IT'S MY PLEASURE TO WELCOME YOU TO THE FIRST NINR DIRECTOR'S LECTURE OF 2021. THANKS FOR JOINING US AS WE VIRTUALLY DELIVER THIS DIRECTOR'S LECTURE. WHILE OF COURSE WE'D LOVE TO RETURN TO THE NIH CAMPUS AND TO HOST THESE LECTURES IN PERSON, WE'RE COMMITTED TO DOING OUR PART IN KEEPING COMMUNITIES SAFE AND HEALTHY. BEFORE I INTRODUCE OUR DISTINGUISHED SPEAKER, JUST A FEW HOUSEKEEPING NOTES. AN ARCHIVE OF TODAY'S LECTURE WILL BE AVAILABLE ON NINR'S YOUTUBE CHANNEL. FOLLOWING DR. SZANTON'S PRESENTATION, WE'LL HAVE A LIVE MODERATED QUESTION AND ANSWER SESSION. QUESTIONS CAN BE SUBMITTED VIA THE VIDEOCAST WEBSITE. SO HERE'S HOW THAT WORKS. IS YOUR VIDEO IS FULL SCREEN, YOU'LL NEED TO CLOSE THE FULL SCREEN MODE, THEN UNDER THE VIDEO, CLICK THE LINK THAT SAYS "SEND LIVE FEEDBACK," ENTER YOUR QUESTION THERE, AND YOUR QUESTION WILL BE SENT TO THE MODERATOR. ON OUR END, DR. JERRY MILLER, CHIEF OF THE NINR OFFICE OF PALLIATIVE CARE AND END OF LIFE RESEARCH WILL MODERATE THE QUESTION AND ANSWER SESSION. THE NINR DIRECTOR LECTURE SERIES BRINGS RESEARCHERS FROM ACROSS THE NATION WHO ARE ADVANCING NURSING SCIENCE IN SIGNIFICANT WAYS TO SHARE THEIR WORK AND INTERESTS WITH A TRANS DISCIPLINARY AUDIENCE. NINR HAS LONG SUPPORTED RESEARCH THAT INCLUDES THE HEALTH AND QUALITY OF LIFE FOR PATIENTS AND COMMUNITIES. NOW MORE THAN EVER, WE SEE THE NEED FOR MORE AND BETTER KNOWLEDGE, TECHNOLOGY, HEALTHCARE, AND PUBLIC HEALTH SERVICES TO IMPROVE OUR NATION'S HEALTH. WE'RE COMMITTED TO FUNDING NURSING SCIENCE THAT SOLVES THE MOST PRESSING HEALTH PROBLEMS AND THE MOST STUBBORN HEALTH INEQUITIES BY COLLABORATIVELY TAKING NURSING SCIENCE TO NEW LEVELS. IN THIS SPIRIT, I'D LIKE TO INTRODUCE TODAY'S SPEAKER, DR. SARAH SZANTON. DR. SZANTON'S RESEARCH FOCUSES ON DECREASING BARRIERS TO AGING IN PLACE, INCLUDING ADDRESSING SOCIAL DETERMINANTS OF HEALTH. SUCH AS FINANCIAL STRAIN AND DISCRIMINATION. SHE IS THE HEALTH EQUITY AND SOCIAL JUSTICE ENDOWED PROFESSOR AT THE JOHNS HOPKINS SCHOOL OF NURSING. DR. SZANTON CO-DEVELOPED THE COMMUNITY AGING IN PLACE, ADVANCING BETTER LIVING FOR ELDERS PROGRAM, OR CAPABL, WHICH WAS TESTED IN TRIALS NOW SCALED TO 32 SITES IN 17 STATES. THE PROGRAM COMBINES HANDYMAN SERVICES WITH NURSING AND OCCUPATIONAL THERAPY TO IMPROVE MOBILITY, REDUCE DISABILITY, AND DECREASE HEALTHCARE COSTS. SHE CURRENTLY LEADS THE NINR-FUNDED PROMOTE P30 CENTER, MANAGING MULTIPLE CHRONIC CONDITIONS, STUDYING SOCIAL DETERMINANTS OF HEALTH, AND PROVIDING COMMUNITY-DRIVEN CARE ARE THE PILLARS OF THE PROMOTE RESEARCH CENTER. AMONG HER MANY AWARDS AND HONORS, SHE WAS THE 2019 HEINZ AWARD WINNER FOR THE HUMAN CONDITION AND IS A PBS NEXT AVENUE INFLUENCER IN AGING. SHE HOLDS DEGREES FROM HARVARD, JOHNS HOPKINS AND THE UNIVERSITY OF MARYLAND. THANK YOU SO MUCH FOR JOINING US. PLEASE HELP ME IN WELCOMING DR. SZANTON. >> THANK YOU SO MUCH, SHANNON. IT'S A PLEASURE TO BE HERE. AND WITH ALL OF YOU, IT'S VERY STRANGE TO GIVE A TALK TO PEOPLE I CAN'T SEE, BUT YOU'D THINK WE'D ALL GET USED TO THAT A YEAR INTO THIS VERY DIFFICULT TIME. LET US BEGIN BY HONORING THE LAND UPON WHICH NIH SITS, THAT ORIGINALLY BELONGED TO THE TRIBE AND THE LAND WHEREVER YOU SIT OR STAND NOW. ACCEPT FOR NATIVE AMERICANS, ALL OF US WERE EITHER BROUGHT HERE AGAINST OUR WILL OR CAME HERE AS IMMIGRANTS. AS A COUNTRY, AND AS SCIENTISTS, WE OFTEN ACT AS THOUGH CONTEXT IS NOT KEY TO MOVING KNOWLEDGE FORWARD. EVEN IF OUR RESEARCH IS WITH THE GUT MICROBIOME OR DNA METHYLATION, OUR NATION'S HEALTH IS BEST SERVED WITH CONTEXT IN MIND. IS THE PERSON WHOSE CELLS WE EXAM EXPERIENCING FOOD INSECURITY OR HOUSING INSTABILITY? ARE THEY A CAREGIVER? DID THEY GROW UP ON A RESERVATION OR IN A RED LINE SEGREGATED NEIGHBORHOOD? TO ALL THE NURSE SCIENTISTS AND ASPIRING NURSE SCIENTISTS WHO HAVE JOINED TODAY, THIS IS OUR MOMENT. BEYOND THE SPOTLIGHT, WE'VE RECEIVED FROM THE EXTRAORDINARY CARE THAT NURSES HAVE PROVIDED DURING COVID, THIS IS OUR MOMENT FOR GROUND BREAKING RESEARCH. AS NURSE SCIENTISTS, WE ARE AT THE INTERSECTION OF MANY FIELDS. WE UNDERSTAND AND CAN STUDY FROM BIOLOGY TO SYMPTOMS TO WHOLE INDIVIDUALS, TO FAMILIES AND COMMUNITIES. TOGETHER, AS WAS MENTIONED, OUR MISSION IS TO IMPROVE THE HEALTH OF INDIVIDUALS, FAMILIES AND COMMUNITIES. THIS IS OUR LANE. IT'S A BIG LANE, A POWERFUL LANE. AND TO THE PEOPLE JOINING WHO ARE NOT NURSE SCIENTISTS, WELCOME. WE'RE HAPPY TO BE WITH YOU IN THIS SPACE. IN MY RESEARCH TALK, I'LL HAVE SEVERAL THREADS I'M HOPING YOU'LL LISTEN FOR. ONE IS RESILIENCE AND STRENGTH BASED APPROACHES RATHER THAN DEFICIT APPROACHES, STRUGGLE AS THE SOURCE OF INNOVATION, INCLUDING DISABILITY AS A SO IS SOURCE OF INNOVATION, EQUITY THROUGHOUT THINKING STRUCTURALLY RATHER THAN JUST INTERPERSONALLY, USING DATA TO LEVERAGE CHANGE, AND WORKING WITH PEOPLE AS THEY ARE WITH WHATEVER CHRONIC CONDITIONS THEY HAVE, WHEREVER THEY ARE ON THE ABILITY AND DISABILITY SPECTRUM, HOWEVER THEIR FAMILIES SHOW UP OR DON'T. THE WORK ISN'T PUBLISHED, ISN'T DONE WHEN WE RECEIVE THE PAPER OR RECEIVE THE GRANT. I WILL BE SHOWING YOU WORK THAT'S BEEN PUBLISHED AND WELL FUNDED BY NIH AND I'M GRATEFUL FOR THAT FUNDING, BUT WE DIDN'T BECOME NURSES AND WE DIDN'T BECOME RESEARCHERS TO HAVE PAPERS IN JOURNALS. THAT'S HOW WE MEASURE SUCCESS IN A PROXIMAL WAY, BUT THAT IS NOT HOW WE IMPACT THE WORLD. SO THE TITLE OF THE TALK AS YOU CAN SEE IS LEVERAGING STRENGTHS TO ACHIEVE HEALTH EQUITY: FROM CLINICAL INSIGHT TO PROGRAM OF RESEARCH . THIS SLIDE IS FROM THE ROBERT WOOD JOHNSON FOUNDATION, AND IT'S DEMONSTRATING THE DIFFERENCE BETWEEN EQUALITY AND EQUITY. IN THE UPPER ROW, EVERYBODY HAS THE SAME SIZED WHEELS ON THEIR BICYCLE, WHETHER THEY FIT THEM OR NOT. BUT IT'S NOT ENOUGH TO PROVIDE SOMETHING TO EVERYONE AND EXPECT TO WORK FOR THEM. IN THE BOTTOM ROW, THE EQUITY ROW, THERE ARE DIFFERENT KINDS OF BICYCLES