Advancing Health Podcast

00;00;01;03 - 00;00;23;00
Tom Haederle
Health care providers coast-to-coast have seen a significant rise in the past several years in the demand for behavioral health services. Broadly speaking, behavioral health encompasses those things that affect overall well-being, including mental health issues and substance use disorders. Many hospitals and health systems want to fully integrate behavioral health treatment as a core part of patient centered care.

00;00;23;05 - 00;00;37;15
Tom Haederle
But there are barriers that often stand in the way and make it more difficult.

00;00;37;18 - 00;01;14;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this month's Leadership Dialogue Series podcast, Dr. Joanne Conroy, CEO and president of Dartmouth Health and 2024 Board Chair of the American Hospital Association, explores how hospitals and health systems can best meet the need for behavioral health services with Dr. Jeremy Musher, chief behavioral medical officer at Lifepoint Health in Brentwood, Tennessee. They discuss how to overcome some common obstacles to effective treatment, including access issues, reimbursement challenges, and the stigma of receiving treatment.

00;01;14;21 - 00;01;18;15
Tom Haederle
And, they offer possible solutions. Let's join them.

00;01;18;17 - 00;01;46;28
Joanne M. Conroy, M.D.
Thank you for joining us for another deep dive into a very important topic on the Leadership Dialog series. It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. Today's discussion is critically important and it impacts all of us. It can be our own experience or the experience of a family member or a friend.

00;01;47;00 - 00;02;20;09
Joanne M. Conroy, M.D.
And the issue is mental health. We know concerns around mental health have only worsened over the past few years. Those needing mental health services have long been stigmatized, and unfortunately, reimbursement for their care has been lagging for decades. Access to adequate mental health is perhaps the single most challenging obstacle that we all face as health care professionals at this moment in time. And finding these services is even more difficult in rural areas.

00;02;20;11 - 00;02;50;14
Joanne M. Conroy, M.D.
With the mental health crisis worsening, hospitals and health systems are finding themselves more active in developing an advocating for solutions. At Dartmouth Health, like other organizations, we're working to build a stronger infrastructure to meet our patients behavioral health needs. Across the continuum of care. And we are super fortunate today to have our guest, Dr. Jeremy Musher, who's chief behavioral medical director at Lifepoint Health.

00;02;50;17 - 00;03;14;19
Joanne M. Conroy, M.D.
Lifepoint Health is a health care delivery network with facilities in 31 states. The system includes 60 community hospitals, but also more than 60 behavioral health or rehab hospitals, along with hundreds of other sites of care that span the health care continuum. Jeremy, before we jump into our discussion, I know that the audience really likes to get to know our guests a bit.

00;03;14;22 - 00;03;31;23
Joanne M. Conroy, M.D.
So I'm going to ask you to please share a little bit more about yourself and your journey into health care, specifically towards behavioral health. And I also wonder if our paths may have crossed the South Carolina when you were at the University of South Carolina, because I was in Charleston for a long time.

00;03;31;25 - 00;03;58;13
Jeremy Musher, M.D.
I don't recall our paths crossing, but, we may have. I was there for a while. Actually, I started, doing my residency. I completed that in the Navy. So I was, Armed Forces scholarship student and, did my residency in the Navy and then was on active duty for a total of about six years. As you mentioned, I've worked in academia.

00;03;58;15 - 00;04;28;08
Jeremy Musher, M.D.
I was, the residency training director or vice chair of the Department of psychiatry and associate dean for student affairs at the University of South Carolina. And in more recent years, I was the medical director for the psychiatric emergency services at Western Psychiatric at the University of Pittsburgh. I've also in the past been a psychiatric surveyor for CMS under the conditions of participation.

00;04;28;11 - 00;04;58;05
Jeremy Musher, M.D.
And then for about 25 years had a private consulting company working with psychiatric hospitals and systems to ensure compliance with regulatory guidelines. I've also represented the American Psychiatric Association as the advisor to both the CBT panel and the RV Update Committee for about 15 years. About eight years ago, I joined the national psychiatric company Springstone as the chief medical officer and chief clinical officer.

00;04;58;07 - 00;05;09;14
Jeremy Musher, M.D.
And then we were acquired, a year ago February, by Lifepoint Health. And now we are the Lifepoint Behavioral Health within Lifepoint.

00;05;09;16 - 00;05;38;07
Joanne M. Conroy, M.D.
So behavioral health has become an incredibly important aspect of delivering care, not just at a facility level, but at a system level, which is probably behind the acquisition of Springstone by Lifepoint, really understanding that they had a gap in their services that they had to fill. But that gap has gotten wider during the pandemic and the economic challenges of the last few years.

00;05;38;07 - 00;05;48;21
Joanne M. Conroy, M.D.
And I think people believe that, you know, access is still very, very difficult. What trends have you observed as you kind of look from a national level?

00;05;48;23 - 00;06;26;05
Jeremy Musher, M.D.
According to the World Health Organization. in the first year of Covid, the global prevalence of anxiety and depression increased by about 25%. And in the United States, before the pandemic, about 8.5% of adults experienced elevated depressive symptoms. But in the early months of the pandemic in 2020, that number climbed to almost 28%. 2021 it was about a third of all U.S. adults, about 33%. Among young people aged 10 to 24

00;06;26;07 - 00;07;03;29
Jeremy Musher, M.D.
suicide is the second leading cause of death in the US., with rates rising for decades. Between 2016 and 2022, children's hospitals saw 166% increase in ER visits for suicide attempts and self-injury among children 5 to 18. Youth suicide during Covid increased. The median monthly overdose deaths among persons age 10 to 19 increased over 100%, with 90% of those involving opioids, most of which were fentanyl.

00;07;04;01 - 00;07;25;22
Joanne M. Conroy, M.D.
So you are looking at this from a national level, though, and I'm sure you say, why? As a group of leading health professionals, especially around pediatrics, those are scary statistics. As leaders, how do you devise a solution for that? Or how do you create a safety net for that? It seems an incredibly difficult problem to put your arm around.

00;07;25;24 - 00;08;12;28
Jeremy Musher, M.D.
It is. And it really takes coordination and cooperation amongst, both the health care providers as well as the government. Right now and for some time, part of the difficulty in gaining access for patients has been because there aren't enough psychiatrists, there aren't enough behavioral health providers. Part of that is reimbursement issues...the barriers to access that CMS has, because of rules that haven't changed over many years, including Medicare, has a 190 day limit to lifetime mental health admissions.

00;08;13;00 - 00;08;59;29
Jeremy Musher, M.D.
The institutions of mental disease, the IMD exclusion prohibits Medicaid from paying for psychiatric admissions and freestanding psychiatric hospitals for people aged 21 to 64. And something we struggle with all the time is the inpatient documentation and staffing requirements CMS has under the two special conditions of participation. All of these things, along with the payers and their authorization limits that psychiatry has that are different frequently than acute care, make it difficult to provide the services that so many people need.

00;09;00;03 - 00;09;24;06
Joanne M. Conroy, M.D.
So let's talk a little bit about that pediatric population. We had a seminar for adolescent behavioral health a couple of years ago, I think. It was after the first wave of the pandemic when we thought it was safe, even though it really wasn't over. But we, you know all met in a ballroom, really kind of talking about the issues that adolescents and kids were facing.

00;09;24;09 - 00;09;51;10
Joanne M. Conroy, M.D.
And what amazed me was the burden that we put on school nurses, and probably the lack of infrastructure to support them. Because they're kind of on the front line in the school systems, identifying some of these needs. It's a kind of a really robust kind of health system, or the alternative sites where you can actually identify these kids early and maybe get them help.

00;09;51;12 - 00;10;02;03
Joanne M. Conroy, M.D.
Is that on the radar screen? It's almost like not just giving care within your facilities, but what are you doing in the community to really identify these kids early on?

00;10;02;05 - 00;10;41;18
Jeremy Musher, M.D.
Well, we do work in some of our locations with local school systems, for instance Most of the work we do is, unfortunately, after they've been identified and come to the hospitals. But with the education that goes on, both we provide and many others provide in the communities, it is that identification comes earlier. We have in all of our freestanding psychiatric hospitals, an assessment area, sort of like, mini emergency room.

00;10;41;20 - 00;11;23;02
Jeremy Musher, M.D.
And we see adolescents come all the time where we're able to give a screening and an evaluation and determine if their services are needed and if so, what level of care. So that helps get adolescents and sometimes younger kids into the system of care. We also work with primary care providers and pediatricians in terms of providing the kinds of backup and expertise that sometimes they need in order to treat more severely ill, kids.

00;11;23;05 - 00;11;50;08
Joanne M. Conroy, M.D.
You know, we've invested heavily in telehealth, and we offer a lot of tele psychiatry, both to our emergency rooms, but even to our primary care clinics, if they have questions about resources or a diagnosis or a child where a telesite visit can actually help. How prevalent is that across the industry and is it something that we should invest more heavily in?

