The Perfect Storm of COVID‐19 in Nursing Homes: A Podcast with Joe Ouslander

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have on zoom with us today?

Alex: Today, we are delighted to welcome Joe Ouslander who is current executive editor at the Journal of the American Geriatric Society or JAGS and the incoming editor in chief as well as professor of geriatrics and medicine and senior advisor to the dean for geriatrics at Florida Atlantic University, college of medicine. Welcome to the GeriPal podcast, Joe.

Joe: Yeah, thanks for having me.

Eric: It’s great to have you on, Joe. We’re going to be talking about your article in JAGS titled COVID-19 and Nursing Homes: Calming The Perfect Storm, including why is it right now a perfect storm in the nursing homes due to this pandemic. But before we do, do you have a song request for Alex?

Joe: Well, I think Riding on The Storm by the Doors would be a good one.

Alex: Yes. This is a perfect storm. And you’ve had some storms in Florida.

Joe: They come and go. That’s right.

Alex: Yeah. I hope it’s a calm season.

Joe: We’ve been lucky so far.

Alex: Yeah. All right, here we go. Just the beginning of the song, which is a famous, terrific song by the Doors. All the action is in the keyboard. I’m not going to be playing the keyboard, but we’ll give it a try with just the intro here. (singing).

Joe: That was good.

Alex: Eric, we need you to do keyboards.

Eric: Yeah. If I had any musical talent, Alex, I’d totally be with you. A cow bell, give me a cow bell [laughter]. I will do more cow bell. Joe, why is this a perfect storm?

Joe: That’s a good question. The storm has… there’s multiple ingredients in it. First, it’s the nursing home resident population, the nature of the nursing home resident population. Most nursing home residents are older. They have multiple comorbidities. Many of them are immunocompromised. And all of those features predispose them to infections, including infections with the SARS-COV-2 virus, and also predispose them to the complications that resolve, the short term as well as the longterm complications that can result from that infection and to mortality from the infection.

Joe: The other thing that makes it difficult with the population we care for is we know from several studies, a couple of which we’ve published in JAGS, that show that just like many other diseases, COVID-19 presents atypically in the nursing home population so that the symptoms can be nonspecific. Not even the majority of nursing home residents with COVID-19 have typical symptoms. And they can also be pre-symptomatic for some time. So the nature of the nursing home population makes it difficult. The second factor, the second ingredient-

Eric: Before we go onto the second factor, Joe, do you do nursing homework too?

Joe: Yeah. Oh, yeah. That’s all I do pretty much.

Eric: So when you’re evaluating folks in the nursing home, and Florida was hit pretty hard, because of the asymptomatic nature and they don’t present in the typical ways when you’re working with these individuals in nursing facilities how do you think about that as a clinician?

Joe: Oh, that’s a good question. It’s one of the major recommendations I think clinicians should hear. And that is unfortunately this perfect storm is going to continue for a while and it may get worse, especially with the flu season coming up. You have to have a very high index of suspicion that almost any change in clinical status, any sudden change in clinical status, could be an early manifestation or the manifestation of COVID-19. So unless there is… So for most changes in condition, temperature elevation, subtle drops in PO2, even minor respiratory symptoms, we immediately put residents in isolation and use contact precautions until we know what’s going on. And that’s very important. So that low threshold for putting people in isolation until you can sort out whether they have the virus and during the flu season you can do a rapid flu test and exclude that.

Alex: Yeah. I’m on nursing home call now. I’ve been on for the last week and been on nursing home call any times, but this is particularly stressful. You just feel the weight, the awesome responsibility of having this fragile ship that is just so tenuous and could go down at any time taking not only the residents but the staff at the nursing home with it.

Joe: I think that every time I speak and what I write I think we have to recognize that all health care workers, all of us, all healthcare workers are taking risks, right, in treating people with the virus. But because of the environment, because of the residents and the environment and the nursing home, nursing home professionals, staff and clinicians who go in and out of the nursing home are risking their health, their lives, the lives of their families. And it is really a tragedy that many nursing homes and nursing home staff and clinicians have done this in the face of very inadequate capabilities to test for the virus and personal protective equipment.

