9UNP1206SD_Tom_Hlavacek

- Our second keynote of the day is Tom Hlavacek. Tom is the executive director of the Alzheimer's Association of Southeastern Wisconsin. He both convened and chaired the Alzheimer's Challenging Behaviors Task Force, which produced two reports. And he led testimony, led testimony to the US Senate Special Committee on Aging. His previous work includes directing the Milwaukee Office of Disability Rights Wisconsin, the statewide protection and advocacy system for people with disabilities. Tom is a past recipient of the Joseph P. Kennedy, Jr. Foundation public policy fellowship and served in Washington as a disability fellow in the United States Senate. Tom holds a master's of science degree in rehabilitation counseling from the University of Wisconsin, Milwaukee. So please welcome and please give a very warm hand to our second keynote speaker, Mr. Tom Hlavacek. 
(crowd applauds)

- Thank you very much for having me here today, and thanks, all of you, for being here to talk with me a little bit today about the changing face of Alzheimer's and dementia in Wisconsin and the efforts that are underway right now on the state level, both through the efforts of the state government through the dementia-capable plan but also... Oh, thanks. A clicker. But also through the efforts of everyday citizens who are transforming communities across the state. And it's a great honor for me to be able to convey some of those things that we're seeing from the point of view of the Alzheimer's Association. But we're going to spend a little bit of time talking about why we came up with the need for a plan for a dementia-capable Wisconsin and how that all came about. Some of the negatives that were influencers as we decided to move in that direction, some of the positives, some of the things that made us all realize, I think, that something needed to happen, and to her credit, Secretary Kitty Rhoades of the State Department of Health Services, for her leadership on this because it was really Secretary Rhoades who said in the midst of a big legislative battle that we were having, we actually have to do much more than this proposed legislation. We have to do much more to make our state ready and capable for dealing with the issues that are going to be presented to us by people with Alzheimer's and dementia. 

So as we get into it, I always like to start a little bit with the mission of the Alzheimer's Association to put this in perspective. Many of you know the Alzheimer's Association, but the mission is really easy to say and almost impossible to accomplish, at least right now. And the first part of the mission is to eliminate Alzheimer's through the advancement of research. Our goal is a world without Alzheimer's, as I'm sure is the goal of everybody in this room. To that end, we're the world's largest private nonprofit funder of Alzheimer's research. We're the most prominent advocates on the federal level in terms of getting NIH to spend more money on Alzheimer's research. We convene a gathering of researchers every year. This year it's going to be in Washington, DC, in July. There's already 5,500 researchers from registered for that conference. So it's probably going to break records and be up around 7,000 researchers. 

You can imagine the hallway conversations at that one, but. 
(crowd laughs)

 So we take great pride in our role as international leaders in the battle to actually eliminate and come up with more successful and effective treatments for Alzheimer's. In the meantime, the other part of our mission is providing care and support to everybody that's dealing with it right now. And those numbers are daunting, as you'll see in a minute. Our chapter covers the 11 counties of Southeastern Wisconsin. In that little geographic area of 11 counties, there's 48,000 people with Alzheimer's disease. The state of Wisconsin, close to 120,000. And those numbers are going to increase dramatically with the aging of the Baby Boomers, as you'll see in a minute. We also work a lot on the whole issue of what you can do to live a brain healthy lifestyle. 

That's what the program was this morning. And there are many things you can do in terms of exercise and nutrition and taking care of your health. But what we're going to focus on today is really the driving force behind why Wisconsin is it's taking to try to become a more dementia-capable state. This is our contact information. Those are the 11 counties that we serve. But these were the challenges that we were facing in Wisconsin as we went into this planning process. And it was really driven a lot by a court decision that came along in the middle of a major advocacy initiative that we had going at Southeastern Wisconsin chapter. And it's around the issue of people with difficult behaviors and Alzheimer's. Those of you in this room probably know a lot more about Alzheimer's than the general public, but there's a lot of misconceptions out there about Alzheimer's, including about difficult behaviors and the prevalence of difficult behaviors. But it's part and parcel of the diagnosis of Alzheimer's that there probably will be at some point in the disease process some what are called difficult behaviors or challenging behaviors. 

