Advancing Health Podcast

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Tom Haederle
As many hospital and health system leaders look for solutions to address the root causes of violence in their organizations and communities, some AHA members have already figured out how to make their organizations a safer and more peaceful environment in which to receive care. As we observe AHA's 8th annual #HAVhope today, we look to Pennsylvania-based WellSpan Health to share how the implementation of their Behavioral Health Emergency Response Team has successfully de-escalated incidents of workplace violence by 75% since 2019.

00;00;45;04 - 00;01;11;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this podcast hosted by Jordan Steiger, senior program manager of Clinical Affairs and Workforce with the AHA, she is joined by Dr. Kenneth Rogers, who shares how WellSpan health is leading the way in implementing training and increasing capacity for their team members to respond to situations that could result in violence.

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Tom Haederle
Dr. Rogers is vice president and chief medical officer of behavioral health at WellSpan Health.

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Jordan Steiger
So Dr. Rogers, thank you so much for joining us today. We're really excited to learn more about your work, given that workplace violence is, you know, a problem that a lot of our hospitals and health systems across the country are dealing with.

00;01;30;24 - 00;01;47;12
Kenneth Rogers, M.D.
Yeah, you know, it is a huge issue everywhere. Violence against healthcare professionals is going up substantially over time. And so it is such a huge issue, especially post-Covid, with everybody being frustrated, upset about things. And just on edge.

00;01;47;15 - 00;01;59;00
Jordan Steiger
Absolutely. I know that that will resonate with a lot of our listeners. So before we get started learning about your work, I'd love for you to tell us a little bit about WellSpan Health and just your role within your health care system.

00;01;59;03 - 00;02;29;23
Kenneth Rogers, M.D.
Sure. WellSpan health is a health system with about 20,000 employees. We're located in south-central Pennsylvania. We cover five counties in that area. Comprehensive integrated delivery system in those five hospitals: Behavioral health. We have inpatient services. We have emergency room services. We have Philhaven Hospital, which is a freestanding psychiatric hospital with 137 beds, about total, about 200 beds across the entire system for behavioral health.

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Jordan Steiger
That's great. And what is your role within the system?

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Kenneth Rogers, M.D.
So my role is the chief medical officer for Behavioral Health.

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Jordan Steiger
For Behavioral Health. And you are a physician, correct?

00;02;39;12 - 00;02;41;09
Kenneth Rogers, M.D.
I'm an adult child and adolescent psychiatrist.

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Jordan Steiger
Wonderful. Okay. So I know we're here today to talk about the success that WellSpan has had in de-escalating issues of workplace violence. But before we do that, I would really like to learn just about, you know, your own personal perspective as both a psychiatrist and an administrator. What led you to being so passionate about this work?

00;03;02;17 - 00;03;33;28
Kenneth Rogers, M.D.
So I spent the first part of my career in corrections. A lot of work in juvenile justice. And so one of the things that you learn in juvenile justice is really de-escalation, trying to keep environment safe and really just trying to really think about the environment almost constantly. And so as I progressed throughout my career and working on inpatient child units and in other kinds of settings, you sit there and you look at situations where you're saying that could have been handled so much better.

00;03;34;03 - 00;04;01;05
Kenneth Rogers, M.D.
And a situation escalated that really didn't have to escalate. And one of my positions I had before this was at Parkland Hospital in Dallas. And in Parkland, there was a huge initiative around workplace violence, largely because it's a city-based hospital. There's a mixed population. There's really not a majority population. And so there was a lot of work that was being done in the largest emergency room in the United States around

00;04;01;05 - 00;04;17;29
Kenneth Rogers, M.D.
how do we think about cultural issues? And in those cultural issues, how do we think about workplace violence issues that really arise out of things that people aren't really thinking about, because the perspectives are just so different between the two individuals that often are involved in the situation.

00;04;18;02 - 00;04;29;16
Jordan Steiger
I mean, that makes a lot of sense. I think that context, you know, in the care environment is so important. And I think a lot of this can often arise from just misunderstandings and miscommunications between people.

00;04;29;19 - 00;04;35;02
Kenneth Rogers, M.D.
Absolutely. The vast majority of them are simply misunderstandings or lack of communication.

00;04;35;04 - 00;04;40;05
Jordan Steiger
Right. Which seems like it should be a simple thing to fix, but we know that that's not always the case, right?

00;04;40;12 - 00;04;43;24
Kenneth Rogers, M.D.
When people are stressed, communication is usually the first thing to go.

00;04;43;29 - 00;05;05;13
Jordan Steiger
Exactly, exactly. So since you've been at WellSpan, I think this has been since the beginning of 2019, if I'm remembering correctly. You've implemented what you're calling the Behavioral Health Emergency Response Team, but we'll call it BERT for today because that's a little easier to say. And you've been able to successfully de-escalate workplace violence incidents by 75%.

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Jordan Steiger
Is that right?

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Kenneth Rogers, M.D.
That's correct.

00;05;07;01 - 00;05;11;24
Jordan Steiger
Tell me about that. Tell me how this got started and how you've had such success.

00;05;11;27 - 00;05;37;14
Kenneth Rogers, M.D.
So the BERT team has actually been around for a while. And initially it was a very nursing driven model that really focused on inpatient care and trying to figure out how do we help nurses on inpatient units do a better job. My background is largely from emergency departments. I've spent most of my career working in and out of various emergency departments as a consulting psychiatrist.

00;05;37;16 - 00;06;02;04
Kenneth Rogers, M.D.
And so when I arrived, a thing that became increasingly clear was there were issues on the floor, but a lot of our workplace violence issues were actually happening in our emergency departments. It was happening in places outside of kind of your traditional patient in bed kind of situation, whether it was with families, whether it was with staff members getting into disagreements with each other.

00;06;02;06 - 00;06;22;06
Kenneth Rogers, M.D.
Those are some of the areas where I felt that it was really a problem. And so as we kind of looked at and talked through some of this and we looked at the training we gave a lot of our mental health professionals, we felt like this is something that we could really roll out to the system in general, so that folks had a greater capacity to be able to actually engage in de-escalating situations.

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Jordan Steiger
That sounds great. So it sounds like this is a nursing led initiative, or has that changed at all, as it's evolved over time.

00;06;30;02 - 00;06;48;24
Kenneth Rogers, M.D.
Still tends to be largely nursing driven. for most of the inpatient work. However, in the emergency departments and some of the other areas, there are lots of other people that tend to be more involved, especially mental health professionals. Some of our behavioral health counselors, which are master's level clinicians, that are engaged in a lot of that work.

00;06;48;24 - 00;06;55;15
Kenneth Rogers, M.D.
And so trying to really be more specific based on the areas where people are located.

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Jordan Steiger
That's great. It's always important, I think, to bring up the workforce, you know, because a lot of, hospitals and health systems are struggling with workforce issues right now. So trying to think about who is involved, who it takes to make this successful.

00;07;07;17 - 00;07;08;16
Kenneth Rogers, M.D.
Absolutely.

00;07;08;18 - 00;07;30;12
Jordan Steiger
So you mentioned, you know, the on the floor professionals, those master's level clinicians, those nurses, the people that are really doing this de-escalation. But let's talk about leadership and leadership buy-in. Obviously you as the CMO for behavioral health know that de-escalation works. You know, this is a practice that is evidence based that shows a lot of success.

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Jordan Steiger
But how did you get other leaders in your organization on board with this?

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Kenneth Rogers, M.D.
You know, it really wasn't me trying to get other leaders in the organization engaged. It was the leaders of the organization saying that, Ken, you need to be engaged. Because it becomes increasingly clear, if you're the CEO of a health system, that you've got employees getting hurt. You've got a clear vision that they're folks that their morale is dropping, they're frustrated about coming to work.

00;07;58;16 - 00;08;25;13
Kenneth Rogers, M.D.
They don't find the joy at work anymore, and nobody wants to go to work to be attacked by a patient or a family member. And so that, I think, was the vision that our senior leadership of the organization was seeing. And it was really their vision to say, you know, we need to do what we need to do to figure out how to make our employees feel safe, how to help them and enjoy work and help to send a message that this is a safe place to be.

00;08;25;15 - 00;08;56;04
Kenneth Rogers, M.D.
And so that was where we kind of started this entire process from. And I think the other driver was looking at our emergency departments, which were increasingly busy. We had a lot more boarders at that particular point in time. And as people are staying in emergency departments for, you know, days on end, looking at four walls and you already have some degree of agitation in the background, it leads to issues that you just, you know, shouldn't have in hospitals.

00;08;56;04 - 00;09;05;27
Kenneth Rogers, M.D.
And so there was kind of this buy-in from kind of everybody in the organization from almost day one. This is definitely something that we should address and do something about.

00;09;05;29 - 00;09;29;08
Jordan Steiger
That's great that everybody's on the same page. And I mean, you bring up a lot of really important issues. You know, the joy in work, decreasing burnout, you know, increasing worker well-being. Those are all things that I think we all care about right now, especially as you know, we know that that has kind of ebbed and flowed a little bit over the course of, you know, caring for people through Covid and, you know, kind of this period that we're in right now.

00;09;29;08 - 00;09;37;16
Jordan Steiger
So I think that that's, thinking about this not only from how this benefits your patient population, but also your workforce, I think is really, really important.

00;09;37;17 - 00;09;38;20
Kenneth Rogers, M.D.
Absolutely.

