Palo Alto Medical Foundation

Pre-dawn Cheers and Applause Buoy Spirits of Weary Firefighters

Posted on Sep 4, 2020 in Carousel, Palo Alto Medical Foundation, People, Scroll Images, Sutter Maternity and Surgery Center, Santa Cruz, Uncategorized

The town of Aptos is typically quieter than neighboring Santa Cruz, but last Tuesday that tranquility was broken by shouts of gratitude and applause for firefighters battling the CZU Lightning Complex fires – all organized by Sutter’s Lisa Haux.

“We made so much noise they could hear us across the highway,” Haux said.

Nella, age 8 and Clara, age 5 of Santa Cruz show
off the banner they made for the firefighter tribute.

The pre-dawn event that drew more than 100 community members was spurred by equal parts sincerity and serendipity, said Haux, a compliance officer with Sutter Health. “As part of the Sutter family, I’ve seen the salutes that our frontline healthcare workers have received from first responders – including fire, police, sheriff and ambulance units – thanking our nurses and doctors for their bravery and dedication to duty in the face of COVID-19. Those tributes were so meaningful to us, I thought we could do the same for the firefighters.”  

A small town has no secrets, and Haux learned which hotel was housing most of the out-of-town firefighters and that the end of their shift varied day to day, depending on firefighting conditions. “So I decided to organize a surprise early morning send-off, to lift their spirits at the start of their shift,” she said.

Haux quickly realized that firefighters – like healthcare workers – start work early. To catch the firefighters before they headed to base camp, the community needed to gather in the hotel parking lot, with their signs and balloons, by 5:45 a.m. “I honestly expected maybe 20 people would show up, given how early it was, so I was blown away by the response.”

The crowd was five times larger than Haux’s expectation and even drew reporters from the Santa Cruz Sentinel and KTVU. “When we started it was still dark outside, but we held our banners high as the sun slowly rose. It was awe-inspiring to see the turnout and see how heartfelt the appreciation was from our community to these brave professionals, risking themselves for strangers.”

Crews from across California filled the two dozen fire trucks that pulled out that morning, flashing their lights and waving back in thanks.

Stephen Gray, chief administrative officer for Sutter Maternity & Surgery Center of Santa Cruz and operations executive of Palo Alto Medical Foundation Santa Cruz said that wildfire season is something we know all too well in Northern California.

“Several parts of our network, including our employees who live and serve in these communities, have been personally impacted,” Gray said. “We’re so happy to express our appreciation for the efforts of the firefighters to keep us safe, which helps us continue our mission of serving others.” 

A week later Haux still delights in how her community showed their spirit, saying, “Fire is a horrible way to bring out comradery, but it does show that people really do want to help each other, and we are all in this together.”

Caring for a Newborn in a Pandemic

Posted on Aug 17, 2020 in Carousel, Palo Alto Medical Foundation, Pediatric Care, Quality, Safety, Scroll Images, Uncategorized, Women's Services

This article was written by Anita Mantha, M.D., pediatrician with the Palo Alto Medical Foundation for the August 2020 issue of Bay Area Parent magazine. 

Raising a newborn has never been easy. Nighttime feedings, coping with your own body’s recovery and the constant worry that comes with keeping your little bundle of joy safe are all part of being a new parent. In the midst of a pandemic, that job may be even more challenging. In the era of COVID-19, how do we keep our newborn baby safe, while enjoying the beautiful journey ahead?

If a mother is suspected or known to have COVID-19, how do doctors care for the newborn?

This is an evolving topic, as we learn more about this virus. Many hospitals are currently testing pregnant women around the time of their delivery for COVID-19. You can check with your obstetrician and the hospital team to find out if and when this test is being done if you have questions.

If you do test positive, do not panic. Hospitals have policies and procedures in place to help keep you and medical staff protected. While your care team may look a bit different than you imagined – gowns, face shields, masks and gloves – they will still work hard to support you during your delivery.

Once your baby is born, your care team will likely recommend that you wear a mask and practice good hand hygiene. Your baby may also be tested. Your care team will likely discuss additional precautions around topics such as physical distancing and feeding. Please remember not to put face coverings on children less than 2 years of age.

Can I still breastfeed my baby if I have COVID-19?

