Self-Determination in Action: Giving Families Control, Dignity, and Better Care

Welcome to this new installment of the Home Care Heroes and Day Service Stars podcast. I'm really excited about today's episode because we're talking to Christiana Morales and she is going to talk to us about a very important aspect of care and disability services, which is called. Actually, in California, it's called Self-Determination, and nationwide, it's generally called Self-Direction, and so with that, first of all, hello, Kristianna, how are you?

0:40 - Kristianna Moralls (Selfdeterminationinstituteorg)
 Hi, thank you so much for having me.

0:42 - Kenneth Accardi (Ankota)
 I'm excited to be here. Well, we're excited to have you, and you did tell me that you're not a morning person, and we got you on the calendar at 9 a.m. California time, so I do apologize for that, and thank you for doing it.

0:53 - Kristianna Moralls (Selfdeterminationinstituteorg)
 I will do my best to be on top of it here.

0:57 - Kenneth Accardi (Ankota)
 Oh, yeah, no, you're doing great already, and it's going to be fantastic, so I think because of our audience really having people who are doing home care, a lot of them in agency-directed services, a lot for older folks, some for people who manage folks with disabilities, daycare center people, and all that kind of thing, I'm not sure that everybody really understands what Self-Direction or Self-Determination is, and I guess if you could, you know, maybe just tell us a little bit more about yourself, and then just launch right into the question.

1:35 - Kristianna Moralls (Selfdeterminationinstituteorg)
 So my path going into my involvement with self-determination is that I have a son who's 23 years old. He's been in getting services through what we call our traditional regional center services since he was three years old, and he got into what we call the drop-off, which is when he left high school and went into the real And he was like, what do I do now? And he really struggled. And this is when I was introduced to self-determination. And self-determination really is what we consider the next step in civil rights for people with disabilities. And it is that they have the right to make what we consider common decisions in our lives, how we spend our time, who we spend our time with, where we live, who cares for us, all of those things. They become the person centered person who makes these decisions. And I think. That's really the movement that we're seeing nationally towards self-directed services, and so that's how I became involved in this. And so I started a nonprofit, and I think the question was, is how does self-direction, how is it different than what the traditional services are? And so in California specifically, traditional services are vendored services, meaning you have to work with services that are vendored by our regional centers, in other states, it may be by Medi-Cal directly, and families often don't have a choice who is sent out to work with them. They don't get a choice in how much to pay them, and the turnover was very high, and that's an issue for our family. Turnover, having consistency was a difficult thing, and so I know that for the providers, this was also difficult, right? They were getting minimum wage, and so the beauty of self-direction... We're given a budget of how much we can spend and we get to choose how to spend it, and that means we can set the rate. Now, this isn't true nationally, but in California, we can set the rates for our direct service providers. We get to choose who they are. We hire them, either directly or through a financial management service.

3:49 - Kenneth Accardi (Ankota)
 So it's a lot more. Okay. Yeah, perfect. So a lot more freedom and, okay, so one story that, you know, every time we get to this, I just have to tell a personal story is that one person who moved me is a guy named Jim Thompson. He's actually an advisor to an agency in Oakland that's called Manos, and they actually do traditional services, so agency model, and they actually have an FMS, it's called Essential Pay. And when I, you know, first met Jim, who is, you know, he's an older gentleman, and, you know, I'm not a spring chicken myself, but, you know, he told me that He had a daughter born in the 1960s and who has a disability and was told in literally these words, you know, well, for those people, the best thing we should do is just put them in institutional care. And and, you know, and he said, you know, screw that. That's not going to happen. And as a matter of fact, he has he's been a very successful person. has successful children. And he says that he's most proud of this daughter. She actually, you know, stayed with the family in a time when that wasn't happening. And he came because of her, you know, ability or disabilities, however you want to look at it, was an unbelievably great medical coding person. So she had autism and great memory and ability to do these kinds of things. And I think she worked. I don't quote me on this one. I think she worked for Kaiser. And I think I was told that when she went on vacation, they needed like three people to cover for her because she was so good at this. so so really just, you know, so that story just kind of, you know, tugs. My heart strings every time that, you know, literally as a parent, you know, we were in a situation where the only option was institutional care, and then, you we kind of went to this next model in the evolution, which was more, you know, agency-directed services and things like that, and you're the star, so I shouldn't take too much more time, but one more story is I was at the very first North Carolina self-direction, you know, kind of conference, and one of the people was on the council, there, you know, was telling me stories, he says he has two sons, one has Down syndrome, very, everybody loves this, this young man, very easy to find caregivers, or, you know, service providers, and works great. His other son has autism, and is very physical, and every once in a while has, you know, a situation that is, he's, let's say, acting out, or, you know, it's a little bit hard to, to manage. And, you know, so he just told me that the agencies, when he was in the agency-directed model, that they just, they would find that first service provider, and then that person would quit, and then the second one would quit, and then they would just never fill his cases anymore. And, you know, and he actually told me, and I have some notes about this, that he does some really special things in recruiting for his son. So he looks for somebody that's very close to his age, so they would have common activities. He also looks for people who have background in, like, team sports and things like that, you know, because he knows that if he has somebody who was on the wrestling team or played, you know, team sports and that kind of thing, that, that, you know, that kind of teamwork mentality works better for, you dealing with somebody who's, you know, very physical and things like that. So, so sorry for my two very, very, very big, long stories, but, you know, I guess one thing that touched me, because I didn't understand it, was he said, you know, hey, when he was around the end of high school, you know, he hit the dreaded drop. And I don't know what that means. Could you explain, you know, what that means? And I'm sure whether it's exactly the same in California and other states, I'm sure that other self-determining families would have similar situations.

