Welcome Practice Teams!

Million HeartsQuality Improvement

Team Training Day

Saturday, March 14, 20158:00 a.m. – 1:00 p.m.

Embassy Suites – Dublin, OH

 Located on each table is your team Practice Guidebook Binder and each participant should have been given a folder at registration. Folder contents include:

CMEIn each folder you should have received a CME certificate which indicates that you will receive up to 4 Prescribed credits from the American Academy of Family Physicians. Please keep in mind that the CME credit you earn today is on top of the 20 CME credits you will earn when you complete the American Board of Family Medicine’s MC-FP Self-Directed Quality Improvement Effort (Part IV).

Program EvaluationThe second item I would like to acknowledge is the program evaluation. It is critical that you complete the evaluation at the conclusion of today’s program and return it to the registration desk before leaving. The feedback you provide will help OAFP provide future programming that suits your needs.

Practice Change PackageA copy of the practice change package is enclosed and will be referenced throughout today’s training.

Practice Contact InformationIn effort to keep the lines of communication open among all participants of our QI project, a full list of participating practices is enclosed. Tapping into the knowledge of your peers also participating in the program, is a great way to overcome barriers and learn best practices.

Housekeeping Items

Welcome, Introductions and Connection to the National

Million Hearts InitiativeBarbara Pryor, MS, RD, LD –

Manager, Chronic Disease Section Ohio Department of Health

Collaborating Partners

Million Hearts® is a national initiative to prevent 1 million heart attacks and strokes by 2017. Million Hearts® brings together communities, health systems, nonprofit organizations, federal agencies, and private-sector partners from across the country to fight heart disease and stroke.

Million Hearts Initiative

www.millionhearts.hhs.gov

Website offers:• Practice

resources• Patient

videos• Action

guides• Treatment

protocols

2011-2012 The Ohio Academy of Family Physicians (OAFP) in partnership with the Ohio Department of Health

(ODH) designed a two-part outreach plan aimed to improve cultural sensitivity and communication skills among primary care physicians and a point-of-care patient information package for African-American men who are at risk for high blood pressure and high cholesterol. The tools created included: Physician guide, patient brochure, folder and helpful tip-sheets.

2012-2013 The second phase in the project was to work with a small group of family physicians to pilot the

effectiveness of the educational materials contained in the toolkit and secondarily to provide physicians with guidelines to help them achieve better outcomes and encourage positive doctor-patient partnerships. The “Check It. Change It. Control It.” patient and physician toolkits were developed based on the findings from focus groups with African-American male patients and structured interviews with family physicians “in the trenches.”

2013-2014 The Association of State and Territorial Health Officials (ASTHO), took notice of our partnership and

work product and encouraged us to apply for the Million Hearts State Learning Collaborative Project. Our proposal was selected by ASTHO and partners from the Centers for Disease Control as one of ten states to participate in this national endeavor. An overview of project outcomes is in your folders.

Project History: Where it all started…

For participating practice teams:* Improve the use of EHR data to identify and manage patients with diagnosed but not controlled

hypertension (>140/90) * Ability to create and monitor patient self-management plans systematically through the practice’s EHR* Use a QI framework to develop policies or systems in that encourage team-based care for hypertension

management* Promote use of the Check it. Change it. Control it. Your heart depends on it. Toolkit to address

disparities in blood pressure control among African-Americans

For statewide dissemination to PCMH practices:* Identify practice-improvement strategies that use EHR data and team-based care to improve

hypertension management * Expand Million Hearts to management of the ABCS for all patients in PCMH practices

For focused activities in local counties:* New CDC funding that supports five local public health projects in Athens/Washington, Lorain,

Montgomery, Richland and Summit Counties to establish Hypertension Collaboratives, improve use of EHR data, build support for lifestyle change programs, and link clinical to community services

2015-18 Ohio Million Hearts Objectives

Patient Education - Point of Care Resources Folder printed with information about hypertension and

high cholesterol Self-assessment questionnaire to gauge patient’s risk for

hypertension and high cholesterol Brochure explaining both conditions List of questions to ask their doctor Information sheet explaining blood lipid screening Hypertension and high cholesterol trackers for checking

progress over time Diet and physician activity tip sheet List of factors that will help patients be successful