The word challenging is sometimes disputed. We're not talking about the person with Alzheimer's challenging you or threatening you. It's just the way that they're acting that can be very challenging to know how you should reply or respond. Things like agitation. Things like aggression. Things like abuse. Those things can happen with Alzheimer's, and it happens in a high level. In the study that we did at the association, the lowest percentage that I found in our lit review was 60% of people with Alzheimer's will experience some kind of difficult behaviors at some time in the disease process. In the United Kingdom, in their plan for the United Kingdom Alzheimer's plan, they're using 80%. And what happens when people go to the point of crisis is often a reflection of our fragmented systems of care and how unprepared we are to deal with people with dementia in our communities especially. 

And this court case came along, the Helen EF case, and it started as a Fond du Lac Appeals Court case, went on to the State Supreme Court where the decision was upheld, and basically what it said was, what the court said was there's basically two ways in Wisconsin that you can sort of trump a person's individual rights to make their own decisions and have the state come in and make a decision for you. One is under Chapter 51, which is the mental health commitment law, and one is on Chapter 55, which is the protective placement and protective services statute that was set up for people that because of lifelong disabilities are probably going to be in need of some kind of protection in society. So, many people under Chapter 55 are people with intellectual disabilities like Down syndrome or cerebral palsy, things like that. But it had become increasingly common for counties to use Chapter 51, which is the mental health statute, to detain people with Alzheimer's when they were at the point of crisis and they weren't voluntarily wanting to go for help. And the court, like as many of the advocates, stepped in and said, you know, that's not the appropriate statute. You should be using Chapter 55. Under Chapter 51, people are detained by police. They're put in the back of squad cars in handcuffs. They're transported to psychiatric facilities where they're given heavy doses of medications. We had incidents of people dying. 

In one very high profile case in Milwaukee that was sort of front page news for a couple weeks that was a lot of the motivation behind the task force. So, we're pleased with this decision because Chapter 55, you can do the same things. You can take the person against their will, you can put them in a treatment facility, you can even administer drugs that they may not want to take voluntarily, but the person gets a guardian, and the place that they're taken is intended to be a place that's capable of meeting the geriatric needs of their medical condition and their psychiatric care. And, in fact, Chapter 55 says you can't provide that care in an inpatient psychiatric facility because of the reasons, Chapter 51 and psychiatric facilities were really set up for people with mental illness. And the concept is you're taking away that person's rights, but there's something going on that is treatable for that person. If you take away their rights and you get them back on the appropriate medications, they can function much better in society. They may become completely independent again. Under Chapter 55, it's understood that the person that you detained is probably going to need lifelong protective services because of a condition that can't really be treated, nobody's got a cure yet for Alzheimer's, and the underlying disease process is just going to continue to get worse and the person is going to need ongoing services. So, what we asked for from the Alzheimer's Association in response to that was for a Legislative Council Study Committee to be established. A lot of people don't know much about the inner workings of our state legislature. 

At this time of year you see a lot of it in the paper, probably not all of it the best part of it, but there is a structure that they have within the state legislature called the Special Legislative Council Committee. And what that is, is a bipartisan committee made up of people from the Assembly and the Senate, and they can pick, they usually pick about eight issues a year that they want to study in depth and come up with a comprehensive legislative solution for that will be supported by both parties and by both Houses. And they ask citizens to participate that have some form of expertise. So we wanted the legislature to establish a special committee on Chapter 55 because we knew that counties weren't in a position to actually implement Counties didn't have Chapter 55 protective placement facilities. They didn't have procedures and policies about how you would detain and even transport people. And the legislature went ahead and appointed that committee and asked me to serve on it with a number of other citizens, and it was a very interesting process. And we actually did come out with draft legislation, Assembly Bill 575, that basically said this is what the new system should look like. It created a new level of facilities called dementia crisis facilities that would be across the state available to deal with people in crisis so that they didn't have to go to psychiatric hospitals and they could get appropriate care in an appropriate place. It had policies and procedures about how the detentions would work. But it was all really focused on that one pinpoint moment when you're dealing with a person that's in crisis and something involuntary has to happen. 

That's a very important point in the overall picture, but Secretary Rhoades came to the last meeting of the committee and said, you know what, you guys, this is actually about something much bigger. We have to get at the root causes. We have to understand why aren't we learning about these folks earlier? Why aren't there adequate facilities on the county level? What happens to people after they go through this crisis system? Isn't it going to become a revolving door if we don't have something for them after? And she basically asked the legislature to give her two years to reform the state in terms of dementia services. And so we, as advocates, actually agreed to set aside that legislation and try to work with her to develop a more comprehensive plan, and the way that whole effort got kicked off was a symposium, a two-day symposium that was held nearby here over at Wingspread where about, I think it was about 40 people from across the state were invited to take part in really in-depth meeting about what should Wisconsin look like if it was really to be dementia-capable. At that Wingspread conference, I was asked to provide some background data, and that's some of the stuff I'm going to share with you now, which kind of affirms Secretary Rhoades' position that this is a bigger issue than just crisis. But this is the situation we're facing in Wisconsin right now with the demographics of Alzheimer's and dementia. 