The benefits of breast-feeding have been long documented. One of the benefits is that breastmilk has antibodies that help protect the body against bacteria and viruses, potentially making it all the more important to breast feed your newborn now. In limited studies, COVID-19 has not been detected in breast milk. However, we do not know for sure whether mothers with COVID-19 can spread the virus via breast milk. 

What we do know is that it’s important to practice good hand and breast hygiene while pumping. Also, consider having a caregiver in good health offer bottles of your milk. If you have tested positive for COVID-19, you and your care team can discuss when and how to nurse your baby directly. 

What are the symptoms of COVID-19 in a newborn?

Newborns can have a wide range of symptoms including fever (defined as a temperature greater than 100.4F), poor feeding, being very tired, coughing, congestion, runny nose and/or breathing difficulties. The tricky part about newborns is that these symptoms can be caused by a variety of things, so it is important to discuss any concerns with your care team. The good news is that most children (including newborns born on time) with COVID-19 are asymptomatic or have mild symptoms. Prior to going home with your newborn, consider having a thermometer at home and being comfortable taking a rectal temperature, which is the most accurate temperature reading in newborns. Having your physician’s advice line number on hand is also important in case questions arise.

Can I let family members visit the baby? How do I keep my newborn safe from COVID-19?

Aside from COVID-19, we recommend caution, especially in the first month of life, to prevent your baby from catching an infection. Your newborn has an immature immune system and is at risk for serious bacterial infections. For these reasons, a fever is considered an emergency, and you should seek care for your child right away if it happens.

Now, more than ever, try to limit visitors in the first month of life. Anyone who visits should practice careful hand hygiene, practice physical distancing and wear a mask as much as possible. Please remember, even in the midst of a pandemic, normal newborn concerns still exist: jaundice, weight checks, etc. Please keep all regularly scheduled newborn care appointments and inform your care team if you or your baby are symptomatic prior to these visits so they can determine next steps.

I know moms can go through “baby blues.” Won’t physical distancing only make this feeling of isolation worse?

With all that is going on, it is natural for new mothers to feel as if they are on an emotional roller coaster. The important thing is, even though you may need to physically distance yourself to keep your newborn safe, you do not need to emotionally distance. Make sure to connect virtually with friends and family as much as possible. Connecting with other parent friends via video or phone calls can be helpful as well. La Leche League (llli.org) also provides great support to new parents.

What can I do to help my postpartum worries?

Make sure to take time for yourself and try to maintain a bit of a routine to help feel more balanced. Try to avoid frequently checking the news or social media, as this can lead to more stress. Consider some time for meditation, spending time outdoors or anything else you find enjoyable. Postpartum blues can turn into something more serious such as postpartum depression or anxiety, so please seek help if you are feeling that your mood is making it difficult to function. There are many resources to help, so do not wait to reach out. As things are constantly changing, please check with your healthcare team for updates on the care of newborns in this challenging time. The CDC also offers helpful information here.

Respiratory Care Clinics: How Dedicated Exam Spaces Limit the Spread of Viruses

Posted on May 26, 2020 in Carousel, Expanding Access, Innovation, Palo Alto Medical Foundation, Quality, Safety, Scroll Images, Uncategorized

BAY AREA, Calif. – Its second nature for people to visit their doctor’s office or an urgent care center when they’re sick — or are worried they might be. In early March doctors across the Sutter Bay Medical Foundation prepared for patient demand at these locations by developing Respiratory Care Clinics (RCCs); an outdoor exam experience that keeps potentially contagious people distanced from those that aren’t, while allowing all who need in-person care to receive it.

“We always knew patients would have concerns that were serious enough to need an in-person exam, but not urgent enough for a trip to the emergency room,” said Kurt Vandevort, M.D., inter-regional medical director for the Palo Alto Foundation Medical Group, part of the Sutter Medical Network. “As community-based providers this middle level of care is what we do best, so it was incumbent on us to find a way to keep providing it, safely.”

By March 16th the Sutter Bay Medical Foundation had established fifteen RCCs in cities across the Bay Area, each seeing patients with COVID-19 concerning symptoms (or who reported a potential exposure to the coronavirus), outside of a nearby medical building that needed to stay open and clean for patients with urgent or medically necessary needs unrelated to COVID.