00;09;38;22 - 00;09;50;15
Jordan Steiger
So walk us through maybe a patient situation, de-identified, obviously, but something that sticks out to you that, where this BERT program really was successful.

00;09;50;17 - 00;10;12;05
Kenneth Rogers, M.D.
Sure. I can think of many examples, but I'll give you one that I really think encompasses kind of lots of issues. And this one actually happened on an obstetric service. I had a patient that was there with her family from a Latino background. And if you look at the situation, she spoke relatively good English.

00;10;12;07 - 00;10;39;12
Kenneth Rogers, M.D.
It seemed like she was understanding things, but there was this sense that she was getting increasingly frustrated. And so BERT ended up getting called because she, the husband, the nursing staff, things just seemed to really blow up. She was getting angry, loud, volatile. What's happening here? And so there was a sense that there were risks to the nurses she's about to deliver

00;10;39;12 - 00;11;07;16
Kenneth Rogers, M.D.
so there's risks to the baby. Husband's there, so you know what's really going on? So you arrive in a situation and what was, I think, apparently clear from day one, from moment one, is that you had a person whose English skills weren't great. And so there were pieces of things that she could communicate outward but didn't necessarily fully understand especially in a health care context.

00;11;07;19 - 00;11;31;27
Kenneth Rogers, M.D.
And so some of the health care discussions that were occurring weren't really clear. Her husband was less fluent than she was, and so she was trying to translate things that she was understanding to him, and he really wasn't understanding. And so you had this family that was sitting there frustrating because of lack of communication. And so the intervention had nothing to do with medications or anything.

00;11;31;29 - 00;12;01;00
Kenneth Rogers, M.D.
It had to do with, let's get a translator or someone who is Spanish speaking, to help really work the family through what's happening next so they could become much more engaged and involved in their care and feel more empowered. And so that was actually the intervention that BERT did for that particular day. It seems relatively simple, but it's things like that in a health care context that happen all the time.

00;12;01;04 - 00;12;14;03
Kenneth Rogers, M.D.
People are busy, nurses are busy trying to get things done. Doctors are getting in and out and doing rounds and so people don't pick up on the fact that the patient may not be fully understanding what's going on. So are there things that we can do differently?

00;12;14;05 - 00;12;36;02
Jordan Steiger
I really love that you use that example, because I think oftentimes when we think about, you know, de-escalating situations, we think of a situation of violence. And this is not something that required any kind of intervention in that perspective. It was just really taking that moment, like you said, to understand the patient's needs and course correct. Right. So I think that's a great example.

00;12;36;09 - 00;13;05;18
Kenneth Rogers, M.D.
Right. And so in that particular situation, I think there were really a number of super positive things that happened. One, the nurse that actually did the birth call recognized that things were escalating before they really got to kind of that violence place. So that was the number one thing. I think the other thing was the level of support that she felt to be able to do that, because having done a lot of work to make people feel comfortable that, you know, if you need help, just call.

00;13;05;20 - 00;13;26;22
Kenneth Rogers, M.D.
And so there wasn't a hesitance to do so. But then there were also people that could respond relatively quickly. And having the resources and understanding of those resources to be able to provide them in real time to the staff and patients. Because that was a situation that could have spiraled out of control very quickly, because you could see that the family was getting increasingly upset.

00;13;26;24 - 00;13;41;28
Kenneth Rogers, M.D.
The staff was a little nervous and scared, and you put those two things together and it doesn't lead to a great outcome. But, able to get her calm pretty quickly. Family was actually happy with the situation and the rest of the delivery went smoothly.

00;13;42;04 - 00;13;56;18
Jordan Steiger
Sounds like best case scenario. And again, a great example of why a program like this in your hospital can really be beneficial. One thing I'm realizing I didn't ask you that I think our listeners would be curious about is how are people trained to be on the BERT team?

00;13;56;20 - 00;14;45;00
Kenneth Rogers, M.D.
Our behavioral health professionals working on any behavioral health unit, inpatient or outpatient, go through a three day mandatory training. And in that three day training, the first portion of it is really looking at the phases of escalation and de-escalation and being able to recognize when somebody's at really low level and when they're kind of going up to some of the higher levels and looking at de-escalation techniques to be able to get them to that place. Day two and three are looking at more mental health based interventions and trying to think about more hands on figuring out how do you get people really calm when they're beyond, the place that they can be

00;14;45;00 - 00;15;20;08
Kenneth Rogers, M.D.
de-escalated. So what we've done with BERT is really trying to make sure every employee in the health system gets at least part of day one, so every employee is able to recognize the levels of escalation, levels of de-escalation, and some basic skills to be able to do that. Then for people that are going to do more mental health or BERT related work is really thinking about day two of a lot of that work where you're getting some more in-depth skills to be able to manage some of those more difficult situations.

00;15;20;10 - 00;15;43;25
Jordan Steiger
That makes sense. I love that you focus on giving training to all of your workforce and then, you know, really kind of, focusing in on those behavioral health providers. That's great. So I think, Dr. Rogers, your example of your program is truly one of the best that I've heard of across the country. I mean, being able to de-escalate, you know, violent situations by 75% is pretty incredible.

00;15;43;28 - 00;15;53;20
Jordan Steiger
So if another, hospital or health system is maybe inspired by this conversation to think about this in their own, you know, care setting, what advice would you give them?

00;15;53;23 - 00;16;17;18
Kenneth Rogers, M.D.
So I do think that it's important to make it part of your culture. Because one of the things, for example, that you want is to make sure that the folks that are going to respond to any kind of aggressive incident have training in how to manage it. So, for example, if you think about security force, for example, a lot of security officers aren't really trained in de-escalation in a hospital setting.

00;16;17;20 - 00;16;45;07
Kenneth Rogers, M.D.
They're really trained to manage situations really well. But if you've got somebody that's really in distress in the hospital situation, that training may not work, but security's often the first folks that we're going to call. So making sure that those folks are able to incorporate those de-escalation skills into what they're what they're doing. I think the second thing that's really important is to look at the administrative culture. We started talking about earlier,

00;16;45;09 - 00;17;15;01
Kenneth Rogers, M.D.
what's the buy in? Some hospitals and clinics find themselves really engaged in behavioral health work. It's what they do. They feel very comfortable with it. Others really want to keep it at arm's length. And so trying to develop a culture where responding to behavioral issues becomes the norm and people can do that compassionately and do it without becoming frustrated very easily because it's very patient-centered work.

00;17;15;01 - 00;17;38;01
Kenneth Rogers, M.D.
And I think the more people understand the patient centered-ness of what we do, the more people are able to really, really engage and be a lot more, lot more involved. And then the third piece I think that's important is to look at the outcomes for staff. If you think about trying to retain staff, trying to train new staff, that's one of the hardest things for health systems to do.

00;17;38;05 - 00;17;57;27
Kenneth Rogers, M.D.
And so trying to think about the return on investment, even if you feel like the time for training, the extra effort we're putting into it may not be worth it. If you're able to retain additional staff members and not have to retrain, I think that's definitely one of them. One of the huge benefits.

00;17;58;00 - 00;18;14;01
Jordan Steiger
Absolutely. Thank you so much for, you know, sharing those quick pieces of advice and your wisdom about this work. I think that you really are kind of leading the way in terms of the outcomes you've been able to achieve. And so we're really, really appreciative that you were able to come share with us today.

00;18;14;04 - 00;18;16;11
Kenneth Rogers, M.D.
Thank you so much. I appreciate you having me.

00;18;16;13 - 00;18;24;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;20 - 00;00;23;16
Tom Haederle
Despite being educated, prepared and committed to doing everything it could to defend against a cyberattack, it happened anyway. When hackers breached the system of San Diego-based Scripps Health three years ago, the incursion forced Scripps to temporarily shut down some of its systems, leaving trauma surgeons, for example, wondering whether it was safe to treat patients without access to their electronic health records.

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Tom Haederle
But even after the immediate attack was contained, cybercriminals caused a second set of problems.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Hospitals and health systems have their hands full coping with the scary reality of a ransomware attack. But on top of that, there are civil liability concerns that limit how much information hospital leaders may share with the public and the media about what's going on.

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Tom Haederle
A false step could lead to lawsuits or government sanctions. In the second of this two-part podcast, Chris Van Gorder, president and CEO of Scripps Health, explores with John Riggi, AHA's national advisor for Cybersecurity and Risk, how his organization responded when cybercriminals attacked. They discuss the need for cybersecurity standards and safe harbor protection from the federal government, so that care providers can focus on mitigating cyber attacks and protecting patient safety without having to look over their shoulders.

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John Riggi
Ransomware attacks targeting hospitals, health systems and our mission critical third party service providers such as Change Healthcare have increased over 300% over the last three years, according to HHS and the FBI. Today, I am so very pleased and privileged to have my good friend and colleague here with us today to discuss this issue. Chris Van Gorder, president and CEO of Scripps Health in San Diego.

00;01;58;14 - 00;02;08;26
John Riggi
Chris, so, again, I commend you for speaking publicly today. One of the things you have done recently is published an article. Is there any other perspectives you'd like to share from the article?

00;02;08;29 - 00;02;28;23
Chris Van Gorder
Well, again, I think my big ones are, you know, hospitals do need to be prepared. And we need to bring our systems up to the highest standards that need to be established for us as to what those are. And they need to flex with time. There's going to be new technology. The ASAC at the FBI said he says, look, he says bad guys, this is their fulltime job.

