Advancing Health Podcast

00:00:00:14 - 00:00:20:16
Tom Haederle
The care needs of military-connected families can be different from those of many other patients who seek care from hospitals and health systems. Often, they're dealing with higher rates of emotional or mental stress. Rehabilitation and recovery efforts take longer on average, and it's not unusual for military families to be providing long-term in-home care to their veteran members.

00:00:20:19 - 00:00:36:18
Tom Haederle
Experts say these unique circumstances matter, and that many caregivers need to be more mindful that they exist.

00:00:36:20 - 00:01:02:07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. As we observe Veterans Day this week, today's podcast takes a look at how hospitals and health systems, not to mention society at large, can do a better job of meeting the special health care needs of military-connected families. Our host is Nancy Myers, vice president of leadership and system innovation with AHA’s Center for Health Innovation.

00:01:02:12 - 00:01:14:17
Tom Haederle
She is joined by Steve Schwab, CEO of the Elizabeth Dole Foundation, and Dr. Kara Walker, executive vice president and chief population health officer, Nemours Children's Health. Here's Nancy.

00:01:14:20 - 00:01:36:05
Nancy Myers
I'd like to welcome everyone to our discussion today, and I'm so honored to be here with both of you to talk about this really cool and important topic. So, Steve, I want to start with you. Big picture. Why should it be important to hospitals and health systems to increase their use of military-informed care? What is the need in this space?

00:01:36:08 - 00:02:19:01
Steve Schwab
Well, that's such a great question to start off. And it's so good to join you both and talk about a topic that's really important, to our country. If you step back and think about the fact that there is less than one half of 1% of our population serving to protect our freedom and security, and it's easy to take that for granted and to lose the fact that our neighbors and our friends and our church members and our colleagues might be somehow military- connected, because it seems like such a small amount of folks, but actually, when you add in the layers of veterans and military-connected families and kids and folks who work in a

00:02:19:01 - 00:02:44:02
Steve Schwab
civilian setting and military-connected care, it actually adds up to a lot of Americans. And so when we talk about military-informed care, we talk about the unique ways that health care systems and health care practitioners can make military-connected populations feel special from the minute they walk in the door. But care needs for military-connected communities is really different and unique.

00:02:44:04 - 00:03:18:26
Steve Schwab
Military-connected patients tend to have increasing rates of mental and emotional stress, PTSD. Many of our military-connected patients have traumatic brain injuries or behavioral health issues. That doesn't mean everybody, but it means that practitioners and systems need to be acutely aware of the kinds of distinct conditions, mental and emotional, that are unique to the military population. And so when health systems think about when those folks come into, like Nemours, for instance, who's ahead of the game on military-connected care.

00:03:18:28 - 00:03:46:06
Steve Schwab
Because when folks come in, we want to ask patients, are you military-connected? We want to ask if children are inside military families. We want to ask spouses if they're caregivers or military or veteran-connected caregivers, because all of those characteristics, all of those roles, all of those conditions come with unique needs. And what it can provide practitioners and systems are a set of protocols that they can use clinically.

00:03:46:08 - 00:04:11:06
Steve Schwab
They can use administratively to have a special touch, and to take those families or those patients through a continuum of care that doesn't just recognize that they're military-connected, but actually embraces it and builds it into the practice from the front desk to the doctor's room, through to the way that practitioners and clinicians follow up with family members.

00:04:11:13 - 00:04:38:08
Steve Schwab
The other thing that I'll say, that’s unique to military-informed care is that rehabilitation and recovery within military and veteran families usually does really include the entire family — so the spouse and the children, as is the case in our work with Nemours. Military children tend to be more aware of what's going on with mom and dad if they have military service-connected wounds, injuries, or illnesses.

00:04:38:11 - 00:04:43:10
Steve Schwab
There's millions of kids across this country who are serving as primary and secondary caregivers.

00:04:43:13 - 00:05:12:09
Nancy Myers
Thanks for that background and Kara,  I want to turn to you. You know, you're a physician. You're a leader at Nemours Children's, which is really in the business of supporting kids and their entire family. Can you talk about what are the examples of the impact on kids and families when providers aren't providing military-informed care? Or conversely, you know, what are the winds that can happen when they are aware of that background in a child's life?

00:05:12:11 - 00:05:40:11
Kara Walker, M.D.
Thank you so much, Nancy. It is truly an honor to serve so many kids across our geographies. And we know that children in military-connected families serve our country too. And so I'm a family physician. I know that the context of which a family is in, at home, at school, in our communities, matters so much to the health that they have personally, but also to the health of their entire family unit.

00:05:40:11 - 00:06:15:16
Kara Walker, M.D.
And so we know that each encounter with a military-connected child or youth provides us an opportunity to recognize their service. And we know how important trust is and trust building and seeing the whole person is in creating health in our nation. This enhances the care that we provide as physicians, as caregivers, as health systems. And we also know that in conversations we have with military families, we get to hear the stories of what it looks like when it's done right.

00:06:15:18 - 00:06:42:12
Kara Walker, M.D.
We know that that means we acknowledge military connections. It means we're checking in with our patients and parents in a way that shows we understand how being part of a military-connected family impacts so much of what it means to thrive. It means it impacts their social supports, their health care needs, but also their mental health needs. So we also know what it feels like when it's done well.

00:06:42:14 - 00:07:12:13
Kara Walker, M.D.
Unfortunately, we also hear stories of frustration when it's not done well. We hear of families who have to be that bridge and have even more burden to act as educators and then orient the entire health system to what it means to have challenges and stressors that can be caused by deployments and relocations, or what it means to be a young person who's also caring for a parent with PTSD or other types of service-related injuries or illness.

00:07:12:16 - 00:07:43:27
Kara Walker, M.D.
So we know both sides of that coin. I think that's where being military-informed can help all of us do more for the patients we serve and our communities. There's a saying that when you know better, you do better. And through our Hidden Helpers Coalition and other work, the Elizabeth Dole Foundation does an incredible job of raising the collective awareness of needs of military-connected spouses and children, particularly for those who are caregivers for injured veterans or service members.

00:07:44:00 - 00:07:51:06
Kara Walker, M.D.
We are so fortunate to participate in this Coalition. It has been part of our journey to know better.

00:07:51:09 - 00:08:13:10
Nancy Myers
So I want to come back to you in a moment to talk to you about how Nemours got involved with the Hidden Helpers Coalition, but Steve, wanted to turn back to you to tell us a little bit about that Coalition. Why was it needed? What types of organizations are you working with and how you feel that hospitals and health care can really contribute to the work?

00:08:13:13 - 00:08:42:21
Steve Schwab
Yeah, well, I think you can tell by Kara's answer that Nemours gets it, and military families notice that. Military-connected patients notice when they walk into a clinical setting or a hospital or a doctor's office, if that physician, if that office has a culture of military-connected care because their experiences serving this country are so unique. And that's really what's been beautiful about the partnership between Nemours and the Elizabeth Dole Foundation.