A month into their operation reporters from The Mercury News and San Francisco Chronicle took notice and wrote about these MASH-like clinics. Now, as Sutter Health resumes more routine patient visits, the RCCs will continue to separate patients with respiratory symptoms from those without, to reduce the risk of exposure to viruses, including the novel coronavirus. Read below to learn more about how the RCCs work and what to expect if you are directed to one.

Call First 

Sutter Health is focused on helping ensure patients have access to the right level of care to match their medical need, but we also understand that sometimes that’s hard for people to gauge. That’s why Sutter Health set up the COVID-19 Advice Line at 1-866-961-2889.

Staffed by a team of nurses from 8 a.m. – 6 p.m., seven days a week, every caller is screened for symptoms linked to coronavirus. Callers are then directed to the most appropriate level of care based on the severity of their symptoms. Patients may be directed to self-monitor at home, to see a provider by video visit or to come to an RCC location where they can receive an in-person exam.

“By linking the RCCs to a pre-screening process (by phone or after a video visit) we can ensure patients coming to RCC do need to be seen in-person, and aren’t ill enough to go straight to the emergency room,” said Dr. Vandevort, who is also the medical director of the RCCs established throughout the Palo Alto Medical Foundation footprint. “When patients arrive at the RCC we also have some information about their chief concerns, thanks to notes entered in our electronic medical record.”

Different, by design 

A physical exam in a parking lot or garage is strange, but the safety that these setting offer is worth the weird-factor. “To protect patients, staff and the community we designed the RCCs to first and fore-most prevent transmission of any virus from a contagious person; that’s why most of them are outdoors and anyone who comes within six feet of the patient is in full personal protective equipment” said Dr. Vandevort. “At the same time we took great pains to try to make the experience similar to what patients are used to when they go to the doctor or urgent care.”

The outdoor RCCs all have a contact-free arrival process, allowing patients to drive-up and call a phone number to “check-in” for their appointment. At every stage of the visit the patient is distanced from others by either staying in their car or in a marked off space within an exam bay.

In addition to an initial temperature check, patients will have their lungs listened to with a stethoscope, have their blood oxygen saturation checked, have their medical history and medications reviewed, and may be tested for coronavirus or the flu if symptoms indicate they should be. Depending on medical need, patients will also receive additional tests and procedures, including imaging scans, blood draws, heart monitoring and more.

The few indoor RCCs are all in buildings, or sections of buildings, that can safely be separated from other areas where patients who don’t have respiratory symptoms are being seen. The indoor RCCs have implemented all the necessary transmission precautions to ensure that spread of a virus from patient to patient or patient to staff is prevented.

Not Just COVID Care

In addition to screening and treating respiratory complaints, the RCCs have filled another important role; addressing non-respiratory related issues reported by patients who have symptoms linked to COVID (fever, cough, shortness of breath). “Just because COVID-19 is here, that doesn’t mean that other illnesses and injuries go away,” said Dr. Vandevort. “One of the best things about the RCCs is that you are being evaluated by a physician who can treat a wide variety of minor illnesses or injuries, prescribe medications or make a dosage change to an existing medication, and otherwise address a whole host of concerns. It’s what we do every day, and in these safe settings, we can keep doing our job even for patients who may have a virus and be contagious.”

In the short time the RCCs have been up and running, doctors staffing them have made unexpectedly important diagnoses and delivered increasingly complex care. “We’ve seen and treated conditions ranging from an appendicitis, to a swallowed fish bone, to an infection requiring IV antibiotics. We’ve done a lot of good.”

Twice the Team 

It’s not easy to run two clinics (one regular and one RCC), simultaneously, just feet apart, but for the safety of our patients and providers that is what we’ve done. “We had to reassign doctors and nurses so we had coverage in both the RCC and the regular urgent care at the same time, some staff now act as a front-door attendants making sure that patients are directed to the right clinic based on their symptoms, and others are runners shuttling supplies between the two spaces.”

All this investment was made for one reason: to prevent the spread of illness. But the RCCs have had several secondary benefits too.

“We’re also helping to preserve hospital capacity by keeping patients from going to the emergency department unnecessarily.” You wouldn’t normally go to the ER for a fever, and the RCCs make sure our smart use of resources stays intact, even during a pandemic.

At the same time, the RCCs have helped refer patients to a higher level of care when that was needed. “Our job is to help stabilize people so they can safely return home, but when their symptoms are serious we help get them to the hospital.”