FOR DIFFERENT PEOPLE, SO THEY CAN ALL PROPEL THEMSELVES WHERE THEY WANT TO GO. SO MY LENS, AND I WOULD ARGUE ALL OF OUR LENS AS NURSE RESEARCHERS SHOULD BE THE SCIENCE OF ATTAINING MEANINGFUL LIFE, THE SCIENCE -- MEANINGFUL DEATH, A MEANINGFUL BIRTH, MEANINGFUL LIFE, DOING WHAT PEOPLE WANT TO BE ABLE TO DO, FREE OF PAIN, FREE OF DEPRESSION, FREE OF HOUSING INSECURITY AND ALL THE OTHER ASPECTS THAT LEAD TO LESS HEALTH THAN THEY MIGHT HAVE. SO AS MENTIONED, MY OVERALL RESEARCH IS IN HEALTH EQUITY AND AGING. I HAVE THREE STREAMS OF RESEARCH. ALL OF THEM, I'VE PUBLISHED IN AND BEEN FUNDED IN. I HAVE MENTEES AND REALLY IMPORTANTLY MENTORS AND ALL OF THEM. AND I'LL BE FOCUSING TODAY IN TERMS OF RESEARCH AND DATA ABOUT AGING IN COMMUNITY. THE OTHER TWO ARE THE EFFECT OF FINANCIAL STRAIN ON HEALTH AND THE EFFECT OF BENEFITS OR INCOME TO IMPROVE HEALTH, AND STRUCTURAL RACIAL DISCRIMINATION AND STRUCTURAL RESILIENCE. I'D BE HAPPY, VERY HAPPY, EXCITED TO TALK ABOUT THE OTHER TWO DURING THE QUESTION PERIOD, BUT I WANTED TO FOCUS A LITTLE BIT SINCE WE JUST HAVE A SHORT TIME TOGETHER. SO DR. ZENK MENTIONED CAPWL CAPABLE. MANY OF THEM LIVED IN CONVERTED CHICKEN COOPS, I'VE WORKED AS A NURSE AND NURSE PRACTITIONER WITH REGULAR ADULTS EXPERIENCING HOMELESSNESS AND FOR A DECADE APROVIDED HOUSE CALLS AS A NURSE PRACTITIONER IN WEST BALTIMORE WITH PEOPLE WHO ARE HOMEBOUND, BY THEIR HOUSING AS MUCH AS BY THEIR PHYSICAL CONDITIONS. I FOUND THAT MY LENS WAS TOO LIMITED, SO MRS. B., SHE WAS ACTUALLY IN CAPABLE, BUT LET ME TELL YOU AS THOUGH SHE HAD BEEN A PATIENT OF MINE IN THE HOUSE CALLS PRACTICE. SHE HAD HYPERTENSION, CONGESTIVE HEART FAILURE AND DIABETES. THOSE ARE VERY COMMON DIAGNOSES FOR PEOPLE AT 80 AND ABOVE, WHICH SHE WAS, AND I MENTION HER CONDITIONS FIRST NOT BECAUSE THAT'S WHAT'S MOST IMPORTANT TO HER, BUT GOING IN, THE WAY I WAS TRAINED, I WAS TREATING IT LIKE IT WAS A CLINICAL VISIT THE WAY SHE WOULD COME TO ME IN A CLINIC, BUT I JUST HAPPENED TO BE IN HER HOUSE. BUT BEING IN SOMEONE'S HOUSE, IT'S PRICELESS, RIGHT? HOUSE CALLS ARE PRICELESS. YOU SEE WHETHER OR NOT THEY CAN GET DRESSED, YOU CAN SEE -- SHE'S ESSENTIALLY IN PAJAMAS HERE. YOU SEE THIS WAS HER WARDROBE AND IT WASN'T A FULL CLOSET BECAUSE HER BEDROOM IS THE DINING ROOM AND IT'S BROKEN WITH SAFETY PINS THAT SHE CAN'T UNDO BECAUSE OF THE ARTHRITIS IN HER HANDS. AND THIS IS HER FLOOR AFTER WE HAD FIXED IT IN CAPABLE. BUT IF SHE HAD BEEN A PATIENT AND THERE HADN'T BEEN CAPABLE, SHE WOULD HAVE TO NAVIGATE THESE HOLES. AND ACTUALLY, IN THIS WINDOW IS ACTUALLY RIGHT NEXT TO HER DOOR WHICH HAD A 2-FOOT BY 1-FOOT HOLE. SO I HAD TO LIKE LEAP OVER TO GET OUT, AND SHE HAD NOT LEFT HER HOUSE IN A YEAR. WHEN WE FIRST CAME TO MEET HER. AND THERE'S EXTERIOR STAIRS LIKE THESE ALL OVER BALTIMORE, I DON'T KNOW IF THAT'S JUST A BALTIMORE THING BUT THERE ARE A LOT OF UNSAFE STAIRS WITH FABRIC ON THEM. BASED ON EXPERIENCES WITH PARTICIPANTS WHO WERE LIKE MRS. B. AND OTHERS WHO HAD TO DROP THEIR KEYS FROM THE SECOND FLOOR TO LET ME IN BECAUSE THEY COULDN'T MAKE IT DOWN THE STAIRS, SOME WHO HAD TO CRAWL TO THE FRONT DOOR AND GREETED ME ON THEIR HANDS AND KNEES TO LET ME IN. I WORKED WITH COLLEAGUES TO DEVELOP CAPABLE, AND -- WHICH WAS ADAPTED FROM THE ABLE PROGRAM. IN CAPABLE, WE ADDRESS THE WHOLE PERSON BY MODIFYING THE ENVIRONMENT AND WORKING WITH THE PERSON TO MAKE THE BEST FIT BETWEEN THE TWO. THAT'S A FOUNDATIONAL IDEA IN GERONTOLOGY, BUT IT OFTEN HASN'T BEEN IMPLEMENTED FROM BOTH SIDES, FROM THE PERSON AND THE ENVIRONMENT. NOW I WAS A LOBBYIST BEFORE I WAS A NURSE OR A RESEARCHER. SO I ALWAYS SEE THINGS FROM THE NEXT STEP. HOW WOULD WE EXPLAIN WHAT WE WANTED WITH A CHART OR SHOW OUR IMPACT OR HOW DO WE TAKE WHAT WE LEARN AND MAKE IT AVAILABLE TO OTHERS? SO FUNCTIONAL LIMITATIONS ARE COSTLY. THEY'RE COSTLY FOR A NUMBER OF REASONS, PARTLY BECAUSE SOMETIMES PEOPLE NEED HELP AND HELP CAN BE EXPENSIVE, BUT ALSO BECAUSE PEOPLE ARE MUCH MORE LIKELY TO BE HOSPITALIZED OR PUT IN A NURSING HOME IF THEY HAVE FUNCTIONAL LIMITATIONS. NOW YOU CAN SEE THIS IS VERY OLD DATA, BUT THE PATTERN REMAINS AND WE'RE ACTUALLY WORKING ON A NEW ANALYSIS TO WORK ON THIS, BUT YOU CAN SEE THAT JUST HAVING CHRONIC CONDITIONS DOESN'T MAKE ONE VERY LIKELY TO BE WHAT ECONOMISTS CALL HEALTHCARE SPENDERS, AS THOUGH THEY'RE SPENDING THEIR MONEY GLEEFULLY ON HOSPITALIZATIONS. IT REALLY WHEN YOU GET TO THE UPPER RIGHT, AND I'M SORRY THAT I'M NOT WITH YOU TO POINT AT THIS, BUT WHEN YOU GET TO THE UPPER RIGHT, WHEN PEOPLE NEED HELP WITH ADLs ORAL IADLs, THINGS LIKE BATHING, DRESSING, GROOMING, GETTING FOOD IN THE HOUSE, THAT PEOPLE ARE REALLY LIKELY TO BE EXPENSIVE. AND THIS IS IMPORTANT BECAUSE OLDER ADULTS WITH FUNCTIONAL LIMITATIONS REALLY DRIVE POPULATION HEALTH OUTCOMES FOR THE WHOLE COUNTRY. SO IF WE CAN BRING THOSE DOWN AT THE SAME TIME AS IMPROVING PEOPLE'S LIVES, HELPING THEM BE ABLE TO DO WHAT THEY WANT TO DO, WE CAN BOTH INCREASE MEANINGFUL ACTIVITY AND SAVE RESOURCES FOR ALL THE OTHER ISSUES THAT OUR COUNTRY HAS. SO IT AN AREA THAT'S RIPE FOR INVESTMENT AND INNOVATION. SO CAPABLE IS FOUR MONTHS LONG, IT'S NOT FOREVER, IT'S NOT ONE VISIT. IT INVOLVES -- I'M SORRY THIS GOT CUT OFF BUT A HANDIWORKER, A NURSE, AN OCCUPATIONAL THERAPIST. THE MAIN FOCUS IS ON ADLs, IADLs AND MEANINGFUL ACTIVITY, AND THE OVERALL COST IS LESS THAN $3,000 OVER THOSE FOUR MONTHS. AND YOU'LL SEE IT SAVES ABOUT 7 TO 10 TIMES THAT MUCH. I'M NOT GOING TO GO THROUGH THE WHOLE PROGRAM AND THE WAY IT WORKS. WE'VE PUBLISHED ABOUT 25 PAPERS AND I'M HAPPY TO DO IT DURING THE QUESTION AND ANSWERS, BUT BASICALLY THE GREEN LINES, THESE GREEN HANDS ARE THE OCCUPATIONAL THERAPIST WHO STARTS AND STOPS THE PROGRAM. THE YELLOW IS THE NURSE. AND THIS IS THE HANDIWORKER. AND ESSENTIALLY, WITH THE OCCUPATIONAL THERAPIST AND WITH THE