00;11;50;08 - 00;11;58;07
Joanne M. Conroy, M.D.
Or if you had money to invest, where would you invest it to help kids in the best possible way?

00;11;58;09 - 00;12;32;00
Jeremy Musher, M.D.
Definitely telehealth would the high on the list. We've been doing telehealth and psychiatry for years before the pandemic. But it really took off during the pandemic. And we've found that we can do groups, via Telehealth, as you said, we can consult with ERs. Even CMS has seen, there are so many advantages to the use of telehealth, predominantly from an access standpoint.

00;12;32;03 - 00;13;03;28
Jeremy Musher, M.D.
They have lowered the barrier to access on telehealth and particularly for behavioral health, going forward. So the site of service won't matter anymore the way it used to. Telehealth makes a big difference. What we've found in our system is the patient satisfaction is, in most cases, equivalent to in-person visits.

00;13;04;01 - 00;13;24;25
Jeremy Musher, M.D.
Plus, you don't have the difficulties of transportation. And so long as the insurers paid for it, that doesn't become a barrier. So, yes, telehealth, for sure would be one of the important areas to increase access going forward.

00;13;24;27 - 00;13;51;18
Joanne M. Conroy, M.D.
Almost 80% of our behavioral health visits are virtual now, and the no-show rate is almost zero. And, you know, we don't always, think about the stigma that was associated with seeing a psychologist or a psychiatrist for not only a child, but even an adult. You all remember where you would enter one way and you'd exit another way.

00;13;51;20 - 00;14;18;14
Joanne M. Conroy, M.D.
It was like reinforcing the stigma, although I totally understand why people did it, but it kind of validated that for everybody. There was a stigma to going to see a behavioral health expert. You know, we are doing some things up here at the college that are really interesting, where people can sense from how a adolescent actually interacts with their phone in terms of texting, identifying behavioral health issues early on.

00;14;18;17 - 00;14;31;22
Joanne M. Conroy, M.D.
Have you heard of a lot of research in that realm, like how do we take a technology that we think causes isolation and try to use it to identify diagnoses before they actually manifest in different ways?

00;14;31;24 - 00;15;24;19
Jeremy Musher, M.D.
Actually, there's been some, I think really interesting research going on. It's not out in the wild so much yet, but, there are apps, that they are working on, on iPhones and other phones, that use, for instance, the accelerometer in the phone to measure movement of the individual. And by using algorithms and AI you can use that information and other information - calls, texting, use of online access, etc. - to say, for instance, this individual has been reducing their movement over this period of time.

00;15;24;21 - 00;15;58;06
Jeremy Musher, M.D.
Maybe they're depressed or other use of the phone to help identify. And then, the apps can proactively reach out to the individual and ask, are you feeling okay? Would you like to reach out to your therapist? Would you like to find a therapist? Those kinds of things. So yeah, we are seeing technology start to be used in ways that I think will make a huge difference.

00;15;58;08 - 00;16;21;29
Jeremy Musher, M.D.
We're also seeing CBT - cognitive behavioral therapy is an evidence based form of therapy for anxiety and some forms of depression, etc.- and there are apps that you can use on your phone or online that help walk through some CBT treatment.

00;16;22;02 - 00;16;51;17
Joanne M. Conroy, M.D.
Wow. And so with technology, although the cause of isolation may be some of the answer to isolation for many individuals in the future, Lifepoint acquired your organization for probably a specific purpose. What do they want to achieve at the Lifepoint health system level, and what would they like to achieve at the community level by adding you to their portfolio of health care services?

00;16;51;19 - 00;17;25;19
Jeremy Musher, M.D.
Before we were acquired, Lifepoint Health had acquired Kindred Rehab about a year before us, and kindred had a couple of behavioral health hospitals. They had just started some interest in, behavioral health hospitals. But by acquiring Springstone, we brought to the table, 18 freestanding psychiatric hospitals, as well as about 35 outpatient clinics, across nine states.

00;17;25;21 - 00;18;04;16
Jeremy Musher, M.D.
So it was a way for Lifepoint to essentially jump start their development of behavioral health resources. In addition, they already had, behavioral health units in many of their acute care hospitals. And so now across...we have about 2,500 inpatient psychiatric beds when you combine the behavioral health units in acute care hospitals with now 24 freestanding psychiatric hospitals across 31 states.

00;18;04;19 - 00;19;01;22
Jeremy Musher, M.D.
So the idea in acquiring us was to get more involved in meeting needs in the communities of patients who needed behavioral health services and they weren't getting them. And part of the model going forward has been to develop joint ventures with predominantly med surge hospital systems who don't have enough behavioral health resources. And so by forming a joint venture with Lifepoint, we together can build a freestanding psychiatric hospital, for instance, or, work in the communities and bring those much needed behavioral health resources to the communities, particularly to more rural communities.

00;19;01;24 - 00;19;12;01
Jeremy Musher, M.D.
The mission for Lifepoint is making communities healthier. And that's what we're moving to do as quickly as we can.

00;19;12;04 - 00;19;37;08
Joanne M. Conroy, M.D.
Well thank you. You know, this topic is one that I think everybody will benefit listening to. And I want to encourage anyone who is struggling with feelings of anxiety or depression to please reach out to someone who can help. You can also visit the AHA.org or AHA's Physicians Alliance website for additional resources that are focused on stress, coping and mental health for health care workers.

00;19;37;11 - 00;19;46;29
Joanne M. Conroy, M.D.
Thank you again, Jeremy. And until next time, thank you everyone for joining us today. I hope you'll be back for next month's Leadership Dialog.

00;19;47;01 - 00;19;55;12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;25 - 00;00;33;17
Tom Haederle
In 2020, Congress acted to prevent any more loss of essential health care services in rural areas due to hospital closures by creating a new designation, Rural Emergency Hospitals. REHs became official on January 1st, 2023, and since then a growing number of rural care providers have voluntarily converted to this category. REHs must provide 24 hour emergency and observation services, and can choose to provide other outpatient services, but cannot have inpatient beds. For rural providers who have chosen this path,

00;00;33;19 - 00;00;49;18
Tom Haederle
it's a significant change, one that has patients asking, what does this mean for me and my community?

00;00;49;20 - 00;01;14;11
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this podcast, we hear from two rural health care leaders who assess how the conversion to rural emergency hospital status is going so far. We learn about the progress REHs are making as a new model for payment and delivery of care, and gain insights on how leaders can build trust and buy in from patients and communities

00;01;14;18 - 00;01;18;23
Tom Haederle
that conversion to this still new category is a good thing.

00;01;18;25 - 00;01;51;15
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico. And Rich Rasmussen, CEO of Oklahoma Hospital Association. We're here to discuss rural emergency hospitals and its progress as a new model of payment and delivery. Welcome, Christina. Welcome, Rich. The Rural Emergency Hospital is a new Medicare provider type created to address the growing concern over rural hospital closures.

00;01;51;17 - 00;02;11;29
John Supplitt
The goal of this new designation is to provide a means to preserve access to essential services for rural residents, and to decrease the likelihood of hospital closures. You each bring a unique and important perspective to the formation of rural emergency hospitals, and I will ask you to share the experience that you have had over the past several months.

00;02;12;01 - 00;02;40;16
John Supplitt
Christina. Guadalupe County Hospital, to get some context. We're located in a remote part of eastern New Mexico on the Pecos Rivers, midway between Albuquerque and the Texas border. This is where multiple federal and state highways converge. It's the only hospital for more than 4500 people living in an area of 3000mi², making you the safety net provider and a resource for emergency services.

00;02;40;18 - 00;02;53;11
John Supplitt
On September 1st of 2023, Guadalupe County Hospital converted from sole Community to Rural Emergency. How has the community responded to the conversion?

00;02;53;13 - 00;03;19;28
Christina Campos
We did a lot of work in advance with our county commission and with our hospital board to ensure that the conversion was almost invisible to the community. The quality of care did not change. The patterns of care did not change. So the community has kind of been quiet about the whole thing. They're just seeing it as trusting that this is a change that we made to be able to ensure the sustainability long term for the hospital.

00;03;20;01 - 00;03;39;08
Christina Campos
The employees were educated, the providers were educated. So we've just had a ton of support, a lot of curiosity. At times there have been some questions: does this change? How do we keep how we keep them? Not necessarily, but it really does change the need for a lot of conversations about patient care on a day-to-day basis.

00;03;39;15 - 00;03;48;20
John Supplitt
So your experience is that it's been largely seamless in terms of the introduction. But you also mentioned there's been a lot of communication that had to be part of the upfront work.