Data Detectives Track the Pandemic

Posted on May 13, 2020 in California Pacific Medical Center, Expanding Access, Innovation, Palo Alto Medical Foundation, Quality, Research, Scroll Images, Transformation

Like a shadow lengthening at sunset or a dark cloud slowly obscuring the sun, the novel coronavirus has the potential to spread silently before positive tests confirm diagnoses in people infected with the virus.

To help get ahead of the curve and prepare Sutter’s integrated healthcare system to manage a potential surge in infections or a re-emergence of novel coronavirus later this year, Sutter leaders are collaborating with researchers and statistical analysts to track infection rates in the Sutter patient population and predict the course of viral spread.

Sutter researchers are experts in data analysis who leverage current and new methods aligned with Sutter privacy safeguards. Their work helps strengthen Sutter’s response to the pandemic. Here’s how:

1. TRACK THE VIRUS: Sutter Health Biobank
Sutter researchers are exploring ways to detect the novel coronavirus before it spreads further, by assessing exposure rates in Sutter’s patient population. This effort is led by Gregory Tranah, Ph.D., Scientific Director of CPMC and Director of Sutter’s Center for Precision Medicine Research.

The COVID-19 Seroprevalence and Surveillance Study will identify blood and serum samples from Sutter Biobank volunteer participants that show antibodies against the novel coronavirus. “Seroprevalence” means the level of a virus or other pathogen in a population, as measured in blood.

“Understanding the surge of infection rate and spread is an important part of preparedness. Epidemiological studies of emerging COVID-19 infections can help determine the burden of disease, develop better estimates of morbidity and mortality, and guide return-to-work and personal-safety decisions based on exposure history,” says Dr. Tranah.

The Sutter Biobank has been enrolling patient volunteers to give blood samples when a blood draw is ordered for clinical reasons. From early December 2019 through March 21, 2020 over 700 Biobank participants had blood samples drawn and archived.

“These samples provide Sutter with a unique opportunity to perform population-based surveillance of COVID-19 exposure when the virus began to spread in Northern California. They represent highly diverse patient data from Sutter’s integrated network. This is meaningful information that will allow us to determine the rate and timing of peak exposure and leveling of exposure rate,” says Dr. Tranah.

“Further, we can use the Biobank samples to find potential evidence of a resurgence of COVID-19 infection this fall. Earlier detection means we can plan for early containment of the virus.”

2. MONITOR VIRAL SPREAD: COVID-19 Surveillance
Researchers and statistical analysts at Sutter’s Center for Health Systems Research (CHSR) are collaborating with Sutter’s Enterprise Data Management, Informatics, Information Services and other operational departments to perform much-needed surveillance on the COVID-19 pandemic and provide insights to Sutter leaders.

Each morning, the CHSR team prepares reports for all Sutter hospitals on the number of patients who have tested positive or are suspected of being positive for COVID-19. They also track total hospital capacity and intensive care unit bed occupancy to help front-line staff with surge-capacity planning.

“Surveillance helps us understand how COVID-19 may be spreading amongst the patients we care for and our healthcare workers, and how we can prepare for potential surges in viral infection rates in the coming months,” says Alice Pressman, Ph.D., MS, Co-Director of CHSR.

Dr. Pressman and her colleagues at CHSR are developing the COVID-19 Universal Registry for Vital Evaluations (CURVE)—a centralized resource for research and quality improvement activities for COVID-19 disease surveillance and modeling, as well as health services and epidemiologic analyses.

“The registry will allow us to conduct research to assess the impact of COVID-19 on the healthcare system, Sutter patients, and our community of employees and healthcare workers,” says Dr. Pressman.

This registry develops the structure for the minimum necessary data to be used for each project, securely within the Sutter network. In turn, the knowledge gained can help to inform patient care and operations as Sutter continues to face COVID-19.

In support of Sutter’s Advancing Health Equity initiative, the CHSR team studied the demographics and clinical characteristics of COVID-19-infected individuals and their outcomes, which helped identify patient subgroups that may be more vulnerable to the disease. Early results indicate there may be inequities by sex, race, ethnicity and socioeconomic status.

“Research during a pandemic is vital to determine which parts of our communities and sub-groups of patients are most affected, so that we can allocate resources and care for our most vulnerable patients,” says Dr. Pressman.