00:08:42:24 - 00:09:19:15
Steve Schwab
Let me tell you about the work that we're doing around Hidden Helpers. In 2014, we did a groundbreaking study with RAND and really put the military and veteran caregiving issue on the map. We stood in the East Room of the White House with then President Obama, Mrs. Obama, and Dr. Biden. And we said this country has a crisis occurring in military and veteran families, 5.5 million families across the country who are providing long-term, in-home care for wounded, ill and injured veterans in a way our country had never seen before because so many veterans were coming home with injuries that they had sustained in war and that they were surviving in rates they hadn't in

00:09:19:15 - 00:09:45:17
Steve Schwab
prior war eras, because of advancements in battlefield medicine, which means the family model of care in this country for military and veteran families has totally changed. Families are now engaged in home health care in a way that they hadn't been. So multiple generations are being impacted, including kids. And so part of what that RAND study told us was there wasn't enough research on the implications of this new caregiving situation in America.

00:09:45:20 - 00:10:14:15
Steve Schwab
Nemours and others joined us as we unveiled an update to that 2014 study 10 years later, that tells us that that number has gone from 5.5 million to 14.3 million families. So in 10 years, we've seen an almost threefold increase in the amount of families across this country. And they're in all 50 states. They're inside military health institutions and VA facilities, but they're also going into places like Nemours and clinical health facilities all across this country.

00:10:14:18 - 00:10:51:19
Steve Schwab
And so we did a research blueprint, and that blueprint from RAND told us that we needed to understand more what was happening with kids and the implications of this caregiving situation on children. And so we did a study, went back to the White House. Dr. Biden helped us launch an initiative called Hidden Helpers three years ago, and we challenged American childcare organizations and health care organizations to come together with government in the private sector in a coalition approach to think about how we can bring special, tailored care and support to these kids.

00:10:51:20 - 00:11:25:18
Steve Schwab
Nemours was one of the first institutions to raise its hand. It has been remarkably leading the front as it relates to innovating care, both technology approaches and clinical approaches, training approaches that are becoming the model for the nation. And that's the whole idea behind this Coalition, bringing these partners together to create programs and innovation and educational interventions to change these kids’ lives and to help them in the school setting, in the health care setting, in their home and to create stronger, healthier families.

00:11:25:21 - 00:11:32:05
Nancy Myers
Thanks. So, Kara, talk a little bit about what are some of the initiatives to improve military-informed care?

00:11:32:07 - 00:12:00:10
Kara Walker, M.D.
Well, I'm so thrilled that when we raised our hand, Steve said, “Yes, let's go and let's run.” Before I summarize our current work, I want to say that the Coalition's focus is on children who have a parent with service-related injuries. The work we're doing at Nemours Children's takes a “yes and” approach. It's really focused that our efforts are designed to benefit caregiving children, plus any and all military-connected children.

00:12:00:12 - 00:12:22:11
Kara Walker, M.D.
So one of the commitments when we joined the Hidden Helpers Coalition was to create this introductory professional development course for providers and others who are in the health care sector. Now, I know as a doc, sometimes we have to sign up for these courses to make sure we're current and we have the best evidence and the best tools.

00:12:22:14 - 00:12:52:12
Kara Walker, M.D.
This education opportunity was developed in partnership with the Elizabeth Dole Foundation. It merged our expertise on, you know, the technical health care medical side, but then we combined it with extensive knowledge of military culture. It created a course that's publicly available on our Nemours continuing education platform at no cost. But I will say that there are very few educational courses that I personally have taken where I teared up.

00:12:52:15 - 00:13:23:17
Kara Walker, M.D.
I got emotional and I walked away with true skills. This course is compelling. It features young adults who are part of military caregiving homes, spouses of injured veterans, as well as physicians, nurses, behavioral health care providers from Nemours Children's. It really is a robust opportunity, and if you want some more resources who want to learn more, dive deep into the course, such as learning more about trauma-informed care, what secondary PTSD is, and many others,

00:13:23:17 - 00:13:52:16
Kara Walker, M.D.
check it out. It really is an incredible course. I'll also say we're very proud of the work that's happening around creating new tools in our electronic medical record. So this summer we added an identifier to our EMR that allows us to document if a child is part of a military-connected home. So, you know, the doc pulls up the electronic screen, you check into your visit and it says maybe your address, your age, maybe what meds you're on.

00:13:52:18 - 00:14:24:18
Kara Walker, M.D.
Now, you can see as a snapshot whether a child is also military-connected. That just gives you a quick prompt to make sure we know the information is flowing. The identifier is there. This is truly unique. Once we have a few months of the data, our team is going to create some sense out of this. We're going to meet to review the data, understand what procedures and trainings need to be in place so that the entire care team knows what to do when they're connecting and interacting with a military-connected patient.

00:14:24:20 - 00:14:31:23
Kara Walker, M.D.
It'll make sure that we adapt, how we interact, how we ask questions, how we ask the right questions at the right moment.

00:14:31:25 - 00:14:50:04
Nancy Myers
I always like to end with, what are a couple of things you can do today as you go back to your own organization, for our listeners. So for AHA members and other health care organizations that want to expand and increase their use of military-informed care, what are the concrete actions you recommend? Where should they start?

00:14:50:06 - 00:15:15:27
Kara Walker, M.D.
Easy. There are two things I would underscore. One, I want to encourage providers, care team members, health professionals who are listening to take this professional development course. It is an incredible opportunity to learn from both our experience at Nemours and the Elizabeth Dole Foundation's expertise, to understand the ability to respond to the unique strengths and stressors of military-connected children and families.

00:15:16:02 - 00:15:48:21
Kara Walker, M.D.
We'll share the course link in the show notes. Check it out. It is no cost, CME, all the good things and lots of incredible patient stories and kids who are doing tremendous work. Second, I want to encourage others who are listening across AHA’s membership to join Nemours Children's Health and being part of the national Hidden Helpers Coalition. There are already a hundred members from a broad range of sectors, but like CHA, I know there are health system leaders who want to be part of this Coalition membership.

00:15:48:24 - 00:16:06:10
Kara Walker, M.D.
It brings you an invaluable opportunity to learn and bring those lessons back to your organization. More than anything, Hidden Helpers Coalition is action focused, so this is a real chance to collaborate on joint initiatives that go beyond the scope of what one organization alone can do.

00:16:06:12 - 00:16:08:19
Nancy Myers
Steve, anything that you'd like to add?

00:16:08:21 - 00:16:30:15
Steve Schwab
Can't beat what Kara just said. We take a more than the merrier approach in this Coalition. If you work with kids, if you work with families, if you work in the health care sector, in the education sector, there's room for you at this table. I think you'll find a really innovative group of folks who are mission oriented, and want to make a difference in the lives of military families.

00:16:30:15 - 00:16:40:02
Steve Schwab
So we really appreciate this opportunity to spread the word and how important it is for all of us to be military-informed, especially as it relates to what we're doing in the health care setting.

00:16:40:05 - 00:17:03:09
Nancy Myers
Well, I would like to thank you both for this important conversation and for reminding us that as we honor the service of our active military members and our veterans, we also recognize the support that we can provide to their families in our hospitals and health systems. And make sure to check out the resources available through Nemours Children's and the Elizabeth Dole Foundation.

00:17:03:11 - 00:17:11:22
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.