NURSE, THE OLDER ADULT WITH A UNIVERSAL ASSESSMENT WHERE THEY PRIORITIZE WHAT THEY WOULD LIKE TO WORK ON, AND I'LL TELL YOU A FEW STORIES LATER ON SO YOU CAN SEE HOW THAT WORKS. AND THE NUMBER OF VISITS ARE RELATED TO HOW MANY THINGS THEY WANT TO WORK ON, AND THEN TOGETHER THE OCCUPATIONAL THERAPIST AND THE OLDER ADULT MAKE A PRIORITIZED WORK ORDER THAT THE HANDIWORKER IMPLEMENTS. AND CRUCIALLY, IN CAPABLE, THE OLDER ADULT IS THE EXPERT. SO SOMEONE LIKE MRS. B., SHE IS THE ONE WHO IS COMING UP WITH WHAT SHE WANTS TO WORK ON. AND OF COURSE WE DON'T WALK IN THE DOOR AND SAY WHAT ARE YOUR GOALS. IT'S BASED ON A CONVERSATION AND AN ASSESSMENT, BUT IT'S NOT PRIMARY CARE, IT'S NOT REPLACING ANYTHING ELSE. IT'S FOUNDATIONAL TO OTHER KINDS OF CARE. AND SO THE CLINICIANS SOLELY SUPPORT -- ELICIT AND SUPPORT THE OLDER ADULT'S GOALS AND WORK TOGETHER TO FIGURE OUT WITH BRAINSTORMING AND ACTION PLANNING HOW TO IMPLEMENT THEM. IN CASE YOU FALL ASLEEP FOR THE REST OF THE TALK, WE'VE FOUND IT INCREASES PHYSICAL FUNCTION, REDUCES DEPRESSION AND LEADS TO FEWER HOSPITALIZATION AND NURSING HOME ADMISSIONS. SO THIS IS A SNAZZY NEW GRAPHIC WE JUST GOT AND IT FOCUSES A LITTLE MORE ON THE O.T. SIDE THAN THE NURSE SIDE BUT I'M HOPING THAT THIS WILL WORK. SO JUST GIVING YOU A LITTLE BIT OF A SENSE. SO IF SOMEONE'S GOAL IS TO PREPARE MEALS MORE EASILY WITHOUT SHORTNESS OF BREATH AND PAIN, YOU MIGHT BE HEARING THAT FROM THE O.T. SIDE, OH, THEY WANT PREPARED MEALS. BUT FROM THE NURSE SIDE, THERE'S SHORTNESS OF BREATH AND PAIN. SO WE'RE ONE HUMAN BEING WHERE ALL THESE COMING TO, SO CAPABLE COME TOGET HER, SO IN THE WORK ORDER, THE HANDIWORKER LOWERS THE CABINETS TO SHE CAN REACH ITEMS AND WE HELP TO ORGANIZE HER SPICES TO HELP HER USELESS ENERGY. AND THEN A REACHER GIVES HER CONTROL WHEN PICKING UP ITEMS. THE HANDIWORKER INSTALLS A STOVE MIRROR, BRILLIANT, OCCUPATIONAL THERAPISTS KNOW ABOUT ALL THESE FANCY THINGS THAT I DIDN'T KNOW ABOUT, SO MRS. R. CAN SEE THE FOOD IN THE POTTS AND PANS WHILE SHE'S SEATED. SHE DOES NOT HAVE TO STAND UP. MANY PEOPLE DON'T HAVE THE STRENGTH TO STAND FOR A WHOLE MEAL PREPARATION. AND SO NOW SHE CAN PREPARE MEALS MORE EASILY WITHOUT SHORTNESS OF BREATH AND PAIN, AND I COULD GIVE YOU, YOU KNOW, MANY HOURS OF EXAMPLES, BUT THAT'S THE IDEA OF HOW IT WORKS TOGETHER. SO WE HAD A PILOT THAT WE DID IN 2010, PUBLISHED IN 2011 IN THE JOURNAL OF AMERICAN GERIATRIC SOCIETY. THESE ARE UNADJUSTED MEANS IN ADLs AND IADLs, YOU CAN SEE THAT THE CAPABLE GROUP IMPROVED REALLY A FAIR AMOUNT AND WHEN WE STARTED CAPABLE, PEOPLE SAID YOU CAN'T BUDGET DISABILITY, IT'S NOT GOING TO WORK. SO WE WERE REALLY IMPRESSED WITH THIS. AND THIS IS COMPARED TO A CONTROL GROUP RECEIVING THE SAME NUMBER OF HOUSE CALLS BUT ABOUT SOCIAL THINGS. SO THIS IS KIND OF CONTROLLING FOR THE CHANGE IN SOCIAL ISOLATION, IF YOU WILL. AFTER, NOW I CAN'T SEE YOU, I DON'T KNOW WHO YOU ARE, BUT I'M ASSUMING SOME OF YOU ARE STUDENTS AND JUNIOR FACULTY, AND YOU HAVE TO REALLY PAY ATTENTION TO YOUR PILOTS. YOU LEARN A LOT OF LESSONS. PILOTS AREN'T JUST TO WORK OUT THE FEASIBILITY OF LITERALLY HOW DO YOU SAVE THINGS, THEY'RE ALSO TO LEARN FROM THE PARTICIPANTS YOU'RE WORKING WITH. WE WENT INTO IT THINKING MORE ABOUT THE SAFETY THAN ABOUT PEOPLE'S INDEPENDENCE AND WHAT THEY WANTED, AND WE REALLY LEARNED TO FLIP THAT, AND THAT SHOULD REALLY ALL BE ABOUT WHAT THE PERSON WANTS. AND CRUCIALLY, IT WORKED OUT THAT IT STILL SAVES COSTS AND IT TURNS OUT THAT THE OLDER ADULTS REALLY ARE THE EXPERTS. HERE'S JUST A VISUAL OF TWO 85-YEAR-OLDS LIVE IN THAT HOUSE ON THE LEFT, AND THAT'S OBVIOUSLY OUT OF CODE, BUT YOU'D BE SURPRISED AT HOW MUCH DANGEROUS STUFF THERE IS IN PEOPLE'S HOUSES. IN 2012, WE GOT BOTH AN R01 FROM NATIONAL INSTITUTE OF AGING AND A CMS INNOVATIONS DEMONSTRATION PROJECT. SO THIS IS SOME RESULTS FROM THE DEMONSTRATION PROJECT, THAT WAS ONE-ARMED, AND YOU CAN SEE THAT 75% OF THE PEOPLE ON THE LEFT IMPROVED WITH THEIR ADLs AND 65% IN THEIR IADLs. THIS IS OVER TIME WITH VERY LOW INCOME OLDER ADULTS, SO YOU COULD EVEN SAY STAYING THE SAME, WHICH IS THE YELLOW, IS GOOD, BUT THIS WAS REALLY HEARTENING TO US, AND OF THE 75% WHO IMPROVED, THE AVERAGE REDUCTION WAS CUTTING IN HALF THE AREAS OF DISABILITY THAT THEY HAD. SO THIS WAS REALLY REMARKABLE AND IT WAS PUBLISHED IN "HEALTH AFFAIRS." WE ALSO IMPROVED, YOU CAN SEE, DEPRESSIVE SYMPTOMS AND THIS IS EVEN COUNTING PEOPLE WHO HAD NO ROOM TO IMPROVE THEM. A CEILING EFFECT, FOR THOSE OF WHO YOU ARE RESEARCHERS. SO THAT WAS REALLY IMPRESSIVE TO US. WHEN I WENT THROUGH, BECAUSE IT WAS A ONE-ARMED STUDY, IT WASN'T BLINDED, AND WHEN I WENT THROUGH THE SPAGHETTI PLOTS TO SEE THAT SOME PEOPLE DID GET WORSE OVER THE TIME, SO I LOOKED AT THOSE PEOPLE AND WHAT HAD HAPPENED, AND ALMOST TO A PERSON, A CHILD OF THEIRS HAD DIED, THEY'D HAD -- ONE PERSON HAD THEIR HOUSEBROKEN INTO THREE TIMES IN THE COURSE OF CAPABLE. SOMEONE ELSE HAD A STROKE. YOU KNOW, SO OF COURSE LIFE HAPPENS AS WELL, AND SOME PEOPLE WILL GET WORSE OVER TIME. BUT IN TERMS OF THE GENERAL MODIFIABLE DEPRESSIVE SYMPTOMS THAT WE COULD HAVE SOME CONTROL OVER, WE WERE REALLY IMPRESSED. AND THEN, OF COURSE, THE HOME HAZARDS IMPROVED BECAUSE WE WERE DIRECTLY IMPLEMENTING THOSE. THESE ARE THE RESULTS PUBLISHED IN JAMA INTERNAL MEDICINE OF THE RANDOMIZED CONTROL TRIAL THAT I MENTIONS THAT NIA FUNDED. THIS IS SET UP THE SAME WAY AS THE PILOT SO YOU CAN SEE THAT IN ADLs AND IADLs, IT'S A REALLY REMARKABLE SIMILAR CHANGE THAT THERE HAD BEEN OF CUTTING ABOUT IN HALF AND THIS IS AGAIN COMPARED TO SOCIAL ATTENTION, WHERE THEY MADE GOALS AND THEY WERE VERY ACTIVE IN TERMS OF WHAT THEY WANTED TO DO BUT THERE WERE SEDENTARY THINGS, SO THEY WERE THINGS LIKE LEARNING HOW TO USE THE INTERNET, PLANNING A FAMILY REUNION, LEARNING HOW TO USE A SMARTPHONE, MAKING SCRAP BOOKS, ALL THINGS WE KNOW ARE BENEFICIAL FOR OLDER ADULTS. THIS IS SHOWING THAT THERE WAS A 30% REDUCTION IN ADL SCORES COMPARED TO CONTROL. 