Physician Toolkit Patient toolkit materials Guidelines for patient-centered communication Guidelines for positive interactions with African-American male patients Lifestyle counseling for changing diet Lifestyle counseling guidelines for increasing activity level Resource list

Smartphone apps Free iPhone and Android versions to help your patients monitor and track their blood pressure readings over time

Bridging Clinical Guidelines to “In the Trenches” Primary Care

“Check it. Change it. Control it. Your Heart Depends on it” Family Toolkit

Check it. Change it. Control it. Apps for iPhone

and Android Phones – Free!

Search with keywords: “Check it”

Importance of Team Engagement and Quality

Improvement

Ted Wymyslo, MD – Chief Medical OfficerOhio Association of Community Health

Centers (OACHC)

The patient-centered medical home is an approach to the delivery of primary care that is:

Patient-centered: Supports patients in learning to manage and organize their own care at the level they choose, and ensures that patients and families are fully informed partners in developing care plans.

Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.

Coordinated: Ensures that care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.

Accessible: Delivers accessible services with shorter waiting times, enhanced in-person hours, 24/7 electronic or telephone access, and alternative methods of communication through health IT innovations.

Committed to quality and safety: Demonstrates commitment to quality improvement through the use of health IT and other tools to guide patients and families to make informed decisions about their health.

Features of a Medical Home(in a nutshell…)

Recognized Patient-Centered Medical Homes in Ohio

Public access to a map of PCMH sites is available on the Ohio Department of Health’s website: www.odh.ohio.gov

* The number of Patient-Centered Medical Homes in Ohio has grown from 157 in June 2012 to 569 as of February, 2015.

* The sites are comprised of 511 NCQA (National Committee for Quality Assurance)-recognized sites, 7 AAAHC (Accreditation Association for Ambulatory Health Care)-accredited sites, and 51 Joint Commission-accredited sites.

I’ve been there! A front office associate calls in sick; you’re several days behind on your billing; there’s a little squabble between your office personnel that may fester; you need to coordinate interviews to fill a vacant office position; your EHR is not working properly, and of course, payroll is due tomorrow. On top of all that, we are asking you to CHANGE!!! Yeah right…

Practice Change Management

It takes time and effort to create positive work relationships, but the payoff is worth it!

AAFP’s Family Practice Management Resources:

Practice management, general Communication Staff management Interprofessional Relations  Office Management  Personnel Management  Practice Management, Medical  Workplace Issues 

Importance of Teamwork

www.aafp.org

What is Quality?

HRSA

Systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.

IOM

High quality care is safe, effective, patient-centered, timely, efficient, and equitable.

Leads to better patient care and outcomes Improves patient satisfaction Enhances patient safety Improves staff satisfaction Improves overall efficiency and effectiveness of

the organization Minimizes liability risk Strengthens the bottom line – payment for

value

Why Quality Improvement?

Three aims• Better care• Healthy People/ Healthy

Communities• Affordable Care

National Quality StrategyMarch, 2011

Six Priorities • Patient safety• Patients as partners• Effective communication and coordination of care• Use most effective treatment and prevention

strategies• Promote use of best practices for healthy living in

communities• Make quality care more affordable with new delivery

models

National Quality Strategy (Continued)

Three Fundamental Questions1. What are we trying to accomplish? (AIM)2. How will we know that a change is an

improvement? (MEASURES)3. What changes can we make that will result

in improvement? (INTERVENTIONS)

IHI Model for Improvement

Consistency/Uniformity in:• messaging, commitment, engagement

The Broken Record Performance Review/Accountability Staff job satisfaction Successful goal achievement

Importance of Team Engagement in Pursuing Quality

“If you want to build a ship, don’t drum up people to collect wood and don’t assign them tasks and work, but rather teach them to long for the endless immensity of the sea”.