00:00:00:11 - 00:00:26:11
Tom Haederle
Often, people with severe mental illness lead shorter lives, sometimes up to 25 years less. For historically underserved populations and minorities, this can be compounded. A recent Kaiser Family Foundation report found that rates of death by suicide are rising faster among black, Hispanic, and other people of color than whites. There are many reasons for this, including access to care, stigma, and even implicit bias in the health care system itself.

00:00:26:13 - 00:00:48:12
Tom Haederle
There isn't one magic solution to all of these problems, but as Denver Health has found out, the integrated care system goes a long way towards reducing health disparities and providing the care that patients need and deserve.

00:00:48:15 - 00:01:11:13
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 Rebecca Chickey, senior director of Behavioral Health Services with AHA, we learn how Denver Health's commitment to integration as a tool for increasing access to behavioral health has benefited the communities it serves by reducing stigma and health disparities.

00:01:11:15 - 00:01:23:25
Tom Haederle
As Matthew Hoag, director of Integrated Behavioral Health for Denver Health, says, a patient can now discretely get all of their health conditions addressed in one place. And that's incredible. Here's Rebecca.

00:01:23:28 - 00:02:07:12
Rebecca Chickey
It is my honor indeed to be here with Matthew Hoag from Denver Health. He has so much experience in the value of integrating physical and behavioral health. And it's an honor for myself and our listeners today to be able to listen and learn from him. Today, we're really going to focus on the value of integrating physical and behavioral health in terms of how it can help reduce health disparities for historically underserved communities, individuals, and communities of color, as well as those individuals who suffer from severe and persistent mental illness, such as schizophrenia and bipolar disorder.

00:02:07:15 - 00:02:50:06
Rebecca Chickey
The reason that these things are so important is what Matthew's going to share with us. But I want to put in just a couple of thoughts. One, when you hear what he says about the importance of integration and the value that that delivers for individuals with severe and persistent mental illness, one of the really important things is that is what people often refer to as bi-directional integration, meaning individuals with severe mental illness often die 17 to 25 years earlier than those individuals without. And that's not due to suicide. That is due to their inability because of poor management in many cases of their mental illness.

00:02:50:09 - 00:03:23:20
Rebecca Chickey
And then health disparities exist across the board for communities of color. And when you begin to look at it through the lens of behavioral health care, unfortunately, the magnitude of those disparities often goes up. So with that as general background, Matthew, can you tell me just a little bit about the realities - as I started talking about - and the vulnerabilities around mental health disparities, and what are those challenges that those individuals face?

00:03:23:22 - 00:03:48:18
Matthew Hoag
Thank you. Rebecca. Before we start, too, I just want to acknowledge my privilege as a as a white male. And just hammer home that I choose to work in a community health center here at our Denver health hospital because I believe in our organization's mission to provide all in our community access to the highest quality and equitable health care, regardless of the patient's background or ability to pay

00:03:48:18 - 00:04:18:15
Matthew Hoag
so really appreciate the opportunity to talk on these topics. You know, what we know is that an estimated 43% of people with mental health concerns are connected to care, and that's a pretty alarming statistic. Some of the realities and challenges for individuals of color, include implicit bias, which comes up quite a bit in how patients might be identified or selected for referrals to behavioral health or identified or even properly diagnosed.

00:04:18:15 - 00:04:39:19
Matthew Hoag
And so this this plays a huge impact for individuals of color. The other thing that's kind of difficult within behavioral health is it can be very difficult to navigate our complex health system, but even more specifically, our sometimes complex behavioral health system, because it can be difficult to know what somebody feels like they need to be connected to.

00:04:39:19 - 00:05:01:26
Matthew Hoag
And so if there isn't really good screening, really good assessments, sometimes individuals and families are at a loss of where to go or where to start, or who even to ask to begin that journey. I think another area that we see, and that we're trying really hard as an organization to impact, is a lack of diversity among our care teams.

00:05:01:28 - 00:05:26:02
Matthew Hoag
We, at Denver Health have community health centers. And what I love about Denver Health is these community health centers are situated in very historic neighborhoods within Denver County, we're I think the fifth largest federally qualified health system in the country. We strive to have those clinics be a reflection of those communities they serve. Really requires us to have staff as a reflection of those patients.

00:05:26:04 - 00:05:50:24
Matthew Hoag
Why that's important is because trust. Trust is incredibly important with the care team to be able to break down some of these racial disparities. Now, where does integrated behavioral health come in with this? I could talk about integrated behavioral health all day. We have really good research that shows that improves patient outcomes, reduce total cost of care, increase access above all to behavioral health.

00:05:50:24 - 00:06:14:17
Matthew Hoag
And we also see that patients like what is incredibly valuable to me is that when I have a medical provider pull me in to consult with a patient for a behavioral health concern, sometimes that patient has been coming to that clinic for ten, 15 years. Their parents had gone there. Their parents still go there for care. Their kids get their vaccinations, get wellness exams there.

00:06:14:21 - 00:06:35:22
Matthew Hoag
And so when I come into the room, I have this unparalleled level of support and trust already because that medical provider who has that trust with that patient says, this is Matt. He's an expert in X, Y, and Z depression, whatever substance treatment. And he wants to come talk with you to see how we can support that goal or support.

00:06:35:22 - 00:06:41:19
Matthew Hoag
You know, let's talk a little bit more about, you know, what's going on over here. And that's the value of integrated care.

00:06:41:21 - 00:07:15:15
Rebecca Chickey
You have talked about the importance of trust. The fact that it's real time, meaning you can call in a medical provider or you can be called in as the expert to help that patient real time. Is that something that you see has also been beneficial in terms of reducing the stigma, because you've used the term trust a couple of times, but often we hear the horrible word, the big thing in the room, the stigma of even seeking or talking about mental health treatment or my anxiety or panic attack.

00:07:15:18 - 00:07:17:13
Rebecca Chickey
Is that another aspect of this?

00:07:17:15 - 00:07:51:23
Matthew Hoag
Absolutely. Stigma, I'm glad you brought that up. Stigma is all about what we're trying to reduce and what our integrated behavioral health can be really substantial. Early on in my career with integrated behavioral health, I specialized within substance treatment and co-occurring as well with other behavioral conditions. But one thing I always when I walked into the room, as I always try to keep in the focus, that it is very likely that the individual that I'm about to meet has had a negative interaction or has been judged for a behavioral health or substance treatment condition at some point prior to meeting me.

00:07:51:26 - 00:08:09:09
Matthew Hoag
And so I try to think about how I approach that from a culturally sensitive way, but also identify and create some safety where I can. I'm very fortunate to have that collaborative medical team to help with that trust, but it's something that we have to be very, very cognizant about because it is a reality that's in the room.

00:08:09:11 - 00:08:32:09
Rebecca Chickey
It's so very important because stigma exists for all of us, regardless of your ethnicity, the location or culture that you've been brought up in, your skin color. But unfortunately for many, many different cultures and even genders, we still see the statistics show that women are more likely to ask for help than men, regardless of everything else.