7:44 - Kristianna Moralls (Selfdeterminationinstituteorg)
 Yeah, and I love those stories. I love both of them. Those are not unusual stories. These are common themes we're seeing. And so the drop-off is actually common across the nation. And because the school district has IDEA laws and they provide a lot of services, when they graduate and they get out of the school system, those services go away. And that's what we call the drop-off, is what do we do now? What are the supports we're going to have now and ongoing? Kind of like that. We're not going to sit in an institution. We're not going to sit in our rooms and do nothing for the rest of our lives. So what's going to happen? So that's what we often call the drop-off is. So we have a lot of people who finish the education. Services, and then sit in their rooms, so that's the drop off. For the stories, those are such common stories, and what we really do here is that, I mean, think about it, I work with, so as an independent facilitator, they're called service brokers in a lot of other states, we work with lots of people, and the first thing in our program is we do a person-centered plan, and we go through and we talk about what are your hopes and dreams, what do you want to do with your life, because everything up to this point has probably been deficit-based, what can't you do, how do we fix you, those kind of things, and where I see so much is my transition age, my clients who are getting to be high school, and you know what, it's not cool to have an adult walking around with you, or your mom coming out with you, or doing things, and so when you talk about hiring people, that's important, and it's important to them. So my son, in particular, wanted to go to junior college. And he didn't want, you know, some old person sitting next to him, making it very clear he needed assistance, those kind of things. So we posted a job, somebody who looks like a student, nobody even knows he has assistance, and he gets all the supports that he needs. So some of that are those kind of things, those kind of stories.

9:52 - Kenneth Accardi (Ankota)
 Yeah, fantastic. I love that. Now, you know, one thing that I took some of the training, I'm, you know, kind of newer to self-determination, self-direction than some others may be, but I did do the applied self-direction training program and things like that. So I think I'm, you know, coming up to speed pretty well. But one thing that they talked about in the first session was how people love this program and how it actually, you know, saves, it actually is less expensive for, for the government, even though folks are, are able to, you know, set their rates and if they're able to get a better quality service. And I guess that, you know, I kind of drilled into that, not on the session, but I asked other people, and they said, well, you know, when you're dealing with a traditional agency that, you know, maybe 50% of the wage that's being reimbursed is going to pay the service provider or caregiver, depending on what kind of program it is, and then the rest is kind of the overhead for the agency, right? So it's, you the people who are doing the scheduling, the hiring, the billing, and then there's also expenses like, you know, like workers, compensation, and things like that, which is part of self-direction, but has that been your experience that actually, that doing the self-determination program or a self-direction program actually costs less, and could you give better examples than I'm giving?