37% ACTUALLY, AND 30% IADLs, AND THIS IS ADJUSTED FOR WHAT YOU CAN SEE HERE ON THE SCREEN. OUTSIDE EVALUATORS EVALUATED THE MEDICARE SPEND, THE COST SAVINGS, SO THIS IS BY SARAH RUIS ET YOU PUBLISHED IN "HEALTH AQAIRS" SHOWING CAPABLE SAVED $2,700 PER QUARTER PER PERSON, AND THEY MEASURED IT FOR EIGHT QUARTERS. SO IN ESSENCE, CAPABLE BROKE EVEN THAT FIRST QUARTER BECAUSE THAT'S ABOUT HOW MUCH IT COSTS, AND THEN THE NEXT SEVEN QUARTERS, MEDICARE WAS SAVING MONEY. AND THEN WE DID THIS IN MEDICAID, WHERE ALONG WITH THE HILLTOP INSTITUTE AT UMBC SHOWED THIS DIFFERENCE, SO THIS IS THE CAPABLE AND THIS IS ACTUALLY COMPARISON, THIS IS MISLABELED AS CONTROL. BUT THIS IS A 10 TO 1 MATCHED COMPARISON, SAME AGE, GENDER, RACE, ZIP CODE, NUMBER OF CHRONIC CONDITIONS, AND HEALTHCARE SPENDING PRIOR TO 2012. THIS DIFFERENCE AT THE BOTTOM IS NURSING HOME, SEE IT SAYS LTC, THAT BY ITSELF, THAT DIFFERENCE BETWEEN 5% OF THE PEOPLE WHO NEEDED NURSING HOME ADMISSION AND 2% IN THE CAPABLE, THAT DIFFERENCE OF 3% WAS ACTUALLY ENOUGH TO PAY FOR THE WHOLE COHORT. SO THAT THE SAVINGS COMES BECAUSE THEY'RE ALSO A LOT LESS LIKELY TO BE HOSPITALIZED. I MENTIONED EARLIER THAT I WAS A LOBBYIST BEFORE I WAS A NURSE, AND ALSO WITH THE MENTORSHIP OF LAURA GITLIN, SHE TAUGHT ME THAT IT REALLY GOOD TO GET ALL KINDS OF MEASURES, NOT JUST YOUR MAIN OUTCOMES, FROM PEOPLE BECAUSE DIFFERENT KIND OF STAKEHOLDERS RESPOND TO DIFFERENT KINDS OF METRICS. SO WE THOUGHT TO INCLUDE ALSO, DID YOU LIKE THIS. DID IT HELP YOU GAIN CONFIDENCE. WHEN I THINK ABOUT THE OVERALL BENEFIT, WOULD IT HELP OTHERS. AND YOU CAN SEE, WE WERE THRILLED THAT THE PEOPLE IN THE CONTROL GROUP ALSO THOUGHT IT HAD A LOT OF BENEFIT. AND THIS IS HAS ANSWERED A GREAT DEAL. YOU CAN SEE THE BIGGEST DIFFERENCES ARE IN SOME OF THIS AGING IN PLACE KIND OF THINGS LIKE GAINED CONFIDENCED, HELPED CARE FOR SELF, HELPED CARE FOR OTHERS, MADE HOME SAFER, MADE LIFE EASIER. SO THIS WAS ALSO A GREAT SIGNAL IN TERMS OF CAPABLE WORKING. SO I'VE GOT A COUPLE OF PATIENT STORIES AND THEN I WANT TO CONCLUDE MORE KIND OF WHAT MIGHT MATTER TO YOU, AND I'LL JUST TELL ONE OF THEM HERE. SO MRS. D. HAD BEEN UNABLE TO GET DOWNSTAIRS IN TWO YEARS. SHE SAT IN A COMMODE CHAIR NEXT TO HER BED. IT WAS A VERY SMALL ROOM SO THAT'S PRETTY MUCH ALL THAT WAS IN THERE. AND WHEN WE FIRST GOT THERE, IT TOOK HER 30 MINUTES TO WALK TO THE BATHROOM. AND THE BATHROOM WAS ONLY ABOUT 30 FEET AWAY. AND SHE WAS PRETTY MUCH NODDING OFF IN HER CHAIR, IN HER COMMODE CHAIR, AND ACTUALLY BOTH THE O.T. AND THE NURSE AFTER THE FIRST VISIT CAME TO ME AND SAID, I DON'T KNOW HOW SHE GOT INTO THIS STUDY AND I DON'T KNOW WHAT WE'RE GOING TO DO, AND WE JUST SAID, WELL, WE'LL JUST TRY TO WORK THE PROGRAM, WORK THE PROTOCOL. AND THE NURSE FIGURED OUT THAT THE FAMILY THOUGHT THEY WERE DOING A GREAT JOB BUT THEY WERE GIVING HER 26 DIFFERENT MEDICATIONS ALL AT ONCE, FIRST THING IN THE MORNING, MANY OF THEM FOR PAIN. THIS WAS A CLASSIC POLYPHARMACY. SHE'D BEEN PRESCRIBED DIFFERENT THINGS FROM DIFFERENT PLACE AND SHE HADN'T BEEN ABLE TO GET IN AND SEE PEOPLE, THESE ARE FROM DIFFERENT HOSPITALIZATIONS, SO SHE WAS REALLY OVERMEDICATED. AND ONCE WE HELPED HER STRAIGHTEN THAT OUT AND MADE A VERY SIMPLE MEDICATION SCHEDULE FOR HER, SHE WAS ALERT AND ACTIVATED AND SHE WANTED -- SHE REALLY WANTED TO COME UP WITH HER GOALS, AND HER FIRST GOAL WAS TO BE ABLE TO GET DOWNSTAIRS AND WASH HER HAIR IN THE KITCHEN SINK. AND TO ME, IT'S AN EXCELLENT PATIENT GOAL, RIGHT? BECAUSE NONE OF US WOULD WALK INTO HER HOUSE AND SAY, YOU SHOULD WASH YOUR HAIR IN THE KITCHEN SINK. BUT THAT WAS REALLY MOTIVATING TO HER. AND SHE IN THE BRAINSTORMING PROCESS CAME UP WITH THE IDEA OF PUTTING LITTLE PLASTIC DECK CHAIRS THAT WE BOUGHT WITH PART OF THE HOME MODIFICATION MONEY THAT SHE COULD -- ESSENTIALLY WOULD DO CHAIR STANDS AND EXERCISES, SHE WOULD STAND UP AND WALK TO THE NEXT ONE AND REST. BECAUSE THERE'S A MONTH IN BETWEEN VISITS, SHE COULD DO THAT AND GAIN A LOT OF STRENGTH. NOW AGAIN, IF WE HAD COME TO HER AND SAID YOU NEED TO DO CHAIR STANDS OR HERE ARE THE EXERCISES I'M GIVING YOU, IT WOULDN'T HAVE GOTTEN ANYWHERE, BUT IT WAS OF HER MOTIVATION AND HER KIND OF BUILDING ON HER OWN SELF-EFFICACY. AND I'LL JUST KEEP IT SHORT AND JUST TELL YOU HER OTHER GOALS, ONE WAS TO BE ABLE TO GET OUT OF BED HERSELF. SHE HAD NOT BEEN ABLE -- SHE COULD ONLY LIE IN THE BED AND HER HUSBAND WHO WAS QUITE FRAIL WOULD COME AROUND THE BED AND PULL HER UP AND KIND OF PLUNK HER ON TO THE COMMODE CHAIR. SO SHE WANTED TO GET OUT OF THE BED HERSELF, AND ALL WE DID FOR THAT, SO REMEMBER SHE'S STRONGER NOW FROM THESE CHAIR STANDS, SO THAT COMBINED WITH MAKING HER BED MORE FIRM WITH JUST PLYWOOD IN BETWEEN THE TWO PARTS OF THE BED, AND A GRAB BAR TO PUSH HERSELF UP FROM, THE FIRST TIME SHE GOT HERSELF OUT OF THE BED, HER HUSBAND BURST INTO TEARS. AND THEN WE PUT BANNISTERS ON THE SECOND -- ON BOTH SIDES OF THE STAIRS SO SHE COULD GET DOWN. SHE STILL KEEPS A PLASTIC DECK CHAIR AT THE TOP OF THE STAIRS. SHE'S STILL NOT STRONG ENOUGH TO WALK ALL THE WAY DOWN THE HALL AND THEN DOWN THE STAIRS, BUT THAT'S GREAT. SHE RESTS AND THEN SHE GOES DOWN THE STAIRS. AND NOW SHE'S LESS ISOLATED IN HER OWN HOME TOO BECAUSE HER FAMILY MEMBERS DON'T HAVE TO SIT ON HER BED NEXT TO A COMMODE CHAIR TO TALK WITH HER. A MONTH OR TWO AFTER SHE FINISHED CAPABLE, HER FAMILY CALLED ME AND SAID THEY WERE ALL GOING TOGETHER, INCLUDING HER, ON A VACATION. TO ATLANTIC CITY. SO SHE'S NOW A VIBRANT PART OF THE ECONOMY TOO. AND SO I JUST LOVE THAT STORY. IT'S A LITTLE MORE EXTREME, IT'S A LITTLE BIT MORE FROM ZERO TO 60 IN A WAY THAN OTHER STORIES. THIS ONE, I'LL JUST BRIEFLY TELL YOU A LOT OF REALLY SMALL THINGS