Antoine de Saint-Exupery

Share the Vision

RWJF – Building a Culture of Health in America

Health vs. Illness Model Prevention/Screening Integration into

Healthcare Sometimes Less is More (Choosing

Wisely) Patient Engagement/Empowerment

Partnering With Patients to Achieve Better Health

Ohio Academy of Family Physicianswww.ohioafp.org

American Academy of Family Physicianswww.aafp.org

Ohio Department of Health/Ohio Patient Centered Primary Care Collaborative (OPCPCC)www.odh.ohio.gov

Patient Centered Primary Care Collaborative (PCPCC)www.pcpcc.org

Additional articles and materials can be found in your practice guidebook

PCMH/ ACO Resources

Ms. Rosemarie (Rose) Eckl – Medicare Beneficiary from Independence, Ohio

Patient Perspective: How the Team-Patient Relationship Impacts

Hypertension Management

Improving Heart Health is a Family (and Practice) Affair

Gary LeRoy, MD, FAAFP – Interim Vice President of Multicultural Affairs and Community Enhancement

Wright State University Boonshoft School of Medicine

29% prevalence among US adults (2011-12)• 33% among adults 40-59• 65% among adults 60+• 42% among non-Hispanic blacks

Approximately 67 million adults have HTN• 35.8 million adults with uncontrolled HTN

Of that total, 5.7 million are diagnosed and untreated and 14.1 million are “unaware”

Reference: Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012. NCHS data brief, no 133. Hyattsville, MD: National Center for Health Statistics. 2013.

Valderrama AL, Gillespie C, King SC, George MG, Hong Y, Gregg E. Vital signs: awareness and treatment of uncontrolled hypertension among adults — United States, 2003–2010. MMWR. 2012;61:703-709

Hypertension Prevalence

79.5% have health insurance 81.9% report having a usual source of care 59.6% have received care 2 or more times in

the past year 17.9% have received care in the past year

National Health and Nutrition Examination Survey 2007-2012

“Unaware” – A Closer Look

African-American male patients are at high risk of cardiovascular disease. No conclusive studies exist that explain why that’s true. Regardless of the cause(s), the effects are alarming: African-American men are 1.5 times as likely as non-Hispanic white

men to have hypertension. African Americans overall have the highest rate of hypertension of all

groups and tend to develop it at a younger age than other groups. African-American stroke survivors are more likely to become disabled

and have difficulties with activities of daily living than their white counterparts.

Nearly 45 percent of African-American men have borderline-to-high cholesterol.

High-Risk Population

38.5% of African Americans have a diagnosis of HTN compared to 33.7% for whites.

In 2011, more than half of stroke deaths in African- American men were before the age of 75, and 37% were before the age of 65.

In 2011, more than 60% of heart disease deaths in African-American men were before the age of 75; over 40% were before the age of 65.

African-American men are 49% more likely to die from stroke and 21% more likely to die from heart disease than white men.

In Ohio, the statistics are staggering

In late 2013, two different sets of hypertension treatment recommendations were issued. 2014 Evidence-Based Guideline for the Management of High Blood

Pressure in Adults (JNC8)1

An Effective Approach to High Blood Pressure Control: A Science Advisory From the ACC, AHA and CDC2

_______________

1James PA, et al. JAMA, 2013 Dec 18.2Go AS, et al. Hypertension, 2013, Nov 15.

Recommendations

Nine recommendations made based on three questions related to high blood pressure management. In adults with HTN:

1. Does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?

2. Does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?

3. Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

JNC 8 Guidelines

Target SBP Target DBP (mmHg) (mmHg)

Patient Subgroup> 60 years <150 <90< 60 years <140 <90>18 years with CKD <140 <90>18 years with diabetes <140 <90_________________________________ General nonblack population: Thiazides, CCB, ACEI, or ARB initially General Black Population: Thiazides or CCB initially CKD: Treatment should include ACEI or ARB Increase dose or add therapy after one month if BP goal not reached

Do not use ACEI and ARB together Refer to HTN specialist if still not at goal

JNC 8 Recommendations

Recommend use of evidence-based algorithms for treatment of HBP as well as lifestyle changes to control HTN

Recommend blood pressure goal <139/89 mm Hg. Lower targets may be appropriate for some populations such as African-Americans, the elderly, people with diabetes or CKD