11:23 - Kristianna Moralls (Selfdeterminationinstituteorg)
 So part of the waiver that funds this requires cost neutrality. Meaning it can't cost more. But what I do see is services, traditional services can tend to be siloed, right? You work on speech, you go to an office and you work on speech. You have very specific things. So I'll give you an example of my son. He wanted to be out in the community. We were able to hire a student. He wanted to go play Dungeons and Dragons. And we have a local store that has a Dungeons and Dragons night and they would go and everybody would play, but he needed support. He couldn't do this on his own. He couldn't get there on his own. He needed support once he was there to kind of join the group. So we hired somebody to go with him. He picks them up. They go to Burger King, not an ad for Burger King, but they like to pick up their food and they go and they play. And this young man that we hired was a psychology major. He was a college student. And we said, hey, would you be interested in doing some training in social, skills? And he said, I would love that. So the two of them went to a social skills training. And he was his coach, my son's coach, and he was able then, if you think about the number of services we were covering with this one person, he was getting transportation, I was getting respite, I was getting a break, he was getting speech, social skills, community integration. So with this one person, we could target so many of my son's goals. So you can see how this has the potential to be much more cost effective. The other pieces is people say, well, if you get, you know, $10,000 for respite, how do you, how can you spend, how do you get these different services and exactly what you said, it's the administrative costs. So even though traditional services are getting paid, maybe I'm just pulling a number out of my hat, $60 an hour, the direct service providers probably getting a minimum wage. So we can say, well, I'm not going to pay the administrative costs, I'm going to hire them directly, I'm personally going to hire them, and then I can afford to pay.

13:31 - Kenneth Accardi (Ankota)
 Yeah, perfect. I love that. And yeah, and as a matter of fact, going back to the same individual from North Carolina that I spoke to, he said that, you the agency, when there were agency-directed service providers were paying minimum wage, which I think was $15 an hour, and he said, you know, I was able to offer my jobs out at $18 an hour or $22 an hour, that kind of thing. And I think that, again, you know, now getting specific to California, although I'm sure it's similar in other places, is that one model when you have employees that are doing the role of the direct service provider is that there's what they call the burden rate, but I mean, what this is covering is certainly workers comp for the employee, and I presume it also covers taxes and those kinds of things. And so I guess if we, and in my experience, the burden rate for the co-employment model, where basically the The FMS provider is sort of co-employing that individual, or they're usually in the low 20 percentile, so let's say it's 21%, and you're paying your self-directed service provider $20 instead of the minimum wage $15, then, you know, with that 20%, like the regional center in California or Medicaid in whatever state might be paying $24 for that service plus a small FMS fee as opposed to, you know, like, I mean, you threw the number $60 an hour. think that services like respite are less and other services like independent living and things like that are more. But yeah, so I think that that really puts a, you know, a highlight on, you know, how much cost savings there can be. But, you at the same time, I mean, let's, you know, let's kind of look at what the family signing up to. mean, essentially, this family is signing up to whatever they're doing to feed their family in their day job. They're also signing up to run a business, right? And they're running the business of their self-determination program. And they're applying for a budget, they're managing that budget, they're hiring the employees, they're replacing the employees, they're doing all those kinds of things. So, yeah, I guess tell us a little bit, mean, both either from your personal experience side or just from, you know, what's going on? What's it like to take on that additional work on your side to be able to do that and the trade-off that you're doing to, you know, to accept that?

16:07 - Kristianna Moralls (Selfdeterminationinstituteorg)
 This is a great thing. So in California, the State Council of Developmental Disabilities did a program study. And what they found was overall outcomes people loved. Everybody said, oh, my God, I mean, I've never seen the percentage. mean, 70% said they would recommend the program to other people. These are really high numbers. Everybody said the administrative burden was onerous. I mean, We do know that. It is something that we are working on in California to reduce that burden, but yes, we're moving from a service where, again, you're using vendored services, so they're all set up by your regional center here, right? You just say, want the service, they talk hours, they don't talk money. So when you go into the Self-Determination Program, as you said, you become an employer, and not everybody has experience doing this, and so it definitely has what we call a steep learning curve. And so it goes from, you know, just, hey, send me somebody over here to, I've got to put a job posting, I've got to interview these people, I have to schedule them, I have to tell them when they're, you know, what their role is. So these are a lot of things that are harder for people to learn who haven't run businesses before. We are seeing people very successful at it, and they partner, they have assistance to do this, they don't have to do it on their own. So in California, we have independent facilitators who can be hired to help them, and all of the money is paid for, so they're not managing the money themselves, like they're not given a check, and everybody uses a financial management service. So we have the financial management services, I think we're up to 31 in California right now, who pay for those bills and help the participants.