00;03;48;22 - 00;04;16;29
Christina Campos
Yeah, it really does. I think what's really important is to have a trust already within the community. Trust - if you're a government entity, you have to have a lot of trust with your county commissioners or your city council. Your providers have to trust that you know what you're doing, and it's something that you have to have built up well in advance of making this big of a change so that when you're bringing it forward, they already know that you have done the legwork, that you have done the math.

00;04;17;01 - 00;04;26;19
Christina Campos
And this is something that is well planned for, well thought out and not just a reflex to a situation that might be happening at that time.

00;04;26;21 - 00;04;48;23
John Supplitt
Right. I understand, that's very good. Let's talk about planning, but let's talk about the planning that takes place from the bureaucratic perspective. There's a lot of planning that went into your application to convert to a rural emergency hospital. You had to provide an action plan that had a description of the services and staffing. You had to have a transfer agreement with either a level one or level two trauma center.

00;04;48;25 - 00;04;58;12
John Supplitt
And then you had to attest for meeting rural emergency hospital conditions of participation. Share with us how the application process worked for you.

00;04;58;14 - 00;05;26;08
Christina Campos
So the application process really isn't that difficult. But what's really interesting is I had done a lot of education to my colleagues throughout the state of New Mexico Hospital Association, so they knew that we were applying for this REH designation already. And after one of our finance calls for the association, the CEO of the level one trauma center in Albuquerque emailed me and said, hey, Christina, how can we help you?

00;05;26;11 - 00;05;43;14
Christina Campos
So I didn't have to ask them for a transfer agreement. We already had one in place, but it was antique. It was already like in sepia, probably typewritten on a typewriter, but we updated it. And so they were our first. And then we also went with one of the level two trauma centers. Another colleague of mine that reached out and said, we want to help.

00;05;43;14 - 00;06;03;03
Christina Campos
We want to be available to you. What's interesting is even though you have these transfer agreements, it doesn't mean you have to transfer it to them. You just have to have those in place. Then on the action plan, we really did a skinny action plan. We just said, this is what we're offering. This is what we're going to continue to offer.

00;06;03;05 - 00;06;24;25
Christina Campos
Obviously we won't have inpatient beds. And then these are the programs that we will anticipate researching to see if they make sense to add on to our community. So it wasn't really detailed, but we were meeting all the criteria. And I think what really helped me a lot as I was going off of the test was recommendations from ensuring access for vulnerable communities that the AHA developed.

00;06;24;27 - 00;06;42;07
Christina Campos
That I knew that there were certain things that we do want to look at offering in our community, but we are going to offer high quality emergency care diagnostics, including lab and X-ray, and then we're going to expand into these other programs. So it wasn't a really heavy lift for us.

00;06;42;08 - 00;06;50;09
John Supplitt
Okay. Christine is referencing a report that was done by AHA on essential services back, I believe it was in 2016, but it still serves.

00;06;50;11 - 00;06;50;28
Christina Campos
It's relevant.

00;06;50;29 - 00;06;57;21
John Supplitt
Yeah, it's still relevant. What about the challenges that you countered in the conversion towards a rural emergency hospital?

00;06;57;23 - 00;07;15;21
Christina Campos
Ours turned out to be kind of like a backwards conversion. It did not go incredibly smoothly. Part of it is that we were so eager to do it. Reached out to our Secretary of Health and our director of regulation licensing, and they said, hurry up and apply. Go ahead and go through the Pecos system and apply. And we did.

00;07;15;21 - 00;07;39;10
Christina Campos
But the state was not ready, even though they're the ones who urged us to apply. And that was in early December of 2022. And our legislature only meets... they're a volunteer group, so they meet in January for either one month or two months. That year was a two month legislative session. I had to go to Santa Fe on a regular basis and educate the legislators, and have this passed as a statute.

00;07;39;11 - 00;07;56;15
Christina Campos
Now, I argued that critical access hospitals is not written in statute. Why doesn't REH have to be written in statute? But that's what they wanted. So then it was you're going to hear the trend of education and communication. I had to educate the legislators. I had to have the governor on my side to make sure the bill was passed.

00;07;56;18 - 00;08;20;15
Christina Campos
They did not put an emergency clause into it, so it did not go into effect immediately. It did not go into effect until June 16th, two weeks before the end of the fiscal year. But I had already applied to CMS. They had already approved the process. And then when it took so long, my application expired. And then it was a question as did I have to ask for an appeal or reconsideration.

00;08;20;16 - 00;08;40;28
Christina Campos
They didn't know how to handle it. My state didn't know how to handle it, and so it just dragged on until I was able to bring together the Dallas director of CMS with my Secretary of Health and all of the people that were working on this. And then there were many other people through CMS that were working on the project and just trying to understand it.

00;08;41;00 - 00;09;01;00
Christina Campos
We were literally building the plane as we were flying it. That meeting, we were able to get everybody to the table, agree on what needed to be done. Everybody wanted the same thing. They just didn't agree on how to get there. And at that meeting, they came to a conclusion and picked a date, made it September 1st and it was a little bit retroactive.

00;09;01;00 - 00;09;08;20
Christina Campos
We got our license from the state immediately. There's still other conversions stuff that's going on, but I think we'll get into that in a little bit.

00;09;08;20 - 00;09;18;15
John Supplitt
Yeah, a little bit. But I guess when we're listening to your story, what we're hearing is that it takes a champion. You build on the relationships that are there and you have to be persistent.

00;09;18;18 - 00;09;21;13
Christina Campos
Incredibly persistent.

00;09;21;15 - 00;09;49;21
John Supplitt
Well, thanks very much. Rich, let's turn it over to you and get you into this conversation for this model to take effect. As Christina has mentioned, states have to have in place legislation that will allow the licensing, certification and then payment of a new provider type and service. But Oklahoma was among the first states to pass enabling legislation. Share with us why this is a priority for your state and how it came to pass.

00;09;49;23 - 00;10;18;20
Rich Rasmussen
Well, thanks, John. It's a great question. I think the big challenge that we experienced in Oklahoma is that we have a large number of rural hospitals PPS that aren't eligible for conversion to critical access. Now, certainly, Congress has some legislation in front of it that can make that easier, allow that to take place again. And so the membership stepped back and said, what can we do to provide some level of support that will allow these facilities to stay in service in serving their communities?

00;10;18;22 - 00;10;38;03
Rich Rasmussen
When the REH opportunity presented itself, the membership quickly jumped on it. The association passed legislation with the full expectation that we would have conversions, and I believe we had the first one in the nation, I think, in Oklahoma. And, you know, that one was then quickly followed by the second one, and now we've had our third conversion that took place this fall.

00;10;38;05 - 00;10;55;17
Rich Rasmussen
And so for the Perry Hospital, there's no way they could have survived. Along with their sister hospital as well in Blackwell. Had they not had this opportunity, they probably would have been forced into a position to close, or the mothership of the hospital system would have to step back and look at how they could perhaps salvage one of them.

00;10;55;19 - 00;11;18;23
Rich Rasmussen
And this created that lifeline. And I think the moral of the story is, is that to prospective payment hospitals, you would have never thought that. I think most of us, you know, when we looked at, you know, the REH opportunity, we thought it would be critical access hospitals and it really wasn't. And in for the state of Oklahoma, we have several others that are evaluating it just for that very reason, because there's no other way they can survive and continue to support their community.

00;11;18;25 - 00;11;42;25
John Supplitt
Christina was referring to the conversation she had with the New Mexico State Legislature, and how they weren't prepared at the moment. Even though they encouraged you to do it. You had to have had some similar experience in Oklahoma, in the sense that in order to get that legislation passed, you had to have a pretty confident and aware legislature that knew the problems that were confronting some of the rural hospitals in order to respond.

00;11;42;27 - 00;12;06;14
Rich Rasmussen
Oh, absolutely. In Oklahoma, there is a real sense of obligation to ensure that hospitals not only survive, but truly have the opportunity to be successful in serving their communities. And lawmakers also understand that real difficult position that these rural PPS hospitals find themselves in. So it wasn't a heavy lift to get them to agree to do that. They very much wanted to be successful.

00;12;06;19 - 00;12;23;21
Rich Rasmussen
And this is a state that by initiative had passed Medicaid expansion. So you had the public was leaning in on this issue and then you had lawmakers are leaning right in behind it to make sure that the health care system in the state would not only survive, but thrive. And I think that was part of the impetus behind the legislation moving quickly.

00;12;23;23 - 00;12;35;28
John Supplitt
There's a lesson there, too, and in the sense that when the community and in this case, the larger community of the state is behind the initiative, it can happen and happen quickly and effectively.

00;12;36;01 - 00;13;01;11
Rich Rasmussen
Oh, absolutely. And without it, you know, you have communities that, like we see in most of the Midwest, the Mountain West, where folks are traveling hours to get to the next facility. And when you're talking about in Oklahoma, where you have a large agriculture community and a large energy sector as well, accidents do happen. And people have seen that happen to their family members, and they could go to the local hospital.

