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2024 Community Provider Advisory Group
Priorities & Guiding Principles to Navigate a Shifting Landscape
December 2024
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Contents
Background .............................................................................................................................. 3
Guiding Principles .................................................................................................................... 3
Key Findings and Priorities ........................................................................................................ 4
Meeting Summaries .................................................................................................................. 5
Appendices ............................................................................................................................ 12
Appendix A: Summary of Current and Upcoming System Initiatives....................................... 12
Appendix B: System Strengths and Gaps .............................................................................. 14
Appendix C: Actionable Steps to Advance System Priorities ................................................. 16
Appendix D: Community Provider Advisory Group (CPAG) Members ..................................... 18
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Background
Alameda County Supervisor Keith Carson and Alameda County Health Director Colleen Chawla
convened the Alameda County Health Community Provider Advisory Group (CPAG) for a series of
strategic conversations between July and October 2024. CPAG members included leaders and
partners from community-based organizations offering services and supports across public health,
behavioral health, justice-involvement, and housing and homelessness, alongside Alameda
County Health leaders. See list of CPAG Members in Appendix D.
Against the backdrop of a rapidly evolving safety net and multiple competing priorities, the CPAG
was charged with developing guiding principles for the group’s work together, and to identify
system priorities to support future planning and investment.
Over the course of five meetings, the group discussed major state and local systems change
initiatives and related impacts for community health, behavioral health, and homelessness.
Presentations from Alameda County Health (AC Health) teams and CPAG members highlighted
emerging issues, promising practices, and planning processes underway in community health,
behavioral health, and homelessness. Group discussion surfaced shared pain points, priorities,
and opportunities for collaboration as the collective system navigates change.
The report briefly summarizes the work of the CPAG and includes several appendices with
additional detail. All meeting presentations and materials can be found on website.
Guiding Principles
To guide the group conversations, planning, and priority setting, the group agreed to:
1. Prioritize equitable care to recognize Alameda County’s diverse communities and reduce
health disparities
2. Identify shared goals and coordination to guide priority setting
3. Keep a systemwide perspective to avoid individual member or organizational biases and
conflicts of interest
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Key Findings and Priorities
The Community Provider Advisory Group found value in sharing information and building
connections across health sectors, with recurrent discussion themes emerging across the
following priority areas:
Across the meetings, the CPAG found that:
• Changing state/federal policies and reimbursement are pushing the system to connect
dots across organizations and sectors. Payors and providers are all being asked to deliver
more with fewer resources.
• An increasingly interconnected landscape brings intertwined opportunities and
challenges:
o Increased collaboration improves access to care and continuity of care for clients
o Collaboration is hindered by antiquated infrastructure and disjointed systems
o Limited resources (people, time, infrastructure, funding) to do increased work
o Persistent challenges with recruiting, training, and retaining workforce
o Balancing timely knowledge sharing and transparency while meeting tight
implementation deadlines
o High administrative burden to administer contracts and/or bill Medi-Cal, especially
for smaller community-based organizations
• A focus on shared communities and clients requires new ways of working together and
ongoing touchpoints.
During the last meeting, CPAG members identified potential ideas that could help to advance the
systemwide priorities identified above. Among the long list of ideas, the following received the most
votes as high priority over the next three to five years:
• Develop a multi-sector effort committed to eliminating specific health disparities
(ex: homelessness, Substance Use Disorder, and focus on African American/Black
health)
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• Create a system and process to enable easy cross-sector referrals for clients
• Implement countywide strategies to support workforce recruitment and retention,
including increasing wages, insurance subsidies, wellness incentives, and
opportunities for training and advancement
• Leverage shared infrastructure and cross-system applications to streamline data
entry, Medi-Cal billing, care coordination, and prioritize client privacy
• Develop more streamlined reporting and contract coordination across Alameda
County Health
See details in Appendix C.
Meeting Summaries
Each CPAG meeting included presentations and discussion. Presentations included key
background information about recent policy initiatives, organizational structure, and
recommended action steps. Each meeting had a focus, though discussions included
conversations across topics given the interconnected nature of serving our clients.