00:08:32:12 - 00:08:45:24
Rebecca Chickey
And then within certain cultures that stigma is at a much higher bar. So it's just uplifting and hopeful that, integration can address those in a way that is seamless in many ways.

00:08:46:01 - 00:09:27:27
Matthew Hoag
Absolutely. And I think what folds into the trust piece is the cultural competency of our staff. And so, you know, our organization and our integrated behavioral team places part of our values as a team is around diversity, equity and inclusiveness and belonging and how that shows up in our clinical practice, being able to identify microaggressions within teams and being able to have open discussions about how that influences us as providers, but also impacts our ability to deliver effective clinical care. Something that is also really important with this - in order to have and to recruit for diverse care teams, is we often put a lot of emphasis on recruitment, but retention is also really

00:09:27:27 - 00:09:32:00
Matthew Hoag
important for keeping that healthy for our teams.

00:09:32:03 - 00:09:38:27
Rebecca Chickey
As we begin to wrap up, are there a couple of things that you think have made Denver Health's program successful?

00:09:39:00 - 00:10:06:18
Matthew Hoag
I think the thing I most appreciate about where I work is the individuals I work with as well. We're a large organization, and we have done some pretty cool things that are a little out there, but we're not afraid to try that. One particular project I want to highlight is we just last year launched a mobile opioid treatment unit, and this was a collaboration between our brick and mortar opioid treatment program and our community health services.

00:10:06:18 - 00:10:27:15
Matthew Hoag
And so this mobile unit actually goes out to two of our qualified health centers, our eastside and westside clinic. And we do walk-ins for opioid treatment, particularly for methadone. And what's amazing about that is if, you know, you know how sometimes there's some realities and difficulties with accessing Opidone and it's, you know, very regulated, very structured.

00:10:27:18 - 00:10:46:12
Matthew Hoag
You usually have to go really early in the morning to receive that. We did something where we enhanced a lot of current patients care, because we have patients who go to the Eastside Health Center, then go across town to you know, their opioid treatment program. It's not quite integrated, but what I would call is it's very co-located and very collaborative.

00:10:46:15 - 00:11:07:05
Matthew Hoag
But a patient can discreetly now get all of their health conditions addressed in one place. And that's incredible. Especially with fentanyl opioid epidemic being able to enhance care in a way that is trauma informed as well as, kind of helping break down some of those barriers to access. I like that we get to do that.

00:11:07:10 - 00:11:15:12
Matthew Hoag
I'm incredibly grateful, and it feels incredibly special to be able to try to do things like that, to really enhance care for all of our patients.

00:11:15:15 - 00:11:37:06
Rebecca Chickey
So the key point, I think, for the listeners is to not be afraid to try. That was unusual. That's out of the box. I think sometimes when we're young, we try everything, right? Sometimes to the demise of our parents or whoever is bringing us up. But we're not afraid to try. And sometimes I think the world changes that perspective.

00:11:37:07 - 00:11:56:04
Rebecca Chickey
So, we need to remember. Don't be afraid to try, because you're all you're trying to do is to improve outcomes and reduce the cost of care and improve somebody's life. Thank you so much for sharing your time and your expertise with us today. Thank you for the work that you're doing across the fine mountain city of Denver.

00:11:56:06 - 00:11:59:01
Rebecca Chickey
And thank you for your passion for your work.

00:11:59:03 - 00:12:00:12
Matthew Hoag
Thanks for having me.

00:12:00:14 - 00:12:08:25
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.

00:00:00:20 - 00:00:36:10
Tom Haederle
The expansion of telehealth services has transformed care delivery, expanding access for millions of Americans who faced barriers to care related to transportation, mobility limitations or geographic isolation. In rural Minnesota, the dramatic expansion of telehealth capabilities, much of it driven by the vision and effort of one passionate physician, has made a tremendous difference in supporting the labor and delivery needs of community residents.

00:00:36:12 - 00:01:11:14
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Women facing long travel distances for regular visits to their obstetrician are less likely to receive the level of care they need, and more likely to experience serious complications and higher rates of maternal mortality. That's why one OBGYN specialist in northern Minnesota has created the Families First Rural Maternity Health Collaborative program, a telemedicine platform for expectant mothers that she calls "My love letter for my patients and the people that I'm called to serve."

00:01:11:16 - 00:01:13:06
Tom Haederle
Let's join the conversation.

00:01:13:08 - 00:01:35:03
Chris DeRienzo, M.D.
Welcome, everyone to our podcast today. I'm Dr.Chris DeRienzo. I'm the chief physician executive for the American Hospital Association. You are joining us from the Leadership Summit. We are in the Innovation Hall, and you can hear all of the energy and excitement at this incredible meeting here in San Diego. And I am incredibly excited to get to spend a few minutes with Dr. Johnna Nynas from Sanford Health Bemidji.

00:01:35:11 - 00:01:43:03
Chris DeRienzo, M.D.
She is a practicing OBGYN, and the story that she has to share will absolutely blow you away. So Johnna, welcome to the program. Thank you for joining us.

00:01:43:04 - 00:01:44:14
Johnna Nynas, M.D.
Thank you for having me.

00:01:44:16 - 00:01:59:04
Chris DeRienzo, M.D.
You've been recognized recently as one of CNN's champions for change, and that's grounded in the incredibly foundational work that you do. Why don't we just start by talking a little bit about what that recognition means to you personally and professionally?

00:01:59:06 - 00:02:14:29
Johnna Nynas, M.D.
Well, it certainly came as a huge surprise. When you come to work every day, you're doing the job that you're doing because you love the work, and you love the people that you're working with and the type of impact that you have on the community. So to be recognized for something that I love so much is truly an honor.

00:02:15:01 - 00:02:41:22
Johnna Nynas, M.D.
When we set out to create the Families First Rural Maternity Health Collaborative program, we really started with the idea of what were the barriers in our community, because the barriers can never be more than the why. And so when we identified all those barriers and started putting the work together and pulling the ideas together and collaborating with each other, it just became this very passionate project of mine.

00:02:41:22 - 00:02:50:04
Johnna Nynas, M.D.
And the way I looked at it when I submitted the final submission was, this is my love letter for my patients and the people that I'm called to serve.

00:02:50:06 - 00:03:07:27
Chris DeRienzo, M.D.
We can hear it in your voice and obviously touches you deeply, personally. And my understanding is you have some pretty deep roots in this part of rural Minnesota. Would you speak to that a little bit and then you know, why you needed to turn to this groundbreaking telemedicine program to support the labor and delivery needs of the people in your community?

00:03:08:00 - 00:03:28:22
Johnna Nynas, M.D.
So I have background growing up in rural Minnesota as a kid on a small family farm. And realizing that it was 30 minutes one direction just to access medical care, that was standard growing up, I didn't know any different. And as I started to go through my medical training and residency, you started to see some of the disparate impact that that has.

00:03:28:22 - 00:04:03:17
Johnna Nynas, M.D.
And certainly the national data supports that. Women living in rural communities are nine times more likely to die in childbirth than women in urban areas. And that's an unacceptable statistic. Where I'm located in Bemidji, Minnesota, we're very geographically isolated. We're four hours north of Minneapolis, and we are surrounded by three different Native American reservations. And unlike the American population, where 1.3% would be Native American, in my county where I live, 22% of patients are Native American.