00;13;01;18 - 00;13;09;04
Rich Rasmussen
The thought of losing that really helped drive the whole narrative around the importance of making sure that we have something in the RH provided that model.

00;13;09;08 - 00;13;34;08
John Supplitt
Excellent, excellent. Let's talk, Christina, about your experience since converting. Payment has been a major focus of providers and policymakers regarding the viability of rural emergency hospitals. You are no longer eligible. In your case, you never received 340B, and swing beds aren't an option under the model you receive, and an additional 5% over the payment rate for hospital outpatient pays.

00;13;34;10 - 00;13;44;04
John Supplitt
And you get an annual facility payment for 2024. That's a monthly payment of about $276,000. Is this sufficient?

00;13;44;06 - 00;14;00;05
Christina Campos
It is sufficient for us. What we did was the math early on. When we were talking about this type of a program with a base payment, kind of similar to a utility model, that you're going to get a base payment for having your ear open. It was intriguing, and I think at the very beginning they were talking more in generalities.

00;14;00;05 - 00;14;19;11
Christina Campos
They weren't being specific about the amount. And then that 5% add on. Well, as a PPS we were getting...as a sole community hospital, we were getting a 7.5% add on. So it's not a bump up. It's a tiny bit of a shaving. And I wasn't really attracted to the program at all until two things happen. Number one, our surveyors came in and said, you don't qualify as a PPS.

00;14;19;11 - 00;14;43;08
Christina Campos
You don't have a high enough census to be a PPS hospital. So we knew we had to do something. Critical access; the math just really didn't work because our sole hospital rate was very generous. It was above cost, so we knew critical access just really wasn't a saving grace for us. When they finally came out with that amount, the 276,000 per month

00;14;43;10 - 00;14;59;20
Christina Campos
and we did the math really quickly to see what we were going to give up. How many admissions are we having? Even if we got reimbursed at our high sole community hospital rate? Is that more or less? That was less. The 3.279 million overall for the year was a lot better for us. So the math has to be very important.

00;14;59;20 - 00;15;19;00
Christina Campos
And I think the other thing that was really important is analyzing the needs of the community. You know, we've talked about what does our community actually need while not being able to have inpatient care. It can sometimes can be difficult on a family because they have to drive. It's not life saving care that you have to have in the community.

00;15;19;01 - 00;15;46;06
Christina Campos
We needed to have emergency services in the community to keep people alive, to be able to get them to other hospitals. And we found also that through the years, through our quality initiatives, our lengths of stay often don't meet that second midnight. People resolve very quickly on modern antibiotics. So we were already struggling to keep them and to get paid for the inpatient stay without them denying it and then having to rebuild as an OBS.

00;15;46;09 - 00;15;49;13
Christina Campos
So it just really suits the way we work.

00;15;49;20 - 00;16;06;12
John Supplitt
Let's talk about quality, safety and the patient focused care. Among the requirements that CMS expects is a quality assessment and performance improvement program. Did you see any challenges in meeting these requirements upon conversion to a rural emergency hospital?

00;16;06;13 - 00;16;31;25
Christina Campos
None at all, because we were already having to meet conditions of participation for PPS, which are stricter than for a critical access hospital. They're a little bit different. We're finding some subtle differences in having to pivot a tiny bit, but if you can meet the conditions of participation and of quality that you had as a PPS or as a CAH, there's absolutely no reason why you're not going to meet the conditions and the quality metrics as an REH.

00;16;31;27 - 00;16;41;25
John Supplitt
Great. Thanks very much. Rich, going back to you. Given the early experiences in your state, do you see rural emergency hospital model expanding in Oklahoma?

00;16;41;28 - 00;17;05;04
Rich Rasmussen
Oh, absolutely. I do think, in fact, we have one hospital that's exploring it right now. With a large number of rural PPS, there really is no option. Certainly there's you know, you've got S 1571, which is before the Senate right now, which one of our senators, Senator Lankford, along with Senator Durbin from Illinois, are sponsoring. That could provide some relief to allow for conversions, again, for critical access that a state could determine.

00;17;05;09 - 00;17;16;10
Rich Rasmussen
But short of that, you know, it's hard to get something passed through Congress. So short of that, this is the only lifeline that we can throw some of these communities. I fully expect that beyond the one that I'm aware of right now, there are others that are exploring the option.

00;17;16;14 - 00;17;20;12
John Supplitt
Well, then what could make this model work for rural hospitals in Oklahoma?

00;17;20;15 - 00;17;45;04
Rich Rasmussen
Well, I think we got part of the apple. I mean, there were some things that most expected would have been part of this package. So allowing REH's to have 340B access to medications. And certainly that part dramatically would help serve communities. Also looking at some type of cost based reimbursement for rural EMS, that's a real challenge that we have as well, that we oftentimes forget about. You know, the swing bed challenge...

00;17;45;04 - 00;18;06;22
Rich Rasmussen
I mean, most of the hospitals that have stepped back and trying to analyze whether they do it or not, was the question of losing that cost based reimbursement for swing beds. And I think if we could fix some of those and maybe we can look at too at some of the issues around distinct park units within these facilities as well, because if we look at behavioral health alone, there's nobody immune from the behavioral health challenges that we have in this country.

00;18;06;22 - 00;18;26;14
Rich Rasmussen
And it's in every stretch of our communities. And so to ensure that we could have a model that not only survives but thrives in these rural communities, I think that's something for Congress to look at. It does not appear that CMS can allow any of these things happen without a statutory change. So I think there's an opportunity for a glitch bill to make the REH even much more effective.

00;18;26;21 - 00;18;36;09
John Supplitt
Let's touch on commercial insurers. We've talked about Medicare and Medicaid, but what's been the response from commercial insurers in terms of this new model of payment and delivery?

00;18;36;15 - 00;19;01;24
Christina Campos
There's such a lack of understanding about REH, and are you a hospital or you're a clinic? We're not a clinic or a hospital. They never heard the definition. They have no idea what it is. So a lot of our contracts with commercials, we kept exactly the same on the outpatient side for ER services or OBS, but we are at least trying to reach out to them to educate them on the new designation.

00;19;01;25 - 00;19;31;18
Christina Campos
There were issues around the taxonomy number that, you know, we kept the same, NPI, so that wasn't the issue. But there is no taxonomy for REH yet that I know of. So we're using an old taxonomy number for rural provider. Where we have seen some challenges is around Medicaid. That it shouldn't be a problem. Some states today have been approved their waiver or their SPA has been approved quite easily to extend their OPPS payments to the REH that they already had in place as a subcommittee provider.

00;19;31;21 - 00;19;42;13
Christina Campos
But right now, we're just trying to iron their out to make sure, because it's not just the payment. The base payment is the Medicaid supplemental payments that if a hospital loses them, would be just very difficult to overcome.

00;19;42;14 - 00;19;43;07
John Supplitt
Yeah. Rich, your thoughts?

00;19;43;07 - 00;20;03;01
Rich Rasmussen
We're fortunate that two of our conversions are tied to larger systems. And so you have the strength of that system and working with payers. But I do think those that are exploring this, that's certainly something to take into consideration. I do know that, you know, we still struggle even with the REHs is like the rest of the nation on the Medicare Advantage plans.

00;20;03;03 - 00;20;23;18
Rich Rasmussen
So that's something we're gonna have to continue to work on. But I did pick up from one of the conversations from one of our administrators, or one of our REHs had indicated that they will receive or they did receive new CCN numbers, and they had to attach those to their REHs. So for those who are considering this, making sure that you do all of this, you know, work at ahead of time, you just kind of like a tabletop.

00;20;23;23 - 00;20;49;00
Rich Rasmussen
What do we need to do? And if you need to bring in some consultants to help you, I know there are a number of them that are out there, but making sure you get it all right because you can't afford to have some of these things disconnected. And I say that because our first REH that did this because they were either first or very close to the first to the with CMS on this, they were approved very early on, I believe it was in April of last year and they didn't get paid till September by CMS.

00;20;49;05 - 00;21;01;15
Rich Rasmussen
My understanding CMS has gotten better on this. So it was just kind of a learning curve for everyone. But for a small community where you're vulnerable financially, making sure you have all of this played out ahead of time, I think is going to be very important.

00;21;01;20 - 00;21;21;12
John Supplitt
Well, there's much to learn. I think we've learned a great deal in the process that's gone by so far. The interest continues to build, whether the consultants agree or not, that interest is continuing to build. And there's been a lot of momentum. And I think as we see some of the tweaks to the legislation, that momentum is going to continue to grow.