Recommend lifestyle modification and consideration of thiazide diuretic for stage 1 HTN (SBP 140-159 mm Hg or DBP 90-99 mm Hg)

For stage 2 HTN (SBP >160 mm Hg or DBP >100 mm Hg) recommend combination therapy with a thiazide diuretic and ACE inhibitor, ARB or CCB

If goal BP not reached, increase medication dose or add drug from a different class; address adherence; advise on self-monitoring.Consider referral to HTN specialist if all primary care options have been exhausted

ACC/AHA/CDC Science Advisory

* Family history* Race and gender* Age* Obesity (BMI > 30 kg/m)* Dyslipidemia* Excess dietary sodium intake* Alcohol consumption

* Smoking* Diabetes* Stress* Lack of physical activity* White-coat syndrome * List of medications

Care Planning: What to document in your Electronic Health Record (EHR)

(Note: Some EHRs have templates built into the system that offers a menu of suggestions that can be added to the patient’s individual care plan.)

Clinical suggestions for creating a personalized, patient self-management plan can address the following:* Weight loss* Exercise* Medication management and

adherence* Behavior modifications:

• Alcohol consumption• Smoking• Excess dietary sodium intake

Patient “buy-in” is critical to success

Sometimes only one intervention is necessary to make a significant health improvement.

Patient Self-Management Care Planning

Self-Management Blood Pressure Planning…

* Prepare teams* Clinical protocols* Empower patients* Encourage payer

coverage

Beginning January 1, 2015, physicians can bill Medicare for “non-face-to-face” chronic care management (CCM) according to the final 2015 Physician Fee Schedule (PFS) adopted by the Centers for Medicare and Medicaid Services (CMS) on October 31, 2014

CMS suggested the following elements to be included in a chronic care plan: • Problem list• Expected outcome and prognosis• Measurable treatment goals• Symptom management• Planned interventions• Medication management• Community/social services ordered• How the services of agencies and specialists not connected to the practice will be directed/coordinated• The individuals responsible for each intervention• Requirements for periodic review and, when applicable revision of the care plan

Additionally, CMS expects the provider to reflect a full list of problems, medications, and medication allergies in the EHR to inform the care plan, care coordination, and ongoing clinical care.

Chronic Care Management Plans

CCM details can be found on the OAFP website: www.ohioafp.org

We all need reminders…Take blood pressure readings correctly, each and every time!

Raise Practice Team Awareness• High-risk populations• Educational materials available to help discuss health behaviors• Appropriate blood pressure readings• Care management planning with patient engagement

Encourage Data Exploration Encourage clinicians to explore their data Use registry functionality Explore existing reports in EHR Engage their EHR vendor

Develop a Protocol and Action Plan Reach Out to Partners

HSAG & CliniSync Ohio Academy of Family Physicians & Ohio Department of Health and Million Hearts National Collaborative Ohio Association of Community Health Centers Peer practices engaged in this QI initiative

Keep Patient-Centered Share and Repeat Best Practices

What can you do to affect change?

Participating in this QI initiative is the best first step!

Million Hearts Practice Change Package:

Your Tool for Population Management

Carol Saavedra, Health Informatics Specialist - HSAG

Practice Benefit:Electronic Health Record Data Collection

Assistance

Questions about pulling data from the following EHRs?* Allscripts* Athena Clinicals* Centrix-Healthland* GE Centricity* Greenway Medical Technology* Epic * McKesson Practice Partner* NextGen

Cathy Costello: CCostello@ohiponline.org or (614) 664-2607Scott Mash: smash@ohiponline.org or (614) 541-2296

Questions about pulling data from the following EHRs:* eClinicalWorks

* e-MD's

Carol Saavedra: CSaavedra@hsag.com or (614) 307.1830

EHR experts are here to help you!

QI Plan Cover SheetProvides an overview of your practice’s aim statement, baseline measurement and targeted goal. Suggested practice interventions are listed for consideration.

Practice Change Package

Practice Change Package

Protocol and Action StepsThis tab houses your practice’s protocol and action plan. Its contents will be developed as part of today’s activities.