Joe: The way I make the analogy in the paper is that nursing homes have been dealing with this blindfolded with their hands tied behind their back, blindfolded in the sense that they don’t know who has the virus because they don’t have adequate testing capability. Many of them don’t. It’s getting better. And they haven’t had adequate personal protective equipment. So it is really, really a scary situation. And I admire the people who do this. I go into the nursing home twice a week, but I try to be as careful as I can be. So there are many other elements of this storm. One is the physical environment. You have a congregate living setting where there’s generally congregate dining, congregate therapy activities that can facilitate spread of the virus. Taking care of nursing home residents is a high touch activity, and especially when you have to monitor them carefully and pass medications. So-

Alex: Or bathe them. Yeah. You can’t social distance when somebody needs help with daily activities that necessary. Yeah.

Joe: Yeah. It’s hard to do it. It’s hard to do it. So it’s not surprising that there’ve been these tragic outbreaks of COVID-19 in nursing homes that have led to lots of deaths. So when we wrote the paper the latest data that we had was in the second week in July, and there had been about 38,000 deaths of nursing home residents. And today, if you look on the CMS website there’s been 48,000. There are close to 300,000 nursing home residents that have documented infection or suspected infection. I don’t know where the data came from, but I’ve read in newsletters that over 500 staff in nursing homes have died. So it’s a really a serious situation.

Eric: So, I mean, that’s like, what, a third or a quarter of all COVID deaths are within nursing homes if you had to extrapolate that data?

Joe: So that’s a good question. Those data are known. So the proportion of deaths from COVID that occur in nursing homes and assisted living facilities is close to 50% and it varies state by state. It’s as high as in the 70% range in some States. Those data are published. It’s cited in the article. And there’s a data from Canada that showed that in Canada 80% of deaths from COVID are in longterm care facilities. So one of the ways that this pandemic is going to get perpetuated is by the virus continuously causing clusters of infection or outbreaks in facilities.

Eric: So we’ve done several podcasts about nursing homes and COVID. And early on, one of our podcasts, what struck me was the impact on staff, including… You have a fair amount of staff who work at different nursing facilities. And if there is a COVID outbreak at one facility, they were no longer allowed to go into that facility because they didn’t want it to be spread amongst other places. And that’s just one of the myriad of things that we heard about its impact on nursing home staff. And you just mentioned another one is you said 500 deaths in nursing home staff.

Joe: Yeah. I don’t know where that data came from, but the other thing is that staff can infect their families as well. So there’s different aspects of that. I mean, it is a scary situation to have to go in and be in this high touch situation, caring for vulnerable older people who can get the virus easily and transmit it to you. But there’s also the fact that many staff and nursing homes are not… A lot of the direct care is done by nursing assistants, who get very low wages, and it would be very hard for them financially to stop working. So it is an issue to try and educate staff and compel them not to come into work if they’ve been exposed in their personal life or if they have symptoms because they don’t want to miss work. And that’s a tough situation.

Joe: One of the things that I think is important to emphasize is that because of the ingredients of the perfect storm that we’ve been talking about, I make the analogy in the paper, we say that nursing homes are like a tinderbox, and it only takes one person, whether it’s a new admission from a hospital, a resident who’s going in and out of the facility for dialysis, or one staff member to light the fire. And it can result in rapid deaths. So we published a paper in JAGS that is very striking. It was a study done early in the pandemic in a Connecticut nursing home. And I’d encourage listeners to go look at that study because we published the heat maps in the facility. And in one day the heat map showed five people who had been tested because that’s how many tests they had. Less than three weeks later, there were 40 or 50 deaths, less than three weeks later, and many other people infected. So this virus can spread like a California wildfire.

Alex: Yeah, which we are in the middle of-

Joe: I know. I know.

Alex: … surrounded by at the moment-

Joe: I’ve been there. I lived in LA for a long time.

Alex: Absolutely. And the heat maps are a visual way of seeing just how devastating the spread can be and how rapid. You talk in the article about how just as there’s likely an under count of COVID infections nationwide there’s likely an under count of COVID deaths nationwide. There is almost certainly an under count of COVID infections and perhaps COVID deaths within nursing homes as well. Do you want to talk a little bit about the reasons for that? It’s already such a huge proportion-

Joe: Yeah. It is.

Alex: … of the impact, and yet it may be an under count.