00;21;21;14 - 00;21;50;19
John Supplitt
I want to thank my guests, Christina Campos, CEO of Guadalupe County Hospital in Santa Rosa, New Mexico, and Rich Rasmussen, CEO of Oklahoma Hospital Association. Your perspectives on rural emergency hospitals as a new model of payment and delivery are greatly appreciated. And as this model continues to evolve, we'll be looking to you and your colleagues for continued insights into what works and how we can make this model better for patients, hospitals, and the communities we serve.

00;21;50;21 - 00;22;00;11
John Supplitt
I'm John Supplitt, senior director of Rural Health Services. Thank you for listening. This has been an Advancing Health podcast from the American Hospital Association.

00;22;00;13 - 00;22;08;23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;21 - 00;00;46;17
Tom Haederle
Community health workers are a bridge between social and clinical care and serve as an invaluable part of the workforce for hospitals and health systems. They provide essential outreach, education, informal counseling, social support, and advocacy to populations dealing with unmet social needs - vital services that often go beyond the professional scope of clinical care teams. In New York City, Montefiore has taken its appreciation for community health workers to a new level, creating an Institute to standardize their training and ensure that the patients it serves are getting the best possible care in the hospital and beyond.

00;00;46;19 - 00;01;10;26
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Montefiore's Community Health Worker Institute was launched in the summer of 2021 as an expanded investment in how the health system recruits, trains and integrates community health workers into clinical care teams where they offer needed expertise in dealing with social determinants of health.

00;01;10;29 - 00;01;39;16
Tom Haederle
In this podcast, Rebecca Chickey, senior director of Behavioral Health, Clinical Affairs and Workforce with AHA, speaks with two experts from Montefiore about how its Institute is achieving its goals by improving access to health care for disadvantaged populations. Renee Whiskey- Lalanne is director of community partnerships at the Community Health Systems Lab at Montefiore's Albert Einstein College of Medicine, and her colleague, Dr. Kevin Fiore, is vice chair of community health and engagement.

00;01;39;18 - 00;01;41;08
Tom Haederle
Let's join them.

00;01;41;10 - 00;02;07;07
Rebecca Chickey
Thank you, Tom. It's an honor today to be here with two wonderful experts from Montefiore. Kevin and Renee, thank you for your time and most importantly, your willingness to share your expertise. So my first question to you today, can you describe Montefiore's Community Health Worker Institute, specifically why it was created and how long it's been in existence.

00;02;07;08 - 00;02;09;21
Rebecca Chickey
Renee, I think I'll turn that one to you.

00;02;09;23 - 00;02;31;22
Renee Whiskey-LaLanne
Thank you Rebecca. We officially launched in July of 2021, and so our first patient in June 2022. But I think it's important for us to just talk about our history with working with community health workers. Montefiore-Einstein has worked with community health workers since the 1970s. And in various models

00;02;31;25 - 00;03;01;27
Renee Whiskey-LaLanne
mostly in in part working with community-based organizations to employ community health workers and work in partnership with our system to serve our patients. But this institute is really a new approach. This is a new standardized, full investment. And to standardizing how we recruit, train, professionalize and integrate community health workers onto clinical teams to help address health related social needs for our patients.

00;03;01;29 - 00;03;31;28
Renee Whiskey-LaLanne
The model is really a solution to a problem that our health system has. We don't really have expertise or haven't in the past had expertise on clinical teams for how to address these social needs. And we see community health workers as a premium solution, for how we do that, but also as an investment in workforce. It's really working with community members to solve a problem and working alongside them to professionalize them and grow the health care workforce within our system.

00;03;32;00 - 00;03;55;21
Rebecca Chickey
Wow. Not only have you been at this since the 1970s, but now you are refining, enhancing, and expanding the work. That is great, and it's also a heavy lift. So, Kevin, I'm going to turn to you and say, so where did you start on your journey to create this program? What were some of your first steps for those who might want to follow in your footsteps, and how was hospital leadership involved?

00;03;55;23 - 00;04;32;04
Kevin Fiori, M.D.
It's a great question, Rebecca. And I would say you just to follow up a little bit on what Rene mentioned. We've learned a lot as a health system on how to do this well, and also some of the mistakes that we've made in the past. And I think one of the big things that we've learned and really initiated, sort of the genesis of this, this newer version of community health workers within our health system is the idea that, you know, we wanted to think about a workforce that could support a family unit.

00;04;32;06 - 00;04;57;09
Kevin Fiori, M.D.
And what I mean by that, a family unit who doesn't look at our health system as internal medicine, pediatrics, you know, obstetrics and gynecology, but really is coming to our health system. And so we needed a way to have a workforce that could follow families and support families across these silos that we have just by the nature of medicine, of clinical medicine.

00;04;57;11 - 00;05;23;08
Kevin Fiori, M.D.
So what happened was, you know, in the wake of the acute start of Covid in New York City - and the Bronx was a place that got hit particularly hard -we saw an immediate need to do a better job in terms of supporting families who had these unmet social needs. We had social needs before Covid started, of course, in Bronx County, New York.

00;05;23;10 - 00;05;46;11
Kevin Fiori, M.D.
But in the immediate wake of Covid, you know, we just saw a dramatic shift. And so that initiated a conversation with, our health system leadership about, you know, we need a new approach. How are we going to deal with this week? We already have, you know, overwhelmed clinical teams with our nurses, our social workers, our clinicians.

00;05;46;13 - 00;06;13;00
Kevin Fiori, M.D.
And so just adding to the list of things that they do was not an acceptable, you know, solution. And so we really looked at what are the assets that we already have in our community, and you don't have to look very far in the Bronx, you see, because they come into our clinics, patients who have amazing, you know, expertise in how to navigate sort of the existing resource landscape.

00;06;13;03 - 00;06;31;07
Kevin Fiori, M.D.
And so the idea was, well, how can we better integrate them within our health system. And we knew to be able to do that, we had to have a centralized structure. That was an idea that we pitched to our chief medical officer, Andrew Racine. And, you know, his response was, what do you need? You know, how can we do this?

00;06;31;08 - 00;06;53;28
Kevin Fiori, M.D.
How do we invest in this? And so that, you know, that journey started in 2021. And the other thing I'll say about where our journey started is we were thinking about this as we needed to develop a program that could be scaled across our enterprise. So we were not looking to set up a one clinic, one practice, one hospital solution.

00;06;54;01 - 00;07;08;20
Kevin Fiori, M.D.
But how does a health system integrate this workforce across our enterprise, in hematology, in pediatrics? And so to do that, we knew we needed a centralized structure.

00;07;08;23 - 00;07;37;08
Rebecca Chickey
You just said several phenomenal words: scalable, coordination, pushing down silos. And I think you used it that the term integration of this individual who is going to support the family unit. All of those are, I think, things that every hospital and health system aspires to. So each of us may approach it in a different way, but this community health worker training program sounds phenomenal.

00;07;37;10 - 00;07;58;24
Rebecca Chickey
You also mentioned the term investment. And so my next question and Kevin, I'm going to stick with you for a moment: Is this program, this training program of community health workers, is it financially viable? Because the reality is no margin, no mission. And so, how have you been able to support and begin to scale this work?

00;07;58;27 - 00;08;26;24
Kevin Fiori, M.D.
It's a great question, Rebecca. And I think it is probably a central question. And it was the first question that we asked when we started. Just to take one step back, I have been involved with setting up a community health worker programs across the globe for the past 20 years. And my observation is that what we usually do is we just try to put the program into place and think about, like, how are we going to pay for it afterwards? There's immediate need,

00;08;26;24 - 00;09;03;20
Kevin Fiori, M.D.
there is a fire. Let's grab a bucket of water and put it out. And we didn't do that this time around. And so, what we did was we thought through, okay, what are the kinds of things that we think our CHWs will help our health system do better? And our initial focus was looking at missed primary care appointments. We had seen in our data that patients who endured health related social needs, they were missing more appointments than patients that did not.

00;09;03;22 - 00;09;22;23
Kevin Fiori, M.D.
And that missed appointment is a fixed loss for our health system. It's bad for the patient. They don't get the care that they need. In addition, another patient doesn't get the care that they need as well because we usually can't rebook that appointment right away and we lose, you know, $200 or $300 every time that happens because of our fixed costs.

00;09;22;26 - 00;09;50;12
Kevin Fiori, M.D.
So we model the program thinking through how many missed appointments could a community health worker program, a high functioning community health worker program...could it avert? And we started developing the business case for CHW's. So this is in 2021. And then we had some great policy changes that happen in New York State this year, whereby CHW services are now reimbursable under Medicaid.

00;09;50;15 - 00;10;17;28
Kevin Fiori, M.D.
And there's also a program within Medicare. And so we are now because these reimbursement options are new, we are not putting that into our business model as well. And thinking through both in terms of just the reimbursement revenue that we could anticipate from this, the services that CHWs are providing, but also the reduction in waste and costs and improvement in care that the CHW workforce could provide as well.