Practice Change Package

Data Collection PanelThis will be your most utilized tab in the Practice Change Package as it will serve as your practice’s data collection sheet for the duration of the project. Each practice is asked to record patient data on six key measures on a monthly basis and report your findings to OAFP staff by the 5th of each month via fax or email.

Practice Change Package

ReferencesComprehensive list of online patient engagement or clinical resources

Practice Change Package

NarrativeCaptures your answers about the goals and objectives of the program and should be completed in early July after the conclusion of the project. The answers captured in the narrative match the questions required for ABFM MC-FP Part IV credit through the Self-Directed QI Effort process.

Cathy Costello, JD - Director, CliniSyncPLUS Services

Million Hearts: How to Use Your EHR to Improve Quality

Setting Up Your EHR System for Maximum Benefit

Clinical Quality Measure

Reporting is Enabled

Clinical Decision Support Rules are Enabled/Template

s Created

Problem List and Meds List Are Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Clinical Quality Measure Reporting Turned On

Clinical Quality Measure

Reporting is Enabled

Clinical Decision Support Rules are Enabled/Templates

Created

Problem List and Meds List Are

Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Want to track Clinical Quality Measure (CQM) NQF 0018/CMS 165: “% of patients 18 – 85 yrs. with diagnosis of hypertension whose BP is adequately controlled <140/90”

Numerator: Those patients seen during the reporting period whose BP is <140/90

Denominator: Patients 18 – 85 yrs. with diagnosis of essential hypertension w/in 1st 6 mos. of reporting period or previously

Exclusions: ESRD, dialysis or renal transplant; pregnancy

Clinical Quality Measure Report Turned On

Clinical Decision Support Enabled

Clinical Quality Measure Reporting

is Enabled

Clinical Decision Support Rules are Enabled/Template

s Created

Problem List and Meds List Are

Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Clinical decision support is the brains behind an advanced implementation of electronic health records.

CDS: Why It’s Important

Intent is to ensure providers have tools to help them make timely and informed decisions.

Flexibility in the types of CDS interventions employed

Is not limited to “pop-up” alert interventions

Includes problem-based order sets, clinical guidelines, documentation templates, diagnostic support, contextually relevant reference information

Expanded Definition of CDS

Problem List and Meds List Workflow Established

Clinical Quality Measure Reporting

is Enabled

Clinical Decision Support Rules are Enabled/Templates

Created

Problem List and Meds List Are Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Medication reconciliation should be done with each visit; will help you capture the use of “aspirin” therapy as part of Million Hearts

Problem list should be reviewed for any additions or changed conditions

Problem List and Med List

Patient Lists Created

Clinical Quality Measure Reporting

is Enabled

Clinical Decision Support Rules are Enabled/Templates

Created

Problem and Meds List is Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Set the guidelines you are following for Million Hearts as filters:

o Age: Patients between 18 – 85 years with diagnosis of hypertension (>140/90mm Hg)

o Ethnicity: Of these, how many hypertensive patients are African American (drawn from demographics)

o Test Results: Patients between 18 – 85 years under control (<140/90mmHg)

o African Americans between 18 – 85 years under controlo Prescriptions: Make self-management care plans as orderable

orders/prescriptions that can then be tracked through a patient list

Patient Lists

Patient Portal Utilized

Clinical Quality Measure Reporting

is Enabled

Clinical Decision Support Rules are Enabled/Templates

Created

Problem List and Meds List Are

Captured for Each Patient

Patient List is Created

Patient Portal is Used for Patient

Reminders; Patient Education

Process Mapping Exercise Individual Team Work

Gary LeRoy, MD, FAAFP and Kate Mahler, CAE

OverviewWorkflow & Process Mapping Exercise Eliminating unnecessary or wasteful steps in a process makes work run more smoothly and is more satisfying for staff. A workflow & process mapping exercise creates a visual map of the steps that the entire practice team (including the patient) takes to conduct a routine visit where discussions about hypertension risk, prevention, and control are appropriate. Benefits of Process MappingThere are a number of benefits to mapping out and recording your process. Listed below are just a few:• The visual display allows everyone to see what role/contribution their colleagues

make to the overall goal and creates appreciation for what other members of the care team do.