3. A MATHEMATICAL CRYSTAL BALL: Statistical modelling to help predict the future of viral spread
One of the challenges of the COVID-19 pandemic is that scientists don’t fully understand the impact of the virus or its prevalence in our communities.

“One way to help answer these questions is through statistical modeling,” says Dr. Pressman. “We can use infectious-disease models as tools to help us predict the future of the novel coronavirus spread and the potential impact of social distancing and containment efforts on flattening the curve.”

Dr. Pressman and her team are collaborating with researchers from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington to understand the models IHME has published for California state COVID-19 data. “We hope to apply these models to our system to help us allocate healthcare resources and make decisions about future containment efforts.”

Data crunching to help halt a pandemic:
Surveillance is the systematic collection, analysis and interpretation of health-related data. For surveillance of the novel coronavirus and COVID-19, Sutter is using surveillance systems to monitor COVID-19 disease across the system. Surveillance and biobanking can help:
• Monitor the spread and intensity of COVID-19 disease
• Understand disease severity and the spectrum of illness
• Understand risk factors for severe disease and transmission
• Monitor for changes in the virus that causes COVID-19
• Estimate disease burden
• Produce data for forecasting COVID-19 spread and impact
• Improve patient care and help improve Sutter’s response to the pandemic

Coronavirus Science: Two Studies Raise New Concerns

Posted on May 5, 2020 in Carousel, Innovation, Mills-Peninsula Health Services, Palo Alto Medical Foundation, Pediatric Care, People, Research, Scroll Images, Uncategorized

Every day brings new scientific insights into COVID-19 and the coronavirus that causes it. Studies authored by Sutter Health experts examine the virus’s impact on children and diabetic adults.

COVID-19 and Kawasaki Disease

Recently, doctors began warning of a potential consequence of COVID-19 infection in children; some youngsters appear to develop an abnormal immune response that results in symptoms commonly associated with Kawasaki disease or toxic shock syndrome – two rare, but well-characterized inflammatory conditions. The first known U.S. case of Kawasaki disease possibly connected to COVID-19 was reported by Veena Jones, M.D., (lead author) and Dominique Suarez, M.D., both pediatric hospitalists with the Palo Alto Medical Foundation, part of the Sutter Medical Network.

Veena Jones, M.D.

Their six-month-old patient was diagnosed with classic Kawasaki disease, admitted to the hospital for treatment, and subsequently received a positive test result for COVID-19. The main reason for treatment in children with Kawasaki disease is to prevent further complications of the disease on the heart. The patient received appropriate treatment and has since fully recovered and has maintained normal heart function. But the case caused the doctors to question: could the COVID-19 infection have led the patient to develop Kawasaki disease?

“Our patient met the classic criteria for Kawasaki disease, so there was little doubt about the diagnosis or treatment plan,” said Dr. Jones. “But we do wonder if the COVID-19 infection could have caused the Kawasaki disease, especially because Kawasaki disease is widely thought to be triggered by an infection or an abnormal immune response to an infection.”

Dominique Suarez, M.D.

A careful review of the existing medical literature found that COVID-19 co-occurring with Kawasaki disease had not previously been reported, so the doctors decided to write up the case and submit it to the Journal of Hospital Pediatrics for publication. “Researchers still know very little about exactly why Kawasaki disease develops in some patients, so our hope was to accurately describe the novel case that we encountered and share that with the medical community to encourage further investigation and dialogue,” said Jones. In the race to understand the burden of COVID-19 on the human body this kind of early observation by doctors on the frontline can help inform future decisions around diagnosis and treatment.

COVID-19 and Diabetes

Since the start of the coronavirus pandemic many have warned that people with existing chronic illness who contracted the infection would become sicker than those without. Now, research authored by Sutter Health clinician David Klonoff, M.D. suggests that diabetes, one of the most serious chronic illnesses in the world, is strongly correlated with death among hospitalized patients diagnosed with COVID-19.

David Klonoff, M.D.

Accepted by the Journal of Diabetes Science and Technology, Dr. Klonoff’s paper represents the largest study yet reported on outcomes of patients with COVID-19 and diabetes or uncontrolled hyperglycemia. The observational study of 1122 inpatients with COVID-19 at US hospitals between March 1 and April 6, 2020, found that those with diabetes or hyperglycemia throughout their hospital stay had a four-fold greater inpatient mortality than those without diabetes or hyperglycemia. In a further subset analysis, death rates were seven-fold greater among those who did not have evidence of diabetes prior to admission, but developed hyperglycemia during their hospitalization.