Joe: Well, part of it is that the nursing homes haven’t been compelled to report testing results and hospitalizations and deaths until relatively recently. And part of it is that they have not had adequate testing capability. And part of it is that a lot of the nursing home residents are either asymptomatic or have atypical symptoms. So they may actually… And the other part of it is there are some nursing home residents who get the virus and deteriorate clinically so quickly in a matter of hours. They go into respiratory distress and you may not have time to do a test. So I think all those factors probably contribute to some underestimate of the magnitude.

Eric: Yeah. We just started a new policy in the nursing home that I work at, and I think this is nationwide throughout the VA and maybe California too, where everybody postmortem gets COVID 2 testing if they haven’t had one within, I think, 72 hours of death.

Joe: That’s interesting. I had not heard that. That’s an interesting idea. So one of the things that I feel very strongly about is the testing of… There are a couple things. One is the testing of staff, the regular testing of staff. And the reason is that if you’re careful with nursing home residents who are admitted or going in and out of the facility, the vector that’s going to bring the virus into the facility in the absence of in-person visitation is staff and contractors and clinicians like us. And staff, we can have the virus and be asymptomatic. And as society is opening up, I don’t know about yourselves, my wife and I don’t go anywhere except to the grocery store and drug store. And when we do go, we wear a lot of personal protective equipment.

Joe: But a lot of younger staff do go out and can… So as the society opens up, there’s going to be more staff that’s infected asymptomatically and unintentionally coming into the facility, spreading the virus, and they can get… So my understanding is that you can get infected one day and be shedding replication competent virus within 24 to 48 hours. So how often do you have to test people?

Eric: That’s what I was going to ask. If you talk about regular testing, are you talking about daily testing?

Joe: So the CDC now recommends weekly testing. But if you think about what I just said weekly isn’t probably enough. We’re talking about a situation which is we don’t have the tests. Who’s going to pay for the tests is unclear. Different sates are taking different approaches. The CDC recommends weekly testing. For example, some states mandate weekly testing. In Florida the governor has provided support for every two week testing through the fall, but who’s going to pay for all this? But that’s the only way you’re going to stop the tinderbox from lighting. And there are downstream implications of that. So if you test staff repeatedly some of them are going to be positive. They’re going to have to be off of work for 14 days. You have to have a backup staffing plan, and staffing is short. So it’s a real challenge.

Joe: And the one other thing I’ll say I feel strongly about is that since we wrote the article, I actually was able to incorporate some of it, is the CDC has changed their guidance for discharge a patient from hospitals, including into skilled nursing facilities. And I agree with some of that guidance, but I disagree with part of it. A majority of the guidance relates to people who have had the virus, who have been known to have the virus, and the recommendation is they don’t need a test. They just need to be essentially asymptomatic for 24 hours and 10 days out from the onset of symptoms. That’s okay. That’s justified by data.

Joe: But the other part of it to me is wrong. And that is people who have unknown viral status or even somebody who has one negative test they say as long as they meet the other criteria, 24 hours without symptoms, no fever, they don’t have to have a test and they don’t need to be isolated. I don’t agree with that. And the reason I don’t agree with that is because one test, most of the tests have a substantial false negative rate. And I don’t trust one… I’m not going to trust the residents in our facility based on one test. And so I really have a problem with the new guidance. I don’t know how others feel about it.

Alex: Joe, was it true… One of your recommendations too is once they’re in the facility, do you… Our facility quarantines individuals for two weeks after admission to the hospital. So they get another quarantine for two weeks until they can be in the general population.

Joe: Yeah. So I think that if somebody comes from the hospital, let’s say somebody comes from the hospital and has had a test within 48 hours of discharge that’s negative, they come in the facility and they have a second negative test, they have no symptoms, no fever without antipyretics, I think you can reduce the time in isolation. Isolation and quarantine cause their own problems because… One of the facilities I work in has all private rooms. So it’s not that big a deal to put somebody in isolation other than the psychological effects of it. But when you have roommates and you have kind of a limited area you can do quarantining in that can be a real challenge.

Eric: Can I also ask when we’re talking about regular testing, you talk about healthcare providers being a vector. You also mentioned that there are potentially other vectors You have people go into dialysis, maybe people go into a doctor’s office, and then family members. Currently a lot of places just shut down family members. They can’t go in. How should we be thinking about the caregiver support networks for a lot of the patients that are so important for these nursing home individuals?

