what rural community kick in, that becomes a big problem, right? How do you handle that? So we'll talk about that also, uh, in a minute. But of course, limitations with infrastructure are always gonna be a problem. So from an AI perspective, uh, it's a little dense, but you'll get a common theme. What's going on with AI here, right? Literacy gap is extremely important. So, the, the program which we have in India, for example, uh, the postal, so every year we go train them. Everybody's on their phone watching TikTok. Okay? So that's a given. Great. So now they have phones and everything. We said, fine. We'll give you a chat bot, mental chat bot so you can now potentially ask questions to the people you go meet. We heard yesterday about hallucination. So these guys have to be trained in asking the right questions of those models that we build. And then when they go build those models and test it or run it with a, with a, with a patient middle of nowhere, they need to have some sense of hallucination that the machine is not saying something correctly. Could be as simple as, you know, whatever. Right. But that's the other problem. So now how do you train them? They are literate in digital, no question. They have phones, they have TikTok and all that stuff 24 7. But for this specific use case, what are we doing to get them trained right? To go deploy that bot in the community? expertise and software, as I said, right? A piece of software that works in rural Indiana doesn't work in Zambia. Right. so how do you now get experts who can help you build, those training data sets, right? Data quality. Right. Again, a lot of the instruments in these hospitals in those villages are old, so they might have the data, but the format is 25 years old. the developers that are born literally 19 years ago had no idea. Like, I mean, I. I shouldn't be saying this too loud, but Optum, we have a piece of software that runs on dos. Anybody know what DOS is? Well, the old folks we do, but the young people don't. But if it breaks down, all my engineers have just come out of college. They dunno what dos is. So, so, so, so, you know, that's the challenge that sort of comes out of this. And of course, regulatory paperwork, right? I mean, anybody doing, stuff in the US knows EMR interoperability is a problem, is a problem. And it will always be a problem until, you know, epic or someone like that raises their hand to fix it. But that's the other challenge we have as well, right? I mean, it just gets exacerbated when you look at countries like India and of course with, with regulation. So that's the balance I want to strive, right? With innovation and that. So let's look at some solutions. Of course. telemedicine is the, is the very first one, right? I mean, a lot of good stuff is happening in that space. Uh, so the first example, I'll give you 2014, and this is Taiwan. Uh, in Taipei, we were working with, with, with a special use group. So City of Taipei. Fishing is a big thing in, in Taiwan, it's a huge part of the GDP. So fishermen who are coming into the city to get treated for cardiology conditions, right? Surgeries, um, you know, cardio treat treatments. These are fishermen, right? So you have had a complete open heart surgery, but as, as you go back home, the doctor tells you to do three weeks of bedrest. You end doing that. It's the money you're getting on your boat and heading out into the sea, right? Massive mortality because of that. Right? Now, coast Guard, yes. But you gotta communicate with the Coast Guard. How do you do that in, in those sort of conditions? So what we did is we got Holter monitors for them, right? Sounds kind of simple. satellite phones and off you go. You can't change their mindset. They will go work. You can tell them to sit at home for three weeks that aren't happening, right? So they go out. So now how do you track that? So the City of Taipei built a whole, you know, a telemedicine scrub is for these folks, and you can see a massive increase in just utility, right? So yeah, fine, we won't change your. Way you spend your day, but we will hopefully aid you in transferring this information back to a center. And whether you come back, you don't go back, you know, it's, it's up to you, right? So you provide the infrastructure, because again, there's a question of culture trust that comes into play, and I'll talk about that in a minute. Uh, so we talked about this sort of remote monitoring, aging in place, right? All the usual tools, which I think all of us know. but, but, but again, we hit hitting on the point, like, what's the pain point you're trying to solve, right? Does AI help in this situation? Think about it, right? Could you provide a better telemedicine service? Remote diagnostics? We have now started using the butterfly ultrasound devices. You guys know about that, right? so they basically have a lot of AI built into it. Awesome. So now you can start looking at, um, right? And so just seeing the evolution from 2010 to now, it's just been sort of a nice hockey set of, hockey stick effect in terms of technology that's going out and how it's being used, right? So that, that's also important. The second case is chat bots, right? And again. Power to chat bots, right? It's awesome. massive evidence has been collected now with suicides and depression reduction and stuff like that. Totally. Awesome. Try I getting this out in the hands of somebody in rural Indiana who's been farming all their lives, potentially a Vietnam War wet, would they want to talk with the machine or would they wanna go talk with somebody at the local va? So that's that one. That's one on one side. Go to rural India, zombie and all that stuff. Cultural issues, right? They might take onto it. They might be watching tiktoks every day on their phone, but they don't want to talk to anybody on the phone, right? Someone who is not sort of dynamic, right? Well, a chat bot is dynamic. It's, it's prompting, but it's not physical, right? So, which again, might work well, but then we just have to be careful as to how we sort of deploy that use case, right? So again, it's back to the pain point of trying to solve that, trying to understand that very, very last mile, maybe the last inch, I don't know, feet, inch, whatever. But you're getting right into, um, that use case for the, for the family. Of course analytics is a massive component. Um, there's no question about it. With predictive analytics now coming on board. so the link that you have there was something that a friend of mine and I wrote in India. So again, right India now versus India in 2010 is a massive difference, right? Same with Zambia, Vietnam, Australia, you know, but the digital revolution that has happened is been massive, right? So things are definitely changing for the good, no question about that. But then how do we now build on that platform and then go put AI on top of that, right? With all these constraints that we have. A quick example is help map org. You guys heard about this site? Please say yes now. Okay, so 2006 I was at the Harvard School of Public Health and we built this little website, and it's freaking working awesome today. All it did was scrap us, not scrap, scrape the internet, the ministries of Health in different countries, just newspaper clippings in different geographies, and created a heat map of disease outbreaks around the world. Okay? COVID basically put us on the map, literally. And the first few days of COVID, this was the site that everybody in the world used until those people at John Hopkins came and built the John Hopkins D dashboard. I'm sure you guys know that. Now, see, that's what you remember. Not health map org, but we started it. but then the John Hopkins absolutely use the interface. you know, no question, right? But health map org is alive in kicking, it's it's disease outbreaks. So we are now pushing this in a lot of these geographies so that, to make sure that the state government, so the state entities can start predicting outbreaks in these small places, right? So when the second batch of, you know, MRSA happened, um, right, intri and that whole region, the local systems were ready after what happened, you know, 10, 12 years ago, that fiasco that happened, right? So there's a value there. Can AI help? Totally. Right? You're scraping, you're predicting, looking at local, epidem records and everything, looking at history. Geography, weather and predicting things now, right? So people can use that. So it's an open API, open source, people can now extract from that and go build that out, right? So AI definitely applies with predictive, um, you know, public health and outbreaks. Again, back to ai, social engagement. I'm not saying um, you know, AI is not a use case just yet, but yes, I guess it can help you program what events you should go for, right? a Yelp, right. If you could use that, that kind of helps you find the right food. Maybe is there a yelp for your kind of social interactions? And again, I'm not, not the Gen X, ZY, whatever the combination is, but, but, but the older fo folks where the aging community, could we build tools for them, uh, in these sort of social environments. And again, a lot of the times folks like to sort of meet in person rather than, I mean that's the, at least my generation, I'd rather meet somebody in person than do a Zoom thing, right? I mean, if nothing is possible, I'll do a Zoom. That's great. But you wanna sort of meet people, shake hands. but of course this new generation is a whole different ball game, right? My son is a teenager in high school, you know, we know all friends come home in the basement, right? For a big game night and then all are on their phones, right? It's like dudes run the table, you know, have fun at it. No, they, anyway. so you just have to see how, you know, these things play out with these individuals. Rehab, excellent use case, right? So in India, and even in, um, in Papua New Guinea, we have a little center as well that people have hip surgeries, knee surgeries. Now they have some sensors on that to monitor their sort of progress progression post-surgery. You can track all that now through phones and apps and, you know, back to Maine sites to sort of determine that. So definitely a lot of use cases, but I think the biggest one is independent living. So just FYI for you all. Uh, 2006 I was in, um, I was in Italy, bologna, I dunno, 50 kilometers from bologna someplace. we, we, we go beat a whole bunch of old folks or the chitchatting, you know, smoking cigars and having a good time. of course they've been smoking cigars all their life, but no sign of cancer. Okay, that's okay. That's something something is working in, in, in the water there. But then we started talking about nursing homes. There is no word for nursing home in, in Italian, whatever, so you guys know that. I'm sure there is one now, but there was none. So they said, whatcha talking about so well then, well independent living and how does that sort of work? All of a sudden you realize that is not a concept there anymore. And India, Latin America, a lot of these countries, Mexico, they all live at home. There's no living home. So you can build an AI model to train nursing, you know, staff and everything, but it might not work in Brazil. So start thinking about that as well, that like, what is those, like what are those pain points you're really trying to solve, in that market? And of course language. This is definitely a positive that's coming out of ai. India alone. Every 500 kilomet. The language, the script, and the dialect, everything changes. So even within India, I cannot build a map just for one state because it's gonna be compatible in the state across, I dunno, 800 kilometers away. Right. Spain, of course, my son is doing AP Spanish, so I know that Mexican, Spanish, and Spain, Spanish is all different. which I didn't know. But, but again, dialects become important, especially when you're communicating with these sort of voice recognized devices. Right? So are they, are they going to miss something? Is they gonna, is gonna hallucinate based on a Yeah, it's Spanish. It does Spanish, but then the dialect, is it actually making any sense? Because there are words and actions that you do in a certain kind of language framework that doesn't work right in a different flavor of Spanish. So use, use case with, uh, when you talk about regions and things like that. So a couple of case studies, uh, this was, uh, right through COVID. Minnesota State. again, rural Minnesota is different than rural Zambia. Uh, but again, a couple of companies that built, um, some great AI products. Uh, and of course we know through COVID, smart Exam Company doesn't exist anymore. So this is what happened during COVID, right? A lot of telemedicine use cases, seven, 800% spike in, uh, telemedicine news of what happened after that, right? I think we're back to what it was, 10, 12% before COVID. So a lot of these companies that got a lot of the COVID money ran out of innovation and just died, right? But, but some good came out of that. People realized there's important value here, but then, then the business comes into play, right? If you're a little private company building telemedicine software, what's your ham? What's your Sam, right? What's your go-to-market strategy? You know, what's a target market? And then all of a sudden, a lot of the stuff till gets to the bottom of the pile. It fizzles out as, as a use case, right? Again, something like this can work awesome in Africa. And a quick story about Africa. My wife is from Zambia. Every time I say Africa, she just loses her mind. She says, dammit, that's a continent. I said, I know. And right. And, and she gets really upset. But, but again, within Africa itself, right? I mean South Africa and Namibia, right. Places like that. I mean, technologically advanced, right? They're moving in the right direction. University systems, right? Clinical care is great. Going to the middle, DRC Rwanda, edit three and stuff like that. It's a different world right now with Kenya. Tanzania, yes. A lot of safari tourism. You know, there's a lot of good things happening there. But again, the continent is different. So when I say something works for Africa, no, it does not work for Africa. Right? What is it working for? So in Zambia we had the same problem, when you went, oh yeah, it's like South Africa, right? We built it there. So it's gonna work in Zambia. No, it does not. Right? So how do you sort of build and sort of build, these sort of cases. Second one, I think the Johnson and Johnson folks mentioned something about this rural, Pods, you guys from j and JI missed your session, sorry. But you know, this is, ARPA and Michigan have this sort of unit. so again, mobile units, right? That move in. and, these have televisions and, you know, uh, monitoring stations and diagnostic services and all that good stuff. So again, it's, it's up little healthcare in a box maybe, or a lab in a box. Diagnostic is all part of that. When I was at Roche, we did build some, ts or laboratory in a test tube. This is, flu COVID, MRSA testing, right? So just do a quick no stop stick in this little box. I mean, it says because a Keurig machine that can be part of this somewhere. So that was the idea. That's what we contributed. but again, this stuff, uh, works really well. Now again, how does AI play into this? I guess the diagnostic monitoring maybe has some ai then I guess we can check that box. then again, I, we mentioned South Africa, right? We built this, um, sort of satellite thing because I can, I just said going to the interiors. 