The study also demonstrated that during a hospitalization for COVID-19, the presence of diabetes or hyperglycemia was associated with a longer hospital stay and slightly worse kidney function.

“I am now analyzing the same database to determine whether COVID-19 patients with diabetes and uncontrolled hyperglycemia, who were better controlled in the hospital, had better outcomes,” said Klonoff. If an association between greater survival and achieving target glycemia (following initial hyperglycemia) is demonstrated, and acted on, lives could be saved.

“These data may have wide implications for how we care for COVID-19 positive patients who experience hyperglycemia during their hospital stay or who have already been diagnosed with diabetes.”

The Digital Doctor Is In: Healthcare Services You Can Access at Home

Posted on Apr 17, 2020 in Carousel, Innovation, Palo Alto Medical Foundation, Scroll Images, Uncategorized, We're Awesome

SACRAMENTO, Calif. – Receiving sound medical advice is more important now than it’s ever been. Albert Chan, M.D., chief of digital patient experience at Sutter Health, shares how you can get advice and take action, all from your living room.

Dr. Chan answers questions from Sutter Health staff in the Q&A below.

Search Your Symptoms

Q: Google has reported a surge in searches related to COVID-19. Are search engines able to give results that can help real people get the counseling and care that they need right now?

Albert Chan, M.D., Sutter Health’s
chief of digital patient experience

A: Many people who develop a fever, shortness of breath, or cough right now may be concerned that they have COVID-19. While Google, WebMD and other online tools are good at providing general guidance, they can’t suggest concrete care options, because they aren’t connected to a group of medical providers.

Sutter Health’s online Symptom Checker is a little different. After entering your brief medical history and current symptoms, you will receive a personalized health assessment and can then enter your location to find nearby care options offered by the Sutter Health network.

Originally launched in February 2019, I see the Symptom Checker as a way to help patients decide whether to engage in self-care or to seek care, if they need an in-person appointment or a video visit, and if they need to be seen now or soon. These distinctions are incredibly apt as we face the COVID-19 outbreak, concurrent with flu and allergy seasons. I’m proud that the Symptom Checker has been updated to recognize a possible COVID-19 infection, and guide patients appropriately.

Turn to the Telephone

Q: Having a trusted source of information and the ability to talk through your symptoms is desperately needed right now — what is available to the public?

A: The public has a few options, one of which is the Sutter Health COVID-19 Advice Line at 1-866-961-2889.

Staffed by a team of nurses from 8 a.m. – 6 p.m., seven days a week, every caller is screened for symptoms linked to coronavirus. Callers are then directed to the most appropriate level of care, including self-care at home for those with mild symptoms.

Please note: The COVID-19 Advice Line is intended for people who are ill or caring for someone who is ill. For general information about coronavirus, please refer to the Centers for Disease Control and Prevention (CDC) website. The COVID-19 Advice Line is not for emergency situations. If you think you are experiencing a medical emergency, please call 911 or visit the nearest emergency room.

Seeing is Believing

Q: Some things are hard to diagnose or make decisions about over the phone, what other options are available for patients?

A: Patients can get virtual care from their phone, tablet or computer through Sutter Video Visits. This video gives you a sense of the video visit experience.

We offer a couple of options:

Video visits are expanding to address many primary and specialty care needs. Patients can now call or message their care team via My Health Online to check the availability of video visit appointments with their clinicians.

If you have not yet enrolled in My Health Online, you can now sign up online.

We also offer same-day video visits with our Sutter Walk-In Care clinicians daily from 8 AM to 8 PM for common health issues. Patients can self-schedule a video visit appointment by logging into My Health Online or calling (800) 972-5547 for same-day appointments.

Currently we are conducting virtual assessment of respiratory symptoms daily, which provides both convenient access to care to patients at home and minimizes the risk of spreading illness to others. These video visits can also provide clinicians with the information necessary to decide if a patient ultimately needs to be seen in person at one of our clinics or the hospital.

For more information about COVID-19, please visit Sutter Health’s resources page.