INCLUDING A SUPER EAR WHICH COULD ALLOW HER TO HEAR, SWITCHING FROM ALEVE TO TYLENOL, EASIER TO TAKE A BATH. SHE SAID TO ME WHEN I VISITED HER, IF I HAD 10,000 TONGUES AND THEY COULD ALL SPEAK AT THE SAME TIME, I COULD NOT PRAISE THE CAPABLE PROGRAM ENOUGH. FOR HER, SHE FELT LIKE IT REALLY CHANGED HER LIFE. SO WHY THIS WORKS, I TALKED ABOUT PERSON-ENVIRONMENT FIT, THAT'S A BIG PART OF WHAT'S HAPPENING. THE PERSON IS GETTING STRONGER, BEING ABLE TO THINK OF NEW SOLUTIONS AND BEING ABLE TO PLAN, AND THEN THE ENVIRONMENT IS M COULDING UP TO MEET THEM. THEY'VE GOT A SECOND BANNISTER, WIDER COMMODE, OR A STURDIER BED, OR LOWER CABINETS OR A MIRROR OVER THEIR STOVE. IT UNLEASHES PEOPLE'S MOTIVATION. PEOPLE GET EXCITED WITH CAPABLE BECAUSE THEY SAY THINGS TO US LIKE, NO ONE'S EVER REALLY LISTENED ABOUT WHAT I WANT TO DO OR WHAT'S IMPORTANT TO ME. AND THEN THEY ARE ABLE TO DO THOSE THINGS AND THEN THEY LOOK FOR NEW CHALLENGES. WE HONOR THEIR STRENGTHS AND THEIR GOALS AND THEIR INNOVATIVE SENSE. HOW THEY'VE ALREADY BEEN ADAPTING TO GET SOMETHING DONE AND HOW CAN WE BUILD ON THAT. AND THEN OF COURSE WE PROVIDE THE RESOURCES TO ACHIEVE THOSE GOALS. SO WE DON'T COME IN AND SAY YOU REALLY NEED A SECOND BANNISTER HERE. WE PROVIDE IT. IT'S PART OF CAPABLE AND IT STAYS AS A VISUAL ENVIRONMENTAL QUEUE FOR THEM TO PRACTICE WHAT THEY WANTED TO DO. YOU BETTER BELIEVE THAT HAVING THOSE CHAIRS ALONG THE HALLWAY WAS A REMINDER. OH, YEAH, I WANT TO BE ABLE TO GET DOWN THE STAIRS AND DO THOSE. AND I MENTIONED BUILDING SELF-EFFICACY FOR NEW CHALLENGES. SO IF YOU THINK ABOUT IT, FUNCTION -- IT'S WHAT WE ALL DO. WE BRUSHED OUR TEETH, WE MOVED AROUND, AND THAT'S WHY WE CARE ABOUT HEALTH, WHY? THAT'S WHY WE WANT TO PREVENT HEART ATTACKS, STROKES AND DEPRESSION, IS SO THAT WE CAN DO THINGS. AND POOR FUNCTION IS COSTLY. IT'S WHAT WE CARE ABOUT, AND IT HAS BEEN VIRTUALLY IGNORED IN CARE EXCEPT FOR WHEN SOMETHING HAS HAPPENED, LIKE AFTER A HIP SURGE REAL OR AFTER BYPASS. WE'VE SHOWN WITH CAPABLE IT CAN BE MODIFIED QUITE A LOT. SO CAPABLE IS NOW IN 33 PLACES AS WAS MENTIONED IN THE INTRODUCTION. AND HUD ACTUALLY JUST ANNOUNCED YESTERDAY THAT THEY ARE RELEASING $30 MILLION FOR UP TO A MILLION DOLLARS A SITE FOR NEW SITES. AND THERE'S ALSO ALL KIND OF OTHER PAYOR POSSIBILITIES THAT I'M HAPPY TO TALK ABOUT. I RECOGNIZE THIS IS A RESEARCH TALK AND NOT A LOBBYING TALK SO I WON'T GO TOO FAR DOWN THAT PATH, BUT I'M MENTIONING IT BECAUSE AS YOU DEVELOP WHAT YOU'RE DEVELOPING, YOU'RE GOING TO ALWAYS WANT TO THINK WHAT IS THE NEXT STEP AND HOW DOES IT GET FARTHER, HOW DOES IT GET BEYOND THE JOURNAL OR YOUR OWN UNIVERSITY. AND WHEN HE WAS RUNNING FOR PRESIDENT, PRESIDENT BIDEN SPENT A WHOLE MINUTE TALKING ABOUT CAPABLE IN A SPEECH THIS SUMMER. I WAS ACTUALLY DRIVING FROM ALABAMA TO BALTIMORE AND MY PHONE JUST LIKE LIT UP WITH PEOPLE TELLING ME THAT IT HAPPENED. AND THE P TACK, TAC UNANIMOUSLY BACKED CAPABLE AS WELL IN 2019. SO HOW DOES THIS RELATE TO YOU AND BACK TO YOU? SOME PEOPLE TALK ABOUT A THREE-LAYER CAKE OR THIS IDEA OF A TREE, BUT RESEARCH -- NIH IS TRYING TO IMPROVE HEALTH, RIGHT? BUT WHAT NIH DOES IS THE RESEARCH PART AND THE RESEARCH ENVIRONMENT PART, HELPING UNIVERSITIES GET BETTER RESEARCH ENVIRONMENTS AND HELPING INDIVIDUAL RESEARCHERS AND TRAINING GRANTS THRIVE. SO THAT'S KIND OF THE SEEDLING -- I'M SORRY, THAT'S THE GROUND AND THE SEED, SO WHERE YOU ARE AS A RESEARCH ENVIRONMENT AND THEN YOUR IDEA. SORRY, MY LIGHT GOES OUT AND THEY DON'T MOVE. SO THAT'S THE FIRST STAGE. BUT IT'S CERTAINLY NOS THE FINAL STAGE, RIGHT? AND I THINK NIH RECOGNIZES THAT, THAT THEY'RE AT THE BEGINNING. AND THEN -- SORRY, I GUESS I COMBINED THE FIRST AND SECOND, BUT THE MIDDLE ONE IS PHILANTHROPY. IF YOU LOOK AT THESE 33 SITES, A LOT OF THEM ARE PAID FOR BY FOUNDATIONS. SOME OF THEM ARE NOT, SOME OF THEM ARE THROUGH VALUE-BASED PAYMENT, BUT FOUNDATIONS CAN JUMP IN WHEN YOU ALREADY HAVE A GOOD IDEA, YOU'VE TESTED IT A LITTLE BIT, AND THEY WANT TO SPREAD IT. BUT THEY'RE NEVER GOING TO BE THE ANSWER, RIGHT? WE'RE NEVER GOING TO GET EVERY MEDICARE BENEFICIARY TO GET CAPABLE BECAUSE OF FOUNDATIONS. SO THEN AT SOME., YOU HAVE TO GROW INTO A TREE WHERE THE FISCAL INCENTIVES ARE ALIGNED AND/OR THE POLICY ENVIRONMENT OR BOTH. SO IF YOU CAN GET SOMETHING TO BE A BENEFIT OR IF IT MAKES MARKET SENSE FOR INSURER, AND LOOK AT IT THIS WAY, IF YOU DEVELOPED A DRUG, YOU WOULDN'T EXPECT FOUNDATIONS TO BE GETTING THE DRUGS OUT PEOPLE, YOU WOULD EXPECT INSURANCE PLANS AND FOR THEM TO BE COVERED BY MEDICARE. BUT WITH BEHAVIORAL INTERVENTIONS, IT'S A LITTLE TRICKIER. SO AS NURSE SCIENTISTS, YOU ALREADY HAVE THE IDEAS, AND THE IDEAS ARE GROUNDED IN REALITY AND READY FOR PRACTICAL CHANGE. AND YOU SEE WHAT MATTERS AND CRUCIALLY YOU ALREADY KNOW HOW TO COMMUNICATE REALLY WELL. THINK ABOUT HOW YOU CHANGE WHAT YOU SAY DEPENDING ON WHETHER YOU'RE TALKING TO A PEDIATRIC OR A WORRIED PARENT OR AN OLDER ADULT. LIKE WE NATURALLY CHANGE HOW WE SPEAK, BUT SOMEHOW WHEN WE THINK OF RESEARCH, WE JUST TALK IN ONE KIND OF A WAY IN RESEARCH-ESE, BUT YOU DO KNOW HOW TO COMMUNICATE. THESE COMMUNICATION SKILLS TRANSLATE FROM PATIENT TO POLICY MAKERS. SO IF YOU WORK YOUR IDEA STEP BY STEM, YOU CAN MAKE THESE KINDS OF CHANGE. I WANTED TO JUST MENTION A FEW LESSONS I'VE LEARNED ALONG THE WAY. IF YOU WANT TO BE A REBEL, YOU HAVE TO REALLY FIRST FIGURE OUT WHERE YOU ARE WORKING AND WHAT MATTERS TO THE PEOPLE WHO MAKE DECISIONS AND EXCEL IN THAT. SO I'M AT JOHNS HOPKINS, WE'RE A RESEARCH UNIVERSITY. I WORK VERY HARD TO MAKE SURE I'M DOING WHAT NEEDS TO BE DONE HERE, AND THEN I FIGURE I CAN TRY TO UP-END THE SYSTEM AS WELL. YOU CAN BUILD FROM YOUR INSIGHT. COMMON SENSE IS REAL. AND YOU CAN STUDY IT METHODICALLY. IT'S IMPORTANT TO USE COMPELLING STORIES AND TO BECOME BETTER AND WORK AT BECOMING A GOOD