4G becomes 3G becomes two G, and there is no G anymore, right? Once you go in. And so that's why, um, our HOS is a real, rural health operating system. One of the cool word. So that's what we built. Uh, but again, it is just in a box kind of a solution, right? So satellite, communication, solar, with those boxes, basic diagnostic capability with those boxes. And how do you sort of get out there and uh, just get basic healthcare I'm taken care of. But again, the other component is proactive care, right? I mean, in the, in the US we talk a lot about, you know, we only go to the hospital when we are sick, right? So it's the health versus wellness, right? The proactive care side of things. I think all these countries also deserve wellness, right? So what can we do to be more proactive in terms of health in these different communities, right? So that's the other piece is health versus wellness and how that comes into play. So these little devices, we did a little project with, uh, with Apple and then before Apple with Samsung. all these magical devices, but well, who's gonna charge it? How's it gonna get charged? And, you know, the Apple watches die within like, what, 10 minutes? No, I'm sorry, 24 hours. they had a lot of, I mean, again, I, I bless their heart, no question, right? Apple gave us a whole bunch of these, the original Apple one watch thing. That stuff didn't last more than 12 hours, right? So again, we didn't know that, right? I mean, of course we knew, but we didn't realize how important that was because when we went back after a month to look at the results, they said we stopped using it because we know how to charge it. Oh wait, we didn't teach you how to charge it, not the learning, right? So again, it is those simple things, but now they know. Now Garmin, we are doing a deal with Garmin, Garmin devices last, I'm not advertising Garmin versus Apple, by the way, their devices last long, right? They have the solar stuff now. So, you know, the Phoenix five seven, part of the thing is, has all these magical features, but I can start thinking about that. how does AI come into play There? Gotta go find a way. and again, this is how, um, sort of a state can actually jump in to make a difference. Right Now, this is slightly old, but Queensland, you know, that's at north east part of Australia. You know, the Brisbane, the Gold Coast, and this is from where we went to Papua New Guinea. the state kicked in, I said, no, we've gotta solve this problem. So Telstra folks yesterday, right? They showed you that all the population sits for like 27, 20 8 million, eight in Sydney, seven in Melbourne. Well, that's all in this corner here. This is rural Australia. The whole country, I shouldn't say that, but is rural. Right? And how do you make connectivity important there? I guess that is job number one. AI is not job number one in, in, in Australia, in the sort of middle part of Australia, right? Um, so the, the, the government has created a whole bunch of programs. And so even if you don't have service, if you try to go cross country in those little, pockets of villages that they have, you can connect for emergency purposes. Excellent ai. How does it come into play there? Well, let's go find a way. I'm sure there is a thing of detecting signal predictability and something, there's something there, right? But once you cross that, now that you have that infrastructure, now we can start thinking AI in that space. Right? So just to sort of wrap things up now on the ethical, you know, framework side of things, again, as I said, right, you gotta to balance innovation with, sort of credibility. Um, right. Trust is a massive issue. So a lot of conversations, I mean, we were in Turkey ism is this little place that's, you know, well it's a two hour flight from, from Istanbul working with the local university system there, you know, trust was an issue there. Trust was issue. In Zambia, it was the same issue in Vietnam, right? So you just assume that people will jump on every technology you give them. Like my teenager does. They don't want stuff. They might have a phone, but lo behold, they still have the Nokia phones. From 2006, 2007, because they're digitized. Digitized means you can connect and you can do your bank transactions. You don't need a super fancy iPhone for that. You just have a phone. India alone, I mean, I kid you not, I mean, I left the country 30 years ago, but now when I went there last year, I pulled out my wallet for cash. They don't take cash anymore. Even a street vendor selling corn has a QR code on the phone. And of course I did that. Discover called me and said, well, we cannot process a transaction or an international country. You didn't call us up before. I said that's the situation, right? So massive improvement, but digitization doesn't mean digitization in a bandwidth sense or pro, you know, cameras and and stuff like that, right? So you might be digitized, but you're not digitized for this, right? Can I run LLMs in that little environment constraint environment? I don't think so. Can I run a small little. We have small LLM models. So we've been working, you know, with, uh, with Tropic as a matter of fact, the, the models are really tiny. Oh yeah. They sit on the phone. Yeah. Not on Nokia phone from 2006. It barely has, I don't know, 10 GB of memory or something total. So, but then should you make one for the phone silence? Right. I mean, all of us know when the Apollo thing went up to the moon in 1960, but, but it went, that total software is just a few kilobytes. So you can build tiny software that runs, but of course from where all the computer scientists, you know what the problems are. But can we start truly building those light operating systems? So within, in South Africa, that's what we tried to do was this real, rural health operating system that was a tiny little light os just to do basic communication for signal communication. And that said nothing else, even though that was a phone. So that innovation is needed. And of course, once you have that, then you can build AI on top of that. And I talked about trust, I talked about equity yesterday. Someone mentioned impartiality. That is important, right?'cause everybody should be treated equally. There is no two ways about it. but again, you gotta start where you can make progress. You can show progress. and the true fact is a funding agency can fund you, right? So once Bill and Melinda Gate Foundation think this is a good idea, trust me, it'll spread. There's no ways about it. One has to be proactive about NGO engagements because everybody means, well in the middle of Africa, middle of, you know, Vietnam or whatever, but everybody had their own interests in mind, right? Malaria eradication or something else. Or something else. There is no collective thing, right? Because these little governments. Just want the money coming in for those specific conditions. Right? What can we do proactively to sort of stitch all that together? And, and one plus one is we know is gonna be more than three, right? So that, that's the logic. and then the next steps really, is training. As I said, it became an eyeopener for me when I just thought people had phones, so they knew how to use the phone. No, they do not. Right? Why? Because the use case we're telling them is different, right? Pollination, GBT and, and stuff like that. then of course interoperability. I mean, if you thought Epic is an issue in Amer, in, in, in America it's way worse. At least Epic has what, 50, 60% of the market share. So at least all hospitals here have epic. So I hope they can talk with each other. But rural, it's a whole different ball game, right? And I think trying out these pilot programs and all that is important because again, the local governments will only see the value when you deliver something that is real, right? So when I did that telemedicine thing. We absolutely had no traction from the local healthcare system and local governments. Right. so what we said, okay, fine, so let's look at anemia right in, in pregnancy, in maternal health. And there was another NGO that was pushing, from GSK, this thing called shark overall, that's a iron supplement that a lot of that rural communities, really whole Asia they use. We just partnered with them and we helped them identify who were the women at risk of Iron. That was just a proactive reach out to this other NGO O, which also had the same intent in mind was to get people to take iron supplements, but with pregnant women, all of a sudden you started seeing the value in what was coming out of that. So then telemedicine builds on that and then all that other stuff sort of easily positive. And that's what led us to some of the Gates Foundation money and things like that. But that was the whole idea, right? Malaria eradication is another one. Can telemedicine help with detecting that or outbreaks? So that's exactly what we're doing now with the Health map org to detect outbreaks. And then how that thing can actually move into different cities based on the seasons. Right? Monsoon seasons are different in India, so a lot of mosquito populations grow. so it's just a predicting that, you know, it all sort of falls in place. Right. So, just to wrap things up, again, it is real. I mean, I didn't wanna say AI isn't happening. It is happening now for sure. But again, globally, let's think about rural Indiana and rural India, right? If you can keep those words in mind, start thinking how one can start looking at rural, as a use case. And I think most importantly, collaboration, like I think Desh mentioned about interdisciplinary and all that good stuff. in the field, in the ground. I mean, we can sit here in this room and build all kinds of task forces and working groups, right? But, but in the field, people who have requirements, cold chain refrigeration for their medication that's coming in, they're on a clock to get it out of the way, right? If you say, oh, no, but, but wait, we have this thing and then we can, no, no. What is their use cases to get those medicines a sap in the hands of people that need it? Can telemedicine AI help in detecting what those populations are and then helping them move there? Right? so that is the, the true sort of value get insert in the field. So I think that's all she wrote. That's my story. And as usual, I, you know, if you wanna take a quick picture of the 10 top AI use cases today, I, I, and it's a little screenshot, but these are real cases. This is all working. Um, so we have done most of these things already. Um, so if you guys need more information, more help, let us know. but we've just published a few papers. We try to keep it on the down low or dl, that's what they say. Um, because again, right, I mean, I think all of us need to be catalysts, right? I mean, catalyst is, all of us know, I mean, chemistry, right? This is my son's common app essay, and he educated me on that. that end of the day, right, you have to be the change that transformation, right? You don't have to be flashy, you don't have to have all these press releases and stuff like that. But, but just quietly find what the problem is and go solve it. Right? Be be a catalyst, just move things around. Um, and then good things will happen, right? But again, think end user. Think the last, last mile, I saw a lot of posters yesterday. Awesome. That the kids are thinking that if at least half of them can actually get it implemented in rural community, huge success, right? For all of us of what can we drive that? So I think I'm right on time. Thank you. Some questions? Yeah. Pre for questions. Yep. Yeah.

