SMMC CULTURAL COMPETENCY PROGRAM Purpose The intent of Molina Healthcare of Florida s (MFL s) Cultural Competency Plan (CCP) is to ensure the delivery of culturally competent services and provision of linguistic access to all enrollees including those with limited English proficiency. The Cultural Competency Plan describes how individuals and systems within the Health Maintenance Organization (HMO) shall effectively provide services to people of all cultures, races, ethnicities, and religions in order to improve quality and decrease health care disparities. The cultural competency program consists of provider orientation training, employee training, and quality monitoring programs. The training of employees and providers, in tangent with quality monitoring services are the cornerstones of a successful culturally competent service delivery. An integrated quality approach is aimed at enhancing the way health care providers supplement the needs of MFL members, service delivery and program development so that cultural competency becomes a part of everyday life. CC Program Relevance Cultural Competency is one of the main components in closing the disparities gap in health care. It is the avenue used for members and providers to come together and discuss health concerns without cultural differences hindering the conversation. Health services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes. 1 Culture and language influences: (1) Health, healing and wellness belief systems (2) How illness, disease and their causes are perceived by the member and/or caregiver(s) (3) The delivery of services by the provider, who views everything through his/her set of values. The divisions of race, ethnicity and culture are sharply drawn in the health and healthcare of people in the United States. 2 Despite progress in overall national health, there are continuing disparities in the incidence of illness and death, among African Americans, Latino/Hispanic Americans, Native Americans, Asian Americans, and Pacific Islanders as compared with the US population as a whole. These groups comprise a significant portion of membership in Florida as noted in the table below. Population by Race & Origin (Hispanic) for the State of Florida 2013 Race Population for the State of Florida: 2013 Population White 10,992,388 African American 3,020,029 Asian 499,376 American Indian 39,440 Islander 6,808 Other 57,437 Identified by two or more races 318,066 Cultural Competency Program-2015 Page 1
ETHNICITY POPULATION Hispanic or Latino 4,619,316 Not Hispanic or Latino 14,933,544 Source: United States Census Bureau. The US Census Bureau's 2013 Population Estimates dataset has the most current population estimate data. The US Census Bureau's 2013 American Community Survey dataset has the most current demographic data (i.e. race). Cultural Competency Program Description The Molina Healthcare of Florida (MFL) Cultural Competency Program (CCP) is designed to assist in the proactive interaction of different cultures and individuals with limited English proficiency. The Cultural Competency Program is constantly evolving and education and training is the key to success. MFL defines limited English proficiency as those members who have difficulty speaking, reading, writing, or understanding the English language because they are individuals who: Were not born in the United States or whose native language is a language other than English; Come from environments where a language other than English is dominant; Come from environments where a language other than English has had a significant impact on their level of English language proficiency; Were denied the opportunity to learn successfully in classrooms where the language of instruction is English or to participate due to the limited English proficiency. In order to determine cultural beliefs, staff and providers must first access their own: (1) Awareness of their cultural worldview (one s personal reaction to people who are different). (2) Attitude towards cultural differences (the difference one has with training that increases awareness of cultural bias and beliefs in general and one s training to examine their own beliefs and values about cultural differences). (3) Knowledge of different cultural practices and worldviews (our values and beliefs about equality may be inconsistent with our behaviors). (4) Access their cross-cultural skills (practicing cultural competence communication). MFL defines cultural and linguistic competence as a set of behaviors, attitudes and policies among staff and providers that enable effective work in cross-cultural situations. The program is designed to facilitate and reinforce this concept; developing cultural competence result in an ability to understand, communicate with, and effectively interact with people across cultures. 3 MFL views cultural and linguistic appropriate services as health care services that are respectful of and responsive to cultural and linguistic needs of the member, regardless of race, creed or ethnicity. Program and Policy Review Guidelines Molina Healthcare of Florida will assess the following information indicated below annually in order to ensure its programs are most effectively meeting the needs of its members and providers. Providers have access to the CCP summary as well as the full CCP on the Molina s website along with instructions on how to obtain a hard copy of the Cultural Competency Plan at no charge. MFL monitors complaints in respect to member satisfaction in the area of cultural and linguistic needs in an effort to ensure that each is adequately addressed in a timely manner. The Plan will implement performance measures as well as studies in an effort to identify and improve processes and/or outcomes of health care or services in accordance with the SMMC contract. Cultural Competency Program-2015 Page 2