• A process map allows everyone to see their work in the context of the overall process, which increases staff satisfaction.

• This exercise allows the care team to see where work backs up, where work can be standardized to improve patient flow/work flow and to identify problem areas that can be tweaked for maximum efficiency.

Process Mapping Exercise

1. Identify everyone who is involved in the process of discussing hypertension risk, prevention, and control (patient, physician, nurses, front office staff, medical assistants, etc.)

2. As a group, identify the starting and end points of the process you are mapping(example: from the time the patient appears in the office for an appointment to the time the patient leaves the building with a follow-up appointment scheduled.)

3. Next, draw “swim lanes” and label with the names of each member of the care team.

4. Post the sticky notes in the appropriate lane according to current office process.

5. If in your process you encounter a fork or scenario where two or more outcomes drive future action steps, take a sticky note of contrasting color and write “FORK” on it, then place it on the map in appropriate sequence of steps identified. For example, if the results of the colonoscopy are normal, abnormal or inconclusive, this action signifies a “FORK” and therefore changes course for the following steps in the process.

Steps to Create a Process Map

Is this the most efficient process for the task at hand?

Could members of the care team, not previously identified, be better utilized in this process?

Is the right information available at the right time? Can your workflow be simplified? Could other office processes follow suit to ensure

simplified office systems that maximize the team?

Take time to reflect and ask the following questions:

Tailoring an Office Protocol to Fit the Practice / Action

PlanningGary LeRoy, MD - Interim Vice President of

Multicultural Affairs and Community Enhancement

Wright State University Boonshoft School of Medicine

Million Hearts® encourages widespread adoption and use of standardized treatment protocols for improving blood pressure control. Simple, evidence-based protocols can have a powerful impact in improving practice improvement and patient health outcomes.

Drafting Your Practice Protocol

Protocol Aim:Increase blood pressure control by ensuring that each diagnosed hypertensive patient has a self-management care plan.

Final Charge and Expectations

Kate Mahler, CAE – Deputy Executive Vice President

Ohio Academy of Family Physicians

Please submit your data collection panel by the 5th of each month to Kate Mahler at the OAFP by fax: (614) 267-9191 or email: kmahler@ohioafp.org.

Kate’s contact information is on the back of your practice guidebook. Your final narrative page will not be due until July.

Data Collection Reporting Schedule

Reminder:Data Pull/Registry AssistanceCliniSync and Health Services Advisory Group, two statewide healthcare IT organizations, have offered free technical assistance to all of our Million Hearts QI practices in pulling data from your own Electronic Health Record.

If you need hands-on assistance please contact the people according to the EHR you are using:   

Cathy Costello: CCostello@ohiponline.org or (614) 664-2607Scott Mash: smash@ohiponline.org or (614) 541-2296EHR:• Allscripts• Athena Clinicals• Centrix-Healthland• GE Centricity• Greenway Medical Technology• Epic• McKesson Practice Partner• NextGen

Carol Saavedra: CSaavedra@hsag.com or (614) 307.1830EHR:• eClinicalWorks• E-MD’s

Contact information is printed on the back of your practice guidebook.

• AAFP Prescribed CME is accepted by the following national organizations:• American Academy of Physician Assistants (AAPA) • National Commission on Certification of Physician Assistants (NCCPA) • American Nurses Credentialing Center (ANCC) • American Association of Nurse Practitioners (AANP) • American Academy of Nurse Practitioners Certification Program (AANPCP) • American Association of Medical Assistants (AAMA)

Don’t forget to claim today’s 4 CME Credits!

• Program Website: www.ohioafp.org • Practice acknowledged as a partnering practice• Link to resources and program contacts

• PCMH/ Leadership Webinar Series• Held over the traditional lunch period so members of the care team can participate• CME accredited by the AAFP for .75 prescribed credits each• Free to all OAFP members and their practice teams• Register online at www.ohioafp.org

• Questions?

Practice Support

Don’t forget to pick up a bag of heart-healthy snacks for the drive home!

Thank you!