Speaker 4 32:34

At Core. But the thing that distinguishes. Rural health is, is the inability to use scale for efficiency. Correct. Uh, there, there's a money problem, but that's not unique to rural healthcare. when you think of digital health scales, but how do you keep, advancements in this area? Digital health's gonna be really good at some things. It's not gonna be good at everything. How do you keep it from exacerbating the problem for local and physical infrastructure?

Speaker 2 33:04

You know, I think we just have to keep it simple. I mean, people try to, you know, scale is what, right? You start locally and then you scale globally, right? Don't start with that assumption in mind. If, if, if every solution has to be a piecemeal, standalone, start with that, right?'cause if you start thinking scale right off the bat, it, I'll be honest, I mean, I've done it like 35, 36 countries. Even within a country itself, stuff cannot scale, right? So you just have to work with that constraint. That you aren't gonna see economies of scale. Now again, economies of scale in these countries is a different metric, right? I mean, when we say here, economies of scale means a hundred, 200, 200,000 people and blah, blah, blah. In these small villages that are in a given state, in a given language, given culture, given sort of whatever scale might mean not scale, scale, but maybe it is little scale, right? But even to your question, I think that that's a thing that fundamentally that's what we first started. Of course, we wanted to scale now question, but then it just becomes a reality that if you really want to sort of move the needle, it, it's difficult. That's, that's it.

Speaker 6 34:15

Thanks. yeah. Wonderful overview and wonderful presentation. so I wanna go back to your comment about trust. And you know, I look at these wonderful 10 ways, and they're all about how the healthcare ecosystem can help the people in the rural communities. I feel like we're missing the two ends. One is the trust for the consumer. So what's going to make someone adopt if they don't really trust these outsiders coming in? So just like you put in there, um, supporting the healthcare workforce by automating administrative tasks. Have we ever thought about automating the administrative task for the person and the caregiver? All those forms, filling out, scheduling, knowing if I have coverage and eligibility.'cause we know it's 25% of people stop seeking care because the administrative tasks are so, time consuming. So we have to think of that time toxicity on the consumer caregiver, not just the healthcare worker. And then at the other end of the spectrum, how do we involve the existing community infrastructure in the rural community because they know they have to help each other. Because they know there are no outsiders that are gonna come in. So can we tap into and use AI to actually more effectively give the tools to the community organizations so we can get trust at both ends?

Speaker 2 35:38

Absolutely. And I can give one example for sure that when we introduce Google Sheets, because it's free, right? on the laptop to the caregivers, and they could start tracking things. Now, of course, we didn't expect them to learn how to sort of write a macro, uh, but we built enough for them that they can, they could just start tracking things. Heck appointments, right? When is the next one happening? So a pop-up on your laptop, right? Which any computer 1 0 1 can say, yep, sure, I can do it, but these people couldn't. So we just build these small little applications and you could see a massive uptake, right? And when people talk, oh my God, resource management, supply chain, blah, blah, blah. All they need was a little Google sheet to track. When is the next package of these cold chain medicines coming? Now, could I do an SAP backend and connect to, you know, sure. Whatever, right? But all we told GSK is just send a text message when the thing leaves the dock and we'll update it here. And as soon as they know the medicine comes, they're ready to do the next clinic. They have these open air clinics every week. Maybe it's not coming today. So maybe, hopefully you can give an advance warning to folks, Hey, the thing isn't gonna come at four o'clock, please come tomorrow morning at eight o'clock. Massive value add because again, these guys are all working 24 7 in their forums, taking them out all the way to come and take this. If I could just, and of course now you have these little phones, even Nokia phones, send it at a text message and say, come at eight o'clock, not at four. right. That definitely helps. And then of course, with, um, the burnout and, you know, yes. I mean, and that's the other thing, the challenges we see here, it's the same challenges there as well. But again, when you talk scale, it's, it's multiplied, right? Because it's a pretty small group. Whatever you can do to sort of make their life easy, right? And so again, a simple resourcing thing is good enough. They don't have to go 20 kilometers to pick up. Because again, when these cold chain things come, they, a bus drops it off at the little village and people from other villages come and pick it up from that site. If they can avoid that one hour journey, that itself is burnout, right? So simple things, but at least again, that's what I say, right? If everybody can get a chance to actually go in the field and feel it, then you realize, I mean, a lot of the stuff we discuss really is not needed sometimes, so to be honest. Yeah.

Speaker 7 37:53

But have they used TikTok at all? Like to communicate to rural, okay.

Speaker 2 37:58

Yeah. Excellent. Excellent. Yes. So I didn't sort of say that. But this whole way of, I mean, gamification is another one, right? I mean, how to put the ga Absolutely. There's a lot of stuff that goes on now, through channels and stuff like that, and stuff goes viral really quickly, right? And again, there are influencers in the middle of nowhere as well. There are people like in, um, in Isma, this one little farmer that, also has a little, which we call farm to table here. He has a little setup. A man is viral. He has like 25,000 subscribers in a 45,000 village. So what he says goes right. And so that's how, that's what the clinics happen in his little piz, I guess, whatever they call it, in Turkey, in, in Turkish. So yes, there are influencers. They stuff can go viral and it's a lot of training videos. a lot of the content now, and again, countries like India, all these countries, massive digital push. There's a lot of these, uh, proactive government driven efforts going into play. So you can just start piggybacking behind those efforts for sure. You can do a panel. Thank you.

