NatCon2018 Presentation: An Organization’s Incremental Journey Toward Whole Person Care: Practice Improvement in Real Life

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In 2010, Telecare began a journey to Whole Person Care, bringing greater focus on healthcare and substance use services into our behavioral health programs. 

With limited resources to draw upon, we needed to be cost-conscious and choose approaches that offered the greatest impact and leverage.

In April 2018, we shared our journey and lessons learned in an iPoster session at NatCon18.

View a PDF of the Presentation

Download our natcon iposter session by clicking the image above.

Download our natcon iposter session by clicking the image above.

Workforce Development

As we began to develop our Whole Person Care plan, we found that we needed to address the training challenges of our geographically diverse and multidisciplinary workforce. Telecare has nearly 3,500 staff spread over seven states and a very diverse workforce of behavioral health providers and nursing staff. The entire range of our staff needed to understand the importance of whole health as well as have knowledge of co-occurring substance use and chronic health conditions, and be able to use tools to engage clients and enhance motivation through stage-matched conversations. To address this, we developed an 18-hour Whole Person Care eLearning program that covers stages of change, substance use and addiction education, as well as significant facts on chronic health conditions, culminating in an earned certificate. 

Clinical Practice Improvement

We needed to update and enhance our current clinical practices to include whole health education and lifestyle modifications, as well as explore clinical models for coordinated care that improve outcomes and reduce costs for customers. 

Our Co-Occurring Education Groups (COEG) were developed to reach people in pre-contemplation and contemplation stages of change around substance use. We also created “Smart Sets”: Decision trees that enforce key elements of health integration and identify touchpoints for motivational enhancement. We also partnered with customers to build new coordinated care clinical models that improve outcomes while reducing costs. We tested and refined new processes and then disseminate them broadly to the rest of our programs. Finally, we identified several interdependent evidence-based practices and developed a clinical framework to bring them to staff, matching the critical skills to staff roles and client acuity levels. 

Client Education

The people we serve often do not understand their high-risk physical health conditions, nor do they have fact-based information on the effects of substance use on their health. To assist our mental health providers in regularly educating and engaging clients in conversations around their health conditions, Telecare created easy-to-read, visually-engaging handouts that present a range of whole health topics, including blood pressure, body weight, diabetes, and asthma. The handouts provide education on facts and effects about each condition and offer suggestions for how to manage or prevent the condition. They also inform and empower clients by suggesting lifestyle changes that can directly improve their health and wellness. 

Staff have reported increased confidence initiating conversations by using these handouts, and clients report that they are learning information about their conditions for the first time. We have translated these handouts into six threshold languages to increase accessibility. Our workforce benefits from the handouts as well: staff report that they are using the handouts to learn about and manage their own chronic health conditions. 

Initial Outcomes

Telecare’s Partners in Wellness, the first mental health Pay for Success program in the nation that incorporates our Whole Health tools, is surpassing its success targets, with excess savings of more than $500,000 in the first year. Another program, Inland Empire Health Plan (IEHP), a population management program for high utilizers, has shown statistically significant reductions in psych inpatient, psych ER, medical ER, and IOP utilization, as well as increased contacts with their primary care physicians. (See poster for more details.)

Lessons Learned

We have learned that the following practices greatly enhance our ability to integrate Whole Person Health into our programs:

  • Educating our senior leadership team first. Senior leaders must fully understand and be "on board" with new practices and clinical models before roll-out to the company at large.

  • Engaging all staff to see health equity as a social justice issue, which helps us advocate for the people we serve.

  • Communicating clearly and consistently to ensure comprehension and buy-in from staff.

  • Adapting plans as funding appears and disappears; being nimble allows us to keep up with changes in the healthcare environment.

  • And finally, remembering that small steps matter! Sustaining momentum is important when introducing and learning from new models of care.

More Information

Download our natcon iposter session by clicking the image above

Download our natcon iposter session by clicking the image above

Telecare Whole Person Care Brochures and Information

COEG Resources

NatCon 2018 Presentation: Pay for Success

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In 2017, Telecare opened the nation's first mental health Pay for Success (PFS) program in Santa Clara County, California, called Partners in Wellness.

At NatCon2018, Telecare hosted a lunch and learn presentation sharing initial results from our PFS program, an overview of the PFS model, a clinical overview of the program, and learnings for other systems interested in possible implementation. We are pleased to share the presentation and findings below.