00;02;28;29 - 00;02;53;07
Chris Van Gorder
That's all they do. They're busy, you know, thinking how are they going to, you know, change their systems to be able to defeat everything you put in to protect yourself. Right. And he says, whatever you do, don't be mad at yourself. You could not have protected yourself from this attack. And from that point on, the FBI gave us enormous support, enormous advice, positive advice.

00;02;53;09 - 00;03;13;24
Chris Van Gorder
And they've stayed in touch with us over the years after that to let us know where they can...obviously they can't violate any kind of confidential information and share that. But they've allowed us to know that the information we shared with them was and has been useful. We dumped everything. You know, we told them right off the bat, you tell us what you want.

00;03;13;26 - 00;03;36;08
Chris Van Gorder
We will give it to you. Right? Because if this information helps protect another organization downstream, then that's what we ought to be doing. And so, you know, I think they're fabulous. That's the one agency I can tell you that, I felt had our back during the entire incident and afterwards. I can't say that for anybody else other than the people we hired to help us.

00;03;36;11 - 00;04;02;28
Chris Van Gorder
And there are some great companies, you know, Mandiant, CrowdStrike and others that were wonderful in terms of coming in and helping support my team to clean the systems up. And today we have literally, you know, not only do we have state of the art CrowdStrike and other things monitoring the systems, we keep obviously everything up to date, but we have individuals outside of our organization watching the activity inside our system for the behavioral things.

00;04;03;03 - 00;04;23;28
Chris Van Gorder
So all of those types of things so that if somebody does get in and we're watching how people are acting inside the system, which can be an indicator. So I don't know what else we could do to protect ourselves. And I'm not going to fool myself ever again to believe that it couldn't happen again. And so, I think we need to take this on as a country in a much bigger way than we have.

00;04;24;00 - 00;04;36;04
Chris Van Gorder
And it's happening every day. Our country is being attacked by criminals, protected by what I would call rogue countries. And we've got to do something about that.

00;04;36;06 - 00;05;02;17
John Riggi
Thanks, Chris. Totally agree with you. The attacks are continuing. It's pretty clear to me. I'll offer my opinion that Russia, China, North Korea and Iran are using criminal cyber groups as proxies for their own national interests. And quite frankly, as you said, when this is clearly a national security incident, a national security threat. When an attack occurs, broadly threatens public health and safety

00;05;02;20 - 00;05;23;12
John Riggi
that is an act of cyberterrorism, and we need to respond appropriately. Again, we can prepare as much as we possibly can, but ultimately we need the government to do much more on offense as well. Chris, is there - you know, again, we've had a great conversation. We talked a lot about your perspective. And thank you for being so candid and direct with us today.

00;05;23;13 - 00;05;45;04
John Riggi
I think it will be very helpful for our members. By the way, I is a former FBI agent and the FBI appreciate your comments. And there is no doubt, Chris, I have no doubt that the information you provided was instrumental in the publication of National Threat Intelligence in the weeks and months following your attack. And without attribution, of course, to you

00;05;45;06 - 00;06;17;26
John Riggi
I have no doubt that information helped prevent other attacks. So again, the example you set, leadership example, is really something that I wish many others would emulate. And others are trying to do the right thing, but often they are hindered by advice from outside counsel. Chris, last question. Knowing what you know now, having gone through the experience that you did - painful, years long - what are some of the things you wished you had known beforehand?

00;06;17;28 - 00;06;20;01
John Riggi
You wish that someone had told you?

00;06;20;03 - 00;06;40;27
Chris Van Gorder
Maybe it's good, maybe it's bad. Health care workers are heroic. This is the positive side of it. I mean, any time we see bad things that happen: COVID, we had doctors and nurses and technicians afraid for their own lives, and they came to work every day in those early stages, not knowing whether or not the protective gear would protect them or not.

00;06;41;00 - 00;07;04;09
Chris Van Gorder
We saw the same thing in the cyber attack. The doctors, nurses, they all rallied. Not only during the time of the attack, going to paper, using runners to get information from one place to another, running lab specimens to our central lab, waiting for the lab results, and then driving them back to the hospital. Everything slowed down.

00;07;04;11 - 00;07;24;21
Chris Van Gorder
But the patients were cared for. Well, I was invited to a meeting at the local FBI office to just talk to them about that. And the one thing they were saying, they flat out asked they could people have died in this attack? And I said, yes, they could have. And that seemed to elevate the entire issue for them to a much higher level than just a property crime attack.

00;07;24;24 - 00;07;47;19
Chris Van Gorder
This could be murder, international murder. And, you know, I don't think I ever thought about it quite that way until we were victimized. For months afterwards, because everything we had on paper now, we had to put back into the digital. And the cost implications were absolutely enormous. If we were not a financially strong organization, it could have bankrupted us easily.

00;07;47;19 - 00;08;05;26
Chris Van Gorder
And I would tell you, if the same thing happened to a small rural hospital, they would never have opened up again. They would have gone bankrupt and not been able to open up. So, the resources need to be available for smaller organizations that just don't have the capabilities of a health care system like Scripps. There needs to be funding made available. As it is right now

00;08;06;03 - 00;08;28;16
Chris Van Gorder
we're underfunded, as we know, by Medicare and Medicaid nationally. Right? And if you happen to have a poor payer mix, there's no way in the world you're investing in the necessary cybersecurity, in the systems and people to be able to protect your organization. You will eventually be a victim. Those resources we truly want to protect those hospitals, and we want to save lives.

00;08;28;22 - 00;08;50;05
Chris Van Gorder
The resources have to be made available, particularly to the smaller hospitals and rural hospitals. The systems and facilities that just don't have the resources to be able to do that. We have to take this on. If we want to defeat this, we have to take it on as a country and not as an individual hospital, trying to find the best way it can to protect itself.

00;08;50;07 - 00;09;09;06
Chris Van Gorder
And so maybe my last comment to you, John, is to thank the American Hospital Association and you for bringing attention to this on a daily basis to Congress, to our executive branch, And, you know, doing a podcast like this and keeping it going because everybody out there that hasn't been attacked is sitting there going, I hope it never happens to me.

00;09;09;08 - 00;09;28;23
Chris Van Gorder
So one thing I learned maybe that I should have is I should have had the mindset of it will happen to me and I need to do whatever is necessary to make sure the system's prepared. The drills. You know, I wish we'd done more drills ahead of time on paper. I wish we had extended the downtime from an hour or two to 12 hours

00;09;28;25 - 00;09;49;27
Chris Van Gorder
so that we had more practice doing that. I wish we thought through what do we do if we're down for three weeks, four weeks, five weeks, you know, how are we going to treat patients to make sure that nobody dies on our watch? If I had the knowledge of the experience I had beforehand, there's no doubt I would have done some things differently during the attack.

00;09;49;29 - 00;10;14;12
Chris Van Gorder
And I wish we had ability now to be able to share this experience more widely and safely so that, you know, when there is a victim out there that organizations like ours who have gone through it could provide help to them without them fearing additional liability, without me feeling like I'm risking our own organization, getting involved somehow in litigation because we just went out there to try to help.

00;10;14;19 - 00;10;24;09
Chris Van Gorder
There needs to be some form of attorney-client protection or government protection for organizations like ours to share and help each other when they're in trouble.

00;10;24;11 - 00;10;51;14
John Riggi
Thank you. Chris. One, I appreciate your kind and gracious comments. We are working very hard and the government has taken action. Now the FBI and DOJ officially classify ransomware attacks against hospitals as threat to life crimes. And DOJ classifies these attacks at the same investigative priority as terrorist attacks. Thank you again for your words of wisdom as a victim, as a victim organization to share and help others learn.

00;10;51;17 - 00;11;13;28
John Riggi
And finally, Chris, thank you for your leadership on this and so many other issues. And again, ultimately trying to, as we do in law enforcement, trying to protect and serve at the same time. So we want to close out this podcast in a special thank you to all our frontline health care providers, our frontline health care heroes who every day care for patients and serve their communities.

00;11;14;04 - 00;11;26;12
John Riggi
And thank you to all our network defenders, for what you do every day to protect our health care organizations. This has been John Riggi, your national advisor for cybersecurity and risk. Stay safe everyone.

00;11;26;15 - 00;11;34;25
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;19 - 00;00;35;04
Tom Haederle
In response to the sharp rise in recent years of ransomware attacks targeting hospitals, health systems and third party service providers, caregivers have been urged to stay alert, play defense, have a mitigation plan in place and keep lines of communication open with federal law enforcement. Smart steps and good advice. But even when it's followed, there's no guaranteed immunity against criminal cyber mischief.

00;00;35;07 - 00;01;01;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. San Diego-based Scripps Health did everything right. It anticipated, planned and devoted significant resources to guarding against cyberattacks. Yet in May of 2021, a serious incursion occurred anyway, forcing Scripps to temporarily shut down some of its systems and potentially compromising patient care.

00;01;01;21 - 00;01;23;21
Tom Haederle
In part one of this two-part podcast, Chris Van Gorder, president and CEO of Scripps Health, explores with John Riggi, AHA’s national advisor for cybersecurity and risk, how his organization responded when cybercriminals attacked and breached the defenses even of a well-prepared health system. And be sure to tune in on Wednesday for part two of this important conversation.