Speaker 8 39:19

Wonderful. All right. Why don't we start with, um, bringing our panelists up and then I can do introductions that way. It's okay. Yeah. Okay. I just wanna turn that off. Yeah, that's fine.

Speaker 9 39:50

No, no video. Next session.

Speaker 10 40:03

That was an incredibly insightful conversation, and it really hits home in terms of the kind of the, the importance and significance of trust. and I know Dr. Charlotte and I have talked about that quite a bit in the past couple of years. next we're gonna be talking, uh, to an esteem panel, um, of experts as it relates to, um, senior health, social isolation, mental. We're gonna bring it all together as one. but before we get into things, let me, uh, first make some introductions as well. I'll start with you B uh, B Hayes, chief Community Health Officer at Blue Cross and Blue Shield of Minnesota. My home state, yes, back on, um, butted leads statewide efforts to advance health equity. Strengthen community wellbeing and drive systemic change across the state of Minnesota. With more than 20 years of experience in nonprofit education and healthcare leadership, he's devoted his career to creating fair more connected healthcare systems. He also serves as chair of the Blue Cross Foundation Board and holds an MBA from Howard University. Next, Dr. Emily Ho, a quantitative psychologist and behaviorals scientist and psychometrician. Thank you. Uh, who researches bridge psychology data and decision science. Her work spans digital biomarkers for early Alzheimer's detection, validation, and neuropsychological assessments, and improving medical decision making through behavioral science. Dr. Ho's research has been funded by the NIH and NSF. Featuring by NPR and the Harvard Business Review and published in leading journals including Nature, climate Change, and Alzheimer's and Dementia. She was named a Rising Star of Behavioral Insights by the Behavioral Exchange. Next, Irwin Tan, senior Director of Health thought Leadership at A A RP, where he leads efforts to advance healthy longevity and address health disparities across the aging population. A physician trained in internal geriatric and integrative medicine. Dr. Tan has dedicated his career to helping people live healthier, longer lives. Before joining A A RP, he directed what is now the AmeriCorps seniors and served as the White House fellow and taught medicine at Johns Hopkins University. Born in Indonesia and a proud naturalized US citizen. Dr. Tan brings both global perspective and deep compassion to his work and aging and equity. Finally, Shelly Kendrick, president and CEO of Acumen, also a Minnesota person, Woohoo way to represent guys, uh, president and CEO, of Acumen, one of the nation's leading nonprofit providers of senior housing and services. Since joining in 2012, Shelly has led transformative growth across communities, expanding hospice care tenfold, and driving innovation in senior services. She holds a master's degree, from nonprofit business administration from this very university and a BS in Eastern Michigan University. Please welcome me in, uh, joining our esteemed panel today. So for the past couple of days, we've been fully immersed in the kind of the principles of RISE as we've been talking about responsible, inclusive, safe, and ethical ai. We've explored what it means to move beyond innovation for its own sake and towards solutions that truly serve our communities. This year's health AI track has really been focusing on translating what those principles are into ultimately care delivery, especially in rural and underserved areas where the stakes are even higher and the resources are much thinner. We've heard how leaders across payers, advocacy and senior services are working to move pilots into impact. Today I'm honored to welcome you as a panel and really wanna talk a little bit more about, the profound challenge of how do we build a sustainable social resilience by addressing loneliness and mental health through the power of community. We're gonna explore a little bit more about technology and community-based strategies that can work together to ultimately reduce isolation, strengthen mental health, and uh, excuse me, create environments where adult children and, adults can thrive. We'll examine structural and cultural barriers, the role of data and equity, and the partnerships that can drive meaningful change. Our goal is to move beyond theory to actual insights and insights that not only improve individual lives, but also reinforce the social fabric that keeps our community strong. So, with that, I'm actually gonna start with you, Dr. Ho. your, your work actually focuses on measurement and behavioral science, so can you talk a little bit more about how do we ensure that tools for assessing loneliness and social isolation are both scientifically rigorous and culturally relevant? Especially in rural and diverse communities. Yeah. So, um, mic is off on, could be on sideways. Yeah. Hi. Okay. I'm short. okay. Yeah, so that's an excellent question. So I think first let's maybe, um, I think I'll just kind of preface it by saying Alzheimer's diseases dementia is probably one of the most pressing issues of our time. it we're, um, expected to double our numbers of people living with Alzheimer's and by 2050. Um, and that affects not just the individuals, but the caregivers and their families as we've talked about. So that's kind, just kind of trying to Yeah. Um, yeah. Um. And then I think it's really important to talk about,'cause we're talking about, social isolation and loneliness, right? And so, and, and other kind of, um, risk factors for, Alzheimer's and dementia. And so I think it's really careful to first really be careful about what you're, how you're defining these things. And like, I think a lot of people conflate social isolation and loneliness, for example. Um, social isolation is this sort of objective like, feeling of like your networks, like who you feel like you can call on. Like can you list five people? how far are they from, how close are they? Close ties, distant ties, that kind of thing. Loneliness is more this subjective feeling, that, you know, you could be in a room full of people, you could have five people to call, or 10 people to call, and you still feel lonely. So I think first operationalizing and really clearly defining what it's, and what it isn't is very helpful. And then the, you asked about equitable measurement strategies. I think a lot of it is, is first like translations, right? we, I'm the scientific director of NIH toolbox, which is a set of measurements that, assess cognition, emotion, some motor tests, motor assessments and, and o and olfaction and, and other kinds of things. Anything that's related to health. Basically the NIH toolbox covers. And we're very careful to, um, make sure that our measures are as basically like culture free as possible. Like we kind of pilot it with a lot of qualitative, you know, interviews and kind of say are there like kind of accidental misinterpretations that, you know, systematically bias, like one group's ability to understand the question.'cause you don't want that. You want people to really understand, you know, what, what you want people to, um, really be responding to what you're trying to assess. Not something extraneous, like education level or, you know, rurality versus, Urbanicity. Right. And so, um, we're very careful with our development process. There's a sort of extensive thing. It's not just making a few questions and calling it a day. and, uh, and involving everybody. And, you know, we have translation trans work with experts that translate things in, you know? Mm-hmm. Um, a gazillion languages and they have inroads with communities where, these measures are directly used. So that's kind of, I'll start us off there. Okay. I could say more, but, um, I'll start us off there. That's fantastic. So, um, I, and I'm wondering if you could maybe build off a little bit more on Dr. Ho's response around cultural validity. how do those cultural norms and stigma ultimately influence older adults?

Speaker 9 48:16

Yeah.

Speaker 10 48:17

and, and certainly as they seek help for loneliness. and then ultimately, can you address a little bit more about, um, how these interventions should ultimately adapt into actual reality?

Payer Incentives, Caregiver Shortage, and Data Access

Speaker 11 48:29

Thank you very much for longly speaking and you can please call me Erwin. I think that, as we think about, loneliness and, and social isolation, we need to think about again, like, you know, one in particular is about what do you need, right? Like loneliness is a subjective experience. I think that's an important piece in terms of, some of the solutions that might, might be, relevant for that. and, and as people are trying to seek out social connections, I think the question is do you feel wanted, and I think there those perceptions of aging and do you belong are important as well. we know that one's own self-perceptions of one's future age is associated with mortality. Becca Levy at um, at um, Yale has sort of has seen an association of seven years. If you have a positive view of your own aging, you have a seven year longer life expectancy, right? It's also true in terms of, of how, You know, um, what do you do preventative physical activity? Do you, um, do you have long-term hospital stays? Do you seek out medical care? Those are about our perceptions of ourselves, and those are very much embedded in the zy guess of what, artificial intelligence is feeding off of. Right? So I think that it's important to consider that when we are trying to create, interventions that are culturally appropriate, we also try to think about the end user, who in this case might be an older person. and I think those are things to consider. And one could argue that these perceptions of aging are really our ability to predict where we will be aging in the future. But we know, for example, that people with positive perceptions of aging who have a OE four protein, uh, mutation, which puts you at high risk for Alzheimer's disease, have less risk of developing Alzheimer's disease while those who have an a OE two protein, um, um, you know, you know, a mutation, have a lower risk, actually have higher, more protective, cognitive, outcome. So I think there is potential for actually interactions with, with the, um, with this idea perception of aging. So as we think about the cultural zigas, I think we need to make sure that, that the end user is, um, is considered and that includes age as well as culture.

Speaker 10 50:30

That's fascinating. Thank you. So Ada, so we've heard about measurement and now we've talked a little bit more about cultural context. You talk a little bit more from a payer's perspective. how do things like, you know, insights, how do those things get operationalized?