17:53 - Kenneth Accardi (Ankota)
 Fantastic. All right, so let's talk about that aspect, the mechanics of things. And so I guess I'll do my best to explain California, and you can correct me where I'm wrong, but the way that it works is that somebody like Kristianna for her family is managing what's going on, and if it's somebody like a direct service worker, like that employee who was, you know, taking them to the Dungeons and Dragons, doing all those things, then they have to essentially, you know, prove, just like everybody else that does caregiving or service direction, that they're really doing the work, they're not committing fraud. So they clock in with an app, they clock out with an app. We do this whole electronic visit verification thing that all caregivers need to do, and then somebody needs to pay the bill, and that's what we call in California the FMS or the Financial Management Service, so that's one way there could be an expense that's paid, but then the other way is that, let's say that you mentioned a certain training in certain skills, and maybe that training program has a fee of $750,000. Or whatever the case may be, so in that case, you as the family, you're submitting that expense, and it's going to be paid for, but I guess one thing that people might be curious about is, it sounds so good, are they just going to send me a check for all this money that it's going to provide for my family, and it doesn't work that way, so basically, what's happening is that in California, this FMS company is the one who's reviewing all the expenses, they're kind of reviewing the electronic visit verification, Make sure it's getting submitted to, in most cases, directly to Medicaid or an MCO in California to the regional center. And they're paid a small fee, much less fee than, you a traditional agency for managing that service. And I guess in other states, you know, it's sometimes called a fiscal intermediary and there's all kinds of different terminology. First of all, so how did I do explaining how it works in California?

19:56 - Kristianna Moralls (Selfdeterminationinstituteorg)
 You did a very good job. You got it. You can take over. I'm going to go home now. So a couple of things is that in California, we do have probably one of the most robust self-determination program systems that permits a lot more than other states do. Some other states will only let you hire people. In California, we can pay for local businesses. So I could pay for a karate studio. I could pay for, you know, the YMCA if I wanted to. I could also purchase specific goods. So what we do is we create a spending plan and say this is how we plan on spending the money and the regional center approves it. So these are still Medicaid dollars. This isn't a free for all. We have, you know, rules of what the money can be spent on. And so it's, like you said, it's not like they're going to give us a check and we're all going to go to Hawaii. Like, you know, the financial management service pays off. So I think of them as a bill paying service. But one of the big responsibilities you take on as the participant is, I'm going to track my spending. I can't spend more than is given to me in my budget. And so the financial management services not only pay the bills, but help us kind of keep track of, how much do I have left? And then when we talk about the employees, we have two models in California. Either I can, the participant can hire the employees themselves. They can be the employee of record or the financial management service can hire them on their behalf. And so there's. It's kind of two ways that they can do that, but either way, the Financial Management Service is going to pay the taxes and make sure we have mandated sick time in California. So following all those labor rules, all of those pieces, tax rules, that's what our Financial Management Services help us with.

21:48 - Kenneth Accardi (Ankota)
 Fantastic. All right, so I'm going to be totally transparent. The reason I know Kristianna in the first place is because Ankota has traditionally made software for agency-directed home care and home and community-based services and for adult daycare centers and day habilitation centers. And we have come to know about the self-determination or self-direction movement nationwide, and we really have seen kind of a gap there. We've seen that, as Kristianna described, it's hard for these families to manage and, you know, know where they stand on their budget and, you know, know whether they submitted that expense or not and, you know, keep up on those things. So I guess I'll, I'm kind of asking the self-serving. But if I was a California FMS agency, what are some of the things that would make me, as a self-determining family, choose that FMS over another one?

22:44 - Kristianna Moralls (Selfdeterminationinstituteorg)
 That's such a great question. And so my organization, Self-Determination Institute, we're a nonprofit and we are participant-centered, focused. And so we do consulting with financial management services, and that's actually how we met, was we were consulting with a couple different financial management services. So my number one is always customer service, client, participant, client, forward, ease of use. They have to be, so you have to realize if it's either the participant themselves are running this program or a family member, a lot of times it's mom running this program. And we're not only running the program, we're taking care of this person part of the time. And so we need access when we need access. account. future, access to the prettiest So 24 hours a day, having an app where you can look on it and see, you know, oh my gosh, do I have enough money to do this? I want to pay this person. Was this person paid? Those kind of things. Having that ability to just look at it at any time, make requests for things. It's like, I don't know about you, but if I don't do it when I think about it, it doesn't get done. And so that ability to just say, oh, I need to order this and I ordered it, it's done. So this is, for me as a participant forward organization, this is what we're looking for. We're looking for, again, we said this can be a tough program to learn. And I believe that technology is going to make this easier. We have the ability and that's what I'm looking towards is how do we support these families?