There's about 120,000 people right now in the state of Wisconsin, maybe 123,000 or so, as we know it in 2015. That number is going to increase by 68% in just 20 years, to 202,000 people, and it's mainly driven by the fact that we're all living longer and that the Baby Boom bubble is moving through the population. And this is some of the startling sort of statistics that we helped develop with the state Public Health Department. If you look at that map, in the top part up there you see the darkest counties, and as you go down, it's lighter green. That's the percentage of people aged 65 and older in particular counties. So, actually, if you look at that, Kenosha and Calumet have the youngest populations in the state of Wisconsin right now where 12% or less of the population is aged 65 or older. There's only two counties in 2015, Vilas, way up north, and Door County, where more than 27% of the county's population is over the age of 65, and that's primarily due to retirees that have their vacation homes there. This is what it looks like in 2035. So, more than 27% of the county populations are going to be 65 and older in almost all of the northern tier of states. Here in Racine and Kenosha it's going to be around 20%. 

The statewide average is going to be in the area of about 24, 25%. So, a dramatic shift to a much older population in just 20 years. Further complicated, especially in that northern tier of counties, by the fact that there's a lot of economic depression up there. There's not that many jobs, and so the kids go away to college and typically don't come back. They find jobs elsewhere. What does that lead to? That leads to isolated older adults who oftentimes are living in communities and nobody even knows that they're there. So this is a dramatic population shift that's happening all over the country, and we need to get in front of it and understand just how much of a role this is going to have on our public health systems. But why is it so connected to dementia? Just because the percentage of counties is turning more over the age of 65, why does that cause there to be more dementia? 

The primary reason is that we're seeing increasing survival into old age, okay? So, this is the first generation that's going to see a whole bunch of people typically living well into their 80s and 90s. That's historically never happened before. I have a pair of twin daughters that just had their sixth birthday last weekend. Their life expectancy when they were born is a hundred. Okay. The average life expectancy in the United States right now is inching close to 80. So, people are living for a lot longer period of time, and the main reasons is because we're reining in other things. We're reining in things like cancer, like heart disease, and we're seeing an increasing diagnosis of having Alzheimer's because of that. So the basic stats on Alzheimer's is if you make it past the age of 65, you have a one in eight chance of having Alzheimer's. 

If you make it to age 85, it's closer to one in two. If you're an African American female, it's closer to two in three by the time you're 85 because Alzheimer's disproportionately affects African Americans and Hispanics and Latinos. Twice the prevalence in the African American community, 1.5 times in the Hispanic community, and, on average, Hispanics begin to show the symptoms of Alzheimer's seven years earlier in life than Caucasians. It's also very much a women's health disease because right now about 60% of the people with Alzheimer's are women. Only 40% men. Over 60% of women are the caregivers to people with Alzheimer's. And so it's very much of a women's health issue. Still trying to understand why it disproportionately affects women in the way it does. The people in my morning session already heard me say this, but my partner Monica thinks that it might have something to do with women having to live with men, but, 
(crowd laughs)

 I don't know if that's true. But that final factor and why it's growing so much is growing racial and ethnic diversity. Wisconsin is becoming a much more diverse state. The Hispanic and African American populations are growing at a very steady clip. Seeing a lot more Asian population in Wisconsin. And so, as Wisconsin becomes more diverse, especially African American, Hispanic, you're going to see more dementia because it disproportionately affects those communities. That's sort of a graphic way of looking at it, of the difference of its impact in different multicultural communities. But this is the sort of startling stuff that we learned, we knew about from the Alzheimer's Association. But we're learning more and more from the state public health surveys and from our partnership. We produce a report every year called Facts and Figures, and in 2013, and we do this with the Centers for Disease Control in Atlanta, we produced a report that had a rather startling statistic in it that of the people with Alzheimer's in the United States today, estimates are that as many as 50% are undiagnosed or misdiagnosed. 