Alternative Payment Models:
Pay for Success

Initial Results

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In the first year of operation, Partners in Wellness saved more than $508,482 above the target savings. The program reduced usage well over the target rate for all services, including 81% over the target of psychiatric emergency services visits and 100% over the target for state hospital days. Significant clinical results were also shown: after a year, people with higher depression, psychosis, and drug and alcohol use scores showed significant improvement over time. Anxiety levels (measured through screenings) also improved, as well as physical health measurements such as HDL-C scores. 

PFS Model Overview

Telecare's Partners in Wellness program is an innovative six-year, performance-based contract to deliver publicly-funded services. Telecare is at risk to deliver the savings targets outlined in the contract by reducing clients' use of psychiatric hospitals, psychiatric emergency services, state hospitals, and other mental health services while also ensuring each client’s whole-person wellness. The performance targets are set to fully pay for the program (in savings) and return additional savings at the end of the six years. Dr. Keith Humphreys of Stanford University objectively evaluates the program results. From the RFP process beginning in December 2014 through the January 2017 official launch of the program, more than two years of work went into the development of this program. 

What's Different About Pay for Success?

Pay for Success programs, including Partners in Wellness, include several areas of additional measures and tools, and a higher degree of data analytics, than other programs typically provide. (Click on the chart to the right to see an outline of some of these differences.)

PFS Clinical Model Overview

The clinical care model for Partners in Wellness uses several tools to engage with consumers, also known as partners, on multiple fronts. Physical and mental health are measured through screenings and assessments, and a "whole health" care plan is created in partnership with the persons served. From there, the multidisciplinary team — including several peer specialists — works with the partner to ensure they have adequate housing, medications, physical health supports, care coordination, and assistance in developing recovery tools as they work toward their wellness and recovery goals. Data from health measures and a daily "Wellness Snapshot" are entered and used to produce a Huddle Report that prioritizes the team's treatment and intervention planning in their morning huddle. A monthly report tracks partners' progress over time. Treatments are adjusted as needs change. 

Lessons Learned

One of the most important lessons we have learned in our first year of operations is how crucial it is to have a firm understanding of the community in which we are working, as well as strong relationships within that community. Factors such as other community resources, housing costs, and Conservator or Public Guardian Policies can all make a big difference in the outcomes of Pay for Success programs like Partners in Wellness. 

More Information

 

Director of SUTS: Scott Madover

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To help us better address co-occurring conditions company-wide, we appointed Scott Madover, Ph.D., to take on the role of Telecare’s Director for Specialty Product Services, Substance Use Treatment Services (SUTS).

"We knew we really needed to focus on substance use, and ensure that we were capable and doing our very best to meet those needs. We thought the best way to do that was to hire a dedicated leader, and that's Scott Madover," said Faith Richie, SVP of Development at Telecare.

In addition to working with the Development and Operations departments at Telecare to create plans for how co-occurring programming could better serve our clients, Scott will also assist with Telecare’s planning efforts so that our services are aligned with parity requirements and SUTS funding in multiple states. He will also ensure that Co-Occurring Education Groups (COEG) curriculum is available at all our product types, and recommend new standards for our existing programs so that they are co-occurring capable.

Scott’s clinical training and program leadership experience coupled with his wealth of knowledge in co-occurring disorders positions him very well for this role.

Before accepting his role as the new SUTS Director, Scott has helped lead many of Telecare’s integrated care efforts, including the development and roll out of COEG, our first company-wide substance use education program, and the design and implementation of Telecare’s first pay for success program. He also helped design and oversee the CHANGES program, our first program specifically designed to support people with co-occurring mental illness/substance use needs. Scott has also served as Regional Director of Operations in the Bay Area. 

Health & Wellness Curriculum | A Whole Person Care Status Report

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Telecare has a long-range plan for expanding and deepening its Whole Person Care (WPC) efforts. We began by examining
co-occurring conditions—educating providers and ensuring that Telecare’s Co-Occurring Education Group is available in all our programs. Right now, we are laying the foundation for future efforts by focusing on health literacy.