24:22 - Kenneth Accardi (Ankota)
 How do we get them that information easily? Yeah, perfect. And what we try to do in Encoder specifically is we have an app and It's in the Apple Store and in Google Play, and you can also run it on the web, and it does those things where you can see at a glance, you know, just in one little bar there, it's like, okay, I see how much money I had in my POS, when it starts, when it ends, where it is today, date-wise, am I ahead or behind in my budget, and then if you click on it, can see every expense that you've ever submitted against that, and then if it is the situation where you're submitting an expense, and you have that receipt right in front of you, you could literally just say, I'm putting in an expense, take a picture of it with your phone, and turn it in, and then, of course, on the back end, because of our background with the agency-directed world, we also handled the whole EVV clock in, clock out, and submitting that in California to San Data, and then, you know, having the regional center billing pieces. So, yeah, so we're really, you know, excited, too, about our relationship with Christiana, and because, you know, we just... I want to be, you know, out there and helping these families to do a better job and also making it easier for the FMSs to stand out in a crowd. So with that, now that I've given my shameless plug, I don't even know where to go, you know, with the next question, but I guess just, you know, like, I guess could you try to provide some perspective? I know through even the website and the training from Applied Self-Direction that there are programs nationwide. And, you what's your, you know, what are some perspectives you have on how self-determination or self-direction is working in other states as compared to in California?

26:10 - Kristianna Moralls (Selfdeterminationinstituteorg)
 So we're a little bit late to the game when it comes to something like our self-determination program. The other self-directed services that we have in California, we are, I think we have nationally 50% of the overall population. So you had said, you know, we've got over a million, I think a million and a half people in self-directed services nationally. Thank We have, I think, over 726,000 in California. So Self-Determination Program, that one piece, is our most self-directed. It is kind of our golden child where we want to see things go. So right now, California kind of is the leader. What we have seen, though, because we're a young program, it just became available to everybody July of 2021, every regional center client. So we're still a baby program here. And what we're seeing is, you know, we have to, the program needs to be clear what can and cannot be paid for. Like we were saying, some of those administrative burdens are difficult. And so how do we kind of make it easier, less barriers for everybody? And we do, we can look at other states and say, oh, they had similar things where they'd come out and then they had to kind of contract a little bit and say, okay, this is how it's going to run, know, lessons learned. So, um, And, you know, what I do know, and what the good news is, is that we're seeing an increase nationally in self-directed services. And that's what we want to see. You talked about institutionalization. In my lifetime, when I was a kid, that was the only choice. If you had a person with a disability, with an autism diagnosis, they were put in an institution. And that is almost gone in California. Now, I think we're down to one institution. And so they have we have a commitment to remove them. And so the intention of all of this money spent is for people to live in their homes and communities. And that's the intent of this is to make sure that they are doing that.

28:15 - Kenneth Accardi (Ankota)
 Yeah, fantastic. I love it. Yeah. Interestingly, I mean, we in Ankota for a number of years have supported a program in Missouri called the CDS Program. Consumer-Directed Services. And, you know, it really is, to some degree, a self-direction program. But it has It hasn't felt that different. All I've ever known about this program is that the person receiving care is supposed to find their own, you know, care providers, in that case it is elder care, you know, care for an older person instead of disability, so we use the terminology caregiver. So they find their own caregiver and then, you know, and the reimbursement rates are lower for that as compared to, like, the, you know, agency-directed services, like, with CPT codes like personal care and homemaker and respite and things like that. But, you know, really, other than that, and it makes things, like, very much more complicated from a tax perspective because, you know, because in Missouri, each of these consumer-directed participants, you know, are treated as their own company, so that, you know, that agency that is, you know, providing that oversight, know, they are responsible for, you know, really onboarding the people, doing the background checks, you know, doing most of... What they do other than choosing the people, I guess in some of them, it's self-scheduled, so it's between the consumer and the attendant when the care happens, but when they do get those high authorizations, let's say it's 40 hours a week or higher and things like that, a lot of the agencies do schedule, so it's not that different from that perspective and that type of thing. So, yes, there are a lot of programs that are in a lot of places and they're different, but like I said, I didn't really feel like CDS was that different in Missouri from the in-home programs, and it wasn't until I got to California who's really trying to, you know, put more control in the hands of the families and like the North Carolina programs that were in like the, you know, like the innovations program and the CAP program and that kind of thing, where people are really trying to, you know, put more power into the the family and the individual and if, you know, and not force everybody into the same mold, you know, when you're in institutional care. You're not going to the place to play Dungeons & Dragons, and you're not going to take a course that you would like to take so you could learn more about interpersonal skills, and these things just aren't happening. So I think it's really great. I guess one thing just to touch on, maybe we should have done it earlier, but there's a lot of different terminology, consumer-directed, self-determination, self-direction, FMS, fiscal agent, that kind of thing. And I think that, I don't know, do have any perspectives on, you know, on where that stands, or maybe any other terminologies, just so like people who might have been listening to this are like, oh, that's what that program means.