00;01;23;24 - 00;02;03;26
John Riggi
Thank you, Tom, and thank you to everyone listening in to another one of our Advancing Health cybersecurity podcasts. Ransomware attacks targeting hospitals, health systems, and our mission critical third party service providers, such as Change Health Care, have increased over 300% over the last three years, according to HHS and the FBI. These ransomware attacks, perpetrated primarily by Russia-based ransomware gangs, which are provided safe harbor by the Russian government, continue to result in the delay and disruption to health care delivery, ultimately posing a broad risk to patient safety.

00;02;03;29 - 00;02;30;15
John Riggi
Bottom line: when hospitals are attacked, lives are threatened. Today, I am so very pleased and privileged to have my good friend and colleague here with us today to discuss this issue. Chris Van Gorder, president and CEO of Scripps Health in San Diego, is president and CEO of Scripps Health since 2000. Chris has been instrumental in positioning Scripps among the nation's foremost health care institutions.

00;02;30;18 - 00;03;03;17
John Riggi
With 70 locations, 17,000 employees, and 3000 physicians. Interesting to note for this discussion: Chris is a former police officer. In January 2023. Chris retired as reserve assistant sheriff for San Diego County after 20 years of service. Chris also wrote a book, The Frontline Leader, where he candidly shares his own incredible story, from police officer to CEO and the leadership philosophy that drives all his decisions and actions.

00;03;03;23 - 00;03;18;03
John Riggi
People come first. Chris, I know you have had, unfortunately, direct experience in dealing with a ransomware attack against Scripps Health May of 2021. What can you tell us about that attack?

00;03;18;05 - 00;03;42;06
Chris Van Gorder
Well, I'm actually happy to be able to talk to you about it now because for so many years, our attorneys and others that I really couldn't talk to anybody about it, literally starting on the very first day of the incident. But it was May 1st, 2021, as you said. All of a sudden I got notified at home, actually, that it appeared that we had a hacking and that our systems were compromised and that we were basically shutting everything down.

00;03;42;08 - 00;04;09;05
Chris Van Gorder
Of course, then I made a beeline to our headquarters. We quickly determined that the bad guys had entered our systems and they were compromised, and we had no choice but to shut them all down. And my initial reaction is, how could it have happened to us? I mean, we were prepared. We had not held back on any expenditure for information security.

00;04;09;07 - 00;04;33;15
Chris Van Gorder
And yet somehow we had been victimized. And so my first reaction, obviously, I knew our IS people were doing the right things by shutting the systems down, notifying all the hospitals, moving to our emergency paper systems, which we're very good at using for an hour or two when we have a temporary down time. But not literally, what ended up being weeks at a time.

00;04;33;17 - 00;04;54;12
Chris Van Gorder
I reached out very quickly to our local FBI office. That was my first call. I had a relationship with them having a law enforcement background. And I called the agent in charge and he basically said, Chris, he says, you know, we'll do everything we can, we'll deploy our resources to help you.

00;04;54;14 - 00;05;14;25
Chris Van Gorder
He says you need to reach out to organizations like CrowdStrike and others, to help you with this. And of course, I already had my team reaching out to our cyber insurance company, who immediately gave us the advice to call the attorneys that they use and that we used during the entire event.

00;05;14;27 - 00;05;33;26
Chris Van Gorder
It was Baker Hostetler. And from that point on, I was basically told I couldn't talk to anybody. It wasn't long before the, you know, somebody from the hospital had called the media. The media was reaching out because we're a pretty big system here in San Diego, and when we're impacted, obviously in this case, we have to go on

00;05;33;26 - 00;05;51;19
Chris Van Gorder
emergency diversion. My trauma docs had to decide whether or not it would be safe to be able to care for patients on paper without access to their electronic health records. In the case of our Mercy Trauma Center they decided they could do that. In the case of our La Jolla trauma center they believed that they could not do that.

00;05;51;21 - 00;06;10;25
Chris Van Gorder
And so we allowed a lot of our frontline physicians and clinicians to make some critical decisions early on about whether or not we could safely care for patients or not. And of course, we're obviously activated then, can we care for the patients we have in the hospital? Do we need to consider transferring those patients to other health care organizations?

00;06;11;02 - 00;06;30;27
Chris Van Gorder
We did not in the end have to do that. Everybody thought we could end up taking care of the patients that we could. But it was a disruption to the entire community. The media, of course, was reaching out. And for the very first time, I'm not able to talk to them. And we had some pretty negative media coverage early on because we were not being transparent like we usually are.

00;06;30;29 - 00;06;49;18
Chris Van Gorder
We obviously got our operations going and discovered all sorts of little things. I mean, number one, our young residents, had no idea how to write a prescription. They didn't even know how to use the abbreviations on a paper prescription. But the big thing is patient safety, right? Trying to clean the systems up. Identify what the problem was.

00;06;49;24 - 00;07;11;07
Chris Van Gorder
Deal with a ransomware request which ultimately came in and see if we could get ourselves back to normal. But everything was attorney-client privilege. Everything. All of our meetings were attorney-client privilege. And it wasn't that we were trying to hide any information from government. Obviously, we were going to be as truthful and transparent as we could to government at the right time and place.

00;07;11;09 - 00;07;48;18
Chris Van Gorder
This was all to protect us from class action lawyers, the lawyers that within days of the announcement of the cyberattack were already filing lawsuits against us that were waiting to take advantage of us. And of course, the concern from day one is whatever you, say publicly or otherwise, it's going to be used against you and it's going to cost you even more money downstream in that class action lawsuit, even though if you if you actually carried it all the way to the end, they probably could not win, because these days it would be virtually impossible to tell what information came from what cyber attack across the country and across the world.

00;07;48;20 - 00;07;57;11
Chris Van Gorder
And it has to be tied right back. But that's just immaterial. It was still going to cost a fortune to deal with that. And then we started dealing with it day by day.

00;07;57;14 - 00;08;27;06
John Riggi
You know, you bring up an interesting point. I know you and I have had discussions, sidebars on this about the civil liability concern, which limits comment, public comment, and sometimes limits cooperation, even with federal agencies that are really, truly vested with the mission to help the victim, help understand, how the attack occurred and take that information and issue national bulletins to help warn the nation without attribution to the victim.

00;08;27;08 - 00;08;56;00
John Riggi
And these ransomware vultures inhibit cooperation and limit that information flow to the detriment of, really, the entire sector and the nation, quite frankly. So I think that's something we really have to look at in terms of national policy level. We at the AHA advocating strongly for safe harbor to be extended not only for threat information sharing, but in terms of the impact of the attack.

00;08;56;02 - 00;09;22;02
John Riggi
And, Chris, so, again, I commend you for speaking publicly today. And as you've been always a leader at the forefront trying to help organizations. As you continue to speak publicly and share lessons learned, one of the things you have done recently is published an article, Four Ways Forward in the aftermath of the change Healthcare Attack. What prompted you to write this article

00;09;22;02 - 00;09;37;09
John Riggi
when so many leaders of ransomware victim organizations are reluctant to make any public statements about their attack, someone else's attack, but just offering your perspective? Why do you think that is again, that so many leaders are reluctant?

00;09;37;12 - 00;09;57;21
Chris Van Gorder
Well, I think they're afraid that either a comment they make will be used against them by a government agency, or, somehow be used by class action lawyers or have any way have repercussions for, being transparent. And I think that's a problem. And I think we need to deal with that and I think you've touched on it.

00;09;57;24 - 00;10;27;17
Chris Van Gorder
Number one, there are no standards, for hospitals to comply with right now in terms of cyber protection. And one of the beliefs, I mean, I saw the change, cyber attack, a massive attack and a terrible attack. I actually feel for United Healthcare and Change, having gone through it myself, I know exactly what they were going through, why they didn't initially come out and talk, and why it literally is going to take them months to determine how many individuals were impacted by this, and they'll have to notify all of them.

00;10;27;19 - 00;10;53;09
Chris Van Gorder
The same thing happened to us. It'll take months. We did everything we knew to prepare for a cyber attack, and yet somehow they were able to penetrate. We still don't know exactly how. After having all sorts of forensic analysis, we still don't know exactly. We assume a phish, and somehow they were able to get access to admin credentials and then able to phish around into the system and get the data that they wanted to get.

00;10;53;12 - 00;11;15;24
Chris Van Gorder
That's how we believe it happened. We were able to cut them off. They were never able to get into our electronic health record, but they were able to get into business records. They had all sorts of information, Social Security numbers in some cases, driver's license numbers, identification, etc. and that's terrible, right? And obviously we have an obligation after the fact to do what we can to protect those individuals whose data was stolen.

00;11;15;26 - 00;11;52;29
Chris Van Gorder
But the hospital - our health care system - was victimized by international terrorists, criminals protected by basically a rogue state. Where does the federal government come in in terms of its responsibility to protect us? So, you know, what it struck me is there's kind of in some way we've got to develop some form of protection for our organizations. By the way, we're nowhere near like a big insurance company that makes billions in profit, or a med tech company that makes, you know, millions and billions potentially in profit and probably have a lot of money they can spend on cyber protection and liability and all those kinds of things.

00;11;53;01 - 00;12;11;05
Chris Van Gorder
My health care system lost money from operations last year, right? I mean, if we're doing well we got a 3% operating margin. And as I said last year, we lost money from operations. We'll turn that back around. But we are a small margin business for a $4 billion health care system. What about the small rural hospital

00;12;11;07 - 00;12;30;08
Chris Van Gorder
that has even fewer resources? What I think is, number one, the government has to do something about protecting us. Even the president of the United States has said a terrorist attack or a cyber attack on a hospital is a terrorist act. Well, we need to start acting like that and doing something with these rogue countries, whatever we can do from the federal level.