00:04:03:19 - 00:04:27:06
Johnna Nynas, M.D.
So that really called into light the need to work on those disparate outcomes and the obligation that we had. I think really looking at how we could break down those barriers is what led us to the work that we were going to do, and kind of leaning in with the communities that we serve and work with daily and hearing from our patients what the barriers were that prevented them from getting care was where we started our work.

00:04:27:09 - 00:04:49:08
Chris DeRienzo, M.D.
It's the exactly right place to start, and it's fitting that we're sitting here in the Innovation Hall at the AHA's Leadership Summit, because we know that the challenges that America faces with high quality and safe labor and delivery of care, there's never going to be one solution for those. And so we need the kinds of local innovations that you've been able to drive up in Bemidji as examples that we can then replicate across the country.

00:04:49:08 - 00:05:03:18
Chris DeRienzo, M.D.
So talk to us a little bit more about those key initiatives within the Families First Rural Maternity Health Collaborative, how you sought the funding, how you built those pillars and then what they actually do to bring care in such a unique and innovative way?

00:05:03:18 - 00:05:35:25
Johnna Nynas, M.D.
Sure. We applied for funding through HRSA's Our Moms program around maternity obstetric management strategies program, and we were awarded $3.67 million over four years to do this work. And when we broke the work down, we kind of have some basic pillars that are focused on excellent obstetric care coordination and management, transportation services, prenatal care and education services, support services related to other factors from childbirth, from lactation to home visiting nursing programs.

00:05:35:28 - 00:06:13:05
Johnna Nynas, M.D.
And then lastly, our virtual care program to try to bridge the gap that exists due to distance and transportation. Within the program, some of the things that we're seeing is we've created a very strong partnership with our collaborative partners, which includes Red Lake and Cass Lake Indian Health Services, Scenic River's health system, which is our local FQHC. And then we also have partnership with Primus, which is our Medicaid servicer, and then Beltrami County Public Health and then Sanford Medical Center, Fargo, to provide some maternal fetal medicine outreach for those additional services that we don't have locally.

00:06:13:07 - 00:06:16:15
Chris DeRienzo, M.D.
And how far is that from where you are in Bemidji?

00:06:16:17 - 00:06:21:25
Johnna Nynas, M.D.
So our nearest tertiary care center is Sanford Fargo. That's three hours to our west.

00:06:22:00 - 00:06:22:25
Chris DeRienzo, M.D.
Goodness. Three hours.

00:06:22:25 - 00:06:47:25
Johnna Nynas, M.D.
Yeah. And this whole problem is exacerbated by the fact that since 2019, we have had four regional labor and delivery unit closures. So now I have patients who are traveling three hours one direction to come for a prenatal visit with me. So when we looked into some of the digital options and virtual options that we had available, it became very clear that we needed to change the way we were thinking about this problem.

00:06:47:28 - 00:07:09:01
Johnna Nynas, M.D.
So what would it look like if, instead of expecting my patient who lives in a geographically isolated area in Red Lake, and asking her to come to my clinic 2 to 3 times a week for monitoring for management of her diabetes and her chronic hypertension and or other chronic medical conditions that contribute most to severe maternal morbidity and mortality.

00:07:09:03 - 00:07:37:02
Johnna Nynas, M.D.
What would that look like if I brought that care to her? So one of the ways we're doing that is by really expanding our use of OB telemedicine visits. These can be used for really any visit that doesn't require an in-person appointment for either labs or ultrasound or imaging. Patients are given a low tech kit, including a blood pressure cuff and fetal heart rate monitor that they can use at home for their visits, and then they connect with their medical provider via a digital platform through the My Sanford Health app.

00:07:37:05 - 00:08:06:25
Johnna Nynas, M.D.
The nice thing about this is from a provider standpoint, we made very sure that we didn't limit this to just low risk women. Because the reality is where we're located, if women aren't coming to us to seek care then they're just not getting care at all. And that's unacceptable. So we opened it up to anybody. And what we found is not only are patients very accepting of that telemedicine platform and doing visits themselves, it's also better engaging women in understanding their care.

00:08:06:27 - 00:08:27:17
Johnna Nynas, M.D.
And as a physician, you can appreciate how important it is to have patients who really understand the why behind what we're asking them to do. One example of that is monitoring patients with hypertension in pregnancy. When they come into my office, it's a passive process. Someone's checking their blood pressure, someone's telling them the number of the day and is it good or is it bad?

00:08:27:19 - 00:08:44:13
Johnna Nynas, M.D.
Whereas if a patient's at home and she's monitoring her own blood pressure, I've had to give her some education and some guidance on: this is what I worry about. This is what I don't. These are your parameters for coming in and following up for care. Yeah. So now that patient not only has some insight into her condition, she's taking ownership and responsibility for that.

00:08:44:13 - 00:09:11:04
Johnna Nynas, M.D.
She's reaching out and saying, I am having these symptoms. And I took my blood pressure. I noticed it's high. I think I need to come in, what's my next step? And that takes on a step further within the communities that we serve. So by educating women on these conditions during pregnancy, we're seeing an impact where patients have been cousins or aunties or relatives or friends of other pregnant women who have said, I don't feel good today.

00:09:11:04 - 00:09:24:04
Johnna Nynas, M.D.
I feel like I have a headache, my vision's really blurry. And my patient has said, you know, my doctor talk to me about preeclampsia. We should probably check your blood pressure. That's really impactful if you think of what that can do for communities.

00:09:24:04 - 00:09:43:28
Chris DeRienzo, M.D.
It's impactful and it effectively flips the challenge that we face around maternity care in this country on its head. And we have all heard about the shifts in demographics and changes in the kinds of people living in communities. And we know there's a massive workforce crisis, and that you need several thousand people living in a community just to be able to support one OBGYN.

00:09:43:29 - 00:10:02:00
Chris DeRienzo, M.D.
But what you've done is taken the strength in those rural communities, which we know is a tight knit fabric in this country. And by projecting specialist expertise into those communities, you've tapped into the power of that fabric. It's incredibly inspiring. And at the same time, I know it's got to have been challenging.

00:10:02:03 - 00:10:20:28
Johnna Nynas, M.D.
Certainly has been challenging. Some of the initiatives that we haven't even begun to realize yet is we still need to implement satellite clinics, which are going to be regional hubs where there's already a preexisting clinic. One example is in Panama, Minnesota, which is in Red Lake Nation. They have a medical assistant, but not necessarily a provider.

00:10:21:00 - 00:10:53:25
Johnna Nynas, M.D.
So our next steps are to build out the infrastructure. So there is telemedicine equipment and broadband. Because the reality is not all rural patients have access to a smartphone or broadband. So now instead of expecting a patient to have those tools, that patient can just go down the street to their local clinic and receive that care virtually. And we're working to outfit everything from remote antenatal testing and non stress tests, consults with diabetes educators, nutritionists, potentially maternal fetal medicine all from the comfort of the patient's own community.