Annual review of membership demographics (preferred language, ethnicity, and race) Local geographic population demographics and trends derived from publicly available sources (Group Needs Assessment) as available Network Assessment annually Applicable national demographics and trends derived from publicly available sources Health status measures such as those measured by HEDIS as available Comparison with selected measures such as those in Healthy People 2020 CAHPS Results (annually) Member Satisfaction Survey Results (annually) LTC Enrollee Satisfaction Survey Provider and Community Training Providers and staff supporting providers receive cultural competency training during provider orientation. Training is delivered through a variety of methods such as: Written materials Provider Manual Access to reference materials available through the health plan Continuing Medical Education (CME) Educational Materials and Electronic Library (Diverse Populations Care) Molina Healthcare of Florida actively participates in activities to improve services of the provider network. Practitioners are provided with resources where they may access additional information on government sponsored linguistic/cultural conferences and/ or initiatives that will assist in treating members with limited English proficiency. Molina Healthcare s goal is to deliver excellent service to all we serve including providers. In order to reach this goal, Molina Healthcare has created three (3) Continuing Medical Education (CME) courses, accredited for CME credit (AAFP Prescribed credits approved.)a Physician's Practical Guide to Culturally Competent Care is a free online CME program from the Office of Minority Health. This innovative training is a case-study based curriculum with video vignettes and interactive exercises. Learn how to work with patients from diverse backgrounds and develop cultural competency training for staff. Earn up to 9 free CME credits (Physicians and Physician Assistants), 9 contact hours (Nurse Practitioners), or 9 contact hours (0.9 CEUs) (Pharmacists). Molina Healthcare of Florida also collaborates with community based advocates and organizations such as Read to Succeed, Hispanic Coalition, Families First and Healthy Start Coalition to assist non-english and limited-english speaking members in accessing culturally appropriate and competent services. These community advocates exist in diverse communities throughout counties in Florida and deliver specific services for ethnic communities. Organization Language Activities Hispanic Coalition Branches- Florida City Spanish Spanish Community education meetings with different subjects and services. Relationship for over 5 years- MLK Day, Summer camp programs, Dr. Cleo s Cooking Club, and Thanksgiving food drives. Communidades en Accion Spanish Family Health Fair, Feb 7, 2014. Cultural Competency Program-2015 Page 3
Hope for Miami Family First CULTURAL COMPETENCY PLAN 2015 Spanish/Creole Spanish Toy distribution for children of incarcerated parents. Several parent meetings with educational topics sponsored by Molina. Sembrando Flores Spanish The Health Fair in Little Havana. Read to Succeed South Florida Hispanic Chamber of Commerce Spanish Spanish Bi-monthly reading sponsor programs for children and Molina s Book Foundation grantee. 9th Annual Latino Health and Wellness event on April 24, 2014. Children s Home Society Spanish Health Fair on March 14, 2014. Integrated Quality Improvement Processes MFL conducts assessments at regular intervals to ensure quality standards are maintained through the use of annual reviews of membership demographics (preferred language, ethnicity and race); local group needs assessment, network assessment, applicable national demographics and trends. In addition, Health status measures such as those measured by HEDIS; comparative measures, such as access to health services and education and community based programs that are found in Healthy People 2020. Critical factors in the provision of culturally competent health care services include the understanding of the: Beliefs, values, traditions and practices of a culture; Culturally-defined, health-related needs of the member, families/caregivers and communities; Culturally-based belief systems of the etiology of illness, disease and those related to health and healing; Attitudes toward seeking help from health care providers The application of the above concepts of cultural competency includes ensuring member access to language services such as oral interpretation, written translation and access to programs and services that are congruent with cultural norms. MFL notifies plan members of the availability of free oral interpretation services during enrollment. Members are directly assisted in accessing oral interpretation services 24 hours of the day seven days a week by calling 1-866-472-4585 by member services staff and representatives who speak languages such as Spanish or Creole. Cultural Competency Program Activities The CCP integrates activities that are: (1) Provider Focused (2) Member Focused (3) Plan Focused (hiring of Creole and Spanish speakers, access to telephonic translators) Cultural Competency Program-2015 Page 4