00;12;30;11 - 00;12;58;01
Chris Van Gorder
Now let's establish standards. I have no problem. Joint Commission establishes standards for us on a variety of different things. CMS established standards, and if we comply with the standards, we're compliant. Then let's establish those standards for cybersecurity that the government wants us to do. And if we are compliant, then protect us from the downstream vultures that are waiting to take advantage of a criminal act, you know, perpetrated on a health care system.

00;12;58;03 - 00;13;18;25
Chris Van Gorder
Defend us from that. I don't have a problem giving information to government agencies. Allow us to be transparent so that we can share the information without fear of additional litigation or attack, even by some government agencies. In the end, no agency said that we did anything wrong, nor have we been fined. we're still waiting for the California Department of Public Health to respond.

00;13;18;26 - 00;13;33;21
Chris Van Gorder
We don't know if they'll ever respond or not. We know they ask us a lot of questions. They may or may not respond, but we've decided at this point, this is years afterwards. It's time for us to get out and at least tell people about our experience. And when I saw again what I heard coming out of Congress,

00;13;33;28 - 00;13;56;28
Chris Van Gorder
we need to speak out and talk about our challenges, right. Our recommendations. We have an obligation. We have an accountability to prepare our organizations, no question about it. If we are breached, we have an obligation to let our patients know that they've been breached and provide some protection for them if we can do that. But major fines, you know, major class action lawsuits

00;13;56;28 - 00;14;17;08
Chris Van Gorder
in the end, it costs us $113 million, right? That's money that could have gone to health care, could have gone to increasing our systems. A lot of that went to class action lawyers. The victims, and there were over a million of them, as it were. The those patients or those individuals that data over a million, they got their protection.

00;14;17;08 - 00;14;40;20
Chris Van Gorder
They got $100 each. Those class action lawyers made a lot more than $100 each. That's money again, that could go back into our health care systems and should if we were compliant. The standards established by the federal government and the hospitals, therefore, then should be protected from that outside liability that we're facing today. And you get a lot more collaboration and cooperation.

00;14;40;20 - 00;14;54;02
Chris Van Gorder
And I know a health care system was recently attacked, and their lawyers flat out said, do not call the FBI. Do not call a law enforcement agency. Do not talk to the media. Do not share any information with anybody.

00;14;54;03 - 00;14;56;22
John Riggi
It's terrible advice. I mean, that's just bad advice.

00;14;56;29 - 00;15;05;06
Chris Van Gorder
It's bad advice. But they were trying to protect their client because of all the risk that's out there that surrounds a cyberattack for the victim.

00;15;05;09 - 00;15;30;06
John Riggi
Thanks for all that. And clearly, your point about this is not purely a defensive issue. You could invest your entire budget in cybersecurity and you still wouldn't be safe. I testified before Congress, the Energy and Commerce Committee two weeks ago, and I made that point that hospitals, in the end, are not cybersecurity companies. And no organization, including federal agencies, can be 100% immune from cyberattack.

00;15;30;09 - 00;15;56;18
John Riggi
So we need to recognize that. And again, organizations are victims. We should not revictimize especially when not appropriate. We have an obligation to protect data, protect our patients. You know, it's really interesting, your point on Change UnitedHealth Group and even the American Hospital Association has found many areas where the response from United could have been better.

00;15;56;21 - 00;16;19;27
John Riggi
And because the difference between them and your organization is they are systemic. They affect every hospital and health system in the country. But even when we were offering different viewpoints and criticism quite frankly, we always reminded whoever we spoke to that they were still a victim, that they were a victim of a foreign entity, foreign criminal organization.

00;16;20;00 - 00;16;44;16
John Riggi
As I remind my colleagues, quite frankly and quite often across government, we need more from an offense from the federal government, offensive cyber operations going after these bad guys like we used to do in counterterrorism. You got good groups being provided safe harbor by hostile nation states like Russia, China, North Korean, Iran, law enforcement operations. Chris, you and I are both law enforcement professionals.

00;16;44;19 - 00;16;53;20
John Riggi
We know the FBI can't get over there and put handcuffs on these folks. We've got to look at all our capabilities like we did in counterterrorism.

00;16;53;23 - 00;17;09;11
Tom Haederle
Thanks for listening to part one of this podcast. Be sure to tune into part two of this conversation this upcoming Wednesday. 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;17 - 00;00;33;05
Tom Haederle
Prior authorization means getting approval from your health plan before scheduling a medical service. Insurers called it a plus, a way to protect patient health by making sure a procedure is the necessary and correct one. Many patients and clinicians, however, say prior authorization has become an administrative nightmare, creating miles of red tape that can delay or even deny needed medical care for patients.

00;00;33;08 - 00;00;59;05
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In mid-January and with strong support from the AHA, the Centers for Medicaid and Medicare Services issued a final rule designed to address some of the widespread complaints about prior authorization and the difficulties it can cause. CMS says the new rule will "help ensure that patients remain at the center of their own care."

00;00;59;07 - 00;01;24;08
Tom Haederle
If so, how that will help is the subject of today's podcast. Joining me today to talk through this are Andrea Preisler, senior associate director of Administrative Simplification Policy with the AHA; Jennifer Cameron, executive director of Patient Access, Children's National Health System; and Dr. David Jacobson, division chief of blood and marrow transplantation with Children's National Hospital. Thanks, everybody again for joining me today.

00;01;24;09 - 00;01;42;26
Tom Haederle
I really do appreciate it. Jennifer, I'd like to start with you, if we could. Given your access role at Children's. What have you seen firsthand? What's the impact been that you've seen on your patient population, children and families from how prior authorization is used or misused today?

00;01;42;28 - 00;02;17;14
Jennifer Cameron
Yeah, I think currently it creates some challenges and some barriers. When I say that, I think about the time it takes sometimes to move patients through the approval process. The things that the payers are looking for is really making sure the patients need. Sometimes it's FDA guidelines or even their own clinical criteria. And then we Children's National on the other side, taking it from the provider perspective, trying to marry those two together.

00;02;17;17 - 00;02;41;06
Jennifer Cameron
And sometimes you end up with denials, and we have to appeal and loop that provider in to help support that appeal conversation or it appears to move patients through. Many times it's a lot of back and forth with faxing or online portals and all of the different methods that we have to go about to get these patients approved.

00;02;41;09 - 00;03;09;15
Jennifer Cameron
Ultimately, we continue to push through so we can get the outcome that's best for the patients and families. So that's the kind of world that is now. Do we always agree with the criteria? Not necessarily. But we understand it. And then, you know, our provider group, we'll have a conversation with the health plan to help kind of move those patients through. Most services than before require authorization

00;03;09;17 - 00;03;16;10
Jennifer Cameron
than they've done in the past. So we've seen a shift in the industry that way that more services require authorization.

00;03;16;13 - 00;03;37;03
Tom Haederle
Well, I'm sure that's made the whole process much more time consuming. But I would think in some instances it probably results in a delay of care or even denial of care that really is necessary. So how do you reconcile, you know, possibly putting a patient's own health at risk because the payor wants some information that may not really be necessary from your point of view?

00;03;37;06 - 00;03;58;19
Jennifer Cameron
Well, I would say we always lean towards best for the patient. And we will consult with our providers, and if it's that it must be done then we have to go about doing it. And then we continue to negotiate and talk with the payer on the back end to move it through. But the key is what's going to be best for the patient.

00;03;58;19 - 00;04;17;17
Jennifer Cameron
And we really lean to our providers. If our providers feel that is something that has to happen, then we have to do what's best for the patient. So that's the approach we take. Ultimately, we want to get it approved and many times it may be another test or additional bloodwork or something along that line. And we'll go ahead and get that done and resubmit.

00;04;17;20 - 00;04;49;16
Tom Haederle
Wanted to direct question to David here. According to a 2022 AMA survey, 94% of physicians reported care delays associated with prior authorizations, and 80% indicated that prior authorization hassles led to patient abandonment of treatment in some cases, people just simply stepping away from the process. I wonder, David, as a clinician, what you've seen and what your experience has been with the impact that prior authorization, as it's commonly practiced today, has had on patients and families?

00;04;49;19 - 00;05;30;14
David Jacobson, M.D.
Sure. We do see that sometimes. I deal with the blood and marrow transplantation, which is a very expensive therapy. So there's certainly prior authorization. And we need to make sure that the insurance is on board before proceeding with any case. But I would echo what Jennifer said earlier, but sometimes it seems it takes unnecessarily long and requires a lot of back and forth. Patients that absolutely need the therapy and have a very life threatening disease,

00;05;30;17 - 00;06;06;16
David Jacobson, M.D.
a patient with leukemia, for example, they will definitely get the therapy. There are some patients, though, that are sent to us with more elective type of indications, such as sickle cell disease or Beta thalassemia where the treatment doesn't need to be done immediately. But in those patients, once the hassles start building up, we have occasionally seen that people just get tired of the wait, and give up or go somewhere else.

00;06;06;23 - 00;06;09;00
David Jacobson, M.D.
So it can be problematic.

00;06;09;02 - 00;06;27;27
Tom Haederle
I imagine it must be frustrating at times to feel like you're being second guessed as a care provider, or a direct care provider, or a clinician on scene dealing with the patient, and have somebody sort of asking questions who may not be that familiar with the patient's history and, and sort of second guessing your decisions. How does that impact your day to day work?