We recognize that behavioral health providers need support as they work with clients to address their physical and substance use issues. In May 2016, Telecare introduced Phase 2 of our Whole Person Care initiative: health literacy. The Health & Wellness Curriculum consists of eight online modules on topics such as Diabetes, Cholesterol, Blood Pressure, Managing Our Stress Response, Tobacco Use, and more. Each module is accompanied by visually engaging and easy-to-follow handouts that staff can use to engage clients in conversation about these health concerns.

Though we’re still early in our company-wide implementation, the feedback so far is promising. Here is an update on our progress, as of April 2017. Below, you’ll find:

  • Where We’re Going: Implementation Timeline & Status Update

  • What We’re Seeing: Early Discoveries From the Field

  • More Info: Whole Person Care Goals

Implementation Timeline & Status Update

Right now, we are working on Phase 2: health literacy. Telecare’s programs have the flexibility to implement the health and wellness literacy curriculum at their own pace, but all programs must complete the curriculum by April 2018. Here is a snapshot of our progress over the last year.

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Early Discoveries from the Field

We spoke to staff at three Telecare programs that are moving quickly to fully implement the Health & Wellness Curriculum, a 16-hour, online training program that provides staff with basic knowledge about the chronic health conditions that our clients most commonly face. Here’s what staff have told us about the curriculum’s impact so far.

We're Increasing Linkages to Primary Care

Erich Stevens, Registered Nurse
San Diego Gateway to Recovery

 Early discoveries:

  • More conversations happening

  • More linkage to primary care

  • More physical health therapy

How the curriculum has helped:

  • "I think the modules and quick reference tools for use in the field have been extremely helpful to case managers and other non-nursing staff in better understanding these health issues and how to assist clients with them, which has typically been up to the nursing staff alone."

Why do it:

  • “It gives us more ways to help clients reach a higher level of wellness.”

Clients Are Taking More Initiative in Setting Doctor Appointments

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Tienna Jackson, Team Lead
Gateway to Recovery

Early discoveries:

  • Clients willing to make primary care appointments

  • More physical health therapy

  • Increase in health conversations

How the curriculum has helped:

  • “The worksheets that were available with each module were given to members to help support them in whatever their hopes and dreams are in regards to their health and wellness.”

Why do it:

  • "It reinforces to our staff the importance of addressing both the medical and mental health aspects of recovery with our members, and really, it has been working. Our clinicians and nurses are coming back with stories of how they tell people the importance of seeing a doctor, and members are open to making appointments with their primary care provider on the spot."

We’re About to Help Clients Better Understand How Physical Health & Mental Health are Connected

Rocio Perez, Clinician, Los Angeles Older Adults

Early discoveries:

  • Handouts help show clients how mental and physical health are connected

  • Increased efforts towards self-care

How the curriculum has helped:

  • “The Health & Wellness Curriculum has been especially helpful partnered with psychoeducation. One example is around diabetes. Many of our members are diabetic, and they don’t know what it is to be diabetic, or how it affects your mental health. Having the handouts have made it easier to talk with clients about the different ways to address living and dealing with physical ailments.”

Why do it:

  • “For me, being mentally OK and being physically OK go together, which is how we have implemented it in our office, and I see it working.”

Whole Person Care: Big Picture

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Telecare Partners in Wellness Open House

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Click here to watch the open house celebration for Telecare's Partners in Wellness program.

The Telecare Partners in Wellness program, along with the County of Santa Clara and Third Sector Capital Partners, Inc., hosted an open house for community stakeholders and members on February 8 at their new facility in San Jose, CA.

"Telecare opens many new programs, but this has been a unique experience in terms of the level of effort invested by so many parties to launch this innovative model,” said Anne Bakar, President and CEO of Telecare. "We are thrilled to have been chosen by Santa Clara for this important work. It is in perfect alignment with the value we place on public/private partnerships as the industry shifts toward performance-based funding.”

Opened on September 14, 2016, Telecare Partners in Wellness is the nation's first mental health focused Pay for Success (PFS) project. The program aims to provide community-based mental health services to individuals in Santa Clara County who have a severe mental illness, with the goal of measurably improving wellbeing and quality of life while reducing more costly service usage, including the psychiatric emergency room and inpatient psychiatric settings.

PFS is a performance-oriented contracting model that drives government resources toward social programs that best provide results to the people who need them most. Through this model, Santa Clara County has contracted Keith Humphreys of Stanford University, who is conducting a rigorous 6-year evaluation of the program.