Molina Healthcare of Florida collects and analyzes the following data to ensure the practitioner/provider network meets the ethnic, cultural and linguistic needs of MFL membership. Practitioner Data Languages spoken by practitioner Practitioner gender Education materials provided to contracted practitioners regarding MFL member ethnic, cultural and linguistic needs. Member Data Member ethnicity by county; member sex; member age Member complaints regarding practitioner/provider availability Member complaints regarding cultural and linguistic services Practitioner/member Data Combined language line usage Community Connector Molina healthcare of Florida is innovative in the approach to promote health. Getting members to understand and to follow providers orders is an ongoing challenge in health care. For some low-income members with multiple medical problems, lack of adherence to a treatment plan can lead to a rapid decline in their health, excessive use of the Emergency Department and extra costs. (4) For these members, MFL has found a solution, Community Connectors. The Community Connector program serves as a liaison between the members and the providers in order to navigate patients and promote health within their own communities by providing education, advocacy and social support. The program provides outreach to locate and/or provides support for disconnected members with special needs. Community Connectors support MFL s most vulnerable members within their home and community with social services access and coordination. Community Connectors are directly hired from the community of service. Therefore, connectors usually share ethnicity, language, socioeconomic status, and life experiences with the community members served. In addition, connectors deliver culturally sensitive health services through education, advocacy, and social support. Cultural competency employee training occurs upon hiring and the training focuses on ensuring that connectors are competent in regards to inclusive cultural diversity and sensitivity when interacting with a culturally diverse population. The cultural competency employee training teaches staff members how to effectively communicate culturally sensitive health information to individuals and families from diverse ethnic and cultural backgrounds. The training is a four week process, below is the standard training provided to Community Connectors: Week 1 Week 2 Week 3 Week 4 General Molina Training: HR, introduction to systems, department contact Community Connector Training: CC Role, documentation, safety, communication skills, cultural sensitive approach Shadowing a preceptor Home visits and evaluation Cultural Competency Program-2015 Page 5
Molina Healthcare of Florida Spanish Line Services Molina Healthcare of Florida provides Spanish language lines for Member Services Department as well as the Utilization Management Department and Triage-Nurse Advise Line unit. MFL provides a centralized Nurse Advice Line that offers personalized medical information and counseling to MFL members. This unit is staffed with multi-lingual registered nurses and ancillary personnel twenty-four (24) hours a day, seven (7) days a week. Provider Orientation New Provider Orientation presentation focuses on ensuring that providers are competent in regards to inclusive cultural diversity and sensitivity when treating a culturally diverse population. MFL s cultural competency mission is to communicate to providers the importance of cultural competency and linguistic compatibility. In addition to offering its members a diverse network from which to choose, MFL also strives to provide services that are culturally and linguistically appropriate by employing a multi-lingual staff, which offers a telephonic interpretation. The services provided are regularly evaluated in order to improve the quality of service. MFL has these mechanisms in place to ensure that members have availability to services that are sensitive to their cultural and linguistic needs. Disease Management Molina, as a national Medicaid Health Plan, recognizes that we serve an ethnically diverse membership affected with many risk factors and, as a result of this, disease management programs were created. The programs are free and provide learning materials, advice and care tips: The Breathe with Ease asthma program is for children and adults who are active Molina members. The Healthy Living with Diabetes program is for members 18 years and over with diabetes, where we teach about diabetes