New funds, enduring ills

While cash from Proposition 63 flows into premium mental health services, budgets for traditional care have suffered.

By Scott Gold and Lee Romney

Los Angeles Times Staff Writers

 

September 16, 2007

 

For two years after Alfredo Ruiz was diagnosed with schizophrenia, his family tried -- and failed -- to find him help.

 

His mother knocked without success on the doors of shelters and medical clinics throughout the San Fernando Valley. Meanwhile, her son's illness sent him deeper into psychosis and paranoia. Unemployed and homeless, without access to treatment, he began sleeping under a bridge -- a knife under his body, just in case.

 

Today, Ruiz, 31, is stable and lucid -- and in the vanguard of a novel experiment in healthcare: Proposition 63, California's 1% surtax on incomes above $1 million that will generate $1.5 billion this fiscal year for treatment of the mentally ill.

 

Approved by voters in 2004, Proposition 63 aims to reform the long-troubled mental health system by finding and helping sick people who have historically had little access to care -- youths on the verge of homelessness, the elderly, poor minorities -- and severely ill adults who have fallen through the cracks. Proposition 63's authors hope the initiative will transform California's public mental health system, eventually creating a culture in which illness is no longer a patient's defining characteristic.

 

Ruiz is an early beneficiary of one of Proposition 63's main efforts, a style of therapy known as "whatever it takes" -- based on the notion that mental illness is rarely an isolated problem but is typically accompanied by physical illness, social isolation, educational deficiencies, poverty and other problems.

 

Now, instead of care that was patchwork at best, Ruiz is receiving comprehensive help from a team of more than a dozen clinicians.

 

In the past, if he had been lucky enough to score a spot in a shelter, Ruiz would have been handed an address and a bus token. Instead, his new caseworkers found him a place to live, drove him there -- and stopped to buy him a sleeping bag and toothbrush on the way. No longer overburdened by massive caseloads, they ferry him to appointments to ensure that he receives disability benefits. Not only do his case managers stop in weekly at his shelter to check on him, his psychiatrist visits too, to ensure that his pills are working -- a level of care that would have been a preposterous extravagance not long ago.

 

"They saved our lives," said Ruiz's mother, Maria Orduño.

 

But even as some have begun receiving platinum-level services unimaginable before Proposition 63 -- officials hope that 17,000 people statewide will be receiving "whatever it takes" therapy by next summer -- other kinds of care have deteriorated.

 

Some cash-strapped counties have slashed traditional funding for mental health services, and the state has made cuts too. In almost every corner of California, which has an estimated 1 million people with serious mental illness or emotional disturbance, core mental health budgets are stagnant at best while demand for services balloons.

 

Although mental health advocates in the state are thrilled about a guaranteed funding source that isn't subject to budgetary whims, they worry that innovative programs created with the new money are being layered on top of a disintegrating mental health system that Proposition 63 does nothing to correct.

 

And the new law forbids counties from using Proposition 63 money to backfill -- to pay for programs that existed prior to its passage. That provision was written to protect the new money, to keep counties from making cuts elsewhere that would undermine the promise of the new program. But it has also added to the sense among some healthcare administrators that their hands are tied.

 

"Proposition 63 was a huge policy mistake," said Jeff Smith, executive director of the Contra Costa Regional Medical Center, which cares for scores of poor, uninsured residents. "It took a good amount of money and dedicated it to new services at the same time that old services have been just ravaged. Instead of solving a problem, it just covered it over -- with a nice, fluffy frosting."

 

Early signs suggest that many counties -- as well as the state -- are cutting with one hand even as they are providing new, top-of-the line services with the other:

 

• Los Angeles County, which runs the nation's largest public mental health system, will receive more than $125 million in Proposition 63 money this year to fund an array of innovative programs. But at the same time, a $70-million shortfall in the county's core mental health budget has resulted in long waiting lists at many clinics. Some patients have had their number of visits with therapists cut in half; others no longer receive counseling at all.

 

• As part of a budget crisis, Santa Clara County recently ordered its Department of Mental Health to cut $17 million from its budget -- almost as much as the $19 million it will receive through Proposition 63 in 2007-08.