“With this project and our prior Pay for Success project, the County is better defining our objectives in serving vulnerable populations, and is creating incentives that ensure service providers achieve those objectives,” said Chief Assistant County Counsel Greta Hansen. “Through the evaluations of each program, we will have a much better understanding of how to further increase the impact of these and other programs going forward.”

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Speakers for the event included Anne Bakar, President and CEO of Telecare; Greta Hansen, Chief Assistant County Counsel for Santa Clara County; Kavita Narayan, Deputy County Counsel for Santa Clara County; Toni Tullys, Director of Behavioral Health Services for Santa Clara County; Miguel Marquez, Chief Operating Officer for Santa Clara County; and Caroline Whistler, President and Co-Founder of Third Sector Capital Partners, Inc.

We welcome the chance to participate in this innovative partnership with Santa Clara County and Third Sector, and are honored to have the opportunity to provide services in a new area.

Pay For Success in Mental Health Weekly

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First PFS Initiative to Focus on Those Living With a Mental Illness

Telecare's Pay For Success (PFS) project has been featured on page one of Mental Health Weekly’s October 26 issue. PFS is Telecare's opportunity to share what we learned about people with mental illness and complex challenges.

The Santa Clara PFS program is being designed to serve residents with acute mental illness, who are among the highest users of the county's psychiatric emergency and inpatient services. It is a funding model where the government pays for services only if a service provider, Telecare, achieves clearly defined results.

"For this group, we anticipate reducing their predicted use of these acute and costly services by 35 percent," said Faith Richie, Senior Vice President of Development at Telecare.

Toni Tullys, MPA, Director of Behavioral Health Services at the Santa Clara County Health and Hospital System, praised Telecare’s impressive track record of developing programs that aim to reduce hospital stays, saying that Telecare has "the expertise of working with individuals with very high needs and developing, designing, and implementing services to support the needs of that population."

"We’re bringing government and philanthropy and the private sector together with the unique focus on innovations and outcomes," said Anne Bakar, President and CEO of Telecare.

Preliminary design and planning work is being done now. The program is scheduled to launch in 2016.

COEG Measurement Tools:

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We gathered feedback and outcomes in three ways: written feedback forms, which are provided at the end of each session for facilitators and participants; participant completion of two SAMHSA screenings (AUDIT for alcohol use and DAST for drug use), at the beginning and end of their involvement in the education sessions; and in-person debriefing held for program leadership and group facilitators, once all sessions were completed. 

These screenings and measurements help us establish a baseline for identifying issues, track and evaluate progress, and help foster conversations. 

SAMHSA recommends the use of screening to identify clients who are experiencing issues related to their substance use and/or who are using substances at a level at a hazardous or harmful level. The AUDIT and DAST assess client’s self-reported information about substance use, both measures can easily be scored by any health care provider.

AUDIT (Alcohol Use Disorders Identification Test) "is a 10-item questionnaire that screens for hazardous or harmful alcohol consumption. Developed by the World Health Organization (WHO), the test correctly classifies 95% of people into either alcoholics or non-alcoholics. The AUDIT is particularly suitable for use in primary care settings and has been used with a variety of populations and cultural groups," according to the Integrated Behavioral Health Toolkit, California.

DAST-10 (Drug Abuse Screen Test) "is a 10-item, yes/no self-report instrument that has been condensed from the 28-item DAST and should take less than eight minutes to complete. Designed to provide a brief instrument for clinical screening and treatment evaluation and can be used with adults and older youth,” according to the Integrated Behavioral Health Toolkit, California.

Links to info about Screening Tools (including AUDIT and DAST):
http://www.integration.samhsa.gov/clinical-practice/screening-tools
http://www.ncbi.nlm.nih.gov/books/NBK64190/
http://uwaims.org/bhip/tools-symptommeasures.html
http://www.ibhp.org/uploads/file/ScreeningTool%20Mandy.pdf

Why is COEG Promising?

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Beyond these promising preliminary findings, the Co-Occurring Education Group has other design attributes that can benefit clients and systems of care:

For Clients:

  • COEG is an open curriculum, where participants can join or leave whenever they choose.

  • It is respectful. There is no one right or wrong way to make changes in life.

  • Participants are given tools and resources to use and take steps on their own.

  • Session structure creates a respectful and empowering environment for change.