00;10;18;01 - 00;10;38;24
Kevin Fiori, M.D.
So we're looking at all these things, and we actually believe that CHW programs are viable. And not only they're viable, they're probably essential because whether we like it or not, our patients are coming to us with these health related social needs. So the question becomes, well, it's affecting our ability to take the best care of a patient. Who on are our team

00;10;38;24 - 00;11;05;09
Kevin Fiori, M.D.
do we want doing this? Do we want the MD to take up the little bit of time that they have, to do this, or do we want to take someone who already has expertise because of the shared lived experience with patients? Because they've navigated some of these services themselves. Bring that onto our team. And it's just a much better business option.

00;11;05;12 - 00;11;16;13
Kevin Fiori, M.D.
So it checks both boxes. It's both in our what we think is the most effective strategy for navigating social service services, but it's also the most cost effective.

00;11;16;15 - 00;11;40;05
Rebecca Chickey
That's exceptional. You are singing a song that I love. You know, you planned, you looked at the cost avoidance opportunities. And there probably many more that you didn't mention, reduced readmissions, reduced visits to the emergency department, and then even reaching out improved productivity for that individual or their family members in their own workplace.

00;11;40;07 - 00;11;51;24
Rebecca Chickey
The savings can abound with this type of work. It's just often hard to quantify. Renee, can you share some of the other key success factors to making this training program work and grow?

00;11;51;26 - 00;12;04;02
Renee Whiskey-LaLanne
There are a couple critical key elements that we have to think about. And one was really making sure that we had a clear, established, standardized workflow, one that would be easy to implement.

00;12;04;04 - 00;12;25;20
Renee Whiskey-LaLanne
One that we could clearly establish who's doing what and how and how best to work with your community health worker on your clinical team. And those workflows can really be adapted based on the clinical setting. And so if you're working in the cancer center or you're working in primary care, you know, you can make adaptations based on the clinical context.

00;12;25;22 - 00;12;51;20
Renee Whiskey-LaLanne
But it really helps set the guidelines and baseline for how we're going to do the things that we say we're going to do. The other is we're working very closely with identified provider champions who really help us push this work forward. They help us as problem solvers on the clinical care team. Most of our clinical teams are not really familiar with how to work with community health workers, or what the community health worker role is.

00;12;51;23 - 00;13;12;13
Renee Whiskey-LaLanne
And so we identify these provider champions. We educate them first, and they help us pass the message and really endorse why we're doing this and how best to work with this new member of the team. The other things I think are really important are one, we use data to inform what we're doing. So we want to know of all the data we're collecting

00;13;12;13 - 00;13;44;10
Renee Whiskey-LaLanne
how does this data tell us what we're doing well and what areas we need to improve in. And we use that as a springboard to help improve our program as we grow and we continue to implement. And last but certainly not least, is our work around partnerships. From the very beginning we're thinking about how can we work with community-based organizations, health care training organizations and pipeline programs to really help us identify how we recruit the right types of community members to fill these roles.

00;13;44;13 - 00;14;05;12
Renee Whiskey-LaLanne
How do we best train our community health workers? How do we optimize what they're doing? And how do we provide the best service delivery? And so partners are really working with us from the inception, straight through implementation. And I think that is the really critical part of this, is to have that feedback and continuous improvement mindset.

00;14;05;15 - 00;14;28;08
Kevin Fiori, M.D.
If I can, I just want to add to something that Rene said. We were very deliberate and are still very deliberate about taking a learning health system approach, knowing that, you know, we we're not going to get this perfect at the start. And we still don't have a perfect implementation. And we know that there's always an opportunity for improvement.

00;14;28;11 - 00;14;43;04
Kevin Fiori, M.D.
But the way that one does that, you know, in our our teams mind is we need data. We need data to understand where we're doing things well. But more importantly, we need data to understand where we're not doing well.

00;14;43;07 - 00;15;03;10
Rebecca Chickey
So I think in your own words, you just described, a sort of a performance improvement process, because there are going to be mistakes. And, and that's actually a good thing because, I can't remember who said at first, but apparently we learn more from our mistakes than our success. And that's what science is all about.

00;15;03;10 - 00;15;28;08
Rebecca Chickey
So thank you for, reinforcing the value of data, and taking action from the data when you identify something that can be better than it was. As we, go to the last question and wrap up today's podcast, I want to focus in on what do you want for all of those people listening to this podcast. If there were three things to take away

00;15;28;10 - 00;15;34;17
Rebecca Chickey
what would you want them to remember to leave with the listeners as we close this out?

00;15;34;20 - 00;15;57;09
Renee Whiskey-LaLanne
So three things is hard. But I will start with, I think the first is, you know, integrating community health workers into clinical teams is really critical. That's number one. It's also very challenging and it requires the appropriate amount of investment. So I think that would be my first takeaway.

00;15;57;11 - 00;16;32;16
Renee Whiskey-LaLanne
The second is there are some things that we've learned that are key elements of success, that are agnostic of setting. So it doesn't matter whether you have a community health worker here at Montefiore-Einstein or at another institution down the road. I think you have to think about one, clearly defining what the role is, establishing clear guidelines and workflows around how you're going to, utilize your community health workers and integrate them into teams and establish that communication between them and everyone else on the team so that this works well.

00;16;32;18 - 00;16;48;22
Renee Whiskey-LaLanne
Setting up a foundation for appropriate training, supervision, mentorship and coaching, and making the business case for why it is a valuable investment to have a community health worker, a local expert on clinical care teams.

00;16;48;24 - 00;17;16;24
Kevin Fiori, M.D.
I think as health systems, we need to just think about there is enormous potential with this workforce and actually acknowledging the expertise that our communities bring to health service delivery. But it's not a just, you know, let's put out a job description for CHWs ...community health workers...and some kind of magic happens once you hire them. Really takes some investment and take structures

00;17;16;26 - 00;17;22;06
Kevin Fiori, M.D.
and that's something that we're absolutely committed to. And we're seeing the benefits of that.

00;17;22;08 - 00;17;45;00
Rebecca Chickey
Thank you so much, Kevin and Renee. This was exceptional. For those listening in, I just want to let you know, of course this will be on AHA's Advancing Health channel. And, we will do our best to embed a couple of stories, which is where I learned about this wonderful program because they've been recognized as leaders in this field.

00;17;45;00 - 00;18;10;09
Rebecca Chickey
And I want any of the listeners who want more information on this wonderful program that you have to have the most available. So we'll get that posted with. So thank you for listening today. Thank you Kevin and Renee for sharing this journey. And best of luck as you continue to invest, train and mentor this important component of whole person care.

00;18;10;11 - 00;18;11;20
Rebecca Chickey
Thank you.

00;18;11;23 - 00;18;20;02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;24 - 00;00;30;24
Tom Haederle
Many health care providers have an equally important caregiving job at home. They’re moms, dads, and parents to young children. As the health care field continues to experience workforce shortage issues, hospitals need to ask themselves, what will it take to prevent burnout and keep new parents, and especially moms in the health care workforce?

00;00;30;26 - 00;00;53;01
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this final episode of the award winning series Beyond Birth, we're exploring how health care organizations can better support new parents to enable them to thrive at work and at home.

00;00;54;19 - 00;01;25;18
Michelle Yu
So prior to having kids, I was super invested in my career. And it's not to say that I'm not invested now. I think it's more so that it really defined me and I loved it. I loved my clients. I loved my career. It was a lot of fun. And in hindsight, I realized that my self-worth was very much enmeshed with myself as a professional.

00;01;25;20 - 00;01;38;20
Michelle Yu
That was my value that I brought to the world, and without it, I really wasn't sure what value I had. Now that I can look back and reflect, I was really trying to operate in the exact same way as I did before.

00;01;43;13 - 00;02;06;17
Yara  Mikhaeil-Demo, M.D.
Before becoming a mom, I was very into my career, right. Like I would stay until 9:00, 10:00 p.m. I didn't really have. I mean, I was married, but running home was not my top priority. Writing that paper or seeing the next patient was really my top priority. And then suddenly, like, I had drop off times and pick up times at daycare, and I had sick days and I had to navigate all of that.

00;02;06;20 - 00;02;20;03
Yara  Mikhaeil-Demo, M.D.
And that's when I was like, this is not just a me problem. This is every working woman in general, all parents, to be honest with you. Because a lot of times now, the dads are also the primary childcare provider.

00;02;20;05 - 00;02;42;24
Julia Resnick
There are 24 million working moms in the United States. You just heard from two of them, Michelle Yu and Dr. Yara Mikhaeil-Demo. Both are professionals in the health care field and moms of young children. Dr. Mikhaeil-Demo is an assistant professor of neurology at Northwestern's Feinberg School of Medicine, as well as a physician well-being coach. Michelle is the co-founder and CEO of Josie.