self-care. The Chronic Obstructive Pulmonary Disease (COPD) program is for members who have emphysema and chronic bronchitis. The Heart-Healthy Cardiovascular program is for members 18 years and older who have one or more of these conditions: coronary artery disease, congestive heart failure or high blood pressure. The disease management staff provides education and assists the members, families/caregivers, and recognizes the importance of the following cultural aspects of the disease management process: Relevant printed education material that is culturally sensitive; Importance of a member support network within and around the family of the member; and Care planning and implementation is established and conducted in a culturally sensitive manner, consistent with the members benefit structure. Employee Training Cultural Competency and Service Excellence employee training occurs upon hiring with periodic reinforcement integrated in modules delivered through a variety of methods including, but not limited to one or more of the following: written materials, employee communications of cultural competency concepts in recurrent staff meetings. Cultural Competency Program-2015 Page 6
Member Cultural & Linguistic Needs Evaluation Molina Healthcare of Florida (MFL) assesses the cultural and linguistic needs of its members on an annual basis. Information gathered during the annual assessment is used to identify and reduce cultural and/or linguistic barriers to care through the implementation of actions and/or interventions. MFL ensures that equal access to quality health care is available to its members. An annual assessment of 5% in any language directly affects the appropriate number of network providers, member service staff and written materials. The attached report provides an overview and analysis of MFL s cultural and linguistic needs, interventions and services for 2014. Key outcomes and meaningful trends are presented to allow identification and prioritization of improvement opportunities. Molina Healthcare of Florida identifies the language needs of its members from the following: LTC Enrollee Satisfaction Survey MFL CAHPS 5.0H Medicaid Satisfaction Survey Results Membership population received from AHCA MMA population MFL s Call Center Services Spanish and Creole calls Member complaints regarding cultural or linguistic services MFL Call Center Representatives languages spoken MFL s utilization of telephonic interpretation services I. LTC Enrollee Satisfaction Survey 2014 The 2014 LTC Enrollee Satisfaction Survey was mandated by the Agency for Health Care Administration (AHCA). MFL analyzed the 2014 LTC Enrollee Satisfaction Survey to effectively capture the cultural and linguistic needs of members. MFL has added the following cultural linguistic supplemental questions in the 2015 LTC Enrollee Satisfaction Survey in order to identify opportunities to improve healthcare services and meet the cultural and linguistic needs of MFL s Long-Term Care members. Sample supplemental questions Your Long-Term Care Plan Please think about the written materials your long-term care plan gave you. How much of a problem, if any, was it to understand based on your cultural and/or language needs? A big problem A small problem Not a problem I do not have any special cultural and/or language needs Your Case Manager In the last 6 months, if you did not understand your case manager, what could have helped you better understands? If I had more time with my case manager to ask questions If my case manager gave me a brochure or other resources on the topic If my case manager wrote down what I needed to do If my case manager spoke my language Cultural Competency Program-2015 Page 7
CULTURAL COMPETENCY PLAN 2015 Other: (Please specify) In the last 6 months, how often did you have a hard time speaking with your case manager because you did not speak the same language? Never Sometimes Usually Always About You What is your primary language? English Spanish Creole Other: II. CAHPS 5.0H Medicaid Satisfaction Survey Results 2014 Background DSS has conducted the CAHPS member survey since 1995.The 2014 CAHPS 5.0H survey accurately captures customer feedback and expands the scope of information gathered relative to quality of care issues. DSS designed the survey instrument and mailed an attractively formatted booklet with a cover letter explaining the importance of completing the survey to the sampled members via first class postage. Members eligible for the survey are those 18 years and older (as of December 31 of the measurement year) who are currently enrolled and have been continuously enrolled in the plan for at least five of the last six months of the measurement year. A simple random sample of the required sample size for the population was drawn. To reduce possible confusion and respondent burden, the sample was deduplicated so that only one adult per household was included in the sample. A sample of 604 members was obtained with an overall sampling error of ±4.0% at 95% confidence using the most pessimistic assumption regarding variance (p=0.5). Respondents who give multiple answers, appropriately skipped, or no answer are removed from the base. The charts