Speaker 12 50:47

Yeah, so as a payer, one of the things that we try and do is in a particular, at, at where Blue Cross BlueShield of Minnesota is a one state blue plan. So let me say that first, we are not multi-state, we are focused on Minnesotans. So it allows us to do some things that are a little bit, uh, I think, deeper in engagement. So one is we do have, uh, deep community partnerships, and we'll talk about some community-based practices a little bit later. I think for us it is about how do we utilize the claims and reimbursement process to incentivize greater engagement, greater utilization, greater impact. And so, um, we've done that before. So some examples, uh, we do have a equity amplifier within our provider contracts that incentivizes providers to center equity, to utilize data to drive better health outcomes. We do have, an SDOH, uh, sort of, if you will, incentivizer that the more SDOH screenings and assessments you do, sort of the greater, your, uh, reimbursement could be with that particular population. We also have stood up, what we call community health worker hubs. We, we've talked a lot about community health workers here. Community health workers are in community. They're of community. They understand what is needed in community and how to drive results. And so we have, Winona was mentioned earlier in the, um, presentation. And so we do have a community health worker hub with Winona Health, in that area that drives outreach and gets better engagement, better follow up post discharge, and a whole host of other things within communities and in particular in a rural community where, trust, and, and I would say, I, I do wanna just draw a tangent. I think this, this notion of, equity has gotten circumscribed to a certain space. Um, and, and what we're talking about here is the same thing in terms of trust, access, accountability, sort of autonomy that, folks of color, LGBTQ plus everyone else is asking for. Right. And so when we talk about rural, there are some lessons that we're able to take in it, particular with seniors from some of the other successes we have from other marginalized communities about trust and how do we access that. And so I think for me, there's a number of ways. at Blue Cross we have put doulas, traditional healing, all of that into the claims and reimbursement process. So I want to just talk about like operationalizing it within a payer within our current ecosystem is about sort of incentivizing through our current sort of financial structure, how we incentivize better engagement with seniors, better outcomes with seniors, and also how we, uh, address, social isolation, loneliness, which is we, at least in Minnesota, it is growing. Our populations are getting older. Rural communities are shrinking. And so urban areas are growing, and so not only is it, we have an aging population, but we have a shrinking rural population as well, which will only exacerbate issues around social isolation, loneliness, infrastructure to deliver healthcare.

Speaker 10 53:54

That's fantastic. Answered there. Shelly, so from a care delivery then perspective, what does it take to translate those strategies into a day-to-day?

Speaker 13 54:03

Well, the first thing it's gonna take are caregivers. So whether you're in a community, setting in a facility, we're having trouble finding caregivers. There's not enough caregivers out there. And that's where we think that AI can also help us, by helping caregivers, spend more time at the bedside with the, with the older adult, rather than documenting all of the time. Maybe I have something I can just talk while I'm caring for someone so I don't have to take my hands off of them and then they end up falling. so. That's the biggest issue I see. Whether it's that, and that doesn't matter if it's urban or rural areas, we do not have enough caregivers. We get calls all the time from families not knowing what to do because their older adult or their senior needs help and they, the caregiver is usually the daughter like myself. I'm dealing with it myself, and even though I'm in the industry, I don't know what to do and how to help my mom. And, um, we need payers actually to help us with that as well. So, um, right now, most of the time the families are, are, absorbing the brunt of the costs. So the primary caregiver or the siblings are splitting the cost to help mom or dad get care, whether it's in the home or in a community setting. And many times right now, especially in Minnesota, you can't even get a community setting to take anyone because we don't have enough caregivers. So then they're left to stay at home, which then something acute happens, they end up in the hospital, and then the hospitals get backed up because there's no place for them to go. And that's what we're facing. We'd love to say yes to everyone. We have some empty apartments, but we can't take people because we don't have enough caregivers because the regulations say we have to have so many staff to patients. And, um, that is causing a big issue. So we started building, uh, independent living, for 55 and older, to, uh, uh, affordable housing so that we could address some of the issues with people without homes that are living on the streets. And you'll be surprised how many older adults are living on the streets, uh, because they can't afford, their rent. And so they're deciding, oh, well, I'm going to pay for my prescriptions rather than my rent. So those things are going on too, when we're trying to solve all that. But we need payers to help. We need the hospital systems to help. Uh, someone had me mentioned Epic earlier. Well, we as a provider, we don't have access to that. And we're doing healthcare, we're doing hospice, home care, we're doing all of it. So telehealth, we're doing all of that, but we don't have access to Epic. So sometimes we take, admissions and take some of'em. We don't have all the background. and mental health issues, comorbidities, all of it. We need that information so we can provide the best care possible.

Speaker 10 57:06

Can you cite any digital interventions that you have used that have been successful just in, in. At least trying to augment some of this need around caregiving.

Speaker 13 57:17

So most of the digital, implementation and things that we've used have been through pilot programs or grants that we've received to try it out. But for the long-term sustainability, we don't get the funds in order to keep it. So, during COVID was a perfect example and the technology and the telehealth where we had, telehealth in the home with a, a company called MCare. You can look that up. and we, um, used their system to help, you know, uh, let the person know when to take their medications, that it was time and they could interface with a live person. So, that was something that we did do. And, but since COVID, no way to pay for it. I've got like 50 of'em stacked in, in my, one of my offices. Right. And no, no way to implement.

Data Sharing, Rural Partnerships, and Building Trust

Speaker 10 58:08

Okay, thanks for sharing. Dr. Ho, let's go back to you for a moment. You mentioned the importance of data. So can you talk a little bit more about, um, what unique data sets you've worked with or at least you wish you've worked with or have are currently in existence or perhaps piloting that really could ultimately help us, understand and address social isolation? yeah, so, uh, we, uh, so I'm an assistant professor at, the Northwestern Medical, school of Feinberg School of Medicine. And we have access to a huge, um, sort of, um, EHR well, you know, well characterized, um, individuals. And, um, something that we've, um, we've been, I've been really interested in is early detection and, and finding. You know, the sort of con conventional ways of assessing that, which is just these cognitive screens, some of which are actually quite frankly not very sensitive. They're sort of like thermometers. Like you have a fever, you don't, you don't have a sense of how bad the fever is. Mm-hmm. You don't have a sense of how long you've had, you know, fever, that sort of thing. and so, um, I'm really excited for this project. We're actually gonna try, try ho hopefully in the next couple of months to look at NIH toolbox, like cognition, neurocognitive data. And this is really like state of the art. Like, like they're computer adaptive, like AI powered sort of tests that make it shorter and shorter to assess, give, give you a good sense of cognitive function with very little time. and, and we have, about four, it's part of the Midco study, um, which looks at, looks at, older, um, like people starting in their forties into sixties because you know, the earlier you track and, and detect the earlier you can intervene. And there's been some really promising studies that suggest that, you know, with the right. Kind of mixed cocktail of interventions, you can really, mitigate cognitive decline. So we're gonna look at the cognitive tests, we're gonna track them over time. And then we have access to all of this, like multi, um, multiple chronic conditions and how like the cognitive scores can, be influenced by, you know, the number of conditions you have, how well you adhere to medication and, and you know, things like that. I think there's also, so there's an opportunity, you know, Northwestern's been making a lot of sort of institutional level steps to get our learning, our learning health systems like AI ready, basically, you know, a lot of harmonization, interoperability, you know, things that are just trying to make it easier for, to accelerate scientific discovery.'cause we we're sitting on, you know, everybody, everybody who's attached to a hospital system is probably sitting on a, a gold mine that they don't know how to mine partly because of these interoperability issues. So, yeah. Yeah, absolutely. That's, um, one project, um, that, that I'm excited to pursue in the next, um, coming months. Fantastic. So we've talked a little bit about the research opportunities. Um, Irwin, can you talk a little bit more about what data sharing opportunities could look like for a RP, ultimately to advance kind of the understanding of social isolation caregivers, the impact on the healthcare ecosystem?