  • The sessions start a conversation, which often continues after a group ends.

For Systems of Care:

  • The educational program is replicable and scalable. The COEG Start-Up Toolkit and training can be implemented without astronomical costs.

  • A variety of line staff can lead the groups. The COEG program includes online and in-person training for facilitators and leaders and the Facilitator Guide provides a word-for-word script to run each session. This means facilitators do not need to be licensed in either behavioral health or substance use.

  • People who have previously been in early stages of readiness for change can empower themselves to move toward more active readiness.

  • Curriculum integrates SAMHSA videos and materials on addiction and recovery.

  • The topics and materials appeal to the people we serve.

  • The program is a recovery-centered approach which is client-centered and driven by an individual's hopes and dreams (integrating Telecare’s Recovery Centered Clinical System).


"What we're doing at Telecare is establishing relationships. I think that’s the key to our success." said Scott Madover, Regional Director of Operations. “Something that Telecare does well is engage people about their hopes and dreams. We find a vision that clients can look at and say, 'That's what I want.' They might not reach that hope and dream, but there are a lot of steps that they do reach which will help people feel satisfied and better about themselves. Everyone has to have not just a goal, but a hope of what could be different in their life." 

Pilot Results

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Telecare piloted the manualized Co-Occurring Education Groups at 11 of its sub-acute, residential, skilled nursing, and community-based programs. Once staff and leaders were provided with education about co-occurring conditions and recovery (and trained on the curriculum) the programs implemented the pilots, which ran from December 2014 through May 2015.
 
We gathered feedback and outcomes on the pilots in three ways:

  • Written feedback forms completed at the end of each session (one for participants, one for facilitators)
  • Two SAMHSA-recommended self-report screenings (AUDIT and DAST), which measure a person’s alcohol or drug use; screenings were given to participants whenever they attended COEG  for the first time and again after all the sessions had been provided 
  • An in-person debriefing meeting with all the group facilitators and program leadership, after all the sessions were completed

There were several statistically significant findings from the pilot of the COEG:

  • Participants said the educational material was clear and were confident they could apply it in their lives. 
  • A significant reduction in the percentages of participants who engaged in very high risk and those engaged in harmful drinking, along with an associated increase in the percentage of people who engaged in lower rates of drinking.
  • A 14% reduction of alcohol use and 19% reduction in drug use, according to participants’ pre- and post- AUDIT and DAST screening scores.

"These initial pilot results suggest we’ve developed a program by which people start to make healthier choices in their lives; that's going to lead to a reduction in cost and an increase in people’s well-being," said Shannon.

COEG Overview

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The Co-Occurring Education Groups (COEG) program is a part of Telecare’s larger effort to provide integrated “whole person” care for our clients. To do this, we focus on three fronts: physical health, behavioral health, and substance use.

The COEG program integrates materials from Telecare’s Recovery-Centered Clinical System and SAMHSA. This educational curriculum is heavily focused on Motivational Interviewing and the stages of change, and is designed to help educate those with co-occurring conditions learn about substance use and its impact on mental and physical health. It’s neither forced nor required, and people do not attend the groups as "treatment." People attend the groups because they are curious, want information, and have been invited.  We invite ALL clients to participate (not just those that staff have identified as having problems associated with substance use), through an engaging promotional campaign.

"Typical treatment services are effective for people who have decided they need to make a change in their lives around drug and alcohol use – and sometimes for those who have been mandated to treatment because they have gotten in trouble with the law," said David Heffron, Vice President of Operations. "However these groups provide an alternative for people who don’t think they need or want treatment. Information can be a powerful intervention for people who aren’t yet thinking of making a change."

The COEG was designed and developed at Telecare by David Heffron (Top), Shannon Mong, Director of Innovation Initiatives, and Scott Madover, Regional Director of Operations, with the input and feedback of clients, staff, and leaders at all levels in the organization. Their aim was to combine substance use and mental health services into a single, accessible approach.

"We were thinking about how to intervene with people who haven’t made the decision they want to address their substance use," said Shannon. "We knew that for someone to move from 'No, Not Me' (pre-contemplation) to thinking, ‘Well, maybe I am using substances in an unhealthy way’ takes quite a bit of internal change. It starts with a change in someone’s thoughts and feelings, that can lead to a change in attitude, which then may lead to a change in behavior. Since education is an important first step, we decided to create and pilot our own curriculum to see if the group learning would help people identify healthier choices they were personally interested in making."