below are depicting the Base, which gives the number of respondents who responded appropriately to that question. There are labels for the relevant responses to that question. For example, always, usually, sometimes, and never are possible responses to the question, In the last 6 months, how often did you have a hard time speaking with or understanding your personal doctor because you spoke different languages? (5) Supplemental Questions MFL continuously and systematically examined the previous methodology of the CAHPS 5.0H surveys in order to identify opportunities to improve healthcare services and to enhance the network to meet the cultural and linguistic needs of its members. Supplemental questions were added to the 2014 CAHPS survey in order to develop metrics to measure and analyze the effectiveness of the CCP. Cultural Competency Program-2015 Page 8
Possible selection CULTURAL COMPETENCY PLAN 2015 17a. In the last 6 months, if you did not understand the explanation from your personal doctor, what could have helped you better understand? (Check all that apply) Total 604 No response 10 Appropriately skipped 429 Base 72 MOLINA HEALTHCARE OF FLORIDA 2014 CAHPS 5.0H Medicaid Satisfaction Survey If I had more time with my personal doctor to ask If my personal doctor wrote down what I needed If my personal doctor gave me a brochure or other If someone in the office spoke my language Diagnosis/treatment/care mention If my personal doctor listened to me more If my personal doctor explained things better I always understood the explanation from my Other 0 5 10 15 20 25 30 35 40 Base=72 Less than 20% of respondents selected, if someone in the office spoke my language, could have helped them better understand the explanation from their physician. Molina Healthcare of Florida recognizes the importance of developing competent linguistic services and will utilizes this data to better serves the linguistic needs of its membership. Cultural Competency Program-2015 Page 9
23a. In the last 6 months, how often did you have a hard time speaking with or understanding your personal doctor because you spoke a different languages? Total 604 Multiple mark 62 No response 28 Appropriately 86 skipped Base 428 MOLINA HEALTHCARE OF FLORIDA 2014 CAHPS 5.0H Medicaid Satisfaction Survey 3% 7% 9% Never Sometim es Usually 81% Always 23b.In the last 6 months, if you needed an interpreter to help you with doctors or other health providers, how often did you get one? Total 604 Multiple mark 2 Appropriately 86 skipped Base 419 4% MOLINA HEALTHCARE OF FLORIDA 2014 CAHPS 5.0H Medicaid Satisfcation Survey 3% 9% I did not need these services in the last 6 months Never 50% Sometimes 34% Usually Always Due to these findings, Molina Healthcare of Florida will continuously reinforce cultural education and advocate for providers to use the AT&T translation services in order to satisfy the linguistic needs of its members. MFL addresses language barriers by educating all contracted providers to be well equipped when assisting members with language barriers. Cultural Competency Program-2015 Page 10
35b. Thinking about the written materials and communications your health plan provided you with, how much of a problem, if any, was it to understand given your cultural and/or language needs? Total 604 Multiple mark 5 No response 114 Base 485 MOLINA HEALTHCARE OF FLORIDA 2014 CAHPS 5.0H Medicaid Satisfaction Survey 32.99 I do not have any special cultural and/or language needs A big problem 58.15 A small problem 6.8 2.06 Not a problem III. Qualitative/Quantitative Analysis: According to the Molina s Membership File and based on a total membership of 296,253, the cultural and linguistic information is as follows: Total Number of Membership Language % of Language spoken per membership 163,554 English 55% 86,898 Spanish 29% 45,769 Undetermined 15% 26 Haitian Creole.08% 6 Other.02% Total Number of Membership Race/Ethnicity % of Race/Ethnicity per membership 7,846 African American 2.6% 45,823 Hispanic 15.5% 26,694 Caucasian 9.0% 207,429 Not Provided 70.0% 3 Other Race or Ethnicity 0.0% 8,152 Asian or Pacific Islander 2.8% 306 American Indian or Native America 0.1% Cultural Competency Program-2015 Page 11
The 2014 MMA Population Total Number of Membership CULTURAL COMPETENCY PLAN 2015 Language % of Language spoken per membership 40,801 English 44.25% 19,590 Spanish 21.00% 1,582 Creoles and Pidgins, French-based (Other) 2.00% 30,239 Undetermined 33.00% Total Number of PCPs Language % of Language spoken 11,506 English 54.00% 5,807 Spanish 27.00% 1,391 Creoles and Pidgins, French-based (Other) 7.00% 2,521 Undetermined 12.00% Top 5 Specialties Language % of Language spoken 1,653 English 51.00% 153 Spanish 5.00% 48 1.00% 1,388 Undetermined 43.00% IV. The 2014 Telephone Call Center Statistics Language Total Number of Calls Percentage of Total Calls Combined 228,385 100% English 148,811 65.16% Spanish 69,226 30.31% Creole 10,348 4.53% Cultural Competency Program-2015 Page 12