STORYTELLER. AND I MENTIONED THIS JUST NOW WHEN I WAS TALKING ABOUT THE DIFFERENCE BETWEEN DRUGS AND BEHAVIORAL THERAPIES, BUT THEY SHOULDN'T HAVE TO PAY FOR ITSELF, IT'S A DOUBLE STANDARD WITH PROCEDURES AND PILLS, BUT IT DOES HELP. IF YOU CAN MEASURE COST SAVINGS. BUT ALSO THAT OTHER MARKERS OF VALUE CAN COUNT. DEPENDING ON WHO YOUR STAKEHOLDER IS, YOU'RE TRYING TO CHANGE SOMETHING ABOUT, PERHAPS EMPLOYEE SATISFACTION OR NURSERY TENSION OR BENEFICIARY SATISFACTION, OR THERE MAY BE OTHER MARKERS YOU CAN FIND, KIND OF OTHER PAIN POINTS, WHOEVER THE STAKEHOLDERS YOU'RE WORKING WITH, STUDENT DROPOUT OR OTHER THINGS THAT ARE DIFFICULT FOR THEM THAT YOU MIGHT BE SOLVING. SO IT DOESN'T JUST HAVE TO BE DOLLARS AND CENTS. I WANT TO END BY SAYING IN THIS CRAZY AND VULNERABLE AND TRAGIC MOMENT OF HISTORY, WE ALL HAVE A PLACE TO MAKE A DIFFERENCE. AND I HOPE THAT WE CAN MAKE BIG CHANGES TO THE WAY THAT WE EDUCATE, INCLUDING THE TEST PREPARATION FOR LICENSING, THE WAYS WE TEACH OUR STUDENTS TO THINK ABOUT MEASUREMENTS IN RESEARCH AND HOW THAT CAN CREATE OR DISMANTLE STRUCTURAL RACISM. THE TIME IS WELL PAST TO MAKE A NEW WORLD WITH HEALTH EQUITY FOR ALL. THANK YOU SO MUCH. >> WELL, THANK YOU SO MUCH, DR. SZANTON. THIS IS GERI MILLER FROM NINR. THIS HAS BEEN AN ENORMOUSLY INFORMATIVE, INSPIRING AND I'D SAY VERY MEANINGFUL PRESENTATION. >> THANK YOU. >> AND SO AS EXPECTED, WE HAVE MANY QUESTIONS FROM THE AUDIENCE. SO I'M GOING TO POSE THESE QUESTIONS TO YOU, DR. SZANTON, UNTIL WE NEAR THE FIVE MINUTE TO THE HOUR MARK, AND THEN I'LL PASS THE PRESENTATION BACK TO DR. ZENK FOR HER CONCLUDING REMARKS. SO OUR FIRST QUESTION HAS TWO PARTS, AND IT FOCUSES ON THE REACH AND THE POSSIBLE EXPANSION OF CAPABLE TO OTHER POPULATIONS. THE QUESTION IS, DOES CAPABLE INVOLVE FAMILY MEMBERS OR CARE PARTNERS, AND THEN WHAT ABOUT CAPABLE FOR PEOPLE AND THEIR CARE PARTNERS THAT ARE FACING THE CHALLENGES OF ALZHEIMER'S AND RELATED DEMENTIAS? >> GREAT. THANK YOU FOR THOSE QUESTIONS, DR. MILLER. SO IN TERMS OF FAMILY MEMBERS, WE'VE RECENTLY BEEN FUNDED BY NIDILRR TO ADAPT CAPABLE FOR TOOLS FOR CAREGIVERS, AND ALSO TO ADAPT IT FOR PEOPLE WITH DEMENTIA, AND WE'RE WORKING WITH A FANTASTIC STUDENT WHO JUST GOT FUNDED FOR THE R36 FROM NIH TO WORK WITH US ON THAT. AND WE STUCK AT FIRST WITH PEOPLE WHO WERE KIND OF -- DIDN'T NECESSARILY HAVE CAREGIVERS, SOME OF THEM DID, SOME OF THEM DIDN'T, BECAUSE WE WANTED TO FOCUS ON THE SITUATION BEING THEIRS, WHAT THEY WANTED TO CHANGE ABOUT THEIR LIVES, BUT WE KNOW THAT PEOPLE AND FAMILIES COME IN ALL TYPES AND IT'S IMPORTANT TO TRY TO EXPAND IT FOR ALL KINDS OF PEOPLE. >> THAT IS VERY EXCITING NEWS. AND CONGRATULATIONS ON THE OTHER EXCITING NEWS ABOUT THE HUD SUPPORT FOR IMPLEMENTATION SITES. >> THANK YOU. >> WE HAVE A COUPLE QUESTIONS AROUND THE RURAL, AND CAPABLE IN THE RURAL COMMUNITY. ARE THE CURRENT 33 SITES THAT YOU HAVE IN RURAL OR EVEN REMOTE LOCATIONS, AND HOW DO YOU NAVIGATE THOSE SERVICES WITH LOCAL COMMUNITY OR STATE ENTITIES? >> GREAT. THANK YOU. AND ACTUALLY 50% OF THE NEW SITES HAVE TO BE PARTLY RURAL PARTLY BECAUSE SENATOR SUSAN COLLINS FROM MAINE IS ONE OF THE BIG PROMOTERS OF THAT AND SHE'S VERY CONCERNED WITH RURAL INDEPENDENCE, AND YES, SOME CAPABLE SITES ARE PRETTY RURAL. MOST OF THEM ARE URBAN OR SUBURBAN BUT SOME OF THEM ARE RURAL, AND IN FACT IN HAWAII, THERE'S A PLACE WHERE THEY HAVE TO HELICOPTER IN THE O.T., THE NURSE LIVES ON THE ISLAND BUT THEY -- AND WE HAVE A NEW SITE IN ALASKA THAT'S ON AN ISLAND, AND THERE'S ONLY 3,000 PEOPLE ON THE WHOLE ISLAND. SO YES, IT'S REALLY ACROSS THE SPECTRUM. AND PEOPLE HAVE FOUND -- YOU KNOW, WHAT PEOPLE HAVE SAID TO US IS, FOR THE VERY REMOTE, AND THAT'S THEIR TERM, IT'S NOT MY TERM, I'M NOT SAYING THEY DON'T MATTER. FOR THE VERY REMOTE AREAS, FOR HOSPITALIZATION, YOU'RE ACTUALLY SENDING A HELICOPTER. SO IF YOU CAN SAVE ONE HELICOPTER RIDE, YOU CAN IMPLEMENT CAPABLE FOR MANY PEOPLE. >> ABSOLUTELY. WE HAVE A CAREER-TYPE QUESTION. THANK YOU FOR GIVING SOME WORDS OF WISDOM TO THOSE WHO ARE BEGINNING THEIR RESEARCH CAREERS AND NAVIGATING/DEVELOPING THEIR IDEAS. THIS QUESTION IS, WHAT ADVICE DO YOU HAVE FOR JUNIOR FACULTY WHO ARE DEVELOPING IMPACTFUL RESEARCH TRAJECTORIES OR FOR JUST GETTING FUNDING FOR THEIR, QUOTE-UNQUOTE, OUT OF THE BOX IDEAS? >> WELL, I MEAN, THAT COULD TAKE US -- YOU KNOW, I WOULD LOVE TO TALK ABOUT THAT FOR ANOTHER LECTURE SOMETIME, AND I THINK IT'S A BROAD QUESTION. I THINK THE MAIN THING IS PICKING SOMETHING YOU'RE VERY INTERESTED IN. AND DOING THE BEST YOU CAN TO GET MENTORS WHO WILL SUPPORT YOU. AND IF YOU DON'T HAVE PEOPLE AT YOUR INSTITUTION, IT'S POSSIBLE TO GET MENTORED BY OTHER INSTITUTIONS IF YOU SHOW UP, IF YOU'VE DONE YOUR HOMEWORK, IF IT'S CLEAR, THAT YOU'RE ORGANIZED, THOUGHTFUL, YOU DON'T HAVE TO JUST BE LIMITED TO PEOPLE IN YOUR ORGANIZATION. AND ACTUALLY WHEN LAURA GITLIN, WHEN WE FIRST STARTED TO WORK TOGETHER, SHE WAS NOT AT HOPKINS, WE RECRUITED HER TO JOHNS HOPKINS AND SHE WAS HERE FOR SIX YEARS BEFORE SHE WENT ON TO BE DEAN AT DREXEL. SO I THINK -- GET YOUR IDEAS DOWN ON PAPER AND RUN THEM BY PEOPLE AS MUCH AS YOU CAN. >> THANK YOU. THANK YOU, DR. SZANTON. THIS IS SORT OF A RELATED QUESTION, BUT WITH A LITTLE BIT OF A DIFFERENT AGE GROUP. THE QUESTION IS, I AM A PEDIATRIC NURSE PRACTITIONER. I'M TRYING TO DEVELOP A RURAL HEALTH PROGRAM THAT LEVERAGES TELEHEALTH AND GROUP APPOINTMENTS TO ENGAGE FAMILIES IN PRIMARY AND CHRONIC CARE HEALTH MANAGEMENT. I'VE NEVER DONE A RESEARCH TRIAL OR PILOT BEFORE. HOW DO I CONVINCE MY HEALTH SYSTEM THAT THIS IS A BENEFICIAL ENDEAVOR TO INVEST TIME AND MONEY, AND ESPECIALLY IN THESE TIMES WHERE WE SHOULD BE POISED TO CHANGE THE CLIMATE OF HEALTHCARE? >> THAT'S A GREAT QUESTION. I DO THINK -- YOU DIDN'T MENTION -- OR THIS PERSON DIDN'T MENTION IF SHE OR HE WERE A -- HAVE A