31:10 - Kristianna Moralls (Selfdeterminationinstituteorg)
 Oh my, we laugh that we have our own language, and a lot of it is acronyms. So you almost have to learn a whole new language when you get involved in this. But I'll tell you that self-determination as a philosophy did not start disability-related. This is a, it comes from the United Nations. And it is the idea that human... For people have the right to determine their lives, and so it really comes from political, like, authoritarian governments saying, hey, your people have a right to make choices about their lives. have civil rights. So it came from that, and then we had people that were doing research around disability saying, wait a second, this applies to this. And they brought in self-determination philosophy into disability rights and disability services. And so that's really kind of how it evolved into, and that's why I tie it very deeply to civil rights, that, you know, putting somebody in an institution removes all of their civil rights, and so there's a certain level of ableism involved in this. And so that's, that's really what we're trying to fight against, is that you talked about the amazing talents and things that that person that you talked to had to give to that company, that they were so good that they needed three people. The higher. And this is the thing, it's not just about the person having the ability to go to school. Businesses thrive from our loved ones. They have so much to give to society and society gains so much from them.

32:46 - Kenneth Accardi (Ankota)
 I think it is a win-win for everybody. I love it. Right. So I guess that was the last thing we should talk about is tell us a little bit more about the Self-Determination Institute. And if someone, you know, how could you help folks and what kind of things, what kind of services do you provide?

33:05 - Kristianna Moralls (Selfdeterminationinstituteorg)
 So Self-Determination Institute, we are a nonprofit and we focus from the participants' point of view. So we have a lot of advocacy in politics from kind of the big guys, right? From the financial management services, from the regional centers, from, you know, big entities. And they kind of sometimes forget to realize we're kind of the key stakeholder in this. So we really came to Together to say, one, we want to make sure that the participants have all the information they need. If this is the right program for them, that they can get into it, the Self-Determination Program, they can get into the program. So we've got training for people. We do research and we do focus groups and think tanks to talk about how do we promote self-determination as a philosophy across the state. So not only in just through the program, but across, in every aspect of their lives. They should be able to choose where they live and, you know, who they spend their time with and all of those things. And that's not just the services that we, you know, we were talking about. And then we are talking to what we, instead of siloing out the different groups, we say, we have to work together. We're all partners. So the participants in the financial management services, their direct service providers, the regional centers, we're all partners in this, making this work. And so that's really our goal is talking together, find. Finding solutions, like with Ankota, finding technical solutions that can make this program work simpler, easier, more accessible for everyone.

34:41 - Kenneth Accardi (Ankota)
 I love it. Yeah, I will say that in the training that I got from Applied Self-Direction, that there was one entire training session which was sort of, you know, painting that the picture is a little bit the opposite of that. And they were talking about, you know, these myths having to do with the FMSs. It's like, you know, it's like the myth was, the FMS just never wants to pay my people. Or the myth was, the FMS never wants to pay my bills. Or the myth was this, you know. And what we learned, and it was very nicely done, and it was like kind of, they put some humor into it, is that, you know, really everybody in the program wants it all to work. And that goes, you know, everywhere from the payers, whether that's Medicaid and MCO, the regional centers, to the direct service workers themselves, to the FMSs. To the families, to the participants, and all that kind of thing, and Kristianna, we're very lucky and very fortunate that in California that you are doing all those things to bring those communities together and make the program better, and with that, I think we'll wrap up for today, and we'll thank you for being on Home Care Heroes and Day Service Stars.

35:48 - Kristianna Moralls (Selfdeterminationinstituteorg)
 Well, thank you so much for having me. It was such a pleasure, and see, I made it through, and it was 9 a.m. my time.

35:55 - Kenneth Accardi (Ankota)
 You did it.

35:56 - Kristianna Moralls (Selfdeterminationinstituteorg)
 Thank you.