00;02;42;27 - 00;03;07;26
Julia Resnick
They guide new parents in making the transition into working parenthood through mental health support and other services. I'm Julia Resnick, director of strategic initiatives at the American Hospital Association. In this final episode of the Beyond Birth series, we'll be exploring how health care organizations can support new parents in their workforce. Health care field is experiencing an ongoing provider shortage that is projected to only get worse.

00;03;07;28 - 00;03;39;17
Julia Resnick
The Bureau of Labor Statistics projects that the country will face a shortage of nearly 338,000 nurses and 140,000 physicians in almost all specialties by the year 2036. And while female medical students outnumber their male peers, they are leaving medicine at a higher rate, particularly after having kids. Adding to that, eight in ten health care workers are women. Fostering a sustainable healthcare workforce necessarily has to include addressing the needs of moms and parents. During May

00;03;39;18 - 00;04;01;24
Julia Resnick
we observe both Women's Health Month and Mother's Day, so we're recognizing the dual provider roles played by many people in the health care field. Their medical professionals and parents will be discussing what it takes to create an environment where new parents can do what they love at home and at work. Michelle and Yara, who you heard from at the top, both have intense health care careers.

00;04;01;26 - 00;04;08;27
Julia Resnick
I asked them what it was like going back to work after becoming a parent. Hear what Michelle had to say about her return to work.

00;04;08;29 - 00;04;34;16
Michelle Yu
When I was transitioning back to my big career after baby, I faced a lot of mental emotional challenges and also career related challenges. A lot of questions around, you know, how do I view myself now as a professional and what are my goals? And how do people view me? Did that change at all, and if so, how do I navigate that?

00;04;34;19 - 00;04;57;21
Michelle Yu
And I just had a hard time kind of finding my stride in working motherhood. And I asked other parents. I started to ask other parents if they felt the same, because this is something that I never talk to others about before. And I quickly realized that I was not alone. And that's when I decided to also start doing some research about just becoming a working parent

00;04;57;21 - 00;05;27;12
Michelle Yu
today, and I quickly found that it has shifted a lot in just the last few decades. There's everything from more dual income households. There's more women in the workforce than ever. There's changing family structures, single parent households, blended families, multiracial families. People are also delaying having children, until they are further along in their careers. So what that means is they're going back to these really big roles after baby, and that could be a lot of pressure.

00;05;27;14 - 00;05;56;24
Michelle Yu
One of the things that stood out to me the most is there was a 2019 University of Michigan study, and it found that 4 in 10 female physicians will either scale back or leave their careers entirely within six years of residency. That is really shocking, considering how much time is invested in becoming a physician. And there's also been a few more studies that I've seen, particularly on nurses, especially around, retention for those with children under the age of five.

00;05;56;26 - 00;06;18;18
Michelle Yu
I think that speaks to health equity issues as well. And so I love how some of your prior guests have said that health equity is so important in the perinatal period, and you can't have health equity without a diverse health care workforce, and you can't have a health care workforce that's diverse without women.

00;06;18;21 - 00;06;36;12
Julia Resnick
Yara has had to navigate her new life as a physician mom. And with that comes a multitude of questions. How do you navigate the pressures? What about the time commitments of medicine, all while being a new parent? She certainly isn't alone in facing those challenges and shared her experience with me.

00;06;36;14 - 00;06;56;09
Yara  Mikhaeil-Demo, M.D.
So how do we make coming back to work easy? How do we make that transition easier so that we don't feel like we're alone or isolated? I think there's a lot of isolation that comes with coming back to work, struggling with a newborn, and trying to function at the same level that you had before. Without just slowing down and noticing the difference.

00;06;56;11 - 00;07;23;15
Yara  Mikhaeil-Demo, M.D.
I think that the biggest thing is community. Having group programs for women who are parents, I think is huge. I've led two different, group, of women physicians. and just sharing the experience, sharing the struggle, normalizing it, realizing that we're not alone is huge. One thing that I did was one of the groups was we wrote mission statements about our roles as moms and our roles as physicians.

00;07;23;18 - 00;07;40;10
Yara  Mikhaeil-Demo, M.D.
And every time we have that mom guilt, we can go back to the mission statement and be like, overall, I am meeting my mission statement. If I was five minutes late to pick up, it's not a big deal, right? But trying to take a step back, see the big picture rather than focusing on the small things that we're not doing.

00;07;40;12 - 00;08;03;19
Yara  Mikhaeil-Demo, M.D.
So I think just having that group dynamic where people can come together and share is important, but then also having some guidelines and policies in place to account for that. So my biggest stressor, for example, was childcare. Like unexpected sickness or school closures or things like that. How do you have a policy that allows for, you know, things like that when you have a last minute cancellation?

00;08;03;22 - 00;08;20;16
Yara  Mikhaeil-Demo, M.D.
How do you allow for promotions not to be affected by maternity leave, or by the time that you spend pumping, for example, when you come back? How do you account for that when it comes to productivity? There's a lot of things that systems can do to help parents, especially new parents.

00;08;20;18 - 00;08;34;29
Julia Resnick
So now that we understand the pressures that moms in health careers are facing, what can healthcare organizations do to support their team members that are new parents? Yara and Michelle proposed some minor changes that would make a huge impact on working out.

00;08;35;01 - 00;08;56;29
Yara  Mikhaeil-Demo, M.D.
I think there is a huge push now and understanding of how many new parents struggle. there are support groups that are on system that account for productive for leaves, that block time for parents, for a woman that choose to pump and things like that. Just keeping in mind parents when making decisions. Simple things as meeting times, right?

00;08;56;29 - 00;09;30;03
Yara  Mikhaeil-Demo, M.D.
Like sometimes we have 7:30 meetings or 5:00 p.m. or 6:00 p.m. meetings. And if you have to pick up your, you know, your child, having a virtual option really makes a big difference, right? Like you're still involved but can also able to pick up your child. Or noticing the need for community and providing space for that. We have a program called Ignite where right now I'm leading a woman physician group where we meet once a month and is sponsored by the hospital, and we pay for our meal and we get to talk about our struggles and how are we approaching our days and how can we get better.

00;09;30;06 - 00;09;46;04
Yara  Mikhaeil-Demo, M.D.
So just I think creating that community and encouraging it and also making decisions with the struggles in mind. I think most leaders want to make a different, but just taking the parents voice in consideration when making decisions will be really helpful.

00;09;46;07 - 00;10;13;10
Michelle Yu
Community is just key here. And also just the small things like the meeting times. Yara I hear that all the time. The other thing I will say is I actually recently spoke with a physician executive at UC Davis Health, and this person pointed out to me that there was a study by physician moms group that found nearly 40% of physician moms returning from leave will experience exclusion from administrative decision making or important projects.

00;10;13;12 - 00;10;47;26
Michelle Yu
So I think the other thing here to note is manager and supervisor awareness and training to ensure that they play, because they play such an important role in that individual's overall experience, and making sure that they're equipped to support them. So particularly for clinicians who may have responsibilities outside of direct patient care, you know, having a manager proactively reorients you back to work and take the care to re-onboard you after the return from leave.

00;10;47;28 - 00;11;05;26
Michelle Yu
And also being able to proactively invite you back into those meetings where those decisions are being made. And it's one thing to have you say like, oh, can I go back to this meeting? They're not in my calendar anymore. Versus someone actually saying, hey, we really missed you during these meetings and you bring such an important voice to the table.

00;11;05;29 - 00;11;26;24
Michelle Yu
I'm going to ask that you come back and we'd love to have you join us or something like that. You know, that just that tone that approach is so different. And then on the clinical side of things, I interviewed a few clinicians recently about their struggles and their return to work and something that, especially in primary care, happens is that you're missing this window of time to see your patients when you come back.

00;11;27;02 - 00;12;01;26
Michelle Yu
Sometimes you're taking on their emotions as well, on top of your own emotion, emotions, and your mental and hormonal changes. One primary care physician said that she experienced from her patients, abandonment issues, where they felt they were abandoned by them during that maternity leave. And so just making sure that your workforce is aware of any mental health supports or emotional supports and helping them maybe on-ramp back in a more measured way, so that they can kind of take that on, more slowly.

00;12;01;26 - 00;12;27;08
Michelle Yu
could be really, really helpful. And there's also, policies around blocking time. However, that being said, that doesn't necessarily account for some of the cultural aspects of that actually happening. I.e., is the pumping room actually close enough for me to get to so I can pump in the break time that I have. And as my team and my supervisor support me in taking that time off.

00;12;27;12 - 00;12;49;08
Michelle Yu
1 in 3 physician moms actually face discrimination when it comes to breastfeeding and pregnancy. So again, being able to train your supervisors to know that this is protected time. And then it's important to the organization that you all feel that way. That's part of your values as an organization is so important. And then being able to actually get there and use those spaces is also important.