Okay? What does that mean? How do you know that there's that many people with Alzheimer's? CDC knows that from epidemiologic studies, from disease studies, okay? They know from death rates. They know from autopsies. They know how many people in any population have how many specific diseases. That's how we know that in the United States, there's 5.4 million people, approximately, with Alzheimer's right now. They know that from disease studies, not from diagnostic rates, okay? Only about half of those people are diagnosed, and many of them are misdiagnosed. 

We know that a lot of that's being missed. And we also know that the vast majority of people with Alzheimer's live in the community, okay? Only 10% of people with Alzheimer's or dementia are in a skilled nursing facility. And if you stop a 25-year-old on the street and ask him about Alzheimer's disease and their common picture that they have in mind of someone with Alzheimer's disease, they're probably going to say somebody living in a nursing home. Well, guess what? It's not. It's one out of 10 lives in a nursing home. In addition, in that 90% part, there's only about another 10% slice that's connected to any kind of social supports or human services on the county level. So, about 80% of everybody with Alzheimer's is just out there living in the community. And, as we've learned from the state studies, many of them living alone, many of them living very isolated lives. 

These were actually the numbers from the state survey, the public health survey that we helped the state, they did a component of the state survey on cognitive impairment. These are their findings. About 438 people reported in themselves having significant problems with memory loss. That was about 10%, which is what about we expected to see in a statewide survey And about 275 additional people reported someone in their household that has significant problems with memory loss. That it's getting worse. But when the followup question was asked, of the people with Alzheimer's, or not with Alzheimer's, but with reported memory loss of a significant nature and getting worse, the question was asked, how much help do you get from other people? And this was the startling stuff. 62% said never. That they really never get any help from anybody else in terms of dealing with their memory loss or getting about their daily living. Only another 13% said rarely. 

So, what we have is a group that's becoming more and more cognitively impaired, that's that doesn't get a lot of help from other people. This is a sort of graphic depiction of that response to that survey question. This was also sort of painful to learn, but we sort of knew it already. Of the people that reported cognitive loss that was significant and impairing their ability to do their daily life, which is the definition of dementia, only 28% said they ever talked to the doctor about it, okay? So this is probably one of the clearest indications of stigma that we still have. There's so much stigma attached to Alzheimer's that still drives it underground and doesn't allow us to have good conversations about it. I mean, if these same folks were dealing with heart attacks or strokes or cancer, they'd be talking to their doctor about it, but they're not talking about this health condition with their doctor. Even more disturbing, though, is the stuff on the bottom. Out of the ones that did talk to the doctor, only 13 had a diagnosis given to them, and 135 no diagnosis of any kind was given. So, in other words, it's like, well, it could be this, it could be that. 

Here, you want to try a trial sample of Aricept or something and see me in six months, okay? That's like super bad for docs if someone does come to them for any number of reasons. Obviously, getting connected up to help early on, the treatments that we have for Alzheimer's and dementia right now only work, they work best the earlier that they're used. And there's many reversible forms of dementia that if you're not looking into it in great detail, things like urinary tract infections, thiamine disorders, thyroid disorders, that can all cause the same symptoms of memory loss and confusion and agitation but they're reversible. So if people aren't going to the doctor about it, they're not going to get the fixable things fixed. If the doctors aren't digging deep, they're not going to get to be able to deal with those things either. So, these are sort of the bottom lines that came out of all of that report to Wingspread. We've got this growing numbers that we're facing. Only about 20% are connected up to any form of social support. 50% diagnosed, underdiagnosed or undiagnosed or misdiagnosed, and less than 30% have talked to their doctor about it. 

Over 60% never receive help, and 30% of all those folks that I mentioned are living alone. The people in the community. Really ? Alone, like no husband, no wife, nobody? Shouldn't be a surprise that we only learn about people through crisis. That is our current system. These were the two reports that we produced from the Alzheimer's Association. If you want to look them up, they're on our website, A-L-Z dot org backslash S-E-W-I. I think the footnotes and things like that are in your handout. But they're both available on our front page of our website. 

And handcuffed really was a description of the system that wasn't working, of handcuffing older folks and putting them in the back of squad cars and overmedicating them. We all hold the keys was really designed to describe a better way of doing things in general for the vulnerable population of older adults.