Joe: Oh, that’s a great question. It’s a huge issue. And we tried to address that in the article. So we have to balance the negative psychological effects of isolation and the need to open up our society and our society’s economy with the risk of doing that. So I think that one way to approach that, which isn’t perfect, is to use social media for those who can use it, to use a phone or a tablet to visit with relatives. So one of the factors that we know is associated with the risk of bringing infection into a nursing home or assisted living is the prevalence in the surrounding area. So if the prevalence of the virus in the surrounding area is relatively low then it’s reasonable to have a visitation policy that’s an outside visitation policy with social distancing and masks.

Joe: And a lot of places are doing that. And there are some very good examples of state guidance on this, one of which we referenced. I think it’s from Colorado in the article. So I think there are ways to do it, but allowing visitors in for in-person visits other than for in a situation where it’s end of life care I think is very difficult.

Alex: Yeah. I wanted to ask, one of the lines that struck me from your article, of course we’ll have the link to this article and as well as other articles we’ve talked about in the show notes associated with this podcast on our blog, is the conclusion, “The saddest part of this perfect storm is that many years of inaction on the part of policy makers contributed to its impact. It did not have to be this way. We now have an opportunity to improve nursing homes, to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate care in order to achieve this goal.” So let’s get into this a little bit more detail. What can we do from a policy perspective, from a regulatory perspective, from a clinical perspective? Maybe we’ll start with the clinical because we’ve talked a bit about what it’s like to be a clinician in these nursing homes. What else can our clinicians do now or ought they be doing in order to prepare for the next storm?

Joe: Right. Well, I can’t remember who it was. It was probably Winston Churchill that said, “Don’t let a good crisis go to waste.” So there’s always opportunities and there are… So I’m a clinician. I think a coauthor who is really a world authority on health policy and longterm care could speak more to healthcare reform. I can make some comments on it, but from a clinical perspective, there are at least three areas that we can work on that the pandemic really accentuates the need for us to improve care. The first is reducing the number of transfers to the emergency department and the hospital. That’s good for everybody. And it’s especially important when we’re… Every time you send somebody out they, they could get infected and bring the virus back into the facility and they may need to be isolated again for another period of 14 days, like Eric said.

Joe: So there are a lot of strategies that have been shown to be helpful in trying to reduce unnecessary emergency department visits and hospitalizations. That’s one. The second one is working on the issue of polypharmacy. We know that this is prevalent in nursing homes and there are many reasons for it, but some of it is really unnecessary and predisposes older people to adverse drug effects. But more than that, it requires medication passes and sometimes monitoring like finger sticks for antidiabetic agents and blood pressure measurements for hold parameters on anti-hypertensives.

Joe: So the more you can reduce the number of medications and consolidate the number of times staff has to interact with a resident it’s a win win. The resident that doesn’t get exposed to unnecessary medications, the staff doesn’t have to spend the time doing the documentation and administering the medication. So that’s a second area, and there’s some very good recommendations and tools available for that. The third is, I shouldn’t be talking to you guys about this, but it’s to enhance advanced care planning. And we cited one of the articles that I think Alex you’re an author of. Are you on that article, Eric, also? I don’t know. It’s about palliative care consultations. I know-

Eric: Oh, yes. In New York. Yeah.

Joe: Well, it’s cited. But the issue is that I think advanced care planning has improved in nursing home residents, but we still have a long way to go. And in this situation, I think it’s really critical to address the issue of if you rapidly deteriorate, if you get the virus and rapidly deteriorate, do you want to go back, do you want to go to the hospital, do you want to be intubated, and the implications of that and trying to get people the appropriate directives based on their own situation and their values. So you guys are more expert in that than I am, but I think it provides an opportunity to really focus on that.

Eric: Yeah. And the reason I love your article too because the author references are so great. For example, around polypharmacy with COVID, there was a great JAGS article with recommendations for how to manage polypharmacy in nursing homes in COVID with recs on what to do with medications, new link to that. I got a question though-

Joe: We still know, for example… I wrote an editorial in JAGS. And it was before the pandemic. I wrote it over the holidays. But just as one example we know that 40% of nursing home residents who have advanced life limiting illness are on statins. What is that about really?

Alex: Really.