00;12;49;11 - 00;13;05;10
Julia Resnick
Cultural changes around returning to work after pregnancy need to be ingrained across health care organizations, and new parents should feel empowered to ask for what they need to feel supported. Yara and Michelle shared stories from their own lives of what this looks like in action.

00;13;05;12 - 00;13;20;14
Yara  Mikhaeil-Demo, M.D.
I would say I was lucky when I came back, I think was my second child. My biggest stress was pumping like Michelle was saying. Where am I going to pump? How am I going to pump? And thankfully my my team was like, okay, we're going to block like you tell us what times you want to block and we'll block it.

00;13;20;14 - 00;13;41;21
Yara  Mikhaeil-Demo, M.D.
And I wasn't asked or expected to like make up the time or, or place anything like that. I've heard stories of clinicians being asked to stay extra later or come earlier to make up for the time that they blocked in clinic, which I think is just too much to add to a new parent. so I think this has been really helpful.

00;13;41;22 - 00;13;59;18
Yara  Mikhaeil-Demo, M.D.
I've heard a lot of women now being empowered to really ask for what they need when they come back. Whether it is, like Michelle was saying, graduated duties and you're not, you know, on call your first week in back or you're not on a full panel your first week back. but more and more parents are actually becoming more empowered to ask for what they need to make it work.

00;13;59;21 - 00;14;27;22
Michelle Yu
And I would say there's a lot of organizations outside of health care that I think health systems can learn from in terms of small and actually low hanging fruit, ways to support working parents that don't require significant amounts of investment. One of those things, like I said earlier, we just work with a company, a financial services company, in training their managers on just understanding what are some of the challenges new parents go through when they have a new baby.

00;14;27;25 - 00;14;52;29
Michelle Yu
What are some biases to watch out for. What are some things you can say to show your support. And what are some things maybe you shouldn't say. to someone who may be going through that. That was something that they had. Once they can record it, they can share it with others in the organization. And it's small things like that that I think really signal that you care and that you really want to see a cultural shift.

00;14;53;02 - 00;15;15;02
Michelle Yu
My husband actually works for a bio-tech company, here out in D.C., and they actually have parking spots, for pregnant women, that are a little bit closer to the building, to support them. They also have an on care daycare facility that is has just been such a lifesaver for so many of the team members there.

00;15;15;02 - 00;15;28;01
Julia Resnick
Much like working moms, health care organizations have lots of priorities to juggle. So Michelle and Yara each offered a simple action hospitals can take to change the culture to better support new parents.

00;15;28;03 - 00;15;49;23
Yara  Mikhaeil-Demo, M.D.
I think having a committee of parents to brainstorm ideas that are relevant to that organization would be helpful because I think every organization is unique and different, and academic is different than private practice and different than community practice. But having that be part of their mission, like we're going to include parents, we are going to have a committee, their voice will be heard.

00;15;49;26 - 00;15;51;21
Yara  Mikhaeil-Demo, M.D.
I think that will be helpful.

00;15;51;23 - 00;16;17;02
Michelle Yu
This is really hard to pick one thing, but if I had to choose one thing, I think it would go back to that supervisor manager training component and being able to support them and equip them with understanding how to be more empathetic to this population and how to show your support for this population, how to get creative and solutioning with this population.

00;16;17;02 - 00;16;33;29
Michelle Yu
How to navigate all the tricky scenarios that come with it is one thing that I think a lot of health systems, who probably already invest in a lot of training, to just leverage what you already have and do something in this particular area.

00;16;34;01 - 00;16;55;22
Julia Resnick
A big thank you to Michelle Yu and Yara Mikhaeil-Demo for sharing your expertise and passion for supporting working moms. Your work is paving the way for future moms and parents in health care. We appreciate your dedication to making it better for everyone. This is our last episode of Beyond Birth, but don't worry, we'll continue to cover important topics in maternal health.

00;16;55;25 - 00;17;13;06
Julia Resnick
You can listen to all of our previous Beyond Birth podcasts on the Advancing Health Channel wherever you get your podcasts. And for more resources on maternal health visit www.aha.org/betterhhealth formothersandbabies.

00;17;13;08 - 00;17;21;19
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00;00;00;28 - 00;00;27;14
Tom Haederle
Ask any hospital leader to name the biggest challenges facing their organization, and their answers are pretty much the same, regardless of size. But for rural care providers, the workforce and financial issues found everywhere are harder to solve, and they're looking to their boards of trustees for help.

00;00;27;17 - 00;00;49;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Join us for this brief but on-point discussion of the role board members can play in helping their hospitals and health systems navigate today's pressing problems, and how the AHA's resources and educational materials can assist board members in turn.

00;00;49;23 - 00;01;12;28
Sue-Ellen Wagner
I'm Sue Ellen Wagner, vice president of trustee engagement and strategy for the American Hospital Association. I'm here at the AHA Rural Conference in Orlando, Florida with Barbara Sowada, who's the president of the board of trustees for Memorial Hospital of Sweetwater County in Rock Springs, Wyoming. Barbara, thank you for joining me today.

00;01;13;00 - 00;01;16;14
Barbara Sowada, Ph.D.
Thank you for inviting me. It's a pleasure to be here.

00;01;16;16 - 00;01;23;02
Sue-Ellen Wagner
Barbara, can you highlight the top three challenges that rural hospital boards are experiencing?

00;01;23;05 - 00;01;58;16
Barbara Sowada, Ph.D.
Obviously, workforce stability, including physician recruitment. That is difficult in rural areas. The financial challenges Medicare and Medicaid do not cover the cost of care right now. And then the commercials are, what should I say,  providing their own challenges with pre-authorization and denials. The other part with the commercials is we're just starting to experience in Wyoming narrow networks through Medicare Advantage.

00;01;58;18 - 00;02;18;00
Sue-Ellen Wagner
Thank you for citing those challenges that we've heard at the conference a lot about the financial and the workforce challenges. So given the challenges that you just talked about, rural hospitals do serve a tremendous value to their communities, and trustees represent these communities. So can you expand a little bit more on that?

00;02;18;02 - 00;02;49;06
Barbara Sowada, Ph.D.
Yeah, the challenges, as you know, the no mission, no margin or no margin, no mission. One of the tricks anymore is to find that balance between what is affordable and what are the community's needs. One of the things that I forgot to mention, but is a challenge nationwide, is behavioral health. And again, in rural areas that I don't know whether it's worse in some areas of the country

00;02;49;06 - 00;02;57;03
Barbara Sowada, Ph.D.
yes, mental health is more challenging than in the urban areas. And again, it's a dearth of resources.

00;02;57;05 - 00;03;15;00
Sue-Ellen Wagner
Absolutely. Yeah. We hear a lot about the behavioral health challenges. My colleague Rebecca Chickey spearheads the behavioral health issues for AHA And we do a lot of collaboration with her. So what can AHA trustee services do to help boards, specifically the rural boards?

00;03;15;02 - 00;03;46;01
Barbara Sowada, Ph.D.
I think the things that you are doing right now, the continuing education...the newsletters...you have a fabulous webinar archival board, the education is fabulous. What was really fun today, is one of the AHA - and I cannot remember her name - employees is working with our hospital to become critical access. So your resources are widespread and greatly appreciated.

00;03;46;07 - 00;04;11;11
Sue-Ellen Wagner
Oh that's good to hear. We aim to help our members. Our website is trustees with an "S" trustees.aha.org. As Barbara mentioned, we do have a wealth of information, including some boardroom briefs, which are 2 or 3 pagers, which also includes some questions that board members can ask about specific issues. We do have a brief on behavioral health, so I encourage folks to listen to that.

00;04;11;14 - 00;04;25;27
Sue-Ellen Wagner
As Barbara mentioned, we do have some great recorded webinars on quality and some other issues. Anything else you want to talk about, Barbara? Maybe something at the rural conference that you learned about or heard about that could be helpful to our listeners?

00;04;25;29 - 00;05;01;19
Barbara Sowada, Ph.D.
One of the things that really delighted me and surprised me are there are several presentations on, I would say, building relationships, having more civil conversations, the need to repair community relationships, sometimes even relationships within an organization. That is part of the focus of this week's conference is truly delightful, and I actually encourage you to do more of that, whether it's written or webinars or what have you, because that communication is just key.

00;05;01;22 - 00;05;11;09
Sue-Ellen Wagner
Well, for folks who weren't able to join us at the conference, hopefully they'll visit our website and utilize some of our podcast and webinars. Thank you for being with us today, Barbara.

00;05;11;11 - 00;05;15;09
Barbara Sowada, Ph.D.
Oh, thank you, Sue Ellen. This is delightful and I love the conference.

00;05;15;12 - 00;05;17;24
Sue-Ellen Wagner
Great. Thank you.

00;05;17;26 - 00;05;26;06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.