00:10:53:28 - 00:11:23:07
Johnna Nynas, M.D.
They can come in and they can upload their continuous glucose monitor so we can see exactly how their blood sugar control is, so we can better manage those chronic medical conditions that contribute most to severe maternal morbidity and mortality. But as you can imagine, it's a simple idea. Right. But implementing it is a completely different story. We have definitely run into some barriers when it comes to working between different agencies, and especially with a government agency that we're unintended not realized prior to starting our work.

00:11:23:10 - 00:11:44:15
Johnna Nynas, M.D.
And it's delayed some of the implementation that we want to do, but we're still making forward progress, and we're really excited about that. I think one of the things that we've certainly learned from this is when you're implementing a new mode of delivery for care that's going to be shared across different entities, is to have those conversations with IT

00:11:44:20 - 00:11:51:22
Johnna Nynas, M.D.
teams and legal teams early on in the planning process. Absolutely. Instead of springing it on them at the end.

00:11:51:25 - 00:12:10:19
Chris DeRienzo, M.D.
That is a spectacular recommendation. And we always run into this when we're breaking new ground in health care. But you folks at Sanford have been so incredibly innovative, recognizing that you serve frontier communities, that you've got to innovate in order to get these folks who live in you know, less than seven people per square mile to the kinds of outcomes that you're able to.

00:12:10:19 - 00:12:28:11
Chris DeRienzo, M.D.
That's frankly, one of the biggest benefits that we've seen in the Patient Safety Initiative that the 1500 plus hospitals who are members of the work have said, you know, we spend so much time heads down in operations caring for patients that sometimes it's hard to lift our heads up and hear about the wonderful things going on all across this country.

00:12:28:11 - 00:12:51:24
Chris DeRienzo, M.D.
And so that's part of this innovation workstream. And in just the last couple of minutes that we have, I'm wondering for all of the folks listening in today, by hearing your inspirational story and the incredible work that you're doing up in in rural Minnesota, what advice would you give to people, say, in rural Mississippi or in rural Massachusetts who are facing the same challenges and saying, gosh, I just need to take that first step to get the momentum going.

00:12:51:27 - 00:13:11:21
Johnna Nynas, M.D.
I think one of the most important steps to realize, if you're looking to implement some programming is the time to solve the problem is actually not now. We're not solving today's problem. We're creating the infrastructure to solve the problems that will be in existence to support the communities that we will be 20 years from now. Well, so that's what we're looking to do.

00:13:11:21 - 00:13:14:16
Johnna Nynas, M.D.
And really having that forward thinking mindset.

00:13:14:19 - 00:13:26:08
Chris DeRienzo, M.D.
Again, this has been an absolute privilege, Johnna. Thank you so much for joining us again. This is Dr. Chris DeRienzo, we've been with you live from the AHA Leadership Summit Innovation Hub. And thank you for joining our podcast.

00:13:26:11 - 00:13:34:22
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.

00:00:00:18 - 00:00:30:05
Tom Haederle
An advanced practice provider - or APP - is a health care professional with advanced training to diagnose, treat, or manage medical conditions that don't neatly fit into hospitals existing nursing or medical staff infrastructure. But their unique combination of skills and training have brought advanced practice providers into great demand nationwide.

00:00:30:08 - 00:01:01:02
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. APPs have grown in number and are becoming much more integrated into hospitals clinical teams. Today, their crucial role in serving hospitalized patients across America is practically universal. In this podcast, Dr. Chris DeRienzo, AHA's chief physician executive, speaks with one health system's chief APP about the growing role her colleagues play in health care delivery and health care leadership.

00:01:01:05 - 00:01:28:14
Chris DeRienzo, M.D.
Welcome, everyone to another podcast here. We are at the AHA Leadership Summit in San Diego, and we are here in the Innovation Hall. And it is a true privilege that I get to sit down across the table from one of my good friends, Michelle Schweitzer. She is the chief APP at WakeMed Health and Hospitals in Raleigh, North Carolina. I have a special place in my heart for WakeMed because I got to be chief medical officer of that system before joining the AHA.

00:01:28:16 - 00:01:50:25
Chris DeRienzo, M.D.
And we're here in the Innovation Hub, which is a spectacular place to be because, Michelle, we'd like to talk about what is one of the most significant innovations in care delivery and in workforce over the last 15 years in health care. And that's the emergence of the APP. And specifically, we're seeing now across the country a trend towards roles like yours, chief APPs in hospitals and health systems.

00:01:51:02 - 00:02:00:03
Chris DeRienzo, M.D.
So just to kick us off, why don't we start a little bit around that issue? Tell me a little bit about how you came to that role and frankly, why that role exists at WakeMed.

00:02:00:05 - 00:02:21:09
Michelle Schweitzer
Sure. Thank you. So I will start by saying that I grew up as a nurse practitioner first before I even stepped into leadership. In fact, I went back to school to look at more research and innovative and found my way into leadership instead. Started my career managing just a few APPs, and then worked myself up to managing a whole lot of APPs.

00:02:21:11 - 00:02:25:00
Chris DeRienzo, M.D.
Remind me - what was your clinical role as an APP?

00:02:25:02 - 00:02:30:18
Michelle Schweitzer
It started out in pediatric bone marrow transplant and then it transferred into pediatric surgery.

00:02:30:25 - 00:02:35:15
Chris DeRienzo, M.D.
Now, you don't like sort of the easy outpatient...that's some pretty intense stuff!

00:02:35:17 - 00:03:07:28
Michelle Schweitzer
Yes. I was a PICU nurse before I went back to school. And of course, just like most people, I had a vision of what I was going to do when I finished. And of course, that's not at all what I was doing when I finished. Cancer was never in my book. I wanted to do actually pediatric cardiology, and I did a rotation, in bone marrow and, fell in love with the fact that I can have a patient that was sick as all get out next door and then walk into another room where patients who normally would have never survived is 15 years out and going to college.

00:03:09:00 - 00:03:29:10
Chris DeRienzo, M.D.
Wow. Once you've been in that kind of clinical environment, and I know we share that I'm a neonatologist and, rarely in our world as leaders do you face challenges that that even come close to that personal life or death impact. But it's tough making the transition to management. And it's not really something they teach us in our clinical background.

00:03:29:10 - 00:03:33:09
Chris DeRienzo, M.D.
So talk us through how you walk through that transition.

00:03:33:11 - 00:03:52:04
Michelle Schweitzer
In all honesty, it comes from mentorship. It started out with, you know, watching those that I looked up to and seeing how they were able to influence myself and others around me into growing into the provider that I am. And it made me want to do the same for others. And so that's really what stepped me into leadership versus education.

00:03:52:05 - 00:04:00:03
Chris DeRienzo, M.D.
Yep. And it made you are that leader for hundreds of APPs. How did that role come to exist?

00:04:00:05 - 00:04:17:14
Michelle Schweitzer
In all honesty, I was sitting in a gym and right beside me was the chief legal officer of WakeMed who said, hey, have you thought about leaving your current institution and maybe taking on a larger role, of which she described. And I was like, oh my God, that's something I can I mean, maybe in ten years I might do.