This was the Wingspread Conference that I talked about. From the Wingspread Conference, we identified six priority areas, and the department distilled those down in five focus areas for what became known as the Plan for a Dementia-Capable Wisconsin. The Plan for a Dementia-Capable Wisconsin is also on the front page of our website, and it's on the front page of the Department of Health Services website at Wisconsin dot gov. But I'm going to go through each of the areas in the plan, and then give you an update on where we're at with each of 'em. So, the first area that was really looked at was community awareness and services. And this is really all about the idea of pulling Alzheimer's out of the shadows and getting people connected to help. More things that could be done to identify people earlier, to help people feel like they can get over the stigma and ask for some assistance, to create more dementia-friendly communities, and to provide support for family caregivers. What's happened in this area is pretty phenomenal from the state in terms of their own dedication of resources. 

They created this new position that counties could apply for funding for called dementia care specialist, and the dementia care specialist is intended to do a number of things on the county level, including early detection, early identification kind of efforts, caregiver support efforts, helping to coordinate systems of care on the county level. And right now, at the close of this budget year that we're in right now, there are now 20 dementia care specialists funded that cover 26 counties. Those 26 counties account for over 60% of the state's population. So they've been placed in some of the more populated counties. In two counties, Dane and Milwaukee, they're also adding African American dementia specialists, and they're going to think about moving forward with other discrete areas where they might want dementia care specialists for particular communities like Native American. We've all heard lots of bad news in the state budget. One piece of good news: the governor included the funding for the next two years for the dementia care specialists in his budget, and joint finance did approve that. So we will have these positions for at least two years, but they won't be expanded under the given funding that we have to work right now. Another really nice highlight that came out of it was the Department of Public Instruction has developed an optional dementia curriculum for middle school and high school students, which has been a great thing. There's the high school here, I'm blanking on the name of it that does the fantastic job every year on a dementia curriculum and participates that's more an insolated incident, a semester-long kind of a dementia curriculum. 

This will hopefully make things like that go across the state and become more prevalent because if we're going to change the attitudes, we got to change them in the kids. The AARP, who is here today, did some fantastic statewide teleconferences that reached over 42,000 AARP members. And another big pick up just recently is the creation of a dementia-friendly communities toolkit. How many have heard them this term "dementia-friendly communities?" Okay, some of you have. Okay, so there's two words that get bandied about right now: dementia-capable and dementia-friendly. Dementia-friendly is really looking at communities and their normal every day sort of structures. So, businesses, libraries, civic clubs, organizations, and trying to help them understand that there's a lot of people in their communities that are dealing with this, either as a person with or as a care partner, and you want to create as a friendly of an environment as you can for them at the grocery store, at the pharmacy, wherever. And there's a number of communities across Wisconsin that have adopted these dementia-friendly community principles. There is now a dementia-friendly communities toolkit available online from the Department of Health Services. 

It's in print. It's going to be distributed in a print version very soon. We also put that on the front page of our website. We're very excited about that. Dementia-capable, on the other hand, is really about making communities able to respond on a systems level to dementia. So, adult protective services, law enforcement, all the different things that might have to come into play. The other things that happened in that area that are good, the family care managed care organizations have all established a dementia lead staff person in those entities that are providing very important community-based services. The estimate of the number of people with dementia in the family care program and community programs is high. Out of the overall family care population, it's around 20% of the people have some form of dementia diagnosis. So, making MCOs more dementia-capable, making their provider networks more dementia-capable is great. 

And a lot of them are doing more screening, something that we wish docs were doing more of, but, if they're not going to, let's make sure that somebody is doing more screening of people for dementia. There's been a lot of work in the area of facility based long-term care, which was the second priority area identified, so that facilities are better able to provide care for people with dementia. One of the highlight, standout kind of things about that is the music and memory program, which is now in 250 nursing homes across the state. This is a personalized music program. People get, individual residents get a set of headphones and an iPod that is loaded with the personal music that they listened to throughout their lives. And it's an amazing transformation that happens in people in long-term care facilities, even people in the very latest stages of Alzheimer's. If you put headphones on them with their music from their youth or their adult life, they come back to life in a very interesting way. If you ever want to see an amazing thing about this, Google ¿music and memory and Henry video.½ A YouTube video will pop up of a guy named Henry, who is an African American gentleman living in a nursing home, I believe in New York state, and it's just a dramatic depiction of the change that can happen in people when music therapy is interjected into their lives. A lot of, and it's really part of what we're seeing as sort of a wonderful blossoming of activity programs across long-term care facilities across Wisconsin. 