Meeting 1 – Overview
The first CPAG meeting opened with a presentation by Alameda County Health Director Colleen
Chawla and Deputy Director Aneeka Chaudhry on the background of CPAG and Alameda County
safety net, including Medi-Cal enrollment, homelessness, and the HealthPAC program. They
provided information on the increasing Medi-Cal enrollment in the County over the past 10 years,
the increasing number of people living on the streets, and decreased HealthPAC enrollment. Most
residents served by Medi-Cal and HealthPAC are people of color, with Medi-Cal having significant
Black and Latinx enrollees and HealthPAC being majority Latinx.
Alameda County Health presented on upcoming initiatives that are detailed in Appendix A.
CPAG members shared important issues they wanted to discuss within the buckets of Community
Health, Behavioral Health, Homelessness, and Cross-Cutting Topics. Themes included:
• Cross-system infrastructure, communication, and information/data sharing for care
coordination
• Navigating federal political and administration changes
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• Recruiting, training, and retaining workforce
• Evaluating impact of systems and policy change
• Shared system- and community-level planning, coordination, and prioritization funding
Meeting 2: Community Health
Meeting 2 started with presentations from: Alameda County Health Public Health Department’s Dr.
George Ayala, Evette Brandon, and Carolina Guzman; Alameda Alliance for Health’s Dr. Donna
Carey; HealthPAC’s Danice Cook; Alameda Health System’s Tangerine Brigham, and Community
Health Center Network’s Andie Martinez Patterson.
Alameda County Health Public Health Department presented on the Community Health Needs
Assessment (CHNA) and Community Health Improvement Plan (CHIP). Public Health partners
closely with residents, community partners, and Alameda Alliance for Health and Kaiser on
development of their CHNA/CHIP, which entail multi-year planning and implementation cycles.
The CHNA takes a comprehensive look at the health of Alameda County residents by studying a
combination of social determinants of health and specific health outcomes of individuals,
neighborhoods, and populations. The CHIP is an action-oriented plan that addresses the most
significant health issues identified through an extensive assessment of socio-economic and health
status data.
Alameda Alliance for Health presented on the state’s Population Health Management initiative,
which requires Managed Care Plans (MCPs) to:
• Gather, share, and assess timely and accurate data on member preferences and needs to
identify efficient and effective opportunities for intervention through data-driven risk
stratification processes, predictive analytics, identification of gaps in care, and
standardized assessment processes.
• Focus on upstream approaches that link to public health and social services and support
members staying healthy through wellness and prevention services.
• Provide care management, care coordination, and care transitions across delivery systems,
settings, and life circumstances.
• Identify and mitigate social drivers of health to reduce disparities.
HealthPAC has a long history of supporting the local safety net infrastructure to meet the County’s
indigent care obligations, as well as to ensure access to primary, specialty, ancillary, inpatient, and
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emergency care for low-income uninsured residents. Presenters also shared the ways that
HealthPAC has been used for quality care improvement and system transformations at Federally-
Qualified Health Centers and Alameda Health System.
Meeting 3: Behavioral Health
Meeting 3 included presentations by: Alameda County Health Behavioral Health Department’s Dr.
Karyn Tribble, Vanessa Baker, and Tracy Hazelton; Behavioral Health Collaborative’s Matthew
Madaus; and Building Opportunities for Self-Sufficiency’s Donald Frazier.
Alameda County Health Behavioral Health Department provided an overview of its internal
organization structure and the key initiatives they are tracking, including CalAIM, BHSA
Implementation (Prop 1), CARE Court Planning & System Coordination, Opioid Settlement Planning
System Coordination, Departmental Strategic Planning, SmartCare Billing Implementation, Child &
Youth Service Coordination and Regulatory Change Initiatives, Peer Certification (SB 803),
Lanterman-Petris-Short (LPS) Legislative Change (SB 43), Forensic Services System Redesign,
Health Equity Initiatives, and Alameda County Settlement Implementation.