RESEARCH BACKGROUND, AND IF YOU'RE A PEDIATRIC NURSE PRACTITIONER AND YOU DO NOT HAVE A PH.D. OR -- I WOULD SUGGEST BUILDING A TEAM. ANYTHING WE DO TAKES A TEAM, AND YOU MIGHT HAVE REALLY GREAT IDEAS, BUT TO DEVELOP THEM IN WAYS THAT THE PEOPLE IN YOUR UNIVERSITY AND MAYBE PAYORS AND PROVIDERS ARE GOING TO TAKE -- YOU PROBABLY WILL WANT TO WORK WITH A STATISTICIAN AND PEOPLE WHO APPLY THE THEORY AND ALL THE KINDS OF THINGS WE LEARN IN PH.D. SCHOOL. SO I WOULD START WITH THAT, BUILDING A TEAM, AND THEN LOOKING AT WHAT METRICS MATTER TO THE STAKEHOLDERS THAT YOU'RE TRYING TO CHANGE THEIR MINDS. >> THANK YOU. DR. SZANTON, YOU MENTIONED THE CAPABLE RIGHT NOW IS A FOUR-MONTH PROGRAM. AND GIVEN THAT PEOPLE ARE HOPEFULLY LIVING LONGER AND MORE HEALTHIER LIVES, IN PART BECAUSE OF CAPABLE, DO YOU ENVISION THAT CAPABLE WOULD BE EXPANDED INTO A SERIES OF FOUR-MONTH OFFERINGS OR EXPANDED TO EIGHT MONTHS, ET CETERA? >> SO THAT'S A GREAT QUESTION, AND YOU KNOW, ALWAYS WHEN YOU'RE FIRST TESTING SOMETHING, YOU HAVE TO FIGURE OUT SOMETHING TO TEST AND OF COURSE YOU CAN ITERATE AFTER THAT. AND IN SOME PLACES THAT HAVE IMPLEMENTED CAMABLE, PEOPLE GET CAPABLE, P EOPLE GET A MONTHLY CALL AFTER THAT. THAT MIGHT BUMP THEM BACK IN, PEOPLE CAN GET CAPABLE ONCE A YEAR IF THEY NEED IT. IN AND A PRIMARY CARE PROVIDER IN HOUSTON, SOMEONE CAN GET WHAT THEY CALL CAPABLE LITE AFTERWARD IF THEY HAVE A STROKE OR SOMETHING HAPPENS, SO WE'RE JUST LETTING THE DIFFERENT SITES EXPERIMENT DIFFERENTLY WITH THAT AND WE'LL LEARN FROM THEM WHAT WORKS. >> OUR NEXT QUESTION IS GOING BACK TO WHAT YOU MENTIONED EARLIER ABOUT TRUE INTRIGUING OTHER LINES OF RESEARCH. I WONDERED IF YOU COULD JUST BRIEFLY GIVE US A LITTLE BIT MORE ABOUT THOSE. >> SURE. SO THE FIRST ONE IS ABOUT FINANCIAL STRAIN. FINANCIAL STRAIN IS NOT THE SAME AS INCOME. FINANCIAL STRAIN IS THE BALANCE BETWEEN INCOME AND EXPENSES. IT'S A REALLY PROMISING AREA OF RESEARCH BECAUSE THERE'S A LOT WE CAN DO ABOUT BOTH SIDES, RIGHT? IT'S KIND OF LIKE THE BALANCE BETWEEN INCOME AND EXPENSES. SO FOR EXAMPLE, IF AN OLDER ADULT GETS FOOD STAMPS, CALLED SNAP, THAT CAN RELIEVE SOME OF THEIR FINANCIAL STRAIN AND DR. SAMUEL AND I AND OTHERS HAVE SHOWN THAT SNAP CAN DECREASE FUTURE NEED FOR HOSPITALIZATION, AND NURSING HOME ADMISSION, AND IT'S ACTUALLY DOSE-DEPENDENT, SO CONTROLLING FOR ACTUAL INCOME AND OTHER THINGS, YOU CAN SHOW THAT HIGHER AMOUNTS OF SNAP LEAD TO INCREASINGLY LESS LIKELY HOSPITALIZATION IN THE FOLLOWING YEAR. WE SHOW THAT WITH DATA FROM THE ENTIRE STATE OF MARYLAND. SO IT'S NOT LIKE WE JUST HAD A SMALL SAMPLE. ALSO YOU CAN DO THINGS LIKE I'M SURE MANY PEOPLE IN THE AUDIENCE KNOW WHEN PEOPLE ARE ON $100 MEDICATIONS WHEN THEY COULD HAVE BEEN ON $3 MEDICATIONS. THOSE $97 CAN MEAN REAL MONEY FOR PEOPLE WHERE ALL YOU'VE DONE IS YOU'VE FIGURED OUT HOW TO GET THEM ON A DIFFERENT MEDICATION. AND ALSO DR. LAURA SAMUEL AND OTHERS HAVE SHOWN THAT FINANCIAL STRAIN, PEOPLE WHO ARE MORE FINANCIALLY STRAINED ARE MORE LIKELY TO GET DEMENTIA. SO THERE'S ALL KINDS OF BOTH EPIDEMIOLOGIC RESEARCH TO DO AND THEN ACTUALLY PRACTICAL RESEARCH TO DO ON THAT. IN TERMS OF THE STRUCTURAL DISCRIMINATION AND STRUCTURAL RESILIENCE, BOY, I WOULD LOVE TO TALK ABOUT THAT FOR HOURS. WE JUST GOT A PIONEERS AWARD FROM NIH TO DEVELOP GOOD MEASURES FOR STRUCTURAL DISCRIMINATION AND STRUCTURAL RESILIENCE AND WORKING WITH FANTASTIC PH.D. STUDENTS ON THAT, AND MORE TO COME, BUT WE'RE GOING TO BE GIVING THAT MEASURE INTO A LOT OF NIH STUDIES WHERE WE'LL BE ABLE TO LOOK ACROSS OUTCOMES. >> WE'LL HAVE TO HAVE YOU BACK AGAIN FOR SURE TO HEAR ABOUT THESE, AND CONGRATULATIONS ON THE PIONEER AWARD. >> THANK YOU. >> THIS IS A QUESTION NOW ABOUT ARE THERE ALTERNATIVES, ADAPTATIONS FOR THE CAPABLE PROGRAM IN CIRCUMSTANCES SUCH AS THE RECENT PANDEMIC? >> SO I THINK MAYBE SOMEONE IS TALKING WHAT ABOUT IF YOU CAN'T GET IN THE HOME, FOR EXAMPLE. SO BECAUSE IT'S ABOUT THE PERSON-ENVIRONMENT FIT, WHICH IS A BIG PART -- THE HOME IS A BIG PART OF THAT, WE HAVE TOLD THE CAPABLE SITES THAT THEY NEED TO GO FOR AT LEAST THE FIRST O.T. VISIT, THE FIRST NURSE VISIT AND THE FINAL ONE, AND IN BETWEEN CAN BE BY ZOOM OR BY PHONE, BY FACETIME. WE THINK THAT COVID DEFINITELY ALLOWED THE PLACES PAUSE. A LOT OF THE PLACES ARE HOME HEALTH AGENCIES WHO WERE STILL PREPARED TO GO IN PEOPLE'S HOUSES BECAUSE THEY WERE DOING THAT ANYWAY, BUT WE DO THINK THERE'S KIND OF UNLIMITED ABILITY TO ADAPT CAPABLE AS LONG AS PEOPLE STICK WITH THE BASIC PRINCIPLES WHERE THE OLDER ADULT IS IN CHARGE, IT'S ABOUT BUILDING SELF-EFFICACY, IT'S ABOUT MEETING THEM WHERE THEY ARE AND HAVING AN O.T. AND SOMETIMES THEY TRY TO KICK OUT THE O.T. AND SAY, CAN WE HAVE SOMETHING DIFFERENT, AND WE'VE BEEN VERY STRICT, O.T., NURSE AND HANDIWORKER, BUT BEYOND THAT, THERE'S A LOT OF ADAPTATION POTENTIAL. >> THANK YOU. WE ARE RECEIVING MANY, MANY CONGRATULATIONS AND EXCITEMENT ABOUT HEARING ABOUT THE CAPABLE PROGRAM. A LOT OF INDIVIDUALS FOR THE FIRST TIME. SO THERE ARE SEVERAL QUESTIONS ABOUT JUST ASKING WHERE CAN I FIND OUT MORE? WHERE CAN I FIND THE INITIAL RESEARCH ABOUT THIS PROGRAM? >> SO THANK YOU, AND I WISH I COULD SEE THE QUESTIONS TOO. BUT MY LAST NAME IS UNUSUAL ENOUGH THAT IF YOU JUST GOOGLE SZANTON, JOHNS HOPKINS, CAPABLE, EUM COME TO YOU'LL COME TO OUR WEBSITE. OR IF YOU'RE IN PUBMED, YOU CAN JI JUST SAY SZANTON CAPABLE IT WILL COME UP, OR SZANTON GITLIN, YOU'LL SEE ALL THE PAPERS. I'M ALSO HAPPY TO SEND THINGS TO PEOPLE, BUT I THINK THEY'RE PRETTY EASY TO FIND. >> WE'RE GETTING A LITTLE BIT CLOSE TO WHEN WE'LL HAVE TO END OUR Q & A. I HAVE ONE QUESTION HERE ABOUT HOW WOULD YOU CALL THIS WORK NURSING SCIENCE? WHAT MAKES SOMETHING NURSE SCIENCE IN YOUR VIEW? >> WELL, THANK YOU. YOU KNOW, I THINK THAT IN THE PAST, WE'VE BEEN TOO LIMITED OF WHAT WE THINK OF AS NURSE SCIENCE. AS I