 

• Fresno County will use its $8.6 million in Proposition 63 funds to provide exhaustive care to 540 severely ill residents and for rural outreach, among other programs. But the county is simultaneously cutting about $8 million from the rest of its mental health budget. More than 140 of the county's 636 mental health staff positions have been eliminated, and the county will curtail services for about 650 clients with less severe conditions, such as depression and anxiety.

 

• Shasta County will receive $2.7 million in Proposition 63 money. But the new funding comes as the county has been forced to devote an increasing chunk of its mental health budget to expensive Medi-Cal cases -- leaving about $2 million less for standard patient care than before Proposition 63 began. The Health and Human Services Agency has laid off six of its nine psychologists. And the county now serves 500 fewer patients than before Proposition 63.

 

• In August, Gov. Arnold Schwarzenegger eliminated funding for a successful $55-million program for the homeless mentally ill -- the program that served as the model for Proposition 63. Advocates say the cut violates the new law, which specifically forbids the state from dropping below the funding commitment it had made to mental health before Proposition 63. Mental health advocates express conflicting feelings about the new law.

 

"The acknowledgment that mental health care is broader than medication and psychotherapy is brilliant. It's wonderful," said Marta McKenzie, director of the Shasta County Health and Human Services Agency. "But how do you build this new set of programs for a small population when you have this overwhelming set of responsibilities for this larger group of clients?"

 

An attempt to fill gapsProposition 63 was written amid a growing perception among advocates, lawmakers and the mentally ill themselves that there were huge gaps in mental health care -- particularly at the community level, which had been stressed to the breaking point by the closure of large, outdated mental hospitals starting in the 1960s. It was a national problem but particularly acute in California.

 

"Forty years is long enough to wait," said state Sen. Darrell Steinberg (D-Sacramento), a Proposition 63 author. "This is the unspoken issue of our time."

 

About half the measure's funds are aimed at the style of "wraparound" care being received by Alfredo Ruiz. Addressing all the needs of someone with severe mental illness is expensive: The state estimates the cost at an average of $15,000 per client per year.

 

But this type of intensive case management made possible by Proposition 63 can interrupt an even costlier cycle of crises, studies have shown. And partly because it expects consumers to be involved in their own care, it can help severely mentally ill men, women and children function and even thrive.

 

Across the state, mental health officials say, they are also seeing the benefits of other programs funded by Proposition 63.

 

In San Luis Obispo County, for example, a new free counseling service for poor Spanish-speaking residents is at capacity. In Monterey County, parents are learning how to help their adopted children recover from trauma and abuse.

 

And in Tulare County, a severely mentally ill man in his early 20s is in stable housing -- along with his siblings and parents -- after a caseworker found them living in tents. Before Proposition 63, regulations would have forbidden the county from helping the young man's family members, without whom he would falter.

 

"He invited us to his bedroom, which was two pieces of canvas," said Walt Lunsford, chief operating officer of Turning Point of Central California, which is running Proposition 63 programs in several counties. "Now he's getting mental health treatment. And, not surprisingly, he's getting better."

 

Los Angeles County is the largest beneficiary of the tax; the county could receive more than $1 billion in the next five years, and dozens of new programs are underway. Downtown, trained professionals have started accompanying police on 911 calls involving people with mental illness to defuse situations before they become violent. In Van Nuys, a clubhouse will target the social isolation that plagues many people with mental illness. And hundreds of patients will be treated through "whatever it takes" therapy.

 

The new programs are already showing results. At a recent morning meeting at a county clinic in Granada Hills, a social worker's announcement was met with cheers: "Eric and I went for a walk."

 

Eric, diagnosed with schizophrenia, had not left his house for nine years. His Proposition 63-funded social worker had worked for nearly three months to lure him out -- time she could never have devoted under her previous caseload. Social workers operating in Proposition 63 programs often average fewer than 15 clients each; under the old system they might have carried 90 at a time. "We've been given a gift," said Wendi Tovey, director of the Granada Hills program.

 

But some county residents -- those who don't need the kind of intensive treatment offered in the new programs -- are receiving less care today than before California launched its ambitious reform effort.

 

For 10 years, Vernon Hemingway, 52, relied on free group counseling sessions in his skid row neighborhood to stave off the debilitating bipolar cycles that had cost him a stable, middle-class life. But as part of L.A. County's push to close a budget shortfall, the program was recently pared back severely.

