Manson asked how each health care system has trained and involved important decision-makers, particularly within the local community. Shore explained that the involvement of VA leadership and tribal leadership was critical to his work. He said that in every community where they set up basic health services, they have talks with the tribal council and involve this leadership as well as the local leadership of the VA. He agrees that the support of local and regional leaders is essential to success. He added that the involvement of executives at the national level is the key to extending the models to other sites. Manson agrees and explained that generating an early series of small, but effective models can inform other levels of advocacy.