MENTIONED KIND OF IN THE BEGINNING, OUR LANE AND OUR NURSING SCIENCE IS REALLY CONTEXT, IS SEEING THE PERSON ALL THE WAY FROM THEIR CELLS TO THEIR ORGANS TO THEIR WHOLE INDIVIDUAL SELF, TO THEIR FAMILY, TO THEIR COMMUNITY AND SOCIETY. THAT'S WHO WE ARE AS NURSES. THAT'S HOW WE WERE TRAINED. WE DON'T JUST LOOK AT A DISEASE OR JUST LOOK AT, YOU KNOW, THE TOXIC ENVIRONMENT OR SOMETHING. WE SEE ALL OF THAT. AND TO ME, THAT'S WHAT MAKES NURSING SCIENCE. >> WE'RE GETTING VERY CLOSE TO THE FIVE-MINUTE MARK SO I'M GOING TO ASK THE VERY LAST QUESTION. HOW HAVE YOU USED THEORY IN YOUR WORK? DO YOU SEE THEORY AS IMPORTANT IN DEVELOPING IMPACTFUL RESEARCH? >> I DO! THANK YOU FOR THAT, AND PROBABLY SOME OF MY MENTEES AND PEOPLE I'VE TAUGHT ARE LAUGHING RIGHT NOW, BECAUSE I'M ALWAYS TALKING ABOUT LIKE THE QUOTE, IT'S SURPRISING HOW USEFUL THEORY IS. IT IS SO USEFUL. I THINK THAT CAPABLE AS A GREAT EXAMPLE -- I DON'T MEAN IT'S GREAT, BUT IT'S A USEFUL EXAMPLE OF THE DISABILITY, IT'S ALL ABOUT FUNCTIONAL LIMITATIONS AND THEN FACTORS THAT CAN MAKE THEM WORSE OR BETTER OUTCOMES, AND EXACTLY ABOUT THE PERSON-ENVIRONMENT FIT, AND WE TOOK THE PERSON AND THE ENVIRONMENT, THOUGHT ABOUT WHAT WE COULD DO WITH BOTH AND WE WERE GUIDED BY THEE THEORY. ALSO DR. JESSICA GILL AND I WROTE A RESILIENCE THEORY 11 YEARS AGO THAT WE'VE USED IN ALL OF OUR RESEARCH ABOUT THE WAYS IN WHICH, IF YOU ADDRESS MULTIPLE PARTS OF LIKE COMMUNITIES AND FAMILIES AND BUILT ENVIRONMENT, YOU'RE MORE LIKELY TO MAKE A LASTING CHANGE. SO I'M THANKFULLY -- I THINK IT'S UNDERAPPRECIATED IN THE NURSING WORLD AND PEOPLE ARE LIKE, OH, KNOW, I'VE GOT TO USE A THEORY. BUT THINK AGAIN. AND TRY AGAIN WITH THEORY. >> YOU KNOW, I SAID I WAS GOING TO DO THE LAST QUESTION BUT I HAVE A COUPLE THAT JUST CAME IN, AND YOU'RE SO SUCCINCT IN YOUR ANSWERS. LET'S SEE IF I CAN SQUEEZE ONE MORE IN. DO YOU HAVE TIPS FOR DEVELOPING YOUR RESEARCH TEAM AND COLLEAGUES, FOR EXAMPLE, FOR JUNIOR FACULTY, HOW DO WE MAKE OURSELVES ATTRACTIVE AS MENTEES OR COLLABORATORS FOR MORE SENIOR RESEARCHERS? >> WE WERE JUST TALKING ABOUT THAT IN THE CLASS I TEACH YESTERDAY. THE WAY YOU MAKE YOURSELF ATTRACTIVE IS TO SEEM EASY, BE THE EASY BUTTON. COME PREPARED, SEND AGENDAS AHEAD OF TIME, KEEP YOUR EMAILS SHORT. YOU KNOW, SENIOR RESEARCHERS GET FOUR OR 500 EMAILS A DAY, AND WE'RE CONSTANTLY SHIFTING FROM TITLE TO TITLE, AND WE TEND, WHEN WE REACH OUT TO SOMEONE WE DON'T KNOW WHO WE'RE IMPRESSED BY, TO GO ON AND ON AND ON, I'VE DONE THIS, I'VE DONE THIS. KEEP IT SHORT, MAYBE YOU CAN HAVE LINKS TO THINGS YOU WANT THEM TO SEE MAYBE, BUT -- AND KEEP GOING. AND ONLY WORK WITH PEOPLE WHO DON'T MAKE YOU CRAZY. I USED TO SAY -- I WORK WITH ABOUT WITH 50 PEOPLE AND I HAVE 22 SLOTS FOR CRAZY. I NOW HAVE NO SLOTS FOR CRAZY. I ONLY CHOOSE TO WORK WITH PEOPLE WHO I FIND, YOU KNOW, KIND AND GENEROUS AND THOUGHTFUL AND MISSION-ORIENTED, AND YOU CAN DO THAT FROM YOUR WHOLE CAREER. >> THANK YOU. THAT IS SUCH IMPORTANT GUIDANCE FOR SO MANY OF US. LET ME SEE IF I CAN PUSH THE BOUNDARIES OF JUST A LITTLE BIT MORE TIME. YOU'VE GENERATED EXCITEMENT ABOUT YOUR OTHER LINES OF RESEARCH, DR. SZANTON. THAT'S VERY EXCITING. A LISTENER ASKS: SOMETIMES THOSE OF US WHO HAVE HAD A LOT OF EXPERIENCE WORKING WITH THE DISEASE MODEL OF CARE FOCUS A LOT ON THE DISEASED INDIVIDUAL RATHER THAN THE ENVIRONMENT, AS YOU POINTED OUT IS IMPORTANT TO DO. IN YOUR RESEARCH ON STRUCTURAL RACISM, WHAT ARE YOUR THOUGHTS ON HOW TO HANDLE RESILIENCE RESEARCH VERSUS IMPLEMENTATION RESEARCH, FOCUSED ON COMMUNITY OR SOCIETAL MODIFICATION? THAT'S A BIG ONE! >> THAT IS A BIG ONE. YEAH, THAT MIGHT BE TOO BROAD FOR THIS AMOUNT OF TIME, BUT I GUESS I'LL SAY THE FIRST THING -- SO LIKE IN THIS MEASURE THAT WE'VE BEEN DEVELOPING, THE FIRST THING WE'VE DONE IS TALK TO PEOPLE. EVEN THOUGH EVERYDAY DISCRIMINATION OR PERCEIVED DISCRIMINATION HAS BEEN WELL DOCUMENTED BUT WE WANT TO UNDERSTAND WHAT IN THE STRUCTURES, IN EDUCATION SYSTEM, IN INCOME CREDIT AND WEALTH, IN VOTING, IN MEDIA, HAS AFFECTED PEOPLE. AND THEN WE'RE DEVELOPING THIS MEASURE AND PUTTING IT INTO STUDIES. SO WE'RE KIND OF DOING A MIXTURE OF QUALITATIVE AND QUANTITATIVE, AND WITH THE STRUCTURAL RESILIENCE, WE'RE STARTING WITH ASKING PEOPLE FOR MILESTONE PICTURES LIKE THEIR HIGH SCHOOL GRADUATION AND FINDING OUT WHAT STRUCTURES SUPPORTED THEM. OH, IT WAS THIS HIGH SCHOOL TEACHER OR IT WAS MY BREAKFAST PROGRAM AT SCHOOL OR -- AND MAKING JOURNEY MAPS WITH THOSE AND THEN MOVING FORWARD. SO I GUESS THE ONE THING IS, MAKING SURE YOU'RE WORKING WITH ALL KINDS OF PEOPLE AND UNDERSTANDING FROM THEM WHAT MATTERS FIRST WOULD BE JUST A THOUGHT ON THAT. >> THANK YOU. THANK YOU FOR TAKING ON A COMPLEX QUESTION THAT HAS SO MUCH MORE FOR US TO THINK ABOUT. I'M GOING TO NOW PASS THIS BACK TO DR. ZENK, BUT I WANT TO SAY THANK YOU SO VERY MUCH FOR ENGAGING AND ANSWERING QUESTIONS FOR THE ADD YENS. AUDIENCE. WE VERY MUCH APPRECIATE IT. >> THANK YOU, GERI, AND THANK YOU, SARAH, FOR JUST A FANTASTIC LECTURE. THE INFORMATION YOU SHARED WITH US IS REALLY SUCH A GREAT EXAMPLE OF THE UNQUESTIONABLE LINK BETWEEN RESEARCH, POLICY, AND PATIENT OUTCOMES. YOUR PROGRAM OF RESEARCH SHOWS HOW IMPORTANT IT IS FOR INTERVENTIONS TO BE PERSON-CENTERED, AND RESPECTFUL OF PEOPLE'S WISHES AND GOALS. AND I LOVE THE PHRASE "THE SCIENCE OF ATTAINING MEANINGFUL LIFE." I THINK IT'S A MANTRA THAT ALL OF US AS RESEARCHERS CAN KEEP IN MIND WHEN CONDUCTING OUR SCIENCE. AND WHEN WE TAKE INTO ACCOUNT THE WHOLE PERSON AND ALL THE EXTERNAL FACTORS THAT IMPACT HEALTH AND WELL-BEING, I THINK THAT'S WHEN WE'LL DISCOVER WHAT WE CAN DO TO IMPROVE OUTCOMES, ENHANCE LIVES AND ADVANCE HEALTH EQUITY. SO I APPRECIATE EVERYONE TUNING IN TO THE LECTURE, AND I ESPECIALLY WANT TO THANK DR. SZANTON FOR SHARING HER INSPIRING WORK AND HER TIME WITH US TODAY. THANK YOU