 

Sessions once run by professionals are now run by patients themselves. Hemingway says the meetings are no longer useful, that they have become dominated by disruptive, unmedicated patients. Several months ago, he quit. Now he spends most of his time alone, watching TV in a $339-a-month hotel room.

 

"I don't put my business out on the street. That was one place you could talk," he said. "It was the one place you felt safe -- physically and mentally. It meant a lot."

 

Stories like Hemingway's are increasingly common across the state, leading some advocates for the mentally ill to question whether Proposition 63 can transform care in the way its backers envisioned.

 

"It's the same old song," Hemingway said. "They raise your hopes. And then they let you down."

 

Core services sufferingThe new law expressly forbids counties from using Proposition 63 money to replace funding for existing programs and requires the state to at least maintain its 2004 level of mental health funding.

 

But the provisions have not stopped the erosion of the bread-and-butter mental health system -- leaving Proposition 63's architect deeply concerned.

 

"My worst nightmare," Steinberg said at a recent rally against planned cuts to mental health care, "is to wake up 10 years from now and find out that. . . we didn't increase mental health services."

 

The measure, Steinberg emphasized, was never intended as a "cure-all for mental health in California. It's intended to begin -- emphasis on begin -- to make up for 40 years of neglect." Still, Steinberg has noted with growing alarm the false perception that "mental health is now being taken care of."

 

Indeed, across the state, some counties wrestling with budget pressures seem to view the influx of Proposition 63 cash as license to cut elsewhere.

 

State officials who oversee Proposition 63 have threatened legal action if it can be shown that counties are relying on the new program to cushion the blow of budget cuts in the mental health system.

 

In the meantime, old services are sometimes being cut before new ones are up and running.

 

"We are kind of jumping between two precipices," said Santa Clara County Supervisor Liz Kniss. "We are jumping off one because we can't continue to fund what we've funded. And we are waiting to jump to the other side. What I worry about is the canyon in between."

 

Proposition 63 came along at a time when many county mental health departments were in crisis. In recent years, caseloads -- and the cost of care -- have soared while the patchwork of funds that flow to counties for mental health services has failed to keep pace.

 

In Fresno County, current cuts are just the latest in a crisis that has eliminated two-thirds of the adult mental health department staff in three years. Giang Nguyen, director of the Department of Behavioral Health, still calls Proposition 63 "a blessing." In the meantime, she acknowledges, the waits at outpatient clinics will be longer and caseloads in non-Proposition 63 programs will climb.

 

The lament can be heard in county after county.

 

"We're being strangled," said Glenn County Mental Health Director Maureen Hernandez.

 

Hernandez called her small county's Proposition 63 infusion -- about $400,000 for the coming year -- "pitifully small" compared with strains in the overall $6.6-million budget. Proposition 63 will provide a new drop-in center and "whatever it takes" services for five to 10 clients. But families who rely on the county's core services face years of belt-tightening.

 

Said Hernandez: "You don't bring the neighborhood over and feed them when your own children are starving."

 

Left out in the middle Nowhere, perhaps, is the dichotomy as stark as in Los Angeles County, which has a $1.2-billion mental health budget and serves 200,000 clients each year.

 

Patients who are stable -- well enough to function in society and, in many cases, work and live on their own -- are thriving in new "wellness centers" funded by the new law. There, they have access to what many clinicians believe is the last piece in making a patient's life whole again: a group of friends, an art class, an outing to a bowling alley.

 

At the other end of the spectrum, patients who are completely debilitated by illness are receiving what many say is the best public mental health care ever offered in California -- the "whatever it takes" therapy that is helping Alfredo Ruiz.

 

But it's the thousands of patients in the middle -- who suffer from illnesses that are serious but not disabling, and about half of whom are indigent and uninsured -- who have been left in the lurch.

 

"We have people coming in and we have to say: 'I'm sorry, you're not sick enough. But when you get really sick, come back and see us,' " said Marvin J. Southard, director of the Los Angeles County Department of Mental Health. "It's ridiculous. But that's the situation we find ourselves in."

 

Trying to close its $70-million shortfall, the county curtailed services in its mental health clinics partly by eliminating or transferring to Proposition 63 programs 154 staff positions out of about 3,200.

 

Meanwhile, some of the new programs have signed up only about a third of the clients they are expected to care for by the end of the year. At the same time, at the old-fashioned outpatient clinics, many new patients are now added to a waiting list and told to return in a week or two -- a very long time, officials acknowledge, for someone with a mental illness.