The Behavioral Health department provided an overview of the new Behavioral Health Services Act
(also known as Prop 1). This new policy will require a shift of services and funding to people with
the most acute need and increased coordination between behavioral health, homelessness, and
Managed Care Plans.
Matthew Madaus presented on the role of the Behavioral Health Collaborative as an organizing
entity across multiple providers and the gaps these organizations have identified. His presentation
included recommendations to address these gaps, including:
• Creating venues for more coordination across organizations
• Prioritizing improved data exchange between sectors
• Maximize funding using state, federal, Medi-Cal, matching, and MHSA funds
• Redesigning contracts to allow for coordination
Lastly, Donald Frazier presented a holistic model of support for people that includes vocational
services, health and mental health supports, and builds community resilience by investing in
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trusted messengers and community leaders. Video provides an overview of the program, which
currently focuses on African American neighborhoods in West and East Oakland.
Meeting 4: Housing and Homelessness
Meeting 4 included a presentation by Alameda County Health Housing & Homelessness Services’
Jonathan Russell, Jeanette Rodriguez, Lucy Kasdin, and Suzanne Warner and a panel with Bay Area
Community Services’ Jamie Almanza, La Familia’s Aaron Ortiz, and Satellite Affordable Housing
Associates’ Cristi Ritschel.
Housing and Homelessness Services (H&H) provided context on the history of H&H and an
overview of organizational structure and priorities of the department. These priorities include:
• Fund and launch coordinated strategies for homelessness prevention
• Target strategies to prevent returns to homelessness
• Identify dedicated funding sources to expand availability of permanent housing
• Advocate for new and recurring funding to maintain existing programs and develop new
ones
• Continue to build capacity and strengthen coordination among key partners
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The H&H team also shared the Home Together 2026 Community Plan and provided data on the
current landscape of housing and homelessness, emphasizing that despite an increase in number
of people housed, there are more people entering the homelessness system. Homelessness
continues to disproportionately impact Black and Indigenous communities, where Black
households comprise just 10% of the general population, but 55% of those newly experiencing
homelessness. The H&H team shared that reliable funding is needed to maintain existing inventory
and to significantly grow new inventory over time.
The meeting closed with a panel of providers from Bay Area Community Services (BACS), La
Familia, and Satellite Affordable Housing Associates (SAHA). The panel spoke about their
experiences with cross sector partnerships, navigating the complex funding landscape, and
opportunities, challenges, and priorities for each organization. Panelist spoke about:
• Cross-sector partnerships
o Partnerships have been helpful in reducing barriers, adding capacity, and
coordinating care.
o System needs better infrastructure to fund, support, and coordinate partnerships to
make them really impactful for the community.
o Relationship with Medi-Cal managed care plans is new—CalAIM is creating more
opportunities and pathways to work with health plans.
o Health plans need more education/training on new populations and providers need
more training on health plan processes and definitions (PMPM, capitation, etc.)
o Should leverage private philanthropy to incubate and innovate, but then shift to
policy to have regular funding.
• Navigating funding
o Provider organizations need infrastructure to administer and access funding (ex.
10% match and sufficient cash flow).
o Increasing number of funding streams increases overhead, delays, and
operational/administrative challenges.
o CalAIM is a new funding stream with a steep learning curve and needs additional
resources to administer (billing, data, etc.)
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o Small contracts take a lot of money and resources administer—sometimes more
than the contract itself.
• Opportunities, challenges, and priorities for each organization
o Every organization has a core competency. Alameda County has patchwork of
organizations that that share clients–need to develop strategies to leverage the
entire system and problem solve together.
Meeting 5: Recap & Prioritization
Meeting 5 opened with a presentation by Alameda County Health’s Aneeka Chaudhry, who
provided an overview of the five meetings. The meeting then moved to various activities, including
visioning of the future, brainstorming and prioritizing next steps, and mapping system strengths
and gaps.