Not that there wasn't always activity programming, there was, but we're seeing stuff that is more focused on creativity. Things like music, things like art programming, which actually seems to get a better response out of people with Alzheimer's and dementia than things that they may not understand anymore, like Bingo or things like that. So, really nice stuff to see. The Wisconsin nursing homes have also done a tremendous job, in my opinion, taking up the federal centers for Medicare and Medicaid services on trying to reduce the use of antipsychotic medications in nursing homes. That was a pretty rampant practice back in the '90s. There was a major effort by Senator Claude Pepper and the Pepper Commission to reduce the use of those drugs. They sort of started to spring up again. We decried the use of those drugs in our reports from the Challenging Behaviors Task Force. That's what I was actually called out to Washington to testify on. And the CMS on the federal level started this initiative to try to reduce the use of those drugs in nursing homes. 

Wisconsin was already a pretty good state. We were about 15th or 16th in the country when we started in terms of being on the good side of not using 'em very much. Now we're number three, and for anybody here from the nursing homes, I just like to give you guys all a round of applause 
(Tom and crowd applauds)

 for trying to create a more activity-filled and drug-less kind of environment for the folks that live there. Care for people with significant difficult behaviors is still the area that I think is everybody would agree is where we still need more. This was the third priority area that was identified in the Wingspread Conference. And here's what's been happening. So far, really, what the state has done is tried to partner with all the entities that are involved. They changed it from calling it challenging behaviors to crisis stabilization. 

Fine with me. But, basically, this is a huge area where a lot of work needs to happen on local levels. In the city of Milwaukee right now, county of Milwaukee, there's a coordinated effort underway that involves seven hospitals, 20 community providers, all of the Milwaukee Police Department, all of the suburban police departments and the EMS, the emergency medical services folks, all around this whole issue of dementia and crisis because everybody's seen too many of these situations where somebody pops up in the community, nobody knew that they were there. It could be wandering, it could be a domestic violence, it could be an exploitation or whatever. Suddenly you realize there's a very impaired older adult living in a home with no support, and what do you do? And so these kinds of really coordinated countywide and systems wide responses take time to develop, but there's promising signs. The state has a guy by the name Stan Schymanski who's been going around and chronicling what local communities are doing around crisis intervention and prevention. There's five communities including Milwaukee, which is unusual, that have been identified as best practices. And then there's some discussion related to the existing county homes. There's still a number of counties that have county nursing homes, and whether they could possibly play an enhanced role in the crisis system. 

The final area that we'll talk about is really around dementia care standards and training. There's a ton of work that always goes on, especially in facilities, around training staff about how do you deal with residents with dementia. This would try to grow that and develop it even further. And, also, for caregivers in other settings, including in community-based settings for family caregivers, the progress that's been made in this area is, the state is actually engaged with UW Oshkosh to do a series of online training modules that people can take and become certified as dementia care practitioners. The two that are out so far are Dementia Generalist and Crisis Response. So it's adding to the overall array of training and service opportunities that are out there for people that are working in the field. We're very supportive of online training. We have a number of them through the Alzheimer's Association. We always feel that to the extent possible they should be augmented by in-person training so that people can get some real life hands-on stuff too, but it's a really positive step in the right direction. The last area was really around research and data collection. 

That stuff is kind of dry, but it's just really around trying to understand Alzheimer's and dementia as a public health issue, gather more data for policymakers and decision makers around that area. These are the key areas moving forward for the Alzheimer's Association as this progresses. We feel like a lot of work still needs to be done in the area of crisis. We'd like to see mobile crisis teams deployed across the state so that people don't have to be taken. They can be treated in place by competent professionals. The care transitions for people with Alzheimer's are difficult themselves. Moving them even to a place that's really good at meeting their needs can be very traumatizing, very upsetting to the individual, and We feel that there needs to be a lot more coordination with law enforcement, and we're promising signs of that happening all over. And a lot more awareness raising around the state, around Alzheimer's and helping to bring it out of the shadows. So, the bottom line, the good news, is that state of Wisconsin has a plan, and it's a plan for a dementia-capable Wisconsin. There's about 40 states in the nation that have dementia plans. 

Ours is probably one of the most activist plans that we've got in the country. Many of them are passed by a governor or a legislature, holy pictures are taken with the advocates, and then the plan sits on a shelf. This is a very active plan. There's a lot going on. There's a lot planned for the future. Obviously, there's a lot in turmoil in Wisconsin right now too with our family care system and what is our long-term care system going to be like, but it's promising to see that all of this good stuff is happening in our native state. So, thank you for your time. This is my contact information and our website, A-L-Z dot org backslash S-E-W-I, for anybody that wants to find anything more about those other reports. Thank you all very much. 
(crowd applauds)