 

The Downtown Mental Health Center on skid row treats about 2,500 of the county's most challenging patients.

 

Within a couple of years, Proposition 63 is expected to offer a one-stop care center there where patients would not only be treated for mental illness but could receive medical and dental care, housing and educational assistance, and other services.

 

For now, however, the center is in a bind. Ten of its 60 employees, including half of its caseworkers, have been transferred to new Proposition 63 programs amid the budget crunch. Others are likely to follow in their footsteps. The result, said Larry Hurst, acting district chief for the county Department of Mental Health's Skid Row Management Team, is "triage."

 

"Now we ask: 'Are Individual A's needs more urgent than Individual B's? What would be the risk of delaying services to Individual B? And for how long can we do it?' " Hurst said.

 

"That's the reality at this time," he said. "It's swallowing that reality that is challenging to our staff. They want to be able to do more. But it's like emptying the Pacific Ocean with a toy pail."

 

scott.gold@latimes.com

 

leora.romney@latimes.com

 

 

Rural areas reap little from Prop. 63

New funds to help the mentally ill are no salve in counties struggling to provide core services.

By Lee Romney and Scott Gold

Los Angeles Times Staff Writers

 

September 17, 2007

 

LOOKOUT, Calif. — A dismayed Chuck Finck stood at his daughter's hospital bedside in Redding, a winding two-hour drive from his home in the alfalfa-rich Big Valley.

 

It was Cheryl Medeiros' fourth hospitalization for psychiatric-related problems in the last few years, each time hours from the family's home in Modoc County, in the state's remote northeastern corner.

 

This time, Medeiros, 34, who has been diagnosed with schizophrenia, bipolar illness and severe postpartum depression, had been rushed to the hospital by ambulance after swallowing half a bottle of anti-anxiety pills. She then contracted pneumonia from inhaling vomit, which meant days in intensive care.

 

Finck, 58, and his wife, Chelley, 57, knew from experience that their daughter would soon be returned to the same rural void in mental health services that had virtually ensured her repeated hospitalizations.

 

In some parts of the state, Proposition 63, a voter-approved surtax on those with income above $1 million, is pumping millions of dollars into innovative new treatments for the mentally ill.

 

But many rural residents have been left out of Proposition 63's richest benefits. Not only do rural counties receive far less of the new funding because of their smaller populations, they also have enormous needs, lagging far behind more populous counties in the types of services offered. The Proposition 63 money can't begin to fill those chasms.

 

Five of California's 58 counties don't have a single psychiatrist. About 30 have no inpatient psychiatric beds, necessitating costly and traumatic trips for patients in crisis. Follow-up care is difficult to coordinate. There is little or no supervised housing that would allow the severely ill to live independently yet close to home. Mental health professionals are difficult to recruit and nearly impossible to retain.

 

Exporting severely ill patients for both short- and long-term care dramatically increases costs. Sending one resident to a state mental hospital for a year, for example, would consume about 10% of Modoc County's budget, depriving others of basic services.

 

Adding to the burden is a disproportionately needy population, spread over thousands of square miles mostly unserved by public transportation.

 

In Siskiyou County, mental health staffers traveled 840,000 miles last year to retrieve clients for care and take them to far-off psychiatric hospitals. As officials there noted in their Proposition 63 grant proposal, a "huge unmet need" remains in a place where poverty, suicide and depression rates exceed state and national averages.

 

The new funds help, say the counties; it's just that demand far outstrips their potential. In Trinity County, $455,600 in Proposition 63 money in the coming year will go in part to a consumer drop-in center and to comprehensive treatment for four patients. But the county -- which relies on video sessions with tele-medicine consultants -- will still lack the services of even a visiting psychiatrist.

 

In Modoc County, where Medeiros and her parents live far from the county seat, the $412,000 Proposition 63 boost this year is offset by a budget crisis that recently caused the county to lay off half its mental health clinicians. Even with the new funds, Modoc County's mental health budget is about 25% smaller than it was in 2004.

 

"The perception was, 'There's all this new money that's being added," said Karen Stockton, Modoc County Health Services director. "People think we can do all these wonderful things. But we're looking at them and telling them, 'We can't.' "

 

As Medeiros' hospital discharge date neared in late May, a frustrated Finck called the county department seeking help.