CPAG members were asked what does their ideal system look like in the next 3-5 years? This word
cloud was generated from their responses:
CPAG members identified ideas that can improve health equity, especially in the areas of access to
care, coordinated service delivery, data exchange, optimizing funding and contracting,
partnerships within and across sectors, and workforce. The highest voted actionable steps
included:
• Develop a multi-sector effort committed to eliminating specific health disparities (ex:
homelessness, SUD, and focus on African American/Black health)
• Create a system and process to enable easy cross-sector referrals for clients
• Implement countywide strategies to support workforce recruitment and retention,
including increasing wages, insurance subsidies, wellness incentives, and opportunities for
training and advancement
• Leverage shared infrastructure and cross-system applications to streamline data entry,
Medi-Cal billing, care coordination, and prioritize client privacy
• Develop more streamlined reporting and contract coordination across Alameda County
Health
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See details in Appendix C.
CPAG members mapped system strengths and gaps across community health, behavioral health,
and homelessness systems. The below themes arose as strengths and gaps across the systems:
• Strengths included: data exchange infrastructure (SHIE/CHR), relationships with
community partners and managed care, strong departments with deep expertise, data
exchange infrastructure (SHIE/CHR), collaboration/strong relationships with community
partners, and coordination of resources
• Gaps included: workforce recruitment and retention, countywide process for managing
data sharing, funding limitations (unsustainable/lack of ongoing funding, low rates, and
administration related to funding), coordination of resources across siloes (city, county,
state, federal)
See details in Appendix B.
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Appendices
Appendix A: Summary of Current and Upcoming System Initiatives
HealthPAC (Health Program of Alameda County) (2011- current)
• Provides care for the uninsured
• Fulfills obligation that all California counties provide care for the uninsured (Section 17000,
Welfare and Institutions Code)
• Priorities: Access to care for low-income people without insurance options and improving
health outcomes
Community Health Improvement Plan (CHIP) (2023-25, + 3-year cycle)
• Long-term Public Health effort to improve the health of Alameda County’s communities
• Framework for community health priorities, bridging safety net and population health
• Priorities: Access to care, including physical, dental, and behavioral health; economic security
and opportunity; and community and individuals free from violence
Medi-Cal Population Health Management (PHM) (2023-ongoing)
• Statewide approach to promote health equity and ensure Medi-Cal members have access to
comprehensive services and supports, improved health outcomes
• Priorities: Improve whole person health for Medi-Cal enrollees, reduce health disparities, and
make meaningful advances in quality
Behavioral Health Department Strategic Plan (2023-25)
• Roadmap to creating more equitable specialty behavioral health services for Medi-
Cal members
• Priorities: Access, community expertise, housing programs, equitable care, re-entry and
criminal justice, acceptable and equitable distribution of funds for MH/SUD
Behavioral Health Transformation (Prop 1) (Jan 2025-Jul 2026, +3 year cycle)
• Effective 2026, transitions the MHSA to BHSA and revises the distribution of funding to focus
on people with serious mental illness & SUD, and housing, includes: Behavioral
Health Infrastructure Bond Act (AB 531) and Behavioral Health Services Act (SB 326)
• Priorities: Inpatient supportive housing and residential treatment beds, permanent
supportive housingoutpatient treatment slots, housing interventions, full service partnerships,
behavioral health services & supports, and training and employment supports
Care First, Jails Last (CFJL) (2022-24)
• BOS resolution approved in 2021, CFJL Task Force issued recommendations in June 2024
• Calls for coordinated criminal justice, behavioral health, and wraparound services to reduce
the number of people with mental illness, substance use, and co-occurring disorders in Santa
Rita Jail
• Priorities: African American Resource Center; collaboration, case management, and reentry;
community-based support; outreach & education; crisis services/5150 & treatment beds;
diversion; funding & financial transparency; housing & residential facilities; staff training &
professional development; and family supports
Home Together 2026 Community Plan (2022-26)
• Goals, strategies, and investments needed to dramatically reduce homelessness in Alameda
County and combat racial disparities in homelessness by centering racial equity