V. Member Complaints :Call Type Cultural/ Linguistic Services Date Call date: 4/3/2014 Call type: language specific material Resolution date: 4/3/2014 Call date: 4/7/2014 Call type: cultural linguistic Resolution date: 4/7/2014 Call date: 7/17/2014 Call type: cultural/language access Resolution date: 7/17/2014 Call date: 8/5/2014 Call type: access/availability Resolution date: 8/5/2014 Call date: 8/5/2014 Call type: cultural linguistic Resolution date: 8/5/2014 Issue: Call Notes Report Call reason: Member received a letter about adult day care but had difficulties reading the material due to language barrier. Resolution: Immediately, the member s case manager was notified and the case was resolved in a timely manner. The member was satisfied and no additional help was needed. Call reason: Member requests to change to a primary care physician (PCP) who speaks Spanish. Resolution: Member was transferred to a Spanish oral interpreter in order to change PCP. Member received a new identification card within 7-10 business days. Call reason: Member used the Spanish language line in order to complain about services. Resolution: The member requested a Spanish representative. Call reason: Member requests a Spanish speaking physician for her child. Resolution: Member was transferred to a Spanish oral interpreter in order to assist the member to make the appointment. Call reason: Member is having difficulties understanding the benefits of their health plan. Resolution: The member utilizes the Chinese language line to ask for assistance. The member s information was updated in order to assist the member better. Member received a new identification card within 7-10 business days. In 2014, there were a total of 5 member complaints related to cultural and linguistic services and 1 member requested to change their primary care physician due to language barrier. As a result, the sample size was not large enough to warrant further intervention. All complaints were individually handled and successfully resolved in a timely manner. Cultural Competency Program-2015 Page 13
VI. The Interpreter Services Activity for 2014 was as follows: Languages Total Albanian 1 Amharic 1 Arabic 15 Bosnian 9 Brazil-Portuguese 12 Burmese 6 Farsi 1 Filipino 3 French 10 French Creole 1 Haitian Creole 454 Hebrew 1 Hindi 1 Hmong 5 Karen 1 Korean 1 Malayalam 1 Mandarin 9 Moroccan Arabic 1 Persian 1 Polish 2 Portuguese 2 Russian 13 Somali 1 Spanish 2,757 Tagalog 1 Vietnamese 6 Visayan 1 Total Call 3,317 VII. Languages spoken by Customer Service Staff: Title Number of Staff English Spanish Creole Director 1 1 Manager Supervisors 3 2 1 Customer Service Representative 91 31 55 5 Cultural Competency Program-2015 Page 14
Conclusion According to the Molina Healthcare of Florida Membership Files, Spanish makes up 29% of the languages spoken by members. Per the U.S. Census Bureau, Spanish is more than 5% in every county with Molina membership, emulating the information in the membership files. Molina s membership reflects Creole as the next top language spoken by membership. Although it has not reached the 5%, the Interpreter Services activity displays that 454 Creole requests were submitted in 2014. In order to ensure that MFL is meeting the 5% language goal, as it relates to provider network, staffing and member materials and to sustain the call center metrics, the following actions have been established: Member Materials are translated in Spanish Member Materials are available in other languages upon request English, Spanish, and Creole prompts are available through the 800 numbers English, Spanish, and Creole individual Queues are available within the Customer Service Department. To accommodate any other languages, Molina provides and maintains a 24-hour access to interpreter services. The Customer Service Representatives utilize these services as well as the Nurse Advice Line for after hour s assistance Race and ethnicity are often thought to be dominant elements of culture; however, providers of care must embrace the broader definition of culture that includes language, gender, socioeconomic status, housing and regional difference. Organizational behavior, practices, attitudes and policies across all health care functions must respect and respond to the cultural diversity of members and the communities served in order to close the disparities gap in health care and bring about better health outcomes. As per metrics measured and trended, Molina Healthcare of Florida has provided access to cultural/linguistic appropriate care for all of the members. Cultural Competency Program-2015 Page 15
Resources 2013 Florida Demographic Population 1 Office of Minority Health- http://minorityhealth.hhs.gov National Partnership for Action to End Health Disparities. 2 National Center for Cultural Competence. The Initiative To Eliminate Racial and Ethnic Disparities in Health (policy statement). Washington, D.C., U.S. Department of Health and Human Services, 1998. 3 Mercedes Martin & Billy E. Vaughn (2007). Strategic Diversity & Inclusion Management Magazine, pp. 31-36. DTUI Publications Division: San Francisco, CA. 4 Grovet, D., & Hernandez, D. (2014, September 4). Community Connectors the Missing Link to providing High Quality Healthcare Health Reform Trust for America's Health. 5 DSS Research. 2014 CAPHPS 5.0H Member Survey. 2013 Decision Support Systems, LP Cultural Competency Program-2015 Page 16