 

Wasn't there some kind of intensive help they could offer to keep Medeiros safe, he asked? Something to end the cycle of ambulance trips and short-term hospital stays?

 

The county told Medeiros it had one avenue remaining. It could seek to become her conservator and place her in a board-and-care home. Because Modoc has no such facilities, the placement would be at least 330 miles away in the Central Valley.

 

For the Fincks, who can barely afford gas to Redding, taking that option would cut their daughter off from family support.

 

Mental illness hit

 

Medeiros' large blue eyes and flashes of childlike innocence offer a glimpse of the happy teen she once was, glamorous in her feathered blond mane and content in her Christian faith.

 

Then, in her early 20s, mental illness hit. She once lay in bed in horror, convinced her organs were slowly dying. During one hospitalization, she believed she was encased in a glass box that might shatter.

 

In four counties over seven years, she learned firsthand about the gaps in rural mental health services.

 

In Tehama County, a visiting psychiatrist tossed a book on the table and told Medeiros to pick her own medication, she and her parents said.

 

Three years ago, after a divorce, she moved into her parents' remote home in Lookout in the Big Valley. The valley in the Southern Cascade Mountains cleaves Modoc and Lassen counties but sits far from the seat of either, offering a life of stark beauty but few services.

 

At first, the county arranged to take Medeiros -- on disability and covered by Medi-Cal -- to the Modoc County seat of Alturas 50 miles away. Every month or so, she briefly visited the county psychiatrist. Since none reside in Modoc, the county retains one from Oregon who drops in twice a month.

 

A case manager encouraged Medeiros to join group sessions on social skills or visit the Al- turas pool in an occasional outing with other clients. But Medeiros said the gatherings hardly seemed worth the half-day trip. She quit.

 

Her next stop was at a clinic just over the Lassen County line, where she found a sympathetic and effective physician assistant and had video consultations with a tele-psychiatrist who provided counseling and medication.

 

But the physician assistant retired this summer, and the tele-psychiatrist stopped working a month before Medeiros' overdose, leaving several thousand patients across the remote north in limbo. Medeiros says the system has "treated me lower than what I am. They're breaking my trust."

 

Medeiros reluctantly returned to Alturas for sporadic services. But daily life was haunted by unpredictable panic and distraction. At 3 a.m. recently, her mother -- who has bipolar disorder -- awoke just in time to find her daughter sipping facial cleanser. She did not require treatment.

 

Housebound, Medeiros was bored and lonely. She longed for her sons. The two eldest live with her ex-husband in Reno, and her youngest, born in August 2006, was taken by Lassen County's Child Protective Services while Medeiros was hospitalized.

 

She wistfully described the treatment she craves, unaware that it is very like what thousands of men and women in more populated places are getting, thanks to Proposition 63.

 

"I need to be close to someone who helps me with my meds, just someone to talk to, someone to calm me down," said Medeiros, who yearns for a "support network" and a place to go, with arts and crafts or guitar classes, massage to relax her and "a little job to help with my self-esteem."

 

"A lot of mentally ill people are like kids," she said. "We need encouragement to stand strong."

 

High expectations

 

Many rural counties had high expectations after Proposition 63 was passed.

 

For some, the funds were a miracle. Sierra County's mental health budget was "devastated" by state cuts in 2004, said Health and Human Services Director Carol Roberts. The new money, $344,800, represented a nearly 50% increase in its budget and will allow the county to restore intensive services to children and youths that had been eliminated.

 

But for many rural counties, the new programs -- which must conform to strict state guidelines -- are layered on top of strained core services. In some cases, core services are not offered.

 

Thrilled Modoc County mental health officials were initially told they might receive $2 million a year from Proposition 63.

 

But as the state refined its funding formula, some rural counties saw their Proposition 63 money shrivel. In Modoc County, which received less than a quarter of what it had initially expected, deep cuts to core mental health services followed. With its clinical staff down to six, it eliminated services last year in some remote pockets.

 

Meanwhile, Proposition 63's bureaucratic demands have hit rural government hard. The law requires counties to hold extensive community meetings on how funds should be spent, to compile statistics on need and to closely track results.