Speaker 11 1:00:59

Yeah, I mean, I like what someone said about what we really need is more time at the bedside or in the person's house. Because I think one of the things, the concerns about, AI is that it's gonna replace people, but in this particular issue of loneliness and, general and, um, and, um, social isolation, it is possible that, artificial intelligence could replace the, that interaction and that the needs of people. but I think what we're trying to do is trying to create opportunities to augment human beings so they can spend more time either at the bedside or more time, creating respite for themselves. So I think those are some of the considerations. I think you look at the successful interventions in the past that dealt with sort of data sharing and coordination of care. I think one of the best examples has been the program for all inclusive care for the elderly. And so that's a program where it started in, um, in Chinatown in San Francisco where you take individuals who are, dual eligible for Medicare, Medicaid, you, they're living at home and you bring them to a center where you have physical therapists, where you have, you know, When you have nurses, we have, physicians of social workers where, once a quarter you even had everyone come together and exchange information and discuss every patient. that's why I became a geriatrician. I saw one of these sessions and the person who was the driver transportation person said, you know, Mrs. So-and-so was poking up the stairs yesterday. And then the nurse said, oh, well bring her R in. Let's see what's happening. Right? But the problem with the PACE program, it's relies on bricks and mortars. It works best in a, sort of, in a urban setting, what is, there's density, scalability, but what if you know, you didn't need the brick and mortars? What if you could create an opportunity for everyone to share that information on a regular basis? And what if artificial intelligence could augment that? So I think that's an example where you take a known process that's shown to reduce, you know, be cost effective, reduce, um, hospitalizations, a allow of people to stay in their homes, right? But then with mono technology, you don't need, you, you, and like once upon a time, physicians would go to people's homes with a black bag.'cause that's all we got, right? That's all we could do. Then hospitals came in existence. We had, we had, you know, tests and um, x-rays and CAT scans. Now it's a, now technology has moved forward where a lot of that can be protected in the home. But what we don't have is ability, organize information. So if we had a comprehensive way to do what PACE does without the brick and mortars, that could be something that could be exported to a rural site,

Speaker 10 1:03:22

right? I love the innovation and technology take on that. I think that's so important and I think that really underscores the importance of the ecosystem that we've talked about. Um, my colleague here at Johnson and Johnson and I, um, have worked over many, many years about really the need to kind of formulate and formalize, a more effective and certainly impactful ecosystem. So that really requires, deliberate thought and deliberate formation of strategic partnerships. So I'm just wondering, ADA, um, can you talk a little bit about some, perhaps some strategic partnerships or relationships that Blue Cross Blue Shield Minnesota has that's really informed your approach to how to address some of these issues from a rural perspective?

Speaker 12 1:04:07

Yeah, yeah, absolutely. So, uh, one of the core beliefs, uh, we have is that community has the answers. And so part of what we then try to do is connect in community. We say we listen and learn, partner and act. And so through that, partnerships have, arisen that we have seen drive deep impact within community. One of those is, and it was mentioned earlier about mobile clinics. So we have, I think that's somebody else. Oh,

Speaker 4 1:04:30

that's,

Speaker 12 1:04:30

this is, yeah, this is a new one.

Speaker 4 1:04:32

Okay. Thank

Speaker 12 1:04:33

you. I think that was the last speakers that just Thank

Speaker 4 1:04:35

you.

Speaker 12 1:04:36

Thank you. Looking out for you.

Speaker 4 1:04:38

Alright.

Speaker 12 1:04:39

Um. So, we, we have a partnership with, uh, a group called, Odom Mobile Clinic. And so Odom Mobile Clinic reaches, uh, about 16, uh, rural, uh, counties within, um, Minnesota engages with members. They have, mobile mammography. They have sort of, if you will, just sort of the annual wellness visits and make emergency. Um, they speak or have access to 23 or 24 different languages. Rural Minnesota is also, uh, having another phenomenon and that it is diversifying as a or faster than, our metro, places. So we have large Somali, Hmong, Latino populations within rural Minnesota as well, which means we, like language is essential if we're gonna deliver care and partner for care. And so the OB Odo mobile clinic reaches thousands of members. the way we found out about Odom, we talk about being in community. it was, for a, sort of, cultural community. This was Ghanaians. Odom had been the trusted source that was, delivering COVID vaccines. And it was through that small work of delivering COVID vaccines that we learned about Odom. And then we were able to mobilize Odom to 16, counties, within Minnesota and tens of thousands of mem members annually. So that would be one way in which right, just, um, we, we talk about just being much more humble in community. Like we are a big organization and sometimes big organizations believe they have the answer. And I think if we would admit we don't,'cause if we would've, we would've, any corporation would have leveraged that for a financial motivation to be the leader. So if we had the answer, we would've acted on it already. We don't. And so part of what we try and do is to get into community that has worked. And then there's a, a, a few other partnerships too within, uh, Wilmer, rural county growing, 50 some odd different languages spoken in that community, rural Minnesota. and so when we talk about sort of partnering to impact folks within that community, it meant a two year deep engagement within that community. For, for us, we saw NPS scores within the nineties right around trust and believing that we were there to assist, but we also saw better health outcomes, greater connectivity within rural, in particular for some of the senior folks there. We also saw a community that was, divided because, you have folks who had historically been there, and you have folks who had just come there. But through that sort of deep engagement, you also saw this cross-cultural connection that, has continued to benefit the community of Wilmer, to this day. And that was about 10 years ago we engaged in that. So I think for, for us, it's about sort of listening within community and then utilizing our resources to, um, sort of in our connections and our network to, to move forward some solutions.

Speaker 10 1:07:37

Great. We, we talked a little bit last night. I'm gonna give you a little inside baseball and my, my dinner with my colleagues last night and, and talking about the, the line of work that we're all doing unfortunately contradicts many times with really kind of the realities of the business world in the sense that there's not a lot of patience for long-term growth and building in terms of relationships. And so it's a very, tight tightrope to balance and to walk on every day. So I'm wondering from, from the lens that each of you are coming in. can we talk a little bit about, it seems trust, I know Charlotte, I'm looking right at you at this one. it seems like trust just continues to be that fundamental kind of core issue, right? And until we start, and I'm learning from you, until we really start learning and earning the trust of these communities and these stakeholders that we're working with, so caregivers from the patients, certainly from partnerships, how do we, how do we start building trust? I know personally I'm involved in working with a lot of the indigenous communities and that is a long historical issue and challenge that we're really facing. And so that takes time. It's unfortunately that's, that's a, does, excuse me, that does not line up with metrics from the business world. So I'm just wondering, could you address a little bit more about that in terms of the trust factor? Anyone anyway? Yeah, feel free. Um, yeah, so, uh, I, I think that there's, um, we've talked a lot in the last couple days about trust in the algorithms and trust in, you know, the sort of big black box, but we, I think, we haven't talked as much as we should have. I think about how do we get, how, like why should, you know, people in the rural communities trust us to deliver interventions to deliver care. Like we have some fancy insight from, you know, some big city like Chicago, or New York City where I'm from and, and we're gonna port it into, you know, Chinle, you know, Arizona, which is where one of the, um, Navajo nations, you know, is that, and I spent some time there, working with, pre, um, pregnant moms and, and looking at their health and how, how, why, why should they care, right? And, um, and I think there's a few sort of underlying principles that I'm, I'm sure Ada can talk with, with more fluency. But, um, from my sort of academic ivory tower, uh, sort of a. Um, stance. you know, there's a sort of ethos of nothing about us without, without us.

Speaker 13 1:10:00

Yeah.

Speaker 10 1:10:01

That has to be, we have to start from day zero really. Like it's not just you get the funds and then you start involving your community stakeholders in this sort of like, you know, sort of milk toast sort of way. Like you, they have to be compensated investigators from the jump. You have to write them in. they have to have voting power. Um, I think oftentimes academics are very eager to, um, test everything and, and just kind of assume that, take a lot of things for granted, right? um, take the fact that there's going to be a, a nurse champion, you know, it's like they're gonna take into a, they're, they're taking a, a nurse champion basically evangelizing this, this sort of intervention in the community centers. Like why should the, the nurse champion do that if they don't know who you are or they don't know enough about this intervention? we take for granted, we. We take for granted that the infrastructure is there, that there's just a lot of, um, un you know, newly graduated undergraduates who are aspiring to go to medical school that have nothing to do, but run our tests, which is not the case in, it's maybe the case at a nice, um, well-resourced, um, university, but not, not everywhere. and, and yeah, we assume that what works, on paper, like in academic papers works in, a lot of different settings where, the situation's very different. Yeah. So,

Speaker 11 1:11:13

I like what you said, um, this theme about, about, trust. Um, I think the, um, the Native American population, United States is, I think a good example. Uh, we talked about how Africa is not mono monolithic, so is the United States, the people in University of Washington, IHME, it's sued for health metrics education. Release a paper in Lancet called 10 Americas. Right? And so, Our previous speakers talked about the demo Democratic, uh, Republic of Congo, where life expectancy is 62. So you look at Native American residents of the Midwest and the Western United States life expectancy in 2024 was 62.

Speaker 9 1:11:48

Mm-hmm.