00;06;28;00 - 00;06;53;18
David Jacobson, M.D.
It's hard. I mean, I think that, I think that checks and balances are super important. Don't get me wrong, but we have a very experienced team of transplant physicians, for example. And, sometimes it does seem like we have to go on the phone with a physician that's much more, much more general and dealing with a lot of different specialties

00;06;53;18 - 00;07;02;01
David Jacobson, M.D.
and they're definitely not necessarily the most up to date in our field. So I wish there were ways to improve the process.

00;07;02;03 - 00;07;22;09
Tom Haederle
Right, I hear you, it sounds like there certainly is room for improvement. And hopefully that's what this CMS final rule, at least has been designed to do that. We're hoping that it does. Andrea, I was thinking your very job title, administrative simplification has got to be music to many people's ears because health care system can be so complex in the first place.

00;07;22;12 - 00;07;37;01
Tom Haederle
How has the widespread practice of prior authorization strayed from its original purpose, if it has, in your opinion? And a second part to that question, if a patient, it's a little bit different. But if a patient's request is denied by their insurer, what are their options?

0;07;37;03 - 00;08;18;10
Andrea Preisler
I absolutely think that prior authorization as it was initially designed has strayed from its initial intent. Its intent was to make sure that patients receive the appropriate care at the appropriate time. It's now morphed into, as Jennifer alluded to, there are just voluminous prior authorization requests. And in my opinion, and I think the data supports this - prior authorization really gets in the way of that patient, physician or patient-provider relationship and can really interfere with ensuring that the patient receives the care in a timely manner that their provider, you know, in their medical judgment, thinks is the best treatment.

00;08;18;12 - 00;08;24;05
Andrea Preisler
So I really think it has strayed from its initial intent and is being abused at this point.

0;08;24;12 - 00;08;34;04
Tom Haederle
As to options that people can pursue if they're denied a claim or a procedure, what can they do? Can it be fought? Can it be appealed? Can it be successfully overcome?

00;08;34;06 - 00;09;02;14
Andrea Preisler
Patients and providers do have options when it comes to initial prior authorization denials. That being said, those options are incredibly cumbersome. They often involve, as both Jennifer and Doctor Jacobson alluded to, those peer to peer conversations which can take often a long time to schedule. Often, you know, Doctor Jacobson, as a transplant surgeon, may be talking to, say, a gynecologist to try to get a treatment approved.

00;09;02;21 - 00;09;29;23
Andrea Preisler
So you're often not really talking to a peer. Right? So that's part of the problem is while these appeal processes take a long time, they're very arduous. Meanwhile, the patient is waiting for this very needed treatment, right? Those people that appeal often have a very hard time reaching an approval. And oftentimes that initial denial will just result in complete abandonment of care altogether.

00;09;29;26 - 00;09;32;06
Andrea Preisler
And that's also highly problematic.

00;09;32;09 - 00;09;52;29
Tom Haederle
As you and I know, Andrea, being, employees of the American Hospital Association, we've watched this process very carefully and made some recommendations that CMS seems to have heeded - some of them - in its final rule that was released in January. Can you explain some of the major changes give a broad overview of what might be done differently in the future as a result of CMS action?

00;09;53;02 - 00;10;27;12
Andrea Preisler
We at the AHA are thrilled with this new, CMS interoperability and prior authorization final rule, as you mentioned, released in January. And what this rule is attempting to do is taking that incredibly manual process of prior authorization with all of the documentation requests, faxing the proprietary portals, etc., etc.. Trying to take that and make it into a fully electronic process, end-to-end that all takes place within the provider's actual EHR or practice management system.

00;10;27;14 - 00;10;51;12
Andrea Preisler
So the idea here is to get rid of all those phone calls, all those faxes, snail mail, portal documentation requests and take that and really make it so that a provider, when they're sitting with a patient, determining that a particular treatment is the most appropriate...presses a button and is able to get an immediate prior authorization approval back.

00;10;51;14 - 00;11;11;19
Tom Haederle
That sounds like an enormous step forward if this plays out the way the rule is intended to. Jennifer, from your point of view, and following up on that, if the rule is implemented and achieves what it's designed to do - from the point of view of a family coming into Children's National for care, let's say, what would be different about the experience going forward

00;11;11;19 - 00;11;15;07
Tom Haederle
in a positive way? How might they see improvement?

00;11;15;09 - 00;11;44;10
Jennifer Cameron
Yeah, I think if it works as proposed, the turnaround time in them knowing that they are approved for treatment is much quicker. Depending on what services need to be authorized, each payer has different guidelines. You know, certain things you can get approved in three days or other things may be 14 days or longer in getting the authorization response back and some even longer than that. It all depends on the complexity of the services being rendered.

00;11;44;12 - 00;12;08;00
Jennifer Cameron
But if the provider can write the order and it can go across and get authorized and provider get a response within the timeline that he is engaging with the patient family, then the patient already knows, you know, they're approved. And now I'm just getting scheduled as opposed to I want to get authorized and then I can get scheduled.

00;12;08;03 - 00;12;29;05
Jennifer Cameron
So it will help thin that timeline out and patients would walk away with a better sense of understanding and security that this is I'm in agreement with my provider that these services is what I need. And oh, yes, I know my insurance company has approved it as well. And even on the reverse, if it denies the provider knows right then and there:

00;12;29;07 - 00;13;07;09
Jennifer Cameron
Okay, we need to figure out how we move this case along the sometimes it all depends on the turnaround time with the payer. You may not find out for a week that the services you requested is now denied, and additional work needs to be done. So I think having the interoperability would be ideal. As long as these guardrails around it I think it would be beneficial not only to the patients but to the providers as they think about how they service care and knowing what services they can have that conversation with the family and move them through the process.

00;13;07;11 - 00;13;35;17
Andrea Preisler
If I can just jump on to kind of piggybacking something that Jennifer mentioned. I think the idea of even if it is a denial immediately upfront, I think that's fantastic for the provider to have that information immediately as opposed to like you said, waiting, you know, a week, 2 or 3 weeks to receive that information so that the provider can then determine, okay, is an appeal the way to go here, or should we explore other treatment options?

00;13;35;24 - 00;13;44;11
Andrea Preisler
I think it's critical and really important that the provider has that information as soon as possible. And I hope that this rule will do that.

00;13;44;13 - 00;13;59;03
Tom Haederle
Great. Great point. David, what is your take on this this new rule from CMS? Do you think it will actually live up to its billing and simplify the process of getting a yes or a no in advance from insurers if a patient needs a medical procedure?

00;13;59;05 - 00;14;33;06
David Jacobson, M.D.
I sure hope so. In our field, there's multiple different sets to get a patient for a transplant. So where we have to start with the blood work from the patient. So something called HLA typing to see if there's a match within the family. That generally requires a person in my department to submit paperwork to the insurance and then to hear back.

00;14;33;06 - 00;14;57;04
David Jacobson, M.D.
And that can take about seven days. And it's generally approved because the indication is clear that the patient has the need for the need for transplant. But I can really see saving time and also see saving a lot of resources.

00;14;57;07 - 00;15;20;11
Tom Haederle
We think nearly all providers would say the same thing that the prospective spending less time on red tape and more time, bedside time with the patient is a big step forward and a welcome one. Andrea, back to you for probably my final question here, administratively speaking, from your understanding of these changes in the CMS rule, will they be easy for a hospital or health system to implement?

00;15;20;14 - 00;15;22;20
Tom Haederle
And do you foresee any bumps along the way?

00;15;22;22 - 00;15;56;05
Andrea Preisler
Implementation will be challenging, but the good news for providers is that the onus of building out and implementing these APIs is entirely on the impacted payers of this final rule. So ideally, providers should not have to do too much work, right? The idea, though, that you know, this API that is being built in order to handle, you know, this enormous volume of work and taking what is currently a very manual process and making it fully electronic, the work can't be overstated.

00;15;56;06 - 00;16;23;09
Andrea Preisler
It's a significant amount of work. We are involved in in that work and ensuring that, you know, the technology underlying this, regulation is appropriate and has the correct, you know, guardrails, as Jennifer mentioned earlier. So we are highly involved in that process. But again, the onus is on the payers to implement these APIs. So we are hopeful that it shouldn't be an enormous lift from the provider side.

00;16;23;16 - 00;16;35;15
Tom Haederle
We are hopeful, indeed. We're near the end here and this is the any final thoughts or takeaways part of our chat. Anything that I didn't ask about that or anybody would like to contribute.

00;16;35;17 - 00;17;01;25
Jennifer Cameron
I would just say, I think that if all of this comes together and, we're able to do that, I think it would really streamline so many of the processes. And I, again, to just reiterate that the outcomes will be better for the patients and families and even the providers as they try to navigate. I think the other piece of it is, as we look at the payers, some of these small payers, there may be challenges with those.

00;17;01;28 - 00;17;19;26
Jennifer Cameron
Where they're not the big payers implementing about the Medicaid NCOs and those type of small payers, just as we, you know, just understanding how they're going to navigate all of that and move that along. But absolutely, I think it would be beneficial for all.