 

"It's been a huge burden," said Nancy Antoon, interim director of Trinity County Behavioral Health Services. Although she is thrilled with her county's Proposition 63-funded drop-in center, she said, "There have been days when I've thought: What if I said 'No, thanks'? "

 

Alpine County, the state's least populous with 1,200 residents, did just that, initially calculating that it would cost more to accept the funds than to turn them away.

 

"These programs are not meant for counties with fewer than 100,000 residents," said mental health Director Judy Molnar. "It just doesn't work."

 

The county has since changed course, beginning the cumbersome application process in hopes of landing funds for a new building in one of Proposition 63's later phases.

 

"That's the problem" with Proposition 63, said Al Urmer, the Los Angeles administrator who runs Alpine's tiny department under contract. "You can't just apply for what you want. You have to jump through all the hoops."

 

Regardless, Proposition 63 has brought the immense needs of many rural counties into the open.

 

Jobs and housing are scarce. Methamphetamine use is rampant. And a growing population of the aging suffers from depression and prescription drug and alcohol abuse.

 

Poverty and disability rates are high: During the last census, for example, 28% of Modoc County residents between the ages of 16 and 64 reported being disabled, compared with 19% statewide. The suicide rate in many northern rural counties, meanwhile, is as much as double the state average.

 

With need everywhere, overwhelmed Modoc County officials -- and community members who by law are part of the decision-making process -- faced tough choices about how to spend their Proposition 63 funds.

 

A small amount is going to train a nascent group of mentally ill men and women to run a peer counseling line. A new family support group will reach out to parents like the Fincks. And teleconferencing equipment will bring specialists to Alturas remotely and help clinicians advance their education through long-distance learning.

 

But the style of care that Proposition 63 was designed to facilitate for the severely ill -- a "whatever it takes" regime that includes housing, job training and psychiatric and medical care -- will go to just five youths and five seniors. All must live near the county seat.

 

As officials struggle to make Proposition 63 dollars stretch while staying true to its philosophical intent, caseloads for bread-and-butter care have risen.

 

"We can do all these wonderful things for a select few consumers," Modoc County's Stockton said bluntly. "But we are having to give up some of the basic things we did for the whole."

 

Jobs top wish list

 

Limitations surface nearly daily. In Alturas during a recent noon hour, members of the client group Rays of Hope filed into Stockton's office for a meeting. The drop-in center that the group envisioned -- with computers, a library for research on illness and a place to simply be -- did not get funded.

 

Meanwhile, the area's mentally ill are eager for benefits that a small rural county like theirs is unlikely to deliver. At the top of their wish list: jobs and training in mental health careers for people like them.

 

Stockton listened carefully at a recent meeting with the group, then broke the news: Her department won't be able to provide much unless the state steps in to help group members train for credentialed professions. Lower-skill peer counseling jobs, she said, will probably add up to only a single position countywide.

 

Still, for a county where mentally ill men and women have never come together to articulate their needs, the sheer existence of Rays of Hope is a victory.

 

"This is the first time in the history of forever that the interests of the consumer are being listened to," Cheryl Maxson, a mental health advocate living with bipolar disorder and sporting a "Revolution of Empowerment" T-shirt from the California Network of Mental Health Clients, told the small group.

 

Rare collaborations are also underway. Modoc is entering into agreements with Lassen and Siskiyou counties to serve some residents far from Alturas. That might bring Medeiros relief or at least a chance to talk with those who have suffered similarly.

 

In Bieber in Lassen County, the Big Valley Family Resource Center will soon employ a mental health caseworker. And the Lassen Aurora Network, a peer group that offers yoga and life skills classes in that county's seat of Susanville, is expanding to Bieber to host peer counseling sessions and other activities.

 

Lillian Arnold, who heads the resource center and sits on the peer group's board, received a grant to learn Sign Chi Do, a therapeutic blend of martial arts and sign language that she will begin teaching.

 

Medeiros hoped she would benefit from the new program. Still, years of disappointment had left her skeptical.

 

"When I moved up here, my life really ended, because there's nothing," she said. "The odds are stacked against me."

 

Late last month, Medeiros once again became paranoid and delusional and was hospitalized. This time, her family agreed to a temporary conservatorship. At an October court hearing, Modoc County will seek to have her placed in a board-and-care facility in Modesto, hundreds of miles from home.

 

leora.romney@latimes.com

 

scott.gold@latimes.com