The COEG program consists of 16 unique sessions. Each session covers a different topic of discussion: from understanding addiction, to recognizing triggers, to reflecting on one's hopes and goals. In some programs, groups are offered weekly; in others, groups are offered several times a week. Each group is moderated by a trained staff member and takes 60 to 90 minutes to complete. Due to the fact that Telecare has so many types of programs, the curriculum was designed to supplement, not replace, the regular clinical services that a program already delivers. Likewise, the curriculum does not contain service-line specific information, therefore, almost any program can use the materials. The groups are open, so new participants can join a group at any time. This flexible drop-in format gives individuals ownership over their future.

Although the curriculum is very structured, the group facilitators don’t tell people what to do. Instead, the groups provide information people may have heard before and the facilitators ask them questions to encourage their own thinking. "I think our job is to engage and develop relationships with our clients, to accept them where they are and to partner with them," Scott said. "Treatment is not the goal of the program. Instead the goal is for each person to gain information that is pertinent for them, which will lead them to make more effective choices and result in better outcomes for their lives. This approach is consistent with a harm reduction model."

How Do You Connect with People that are Hard to Reach? 

The COEG goes beyond just providing information. It creates a place where people can be heard and appreciated in a non-judgmental, non-shaming way. The trust that emerges in the groups offers people a way to tackle the very difficult process of change. Said Scott, "I would want someone to do the same for me."

Care Coordination: Making an Impact on Multiple Levels

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Leaders in our industry are bringing innovative ideas to the table that support meaningful healthcare integration. One such leader is Dr. Peter Currie at Inland Empire Health Plan (IEHP).

IEHP enlisted Telecare to create and run a Care Coordination Pilot Program in San Bernardino, California — specifically designed to serve people with serious mental illness and equally challenging medical needs. IEHP wanted an approach that was cost-effective, clinically effective, and aligned with their mission. They felt care coordination was an approach that would work.

The program started small in 2011, but results have been marked and promising, including:

  • 81% reduction in medical emergency department utilization
  • 76% reduction in psychiatric bed days
  • 61% reduction in psychiatric hospital admissions

This month, we've put together a Care Coordination Case Study to provide a better understanding of this model, as well as insight into the practices that have made it both clinically effective and deeply empowering to clients.
 
In particular, you’ll learn about Charles (watch the video below), whose life has been radically changed by care coordination services.

If you want more information about care coordination as a model, you can read last month’s article, Care Coordination at Telecare. 

Care Coordination at a Personal Level

We are honored to share a personal story from Charles, a client at our Care Coordination Pilot Program. He's been working with Care Coordinator Jerica Gailey, along with the entire treatment team, to transform his life one step at a time. In the video below you'll hear from Charles and Jerica, as well as Dr. Currie, who shares his inspiration and motivation for creating this program.

Telecare's Partnership with Inland Empire Health Plan:  Charles's Story

Integrating Care with Care Coordination

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This is the reality: the most challenging people to serve are the ones with the most diverse, complex, and interconnected needs, including both physical and mental health conditions.

In the past, we've all delivered the best treatment we can, but we've mostly had to do this from within our own specialty areas of care — whether we're medical providers, substance abuse specialists, mental health professionals, benefits experts, housing specialists, or the emergency room staff that step in when the needs get dire. 

We all know it's not enough. The interconnected web of issues our clients face are too deep and wide-ranging for this approach. Early mortality rates for people with SMI and complex needs are tragic. 

Thankfully, health reform is bringing new funding and system change to support meaningful healthcare integration. Now more than ever, we have the opportunity to make inroads and improvements for clients and care systems alike. Collectively, we have the resources to tackle these challenges. And we have the drive, the passion, and the moral imperative to do better. We are now stretching beyond our traditional roles to motivate recovery, save money, and improve outcomes.

Care coordination is a compelling approach because it allows each player in the system of care to continue doing what they do best. It builds trusting, involved, hands-on supports around the people we serve, so they can not only envision a healthier future for themselves, they can successfully move toward the lives they want.

Click here to learn what care coordination looks like at Telecare. And look for next month's newsletter, when we'll share a profile of our care coordination pilot program with Inland Empire Health Plan (IEHP) in Riverside, California.