00;17;19;29 - 00;17;40;22
Tom Haederle
Well, I know that's a widely shared sentiment, and I think we'll all be watching closely and hoping that this rule plays out in real life, real time, the way it's intended to, that it works as advertised. Thank you, Andrea, Jennifer and David for sharing your thoughts on this new direction from CMS about streamlining the prior authorization process to make life easier for patients and providers.

0;17;40;25 - 00;17;55;04
Tom Haederle
And thank you all for joining us today for this Advancing Health podcast from the American Hospital Association. 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;01;10 - 00;00;27;09
Tom Haederle
The population of older adults will exceed 95 million in the United States by the year 2060. As Americans age, the need to adapt models of care to address the unique needs of older adults increases. Also needed models that care for the caregivers of older adults.

00;00;27;12 - 00;01;03;14
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this podcast, Raahat Ansari, senior program manager of Population Health with the AHA talks with Diane Mariani, program manager of the Social Work and Community Health Department at Rush University Medical Center, about customizable interventions to support family caregivers. Rush has developed a caring for caregivers model to share resources and guidance that help family and friends who care for older adults better manage their own health and wellness while meeting their loved ones needs.

00;01;03;16 - 00;01;31;29
Tom Haederle
Rush University Medical Center has been recognized as an age friendly health system, an initiative of the John A. Hartford Foundation and Institute for Health Care Improvement in partnership with the and the Catholic Health Association of the United States. Age Friendly health systems is a movement that aims to enhance care for all older adults by implementing the "4Ms" framework focused on: what matters to the patient, as well as medications, mentation and mobility.

00;01;32;01 - 00;01;35;27
Tom Haederle
Let's join Raahat and Diane in conversation.

00;01;35;29 - 00;01;51;10
Raahat Ansari
Thanks for joining us today. Today we are here with Diane Mariani, program manager at Rush University Medical Center in Chicago. And she's here today to talk to us about Rush's Caring for Caregivers program. Diane, welcome.

00;01;51;16 - 00;01;54;07
Diane Mariani
Thank you, Raahat. So glad to be here today.

00;01;54;08 - 00;01;58;06
Raahat Ansari
Of course, we're we're so happy that you were able to make it and make it here in person.

00;01;58;08 - 00;02;10;07
Raahat Ansari
One of the perks of being is sharing a beautiful city together. That's right. well, I was hoping that you could start off by telling us a little bit about this really important program that you have, the caring for Caregivers program. Tell us a little bit about it.

00;02;10;08 - 00;02;22;16
Diane Mariani
Absolutely. so the Rush Caring for Caregivers program was initiated in 2019, and we received funding from the RRF Foundation for aging.

00;02;22;18 - 00;02;55;15
Diane Mariani
So they're a wonderful source of grant support and funding. And we decided to develop a program for family caregivers because family caregivers are really a critical part of critical support for the health care system. And they're really not recognized. They're kind of under-recognized, undervalued, and, and not really supported. So with that funding, we created a program to ensure that we were identifying caregivers. We were going to be hoping to understand them and what their needs were and then providing support for them.

00;02;55;17 - 00;03;19;28
Raahat Ansari
That's fantastic. And just for our listeners who might not be aware of the organization that you shared, RRF, could you just tell us what the what the organization stands for?

00;03;20;00 - 00;03;34;00
Diane Mariani
Well, they go by RRF Foundation for aging, but it used to be named Retirement Research Fund. And so they really have a focus - and many focuses - but one of the focuses on the health and well-being of older adults. So the program that we created actually does kind of focus on those caregivers that are caring for older adults.

00;03;34;02 - 00;03;55;07
Raahat Ansari
And that makes perfect sense. And that actually especially why you're here joining with us today, to talk a little bit about how the important work that AHA does with the Age Friendly health systems work, which is a program, as you well know, which is geared towards implementing the 4Ms framework, which is focused on providing enhanced care to older adults.

00;03;55;09 - 00;04;37;10
Raahat Ansari
And the 4M’s of that framework are what matters, and making sure we understand what matters to the older adults as well as their family. Medication and making sure they're on safe medications. If there's any need for high risk medications that that's evaluated and appropriately given. Mentation, constantly making sure that the older adult is being cared for and is in a good state and mental state, making sure that their depression and dementia delirium is all being monitored and tracked, as well as mobility and making sure that those older adults are being able to be safely mobile and reducing the risk falls.

0;04;37;10 - 00;04;54;24
Raahat Ansari
But of course, that doesn't necessarily mean that they just sit in the chair and they sit in the bed. And that's definitely not the ideal way to be safe. So can you tell us a little bit about what you do in your program that is specific to these older adults and how you pay close attention to that specific population?

0;04;54;26 - 00;05;25;03
Diane Mariani
Yes, definitely. so Rush is an Age Friendly health system, happy to say. And, so, you know, we really recognize the importance of those 4Ms in the care of older adults. And with our caregiver program, we also focus on those forms for the caregiver, which is really kind of special and unique. So the program really, as I mentioned, let me just say, first of all, that we really had a goal of kind of doing a systems change.

00;05;25;03 - 00;05;52;17
Diane Mariani
And, you know, that's a big undertaking when you're really trying to do a shift, you know, almost a culture shift, you know, just and really getting just system wide, providers, and others to really recognize the importance of these family, caregivers in supporting older adults. And that, you know, their health and well-being is just greatly connected to the health and well-being right of who they're caring for.

00;05;52;20 - 00;06;24;28
Diane Mariani
So in our program, we identify caregivers, including putting them into the electronic health record so that when a provider goes to open a chart of an older adult, it's clearly identified if they have somebody that's providing care for them, contact information, etc.. So this already tells the provider, the health care team, that here is somebody that is kind of working in direct contact with this older adult patient of theirs, and they're an important member of the health care team, and they see them clearly.

00;06;25;00 - 00;06;49;18
Diane Mariani
And then we also do a host of, assessments, evidence-based assessments on caregivers to really identify what their needs are. And this is really geared to their mental and emotional and physical health. And as they are providing care and every caregiver is unique, you know, there's just so we do very individualized, approach in everything we do and we assess their needs.

00;06;49;21 - 00;06;52;14
Diane Mariani
And then we develop a plan of support for them.

00;06;52;16 - 00;07;13;18
Raahat Ansari
That sounds amazing. And I'm so happy to hear that the 4Ms are being applied to those caregivers, because just like you said, that that group of individuals are so important to ensure that they are cared for so that they can provide appropriate care to their loved ones. Can you tell us a little bit about some of the outcomes that you've seen through this amazing program that you have?

00;07;13;20 - 00;07;38;18
Diane Mariani
Sure. Very excited about the outcomes that we're seeing. So for our caregivers, we're seeing, significant reductions in depressive symptoms, anxiety symptoms, and caregiver burden. So now, you know, some people may well what is caregiver burden? Well, we are really looking at and we assess for this. It's really what is the impact on health and well-being. Financial is included in there.

00;07;38;18 - 00;08;03;25
Diane Mariani
Just overall you know, you know, what is the impact as they're providing that care in that caregiving role? And sometimes it's really just about helping them develop a plan for themselves and for the older adult. Sometimes it's bringing in additional resources and support. Sometimes it's really working through family dynamics. That's a big one for many.

00;08;03;28 - 00;08;20;20
Diane Mariani
And I think you really, you know, can't get around knowing and working with family dynamics when you're working with caregivers and care recipients. And it's also advanced care planning. So what's the plan? What's the current plan and what's the future plan. And we help them develop those plans

00;08;20;23 - 00;08;31;14
Raahat Ansari
That makes perfect sense. I heard us talk about the steps of the program and that the first step is identifying this dyad.

00;08;31;17 - 00;08;35;08
Raahat Ansari
How does that how does that work? Can you talk a little bit more about that?

00;08;35;11 - 00;08;49;09
Diane Mariani
Sure. It's really interesting too, because, you know, we use the term caregiver because we have to have some kind of a name to be able to know what we're talking about. But so many that are providing care don't resonate with that.

00;08;49;10 - 00;09;00;10
Diane Mariani
You know, it just doesn't connect with that term of caregiver. It's just something that they do, just like naturally. Absolutely. You know, we hear: I'm not a caregiver. I'm a son, I'm a daughter, right. This is my wife, etc.

00;09;00;11 - 00;09;07;23
Raahat Ansari
So obviously you're going to run the groceries, you're going to take dad to the doctor's appointments.

Diane Mariani
Just what you do if you're a family member.

Raahat Ansari
And that means that you're a caregiver.

00;09;07;23 - 00;09;31;05
Diane Mariani
That's right. You're providing care. So we we're really aware of the language we're using and the approach that we take, because if we just ask, are you a caregiver? We're going to get a lot of no's. And let me just mention to when I keep saying family caregiver. And that's really just to recognize that there's also direct care workforce out there that are providing caregiving, which is very important as well.

00;09;31;12 - 00;09;56;27
Diane Mariani
But when I say family, I really mean family, which could be family, friends, family of choice, neighbors, church members. It's really anyone who is providing some type of care and assistance. So we do really consider language and we ask questions of like, are you providing care? And then we list some of those as you did, you know, shopping and we mention because otherwise you're not thinking about it.

00;09;56;29 - 00;10;18;29
Diane Mariani
And additionally those assessments we do, especially one particular one - it's called the burden scale for family caregivers. It really hones in on that. And it starts to kind of ask about some of those things. And that tool sometimes has somebody to self-identify. They'll sometimes, based on those questions, still kind of say, oh gosh, I am providing care.