• Priorities: Prevent Homelessness for our residents; connect people to shelter and needed
resources; increase housing solutions; strengthen coordination, communication, and capacity
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CalAIM (California Advancing and Innovating Medi-Cal) (2022-27)
• Set of initiatives referred to as “Medi-Cal Transformation”: Behavioral Health, Community
Supports, Dental, Enhanced Care Management, Integrated Care for Dual Eligible Members,
Justice-Involved, Population Health Management, Statewide Managed Long-Term Care, and
Supporting Health & Opportunity for Children and Families
• Priorities: Address physical and behavioral health needs; improve and integrate care; equity
and justice; and collaboration to build healthier state
Social Health Information Exchange (SHIE) (2016-ongoing)
• Fosters the exchange of health and social services information among social
service organizations and healthcare providers
• Supports AC Health and small CBOs with CalAIM implementation
• Priorities: Enhanced care coordination, improved health outcomes; efficiency and cost savings
; equity and social justice; and data-informed decision-making
Data Exchange Framework (DxF) (2022– ongoing)
• Statewide requirement to establish a single Data Sharing Agreement and common set
of policies and procedures to govern and require the exchange of health information
among health care entities and government agencies in California.
• Priorities: Advance health equity; make data available to drive decisions and outcomes;
support whole person care; promote individual data access; reinforce data privacy and security
; adhere to data exchange standards; and ensure accountability
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Appendix B: System Strengths and Gaps
CPAG members mapped system strengths and gaps across community health, behavioral health,
and homelessness systems. The below themes arose as strengths, gaps, and opportunities across
the systems:
Cross System Coordination
• System Strengths
o Cross-sector data exchange infrastructure (SHIE/CHR) and data sharing
o Coordinated planning
o Regional focus on housing & homelessness
o Shared language in some areas
o Shared focus on equity
o Close partnerships with managed care plans
• System Gaps
o Sharing information in real time
o Insufficient data infrastructure
o Coordination of reporting across systems (behavioral health, managed care,
homelessness, population health)
o Disconnect across providers
o Coordination of resources from client perspective
o Siloes (city, county, state, federal)
o Disparate needs across the county
• Opportunities
o Strengthen cross-system data infrastructure to improve coordination of data
sharing and reporting
o Infrastructure to support provider, client, and resource coordination
o County-wide processes for planning and communication to reduce silos address
system needs
Workforce and Expertise
• System Strengths
o County departments with deep expertise
o Hires, trains, and supports community members and people with lived experience
• System Gaps
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o Workforce recruitment and retention
o Connection with people with lived experiences and faith-based partners
• Opportunities
o Countywide strategies to support workforce recruitment and retention, with a focus
on community members and people with lived experience
Comprehensive Community-driven Delivery System
• System Strengths
o Strong baseline of access to care at CHCN and AHS
o Diversity of mobile, onsite, and wraparound services
o Service delivery approach evolves to meet the needs of the community
o Collaborative relationships with community, service providers, and resident
organizers
• System Gaps
o Disconnect between BH mild-moderate and moderate-severe systems of care
o Non-hospital options for crisis situations
o Insufficient mobile (health) care capacity
• Opportunities
o Increased coordination and planning across system to gaps in service delivery
Funding and Administration
• System Gaps
o Onerous reporting requirements
o Resources/funding are not increasing with need
o Ongoing, sustainable, flexible funding
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Appendix C: Actionable Ideas to Advance System Priorities
CPAG members were asked to brainstorm actionable next steps to advance system priorities.
Ideas spanned the areas of health equity, access to care, coordinated service delivery, data
exchange, optimized funding and contracting, partnerships within and across sectors, and
workforce. The group was asked to consider a three- to five-year horizon when prioritizing among
the ideas. These five ideas were prioritized by the most CPAG members:
• Develop a multi-sector effort committed to eliminating specific health disparities (ex:
homelessness, SUD, and focus on African American/Black health).