00:04:17:16 - 00:04:42:27
Michelle Schweitzer
However, the more I thought about it, the more I was intrigued. The ability to really make the position itself, because there wasn't really a chief APP officer. There was a smattering of leaders, but no one who was taking it and pushing it forward. So that interests me. And I interviewed, and luckily they went outside of the institution and let me come in and really gave me the span to allow me to really grow what they asked for.

00:04:42:27 - 00:04:56:14
Chris DeRienzo, M.D.
Well, they made a spectacular choice. But tell us more about that span, because in your health system, that role not only encompasses the employed group, but also has some accountability for many, many more APPs who rotate through an open medical staff.

00:04:56:21 - 00:05:26:07
Michelle Schweitzer
Yeah, the role is, it's dual, as you say. So from a system perspective, my role was really to get to know all the APS within our health system, as well as to work with credentials and med staff and really make sure that we're providing the right level of care across the system, whether they're employed or not. And then from an employment standpoint, I think when I started, it was around maybe 200 APPs and as of yesterday, which you never know, there's about 450  that are employed.

00:05:26:08 - 00:05:34:18
Michelle Schweitzer
So from there, it was establish a leadership structure as well as compensation structure and helping them get to the top of scope of practice.

00:05:34:20 - 00:05:56:08
Chris DeRienzo, M.D.
And as you've indicated, it's an ever evolving field that that you face. This is a relatively new role at WakeMed. It's a relatively new role in lots of hospitals and health systems across the country. Talk to our listeners a little bit about some of the challenges created by the fact that this is this isn't a job that, you know, in even 2012 would have been something that that health systems would think about

00:05:56:08 - 00:06:00:10
Chris DeRienzo, M.D.
and now it's frankly becoming integral to a place like Wake Med.

00:06:00:12 - 00:06:22:03
Michelle Schweitzer
Yeah. I think part of the challenge is that in a lot of areas, having an advanced practice provider come in to an institution that starts out with a very small groups, and then it grows from there. And so then at that point, everybody has their own thought as to what the APP should be doing or can do. They don't really fit in the nursing bucket and they don't fit into the physician bucket, but they have their own kind of bucket.

00:06:22:06 - 00:06:31:21
Michelle Schweitzer
And so establishing what that looks like, and it's not stepping on other toes or taking something away from other leaders is the first step that needed to happen.

00:06:31:24 - 00:06:47:00
Chris DeRienzo, M.D.
We know that there are listeners tuning in from all across the country, and possibly from other countries. Within your state, in North Carolina, when we use the term APP, what are the kinds of people with different clinical backgrounds who fall into the scope of your supervising?

00:06:47:03 - 00:07:14:00
Michelle Schweitzer
So when I think of APP inside of North Carolina, you have pretty much three different directions. So a provider who decides to go the nursing route can be a nurse practitioner, a clinical nurse specialist, a CRNA, which is with anesthesia. A provider that decides to go the medical route would be like your PA, which is a physician assistant, or in some areas called a physician associate, as well as an AA, which is anesthesia allergy assistant.

00:07:14:03 - 00:07:30:27
Michelle Schweitzer
And then you also have the pharmacy route, which is a clinical pharmacist practitioner. Now, depending on your state, depends on whether or not you recognize all of those levels at the same as an APP or not. But I like to say that if you're an advanced practice provider and you can do these things, then you're an APP.

00:07:30:29 - 00:07:50:06
Chris DeRienzo, M.D.
I love it, I love it, and we know that every state has sort of different scopes for how different kinds of providers get to be practicing in hospitals or in clinics, and through the work that you're doing here with us at AHA, I understand that we're beginning to bring some of those perspectives together in a national conversation. You're chairing that efforts.

00:07:50:07 - 00:07:59:28
Chris DeRienzo, M.D.
Talk to us a little bit about how your approach in that conversation with your peers in the states spanning the California coastline all the way up to the coast of Maine?

00:08:00:00 - 00:08:18:22
Michelle Schweitzer
Yeah. So it started with a straw man approach in the sense that we kind of got together. There was a few of us that brought all the people that we could think of all to a room and really dove into what are the main things that we need to focus on, and how do we establish what an APP is, whether you're in California or Maine or Florida?

00:08:18:25 - 00:08:41:03
Michelle Schweitzer
And, you know, obviously that definition doesn't need to be too extra because it needs to really be able to be utilized depending on the legislation within those, those states. And then how can we help those hospitals grow to where they can start and have an APP structure and what that would look like. And whether it's a 200-bed hospital or a system with five hospitals all combined.

00:08:41:05 - 00:09:02:21
Chris DeRienzo, M.D.
It's been an incredible learning process for me. I've been with AHA for a year and a half, and getting to see hospitals all across this country expose me to models of operating so different than I'd seen in in North Carolina. I was in the Midwest recently, and there was a medical staff that had four physicians on it, all full spectrum family medicine, and then more APPs than physicians.

00:09:02:27 - 00:09:22:19
Chris DeRienzo, M.D.
And certainly we know that that scope differs by state. But talk to me a little bit about how you've seen leadership structures differ. Again, one of the great things that we get to do through AHA's patient safety initiatives, our APP group, our chief physician network - is expose leaders who we get: it's like operations, it's hard right now.

00:09:22:21 - 00:09:43:18
Chris DeRienzo, M.D.
You are heads down all day every day. So it's challenging to lift your head up and get a sense of what's going on elsewhere. But what are you learning about as you get to and meet folks like Dawn, who I know is in new Jersey, and others we have within our group from Palo Alto and Kansas. And what are the things that you're hearing that you're saying, oh, this is something maybe we can take back home.

00:09:43:20 - 00:10:01:05
Michelle Schweitzer
Yeah, it's actually really interesting, which is I love the fact that we get together and have these sessions where we can, like, talk through certain problems and to hear from Texas versus Maine and so forth to get an idea. It's also very interesting to see where everybody is in their STEP process of where they're trying to get to.

00:10:01:07 - 00:10:20:24
Michelle Schweitzer
You speak of Dawn, which is actually a great new friend of mine, and we were just talking earlier about where she currently is at her institution and just getting some assistance with, with student placement and things like that. Versus at some institutions, they have an entire center for advanced practice. And how do they start? Do they start with just a committee?

00:10:20:27 - 00:10:39:09
Michelle Schweitzer
Did they start with just one person? And so learning from all of the different APPs from around our country to understand, like where did the grass grew and what took off and what didn't, helps us bring together from an AHA perspective of how we can put out a strategic plan so others can just take that forward without having to make it up as they go.

00:10:39:11 - 00:10:56:22
Chris DeRienzo, M.D.
Let's build on that for a second, because we've only got a couple of minutes left. And I'm curious if there's a chief APP, you know, who's on day one of her job or his job. And they're listening to this podcast because they saw it from AHA and they said, gosh, we want to hear what experience chief APPs are doing.

00:10:56:22 - 00:11:13:18
Chris DeRienzo, M.D.
And I'm on day one and I got to get started. This role has never existed before. Folks are excited, but I don't really even know where I live in this health system. If you were to give that person just three quick hits on, hey, here's the very first steps you can take that will help set you up for success.

00:11:13:20 - 00:11:14:18
Chris DeRienzo, M.D.
What would they be?