00;10;18;29 - 00;10;35;27
Diane Mariani
Or I didn't realize the impact this was having in my life.

Raahat Ansari
That's so interesting. So this assessment specifically, works to identify a burden that a caregiver may be experiencing or,

Diane Mariani
Yes, something. And of course, we hate that word burden, but that's the name of the scales.

00;10;35;27 - 00;10;36;06
Raahat Ansari
Sure.

00;10;36;06 - 00;10;39;19
Diane Mariani
There it is. Yeah. But really it's just what's the impact, right?

00;10;39;19 - 00;11;00;06
Diane Mariani
Because nobody wants to think that their, their loved one is placing a burden. Of course not. But it's really just honing in on like, you know, just what impact it has and how we can support and how we can minimize, any kind of strain that it may have. Bbecause it is an additional task. And some of those tasks are quite intense.

00;11;00;06 - 00;11;11;03
Diane Mariani
Some of them are very medical in nature, and most of us aren't trained in those areas. And we may not have been ready, willing or able to provide the care that we are now expected to be providing.

00;11;11;05 - 00;11;37;00
Raahat Ansari
That makes perfect sense. One of the things that we're expanding into, with the age friendly work that we're doing now, is having a little bit more of a focus on health equity and making sure that we're understanding the individual and their background and the different cultures and the language and, how all of that plays into how one might, one might make their care preferences.

00;11;37;02 - 00;11;42;07
Raahat Ansari
How do you account for that in the caregiver program?

0;11;42;10 - 00;12;04;13
Diane Mariani
That's so important. And so as I mentioned earlier, we really look at each individual caregiver, you know, that caregiver comes to us, or as referred to us, and we're really spending the time to get to know them. In fact, we don't even call it a assessment when we work with them.

00;12;04;13 - 00;12;25;23
Diane Mariani
We call it a getting to know you meeting. Because really, that's what we're doing. First of all, we want to make sure that they're heard because caregivers often go unheard. So we want to know from their perspective what's happening for them, you know, what kind of care they're providing, just what their situation is.

00;12;25;29 - 00;12;46;11
Diane Mariani
You know, sometimes they're living with the person they're caring for. Sometimes they're long distance, sometimes they're an hour. Whatever it is, we have that conversation with them. So as we listen to them and have that conversation, first of all, we're hearing reflecting back what we hear. So we understand, making sure they're heard and understood.

00;12;46;13 - 00;13;11;19
Diane Mariani
And then we do start asking those series of questions that kind of gets a little bit more information identifying their needs, but also what are their preferences. Right. You know, what are their, you know, culturally, you know, sometimes culturally they don't have a choice in providing the care. It's just part of what they do culturally that's not going to change.

00;13;11;21 - 00;13;34;13
Diane Mariani
it can also be part of the culture not to have any additional support come in as far as like a caregiver or outside help...it's within the family. So those are the aspects that we take in and consider and just support that caregiver in developing a plan that works within their beliefs, their values, their culture, etc.

00;13;34;15 - 00;13;44;16
Raahat Ansari
That is amazing to hear that you are working to ensure that, all cultures are accounted for and, and preferences are accounted for as well.

00;13;44;22 - 00;13;53;11
Raahat Ansari
Could you share a story, perhaps about a time when you were able to account for an individual's and a family's cultural preferences?

00;13;53;14 - 00;14;21;07
Diane Mariani
Sure. That's a good question. So there's so many different circumstances. I mean, my mind is swimming right now, but I do have one that I can share with you, that I think we've seen several times, where for this particular person's cultural, you know, viewpoint, as the oldest daughter in this particular family, it was her role.

00;14;21;07 - 00;14;44;21
Diane Mariani
I mean, that's just the culture is the oldest daughter is responsible for the care of the parents as they as they get older, as they need. So that was kind of her designated role. It was culturally part of what she was charged with doing. But she was overwhelmed by it. And her mom was caring for her mom at the time, who was diagnosed with dementia.

00;14;44;23 - 00;15;28;29
Diane Mariani
And, she was also working at the time. And so what we did, what we worked with her on is...because she couldn't change the role and it was not an option to bring in additional help, so to speak. It was really kind of shoring up her, resources, her coping skills, and also, really helping her to understand the disease that you know, her mom had, you know, really giving her some education on dementia and also really some practical tips, and resources for managing some of those behaviors and some of the aspects, you know, that maybe the repetition and asking something, how do you manage that?

00;15;29;04 - 00;15;45;10
Diane Mariani
Some redirecting if somebody is asking over and over - just different tips that she had not known before that really then gave her like almost like a toolkit to be able to use as she proceeded in her role. And it did reduce her burden and some of the anxiety that she was feeling about her role.

00;15;45;12 - 00;15;53;27
Raahat Ansari
That's amazing to hear how you were able to provide benefit to that caregiver within those certain parameters so that that's amazing.

00;15;53;27 - 00;16;11;26
Raahat Ansari
And thank you so much for sharing that. Can you tell us a little bit...I understand that the program is going national and that folks are able to join at no cost to them. can you tell us a little bit about if an organization is interested in bringing this type of program to their organization?

00;16;12;03 - 00;16;13;09
Raahat Ansari
How would one go about doing that?

00;16;13;09 - 00;16;42;27
Diane Mariani
Oh, I'd love to share about that. So, as I mentioned, you know, the program was originally funded by RRF Foundation for Aging for the creation of it, and it continued to support us over the years. And then the John A. Hartford Foundation provided funding for us to pilot test the model in six age friendly health systems to really just see, you know, kind of look at, you know, is it implementable in all settings or in a variety of settings?

0;16;43;00 - 00;17;03;16
Diane Mariani
Looking at maybe scaling and spreading it across the country. So we did do that pilot testing, was very successful. And we did implement in a variety of settings. You know, we did a dialysis center. We did a geriatric primary care setting, we did a caregiver resource center, etc., an ACE unit, which is, an acute elder care unit.

00;17;03;18 - 00;17;27;19
Diane Mariani
So we really got, you know, an understanding of, of, how this could be implemented in just various ways, in different settings. So, based on that success, we were refunded by the John A. Hartford Foundation to then share this model with other age friendly health systems and area agencies on aging across the country.

00;17;27;24 - 00;17;54;17
Diane Mariani
So really, they can just contact myself, or look at our website, Caring for Caregivers Across the U.S. and get in contact. And we are happy to just have a kind of a chat, a meeting to kind of explain the program and then what we do is really, like work with that particular health system to see how is it going to be adaptable for their setting, because not all settings have the same resources available.

00;17;54;17 - 00;18;03;00
Diane Mariani
So we really work with, that setting to, to kind of develop that plan. We do a full training and then offer technical support.

00;18;03;00 - 00;18;14;14
Raahat Ansari
And I just want to get a little bit of clarification, because I think I heard us talk about how you are testing it in a dialysis center and different, and like the ACE unit, which all are, you know, clinical sites.

00;18;14;21 - 00;18;23;19
Raahat Ansari
Did I hear about a caregiver resource center? And is that something that's a little bit non-clinical? And maybe you can expand on that for some of our listeners who might not be as familiar.

0;18;23;22 - 00;18;36;02
Diane Mariani
So one of the sites that that pilot tested for us was Northwell Health, and one of their settings was they have several caregiver resource centers within their health system.

00;18;36;04 - 00;19;03;23
Diane Mariani
And so we tested that model there. It's not a clinical setting. It's not a medical setting, although it's within a medical setting, but it is a clinical setting because it's, like our program at Rush, it's got licensed clinical social workers that are supporting caregivers. So what they were doing was a little bit more like care management for their caregivers and connecting them to resources.

00;19;03;25 - 00;19;10;00
Diane Mariani
But what they weren't doing was what we do is going into those individualized sessions for caregivers.

00;19;10;01 - 00;19;10;07
Raahat Ansari
Okay.

0;19;10;10 - 00;19;17;14
Diane Mariani
So that's what they brought into their resource center. So they kind of enhanced what they were already providing.

00;19;17;17 - 00;19;25;12
Diane Marianiv And that's perfect. So it looks like there's a few different ways to get involved, a few different types of sites that can reach out to you if they chose to be involved.

00;19;25;17 - 00;19;26;13
Diane Mariani
Absolutely.

00;19;26;18 - 00;19;32;12
Raahat Ansari
And I think we're just right on time. So just any last comments or anything that you wanted to share to our listeners today?

00;19;32;27 - 00;19;56;29
Diane Mariani
I think our goal is we just want caregivers to be supported. Because when you support those caregivers, the care recipients are going to do better. And we have outcomes to show that, too. We're seeing reductions in ED visits, lengths of stay and times that older adults are coming into the hospital, which is really important for for them and for health systems at large.

00;19;56;29 - 00;20;21;21
Diane Mariani
And one last thing I'd like to add, is how can caregivers really get this information or get involved or get connected? So for caregivers that are in Illinois, they can reach directly out to Rush University Medical Center at the Caring for Caregivers program. And we can support them. For those that are outside of Illinois, certainly watch for your health care system to be implementing the Caring for Caregivers program.

00;20;21;25 - 00;20;35;24
Diane Mariani
But in the meantime, as we're sharing this model, I would suggest reaching out to your area agency on aging because most of them, if not all of them, do have caregiver supports and can connect you to important resources.

0;20;35;26 - 00;20;39;03
Raahat Ansari
That sounds fantastic. Thank you so much for your time today.

00;20;39;05 - 00;20;47;15
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.