This action would create a coordinating framework for multiple sectors to collaborate on a
shared goal, making it easier to track impact and develop solutions with tangible benefits to
clients. This action would require different aspects of the system to agree on definitions,
metrics, and milestones, and would offer a valuable approach to addressing long-standing,
known disparities. Specific ideas for consideration include a focus on the health of Black
men, or a focus on service coordination for unhoused people with complex health needs.
• Create systems and processes to enable easy cross-sector referrals for clients.
Cross-agency referrals ensure that clients are connected to services in a timely manner.
However, disparate referral processes and insufficient connections across provider
communities pose barriers. While the State is pushing for closed-loop referral tracking,
there is inconsistency across health plans, and providers face barriers due to cost,
technology availability, and other operational factors.
• Implement countywide strategies to support workforce recruitment and retention,
including increasing wages, insurance subsidies, wellness incentives, and
opportunities for training and advancement.
Workforce challenges persist across sectors, and the system needs an infusion of supports
and incentives for employees to choose to work for organizations in Alameda County. While
some elements, such as wages and insurance are limited by funding, other opportunities,
like Community Health Worker reimbursement, are limited by unclear guidance and
insufficient training and billing infrastructure.
• Leverage shared infrastructure and cross-system applications to streamline data
entry, Medi-Cal billing, care coordination, and prioritize client privacy.
A coordinated data sharing infrastructure, such as the Social Health Information Exchange
(SHIE), has potential to improve client outcomes, support compliance with state data
sharing mandates, and help smaller organizations build capacity for billing. Focused efforts
on data sharing agreements and shared platforms can help to overcome barriers posed by
cost and multiple regulatory requirements.
• Develop more streamlined reporting and contract coordination across Alameda
County Health.
Many providers have multiple contracts with Alameda County Health and these contracts
have different requirements. Increased contracting coordination would reduce
administrative burden on providers.
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Other actionable steps surfaced during the brainstorming session include:
• Prioritize positive health outcomes for Black residents.
• Create an ongoing meeting to ensure cross-sector collaboration and policy updates are
shared.
• Utilize the Community Health Improvement Plan (CHIP) to prioritize grants and funding.
• Support grants cover infrastructure and administration costs for CBOs.
• Advocate for lower professional requirements (e.g. Community Health Worker) to increase
Medi-Cal reimbursable staffing pool available to treat clients.
• Increase community housing providers’ voice in Housing Support Program contracting.
• Identify one system for electronic health records, referrals, and data sharing.
• Prioritize clients’ community resources, such as family and friends, during treatment.
• Co-locate case managers and service providers to allow for increased collaboration.
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Appendix D: Community Provider Advisory Group (CPAG) Members
• Board of Supervisors, District 5
o Keith Carson (CPAG Co-Chair)
o Amy Shrago
• Alameda County Health
o Colleen Chawla (CPAG Co-Chair)
o Aneeka Chaudhry
o Dr. Kathleen Clanon
o Dr. Karyn Tribble
o Kimi Watkins-Tartt
o Jonathan Russell
• FQHCs
o Community Health Center Network
o Andie Martinez Patterson
o Safety Net Health System
o Alameda Health System
o James Jackson
o Independent Clinic
o Roots Health Center
o Dr. Noha Aboelata
o Unincorporated
• Resources for Community Development
o Ana Rasquiza
• Medi-Cal Managed Care Health Plans
o Alameda Alliance for Health
Matthew Woodruff
o Kaiser Permanente
Vanessa Davis
• Public Health
o CalPEP
Lisa Ryan
o TriValley NonProfit Alliance
Kathy Young
o Building Opportunities for Self-Sufficiency
Donald Frazier
• Behavioral Health
o Behavioral Health Collaborative of Alameda County
Matthew Maddaus
o Crisis Support Services (988)
Narges Dillon
o La Familia
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Aaron Ortiz
• Housing & Homelessness
o Bay Area Community Services
Jamie Almanza
o Great Expectations
Dr. Chika Ugbaja
o Satellite Affordable Housing Associates
Cristi Ritschel