Speaker 11 1:11:49

So you're not ever gonna reach, uh, uh, Medicare age. Right? and then, um, we talked about Zambia. Zambia's life expectancy is 66. look at, black residents of, um, the southeast US rural black residents. Southeast US life expectancy is a little better. 67, which is the same age as in Ethiopia or Pakistan. Right. So I think those are things that we have to consider as we develop trust. We have to think about that if we, if we have new interventions and if those interventions are likely to be adopted by communities with access initially, that we are likely to exacerbate these disparities. And that's an issue of morals and ethics, but also of trust. Um, last week I was at, um, the Kos. Um, it's an org. Um, it's a meeting of, um, native American elders and I think we're interested in why life expectancy dropped in Oklahoma prior to COVID, and for Native American residents of Oklahoma. And we, we did some data collection where the researchers were, um, included someone who was from the Oklahoma Cherokee Nation. we have a, we have a staff member, a RP from the state office who was a member of the Muskogee Creek, uh, Oklahoma Nation. And so we tried to speak to people with them at the table and uh, and then we presented the data back to the elders. So did we promise we would do that prior to releasing the data, which we'll try to do later on next year. One of the things that came up was kinship health. Right? I think that was an interesting idea that this sort of like, it's sort of similar to the idea of social capital, that we have these ties and relationships. through which, uh, mutual aid and, and trust and, uh, value is exchanged back and forth. That's, we know that social capital is, um, is associated with health outcomes. I think it'd be interesting to think about ways in which, AI can enhance that. Again, we're not talking about replacing human beings in issue of loneliness and social connection. We're talking about augmenting them. And I think it's helping maintain those relationships. The person who might be in contact just, you know, texting with their parent, oh, so how are you doing? You're feeling a weird, like how do you connect the family and all those people around individual to resources, thinking about the PACE model where the bus driver's information could lead to a earlier intervention. So I think, I think I'm off topic.

Speaker 8 1:14:06

No, it's, it's perfect.

Speaker 11 1:14:07

but I would say that, just rely on the trusted people in the community. You know? Um, my, um. My next door neighbor gets a ride to church every day. And you could get a, um, an automated car for her, but then she would miss out on the fact that that volunteer from the, from the mm-hmm. Church is actually, important source of connection. She trusts that person. You could get a drone deliver, home delivered meals, but for some people who are home bound, that person who delivers the meals is the only person they'll see all week. Think about that. Another, the human being. So I think those are the people we trust and we should try to augment them instead of replace them.

Speaker 10 1:14:44

That's a fantastic answer, Shelly.

Caregiver Identity, Admin Burden, and Closing Remarks

Speaker 13 1:14:47

I totally agree with that. Especially the, the meals we do, we deliver meals and many times, like you said, that person is the only person that individual sees all week. they don't have family, they don't have a support system and. So we make sure that we give time to that individual that's delivering that meal to spend with that, with that adult that they're delivering the meal to. Um, but I do wanna add on the trust, as I see it. So there's different in differences in age, right? In those that we're caring for. So anyone that's, you know, 75 plus, I think that we have to deal with the daughters, the sons, the caregivers, the people that are the next generation that are going to need care that are aging right now. Someone like me, build the trust with someone like me and listen to what I have to say. Or people my age have to say about what they're seeing with the, what's being, provided or not provided for their mothers and fathers. And, listen to what they have to say and what their pain points are to find the solutions. I think that's how you build the trust.

Speaker 10 1:15:56

How do you deal with, um. People who don't necessarily identify themselves as a caregiver, they're just being, an obligatory daughter. There's somebody who is just, this is what I do. I'm taking care of mom, but I'm not a caregiver. I'm not, I'm not that. So how do you deal with that? Because I think that that's also a huge gap and certainly as I see it, an opportunity, to really start to kind of dive into ultimately getting to that identification of self-identification of caregiving.

Speaker 11 1:16:27

I mean, a RRP has done some work on this issue of, people from different cohorts, different age cohorts being actually being caregivers that, that, um, and it's important to broaden that stakeholder base of who caregiver, caregiver is, right? Whether it's, you know, people who are in college, right? People who are millennials or, uh, and, um, a minority of caregivers are men, but there are, uh, a group of, of, um. A, a sizable group of men are also caregivers, and it's important to consider that if people are to take advantage of any caregiving, uh, resources through the workplace or through any other form of support, they have to identify themselves as the caregivers first. And I think, here's the thing about aging. There is so much of a stigma around aging that, that people like, you know, you know, like the number of geriatricians is shrinking every year, right? That, uh, the stigma that we have on aging is such that it's not only people who are aging, but people who are serving, people who are aging, who sometimes get stigmatized as well. And that's another thing that we, I think we're fighting as well, but I think it's, in trying to figure out, yeah, I think it's important to be making caregiving as something that, is an issue, a sign of respect, something that you can be proud of, as a, as an individual in terms of someone who has, uh, yeah.

Speaker 10 1:17:38

How about from a payer perspective? I mean, many times caregivers are the ones that are making those choices for their parents for a Medicare plan or, you know, just the kind of the day-to-day stuff. What are you doing in your space, ADA?

Speaker 12 1:17:51

Yeah, so, um, so I, I did wanna just trace back to the trust

Speaker 10 1:17:55

Oh, sure.

Speaker 12 1:17:55

Just for one second. Because, the, the effort we did in, in Wilmer, I think was, really sort of indicative of trying to build trust and we still have trust to this day and in there and we, and we cultivate that relationship. Uh, so one, I I do think if we are trying to build trust, we have to acknowledge, that we have not been there, right? That like harm has happened, that, that there is, sort of healing restoration that has to occur. And us as a healthcare ecosystem have been a clear part of that issue. We have been complicit. And so I think about any relationship you have, if you have, done wrong, you don't just skip over it. You don't build trust that way. Just say, Hey, it'll go away. And 10 years from now, you're still bringing up the same thing I did because I, I've, I've never acknowledged it. So I think we have to enter in, into rural spaces acknowledging that things are happening in rural, that's not happening in urban. And part of that is rural fields, abandoned infrastructure is deteriorating. Like where are we all at in that, right? Are we showing up? I think the other thing is we have to share power and resources. One of the ways in which trust has been broken is that we have not gone to the people who are closest to the pain be part of the solution that we have brought in folks, helicoptered folks in, and there is significant resources that has been allocated to those folks who we've helicoptered in to try and help and solve for that community. And then. Autonomy. So one of the things we all crave is autonomy, in particular in trying to find solutions. One of the things we did in, in, in Wilmer was community created a sort of round table and we simply provided funds to that community round table, and they went out and fought the, found the best solutions and they were able to fund those solutions. We didn't say no, we said the, y'all get to use these dollars in your community as you need to. And then the last thing is, is, is action. I think we do a lot of sort of getting insights and then it just is insights and folks are saying, I told you that already, we need you to act. And so I think that becomes important. So then this, this notion of how do we recognize caregivers? I do believe that as, and I'm taking Minnesota as my end of one, but I don't know if, if payers do a great job of recognizing caregivers in the work that they do. And how critical they are. And I think that is an area and an opportunity for us. we have found ways to, incentivize many things within sort of the healthcare ecosystem. And I do believe that there's a way that we can incentivize caregivers, being, recognized. and again, this would take partners, right, compensated in a highly regulated, industry. But that, that is the way in which I, I think we will, uh, con, uh, get better results is to sort of empower, provide autonomy to caregivers as they are the ones who are navigating a really complex system. I work within healthcare too, and it is, I need to call somebody. To say, how does all this work? So I think that's one of the ways that we could do that is, uh, we, we have a mechanism right now that we incentivize behavior that would incentivize outcomes. I think we could use that, to incentivize, and partner with caregivers to get better results.

Speaker 10 1:21:22

Fantastic. Fantastic. Well, we have a few minutes, before we're wrapping up, I, I would really encourage all of you to ask some questions from our routine panel. Oh wait, you got a mic coming? There you go.

Speaker 3 1:21:36

Quick question on that last point. When you talk about incentivizing caregivers, would there be a cost shift from helicoptering somebody in to the caregiver?

Speaker 12 1:21:46

Y Yes. So I think, one of the ways is there, there would need to be sort of this cost shift and so I think, and, and, and that is where we have to be in. I would say better connection with providers and others who, we don't want to like move folks away from providers, but we do want to say that there's probably somebody closer than us or providers who would be able to sort of move, uh, a parent or move, uh, those that their caregiving for in a direction of better adherence and better engagement and better outcomes. So yes, I, I do think there would have to be some form of, sort of, cost or, financial shift that would allow that. I mean, we, we need to take a look at our system as a whole. It isn't getting outcomes we want. You don't just keep doing that. You look for ways in which you can improve it. And I do think, as a payer, how do we partner with, uh, organizations to be able to do that?

Speaker 13 1:22:38

Sure. Uh, so I'd like to just talk about that a little bit too. As far as paying caregivers, we would love to, we've been looking into this and how to do it because we can't find caregivers. So we get these calls that, hey, I, I don't know, my mom needs help and I don't know what to do. Could we as an organization, hire the family member to be the caregiver? You know that that's a possibility. It makes sense, doesn't it? But there's rules. But we could provide the training, we could provide all the guidance. And I think that is potentially one solution that we would, we've been looking at.

Speaker 12 1:23:12

C could I add on to that? Because I do think that that speaks to, I think we have over medicalized some things. We now have peer support specialists and some others with lived experience that help with bh, right. Mental health. I think we should be looking at this. I think we've. Overregulated what a caregiver is, and like how do we sort of get more or, or lessen the burden to show up? Because right now there's a high burden to show up in some of like a caregiver or other ways.