Joe: In the overall scheme of things, statins are a relatively benign drug but…

Eric: Well, Joe, I’ve got a question though. The first part, you talked about clinician trying to avoid hospitalization. I feel like in some ways that’s great, but in other ways, when you have no idea what’s going on because COVID could present in a lot of different ways probably hopefully there are a lot of nursing homes that can just put people in quarantine, run the test, but I’m guessing there’s a fair amount of nursing homes too that will just send everything to the ED, let them figure out if it’s coronavirus or not. And then 10 days later they come back and they’re quarantined. How do we balance that, and how are you thinking about that?

Joe: Yeah. So that’s a great question. I think it depends a lot on the facility’s capabilities, the resources that they have in terms of testing capability, the staffing, the personal protective equipment, but most importantly, the clinicians who work there, the physicians, nurse practitioners, and physician assistants, and the ability to get medications that you need rapidly to manage conditions as well as lab tests. If a facility doesn’t have really strong support from those clinicians and their medical director and the ability to get lab tests and drugs in time then it’s very understandable why they feel compelled to send people to the emergency department and some get hospitalized.

Joe: On the flip side of that there are things you can do. I am very fortunate to work a small part of my time with an institutional special needs plan which is a managed care plan for long stay nursing home residents. In different areas of the country I interact with people who are in dozens of nursing homes, and we do root cause analysis on transfers. And it’s very clear that even when medical staff are available and even when telehealth is available, those capabilities are bypassed. And I’m not even talking about people who are really that ill. Sometimes just basic evaluations like a complete blood count, a basic chemistry panel, a chest X-ray are not done, and people are sent to the emergency department. So I think in those situations, I think we still have a ways to go to prevent all the unnecessary transfers.

Eric: Can I ask you another… Speaking of telemedicine and telehealth, what is the nursing home clinician’s role? Because we have brand new fellows coming in to our fellowship and starting to learn about care for nursing home patients in the setting of a pandemic. How much should we do the traditional let’s go round and see our patients together, and is there a role like we’re doing in clinic of using more telemedicine, which I almost feel like is it’s harder in a nursing facility because we’re no longer allowing our family members to help us out? The now really busy nursing staff, sometimes understaffed nursing staff be the ones setting up these telemedicine-

Joe: And they don’t.

Eric: … whatever telemedicine device-

Joe: Sometimes they don’t. That’s why it’s bypassed. Yeah. No, that’s a great question.

Alex: Do you use it?

Joe: So I have not been using it in the nursing home. This is me personally. I just turned 69 last week. I have a couple of risk factors, but I feel compelled for a couple of reasons, two or three reasons, to go in. I just can’t sit in my home office and pontificate about this issue. I’m one of these people, old timers, that believes that every patient you see you learn from, number one, and number two, there are certain things you can’t do and can’t observe by telehealth visits. So the answer to your question, Eric, is I think there’s certainly a big role for telehealth, but there’s also still an important role to go see the patient.

Joe: As you know, we just accepted over the weekend a wonderful paper written by I think a psychologist about the insights that she could get from a telehealth visit. It’s just amazing. And I think it’ll be a valuable addition for our readers. But I go into the nursing home and see people who are referred to us for various problems. And I talk to them and I look through their records very thoroughly and I examine them. And I think there’s no substitute for that. One area I focus on with the trainees is the abdomen. I worry about people’s abdomen. I think it’s very hard to do a good abdominal exam without a very experienced tele presenter over telehealth. And people can have an acute abdomen and you wouldn’t know it.

Joe: This week is the first week this year that we have our third year medical students who have a required experience in geriatrics are going to be with us. And I’m going to try and do some telehealth visits where they’re going to be on… they’re not coming to the facility. And I’m going to try and show them what I do at the bedside, but I’m not sure that’ll work out.

Alex: That’s terrific. I hope that does work out because that could serve as a model for other institutions. I do want to ask about some policy components and one in particular that just really struck me, builds on something you were saying off earlier about staffing and nursing homes, the need for backup systems of support. And sort of two policy things you mentioned that come out of that. One is that the CNAs, the people provide the daily care in nursing homes are woefully underpaid for what they do. And the second is that we have failed from a government health policy perspective to view our health system is integrated in any way. We’re starting to see hospitals that aren’t affiliated with nursing homes some of them forced to the table to go help staff those nursing homes next to them because if they don’t help them out now when they’re understaffed, those patients in the nursing home will be hospitalized patients the next day. Just wanted to open the window for health policy comments.