Speaker 10 1:23:41

And I think that's part of Irwin's, mention earlier around the stigma. It, it may also be part of that stigma is, well, I don't have a medical background. I can't be a caregiver. There's all these kind of sets of parameters. I don't check the boxes on those. But at the end of the day, you are a caregiver. Yeah, you're making sure her meds are taken, you're making sure she gets to her doctor's appointment, her grocery shopping is done, et cetera, et cetera. That by definition is a caregiver. So I think you're right. I think as we start to rethink this model that clearly is not working, those types of innovations and those types of research and insights that you bring to the table are really gonna be important.

Speaker 6 1:24:20

So fantastic panel. Thank you. I just wanna say there are, a number of programs with paid family caregiving that actually demonstrates short-term cost savings. There are also companies I'm aware of that are actually in the market of training family caregivers to become certified and therefore payable by home health agencies. So those are currently there, and that's something you may wanna tap into. So back to what I was originally, and, and by the way, I'm also thinking, you know, since this is about AI and sustainability, who knows who the caregivers are, every discharge planner, where are we using AI to actually listen to those encounters and pick out the caregivers? So then you can then identify and offer the kinds of supports. And in that caregiving, you'll begin to identify and categorize what are those needs. So you'll get hyper-local data, if you will. So that's just an example of AI and finding caregivers to augment what we don't have already. So my question was actually really different, but I got caught up in the conversation and that's really about, other opportunities where AI can help simplify the administrative, tasks and time for caregivers and professionals as well as, build trust. So for example, thinking about, data collection and surveys. We use surveys to do social isolation and loneliness. Data surveys. Are you food insecure? Do you have nutrition? Okay, can't we use free text the large language and actually extract that from the conversations and save everyone time. Some aware of a very innovative company that's in Massachusetts. They started May of 24. By the end of 24, they had seven town contracts. Why? Because they developed a tech space system where you could ask for services. They understood all the services, different grants, who was qualified for what? Figured that out on the back office. So all the consumer had to do was to call, I need transportation, I need groceries, I need delivery, whatever it is. They could pick it up on text, connect them, and schedule and deliver the service. Moreover, they could check afterwards to say, was the service delivered and didn't meet your expectations so you could audit for the town. It dramatically reduced their staff time on answering phone calls and their data collection to support their grants. Hey, that was seven towns in less than a year. He is now being asked in several states and also starting to support the largest aaas and the cost structure. This is, he has three employees. Doing this because he is using AI tech space and now he's able to take those texts, those free language texts and actually say, I know you asked for transportation, but I think you've got a food issue. And he is now able to deliver food. The second example that I just like to ask,'cause you were, this was about, um, social connection and isolation, and you talked about dementia as an issue. How many in your screening tools are actually checking one of the most calm? What is the highest risk factor for avoidable dementia? Number one, and number two is highly associated with loneliness and social isolation. And thirdly, is hugely prevalent. And that's hearing loss. That is two thirds of all people. 70 and older have clinically significant hearing loss. Only a third ever get hearing aids. If you have significant hearing loss, you have a 50% higher degree rate of loneliness compared to good hearing. If you have, for every 10 decibels of hearing loss, you have an increase, I think 25% or some number like that of social isolation and hearing loss is the single biggest risk factor for avoidable dementia. Mm-hmm. According to the Lancet Commission on Dementia, we now have over the counter hearing aids. You can do that online, you can do hearing tests online. How many are you are using your conversations, your telephone, doing free online hearing tests. Johns Hopkins has a free test doing hearing tests and then offering connection to over the counter hearing aids. And there's some nine Medicaid states that actually require hearing assistance. And there's free FCC services if you have hearing loss for speech to text, caption grade. So I'm just saying we're not tapping into what we already have and maybe we should go where the pain points. Our individuals that we can tap into and create better programs.

Speaker 11 1:29:08

I like what you said about pain points, because again, if the goal is to have more human interaction, how can we augment caregivers to allow them to spend more time, um, you know, or even get, let them have respite, right. So I think of, you know, whether it's, you know, there's gonna be increased burden for anyone who is gonna be applying for Medicare, right? for health insurance. Like, can we create ways in which those, those applications for Medicaid are repeatedly sent out. And, um, so that, people who are unable to fill out the forms themselves can be assisted in actually filling out those forms and that they arrive on time so they don't lose their health insurance. I did a study in 2012, um, with some former colleagues at UCSF where we, we looked at, uh. Volunteering and life expectancy. so volunteers tend to have a robust, uh, life, uh, mortality benefit In our study, non volunteers had a mortality, annual mortality of this was in older adults of around 12% versus 9% in volunteers. But this was not significant. When you looked at people who were limited in driving, it went from non volunteers who had limited driving, had a morta annual mortality rate, 30%. And, uh, volunteers who, uh, had limited driving had a mortality of 15%. So it was something about this interaction of like not being able to drive at how volunteering was protective in some way, potentially because it did, um, you know, drive social interaction and then this was even more significant in rural communities. So I think those are some signals suggest that, you know, one of the ways that AI can help is this issue of transportation. How do you get people to the religious services? How do you get people to their, you know, their barbers and their hairdressers? How do you get people to, to visit their buddies and to watch the game?

Speaker 9 1:30:55

Mm-hmm.

Speaker 11 1:30:55

You know, those are ways in which I think at a very baseline level of transportation, especially in rural America, is a barrier. So how do you address those pain points to get people face-to-face or even online with the people that they trust and the people who are significant social relationships.

Speaker 10 1:31:10

Mm-hmm. Absolutely. Did you have a question back there? Okay. I

Speaker 14 1:31:14

did.

Speaker 8 1:31:14

I,

Speaker 14 1:31:15

I have a 94-year-old dad and a 90-year-old mom. I just moved from

Speaker 5 1:31:19

Florida to be with house and what

Speaker 14 1:31:25

what has confounded me is we move them into an assisted living place and they were in independent living before. They're lonely and, and the hearing loss thing is a big deal. I think they're, they're scared of interacting'cause they're, they're afraid they're gonna miss signals. And, and they, and they have trouble understanding speech, but now they're in this assisted living place. There are people all around them and there are people helping them. Yet they are resistant to interaction still. Their, their only community is the two of them. And once one of them goes, I don't know what they're gonna do. But How do you, how do you combat kind of a resistance to social interaction that grew because they didn't have the tools? Probably, yeah. I mean they're, they're generally kind of introverted, but they didn't have the tools when they needed them to engage. So now there is just no way there. I mean there, there's some poor guy there that does have cognitive problems and I'm like, have dinner with him. Like, sure, because, because that's a service. You'd be helping this guy out if you would have dinner with him. And they said, we don't know. I'm like, well, you can't know'em till you have dinner with them like that. But, but there's such a resistance and it

Speaker 10 1:32:46

is, and I'm sure it's a bigger problem than any of us even realize.

Speaker 14 1:32:49

Yeah,

Speaker 10 1:32:50

right. It's huge. Absolutely. So I'm gonna let Erwin, um, address this and then I'm gonna be the timekeeper. We've got about two minutes and then we need to wrap up, however we are here for lunch so we can continue this conversation informally. I just won't be on mic. so I'll have you do that and I'll give some closing remarks.

Speaker 11 1:33:07

So I'll quote, uh, the Bible since we're at Notre Dame. Uh, Matthew 25 40. whatever you do for the least of us, you do unto me. And I would say that, again, going back to volunteering, it's sometimes actually easier to ask people to do something for someone else that they wouldn't do for themselves. So I think your strategy was very interesting and I think it's, um, giving people a sense of purpose within the community that can let them sort of fall back on roles they had when they were younger. Um, and so purpose and volunteering is one way. To sort of overcome those other issues you may have described?

Speaker 10 1:33:40

That's a great question, by the way, really, because I'm sure there's probably a couple of other people in this room that are dealing with the same thing as we're kind of becoming sandwich caregivers of our kids and our parents as well. So thank you and thank you for everyone for your engagement on this. Like I said, I'm sure we could continue this conversation for a while. just a quick, again, reminder for housekeeping. Um, we were gonna be eating here today for lunch. I'm going to mention the fact that you've got some information on the back of your name tag. Um, that gives you basically kind of a path to, to eat lunch out here, right? And then any dietary restrictions that you may have. just see any person that's stressed in black out there.

Speaker 15 1:34:23

If any of you have dietary restrictions, let the server know and they'll, your food is.

Speaker 10 1:34:31

Absolutely. Absolutely. I wanna thank all of you really, especially our panel today. I think this is, this is something that Michelle and I had talked about, probably, I don't know, a good year ago. And I, I just said this is an opportunity for us to really start opening the conversation up. I think, in spirit of what Natasha, and others have been talking about in terms of exclusivity, inclusivity, excuse me, inclusivity, we've addressed responsible, inclusive, safe, and ethical, um, components in all of this discussion today. And I think it's really important that we keep that conversation going. So thank you again and, uh, enjoy the rest of the day.