Joe: Yeah. So I think there are important health policy considerations about how we view a nursing home. So let me address the most important issue I think, is the under appreciation of the direct care staff. 90% of hands-on care is provided by nursing assistants. They’re very often not valued. It depends on the culture of the nursing home and the organization. But apart from money it’s like faculty in a college of medicine. One of the things that’s important to them is appreciation. And one of the ways you can appreciate nursing assistants other than typical ways of thanking them is to create career ladders for them and have not just one CNA job but have a ladder of jobs that come with some increase in pay based on people’s experience and skills.

Joe: But there are other things that my coauthor, David Grabowski, recommends like hazard pay. And the fact that many nursing homes are run for profit and instead of putting the money that they make into the nursing home and paying these low paid workers a better wage, they keep it for profit. So those are important issues. But the other thing I’ll say is that I think when David Grabowski and I say we need to reimagine how nursing homes work it’s… And it goes beyond the models like the greenhouse model, which is wonderful. I mean, that’s a wonderful model. Right now I believe that too many nursing homes try to do too many things. They try to take care of sick post acute care patients as well as long stay residents, some of whom have had substance abuse problems and severe mental health disorders, and some of whom are 90 years old with end stage dementia. And it’s hard to take care of all those types of people well.

Joe: I personally think that the… And the reason that they take care of the sicker patients is financial because they pay better. And that’s what they say makes their slim margin. Well, that doesn’t make any sense. I think we ought to create facilities that have expertise in taking care of the typical long stay resident and pay them adequately to do that. There’s a subset of those people who have mental health disorders, substance abuse disorders, and behavioral disorders that probably should be in a specialized unit, and the sicker post acute care people who… I take care of people in a nursing home now that when I was a resident would have been in an intensive care unit in a hospital. So nursing homes can do that with the adequate resources that we talked about before, but they ought to probably be specialized in doing that. And some are. So I think to me that’s one of the major things that needs to be looked at.

Alex: And you wrote about this terrific article. So I’ll refer you too and then I’ll refer our listeners too. You and David Grabowski, again, wrote an article in response to paper that Lynn Flint and I wrote with Joanne Lynn about rehab to death, this concept that we first published in a New England journal, and then did a follow up in JAGS about policy changes that could be implemented. And in your response article on editorial talk about how the nursing home just has all these wide range of people. We need to bring it to a close. We didn’t get to talk about Eli Lilly in the New York Times headlines about his new drug.

Joe: Oh, I didn’t hear about that.

Alex: … it’s about monoclonal antibody for nursing home residents.

Joe: Oh, yeah. Well, one of the things I’ll say before we go is just there are treatments on the horizon, and some are being tested in nursing home residents but even the ones that are being tested in these large trials, it’s going to be hard to apply the results to the people we take care of in nursing homes.

Eric: Well, Joe, I want to thank you for joining us today. Really encouraged all of our readers. We’ll have links on our show notes on the GeriPal website to the JAGS article and some of the JAGS articles too that Joe referenced in his paper including the one that I mentioned about polypharmacy in nursing homes in the time of COVID and some of the other great resources. Joe, again thanks for shepherding a lot of these articles too through JAGS, including… I think it’s been an incredibly valuable asset for me too as a clinician being able to reference these.

Joe: Thanks.

Eric: But before we end, maybe we can get a little bit more…

Alex: A little more of the song. Joe, it looked like you wanted to say something. Go ahead.

Joe: No, no, just thank you guys. You guys are great. And I appreciate the opportunity to be on the podcast and work with you on JAGS.

Alex: Well, we love it. We love working with you, Joe, and we love your song here. Doors, a great band. I think this may be the first time we’ve had a request for the Doors. There are few remaining bands out there that we have not heard from on the GeriPal podcast despite being podcast episode something like 130. [laughter]

Eric: It has been wonderful riding the storm with you, Joe.

Alex: There you go. (singing) They got a little Jim Morris in there.

Eric: Thank you, Alex. Thank you again, Joe for joining us.

Joe: Thank you guys. You guys take care.

Eric: And to all of our listeners thanks for being a part of our podcast, and again, if you have a moment please rate us on your favorite podcasting app. Thank you to Archstone Foundation for your continued support. Stay safe everybody.

Alex: Stay safe.