00:11:14:20 - 00:11:47:22
Michelle Schweitzer
The first step would be to know your organization. Where does your organization sit? Right now, what are they focused on and where does the APP fit into that focus? You're better off starting with what you know, obviously, and then going step forward from there. So if the organization is very focused on oh my goodness, Joint Commission is coming soon is everybody set up correctly, then probably your first step would be touching base with credentialing to make sure that your APPs aren't just privileged to do whatever, and they actually have an actual privilege that matches their scope of practice.

00:11:47:24 - 00:12:09:09
Michelle Schweitzer
Second is, know your stakeholders, those that are going to champion behind you, as well as those that are going to put up a fence and know how to break down those fences. Start slow. You're never going to get anywhere if you go too fast. And I guess third is make sure that you say clinical. Yes. Got to be honest, it keeps me grounded.

00:12:09:09 - 00:12:25:12
Michelle Schweitzer
I love my leadership role. I love mentoring all the folks that I have, but the day that I get to go into clinic and just do g-tube care, so to speak, is amazing to me and it helps me stay the person that I am, to be the leader that I need to be.

00:12:25:15 - 00:12:42:13
Chris DeRienzo, M.D.
I knew this was going to be a great podcast, Michelle. I so appreciate those points that frankly, they're relevant to any leader who comes from a clinical background in health care. And any time that we get to spend right at the pointy end of the stick, delivering care or being with the folks who deliver care consistently reminds us why we do the role that we do in leadership.

00:12:42:13 - 00:12:55:09
Chris DeRienzo, M.D.
You are a spectacular leader at WakeMed and now at the national level. Thank you so much for joining us. Thanks to everyone for listening in across the Innovation Hub here at the AHA Leadership Summit, and we will catch you next time. Take care everyone.

00:12:55:11 - 00:12:56:19
Michelle Schweitzer
Thanks.

00:12:56:21 - 00:13:05:03
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.

00:00:00:18 - 00:00:33:06
Tom Haederle
Integration - when a hospital joins a health system to benefit from enhanced economies of scale and pooled capabilities - is one of the many ways that hospitals meet the mission of advancing health. Bringing formerly independent hospitals together under a new administrative umbrella can be a delicate dance and must be done carefully for the arrangement to work and the integration to benefit all care providers and their patients.

00:00:33:08 - 00:00:58:05
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this month's Leadership Dialogue series podcast hosted by Dr. Joanne Conroy, president and CEO of Dartmouth Health and the 2024 board chair of the American Hospital Association, we glean some great insights on the value and challenges of running an integrated health system from one of the foremost experts.

00:00:58:07 - 00:01:13:18
Tom Haederle
Tom Priselac is president and CEO Emeritus of Cedars-Sinai, where he retired in September after more than 30 years of overseeing its growth from a regional hospital to one of the largest and most influential health systems in the country. And now, to Dr. Conroy.

00:01:13:21 - 00:01:38:24
Joanne Conroy, M.D.
It's great to be with you. I'm Joanne Conroy, CEO and president of Dartmouth Health and the current chair of the American Hospital Association Board of Trustees. I'm looking forward to our conversation today with my friend and colleague, Tom Priselac, who will share his insights on running an integrated health system. He's been at it for 30 years and he is an expert on this topic.

00:01:38:27 - 00:02:11:15
Joanne Conroy, M.D.
He knows his stuff. Tom is president and CEO emeritus of Cedars-Sinai Health System, and despite having just transitioned into retirement last month, he was kind enough to join us today. Tom led the transformation of Cedars-Sinai from a regional hospital into a renowned academic health system. He has spent much of his career championing the important role of health systems and, of course, advancing health for those patients and communities served by Cedars-Sinai.

00:02:11:18 - 00:02:28:22
Joanne Conroy, M.D.
So welcome Tom, who knows this topic better than anyone. And we'll start with a broad question to frame the discussion. How do you define what it means to be a health system, and what are the benefits and what are some of the challenges?

00:02:28:24 - 00:02:52:15
Tom Priselac
Well, I think for me, what it means to be a health system is essentially each of the institutions that become a part of the health system, asking themselves whether it's the founding institution as it was in our case, or affiliate organizations that have become part of the Cedars-Sinai Health System or the organizations with which we have joint ventures, which is another vehicle we've used to build our system.

00:02:52:17 - 00:03:30:16
Tom Priselac
I think it really comes down to each of the institutions asking that core question, what is the path forward for my institution that will allow that institution to best serve its community and carry out its mission? As we've gone through the development of the system in whatever structural form, we've always made that an important part of the consideration of, in the case of Cedars-Sinai, asking the question of given the mission of Cedars-Sinai as both a major academic medical center and a full service community hospital to about 3 million people in Los Angeles.

00:03:30:18 - 00:03:57:05
Tom Priselac
The whole purpose in creating the system, and this is literally embedded in the mission statement of the organization. The system exists to optimize the ability of the member institutions better serve their community. That aspect of what I just described applies whether the integration has been horizontal or whether it's been vertical, with integration of our physician network over the years.

00:03:57:08 - 00:04:27:26
Joanne Conroy, M.D.
I think that's incredibly important because health systems are there to really serve their members and their communities, because we don't always actually take care of patients at the health system. They're actually taken care of at the member sites. So when you talk about the commitment to quality and the commitment to excellence, when you bring in new members, that's a delicate balance between imposing something on a member versus creating it together.

00:04:27:26 - 00:04:31:15
Joanne Conroy, M.D.
So, you know, what's been your approach to really try to manage that?

00:04:31:17 - 00:04:53:28
Tom Priselac
That's a great question. And the characteristic you just described of what I guess I would call co-creating the vision of what it means to be part of a system and be a system. That philosophy of doing it in a co-creating way, as opposed to a kind of a top down. We know the answer in your local community way.

00:04:54:00 - 00:05:26:11
Tom Priselac
The former is very much the path that we have taken. And the same is true whether that's the development of partnerships and affiliations with hospitals or other health systems, or again, with the multiple physician organizations that have become part of our physician network. We do a lot of due diligence on the front end to number one, make sure there's a very much aligned set of core values that whether, again, whatever the entity is, that's becoming part of the system.

00:05:26:13 - 00:05:56:06
Tom Priselac
We really start there and spend a lot of time on that question. And we spend a lot of time talking through the philosophy of the institution, which is to take advantage of economies of scale and economies of capability. An important element, I think, that doesn't necessarily always get the same attention. And making sure that there's a common understanding between us and the incoming organization about what that means for them.

00:05:56:08 - 00:06:15:08
Tom Priselac
Back to the point I just made, how the approach that we take in that regard is going to allow that organization to better fulfill its mission, and how that affiliate becoming a part of the institution will allow Cedars-Sinai to better serve its mission.

00:06:15:10 - 00:06:38:23
Joanne Conroy, M.D.
Let's talk a little bit about recruiting clinicians, because I think there's been a little bit of a shift. I know that historically, when there was an academic medical center, you know, people didn't want to leave what was the comfortable academic medical center to actually provide services outside of that organization. I think over the last ten years that's become a little bit easier.

00:06:38:25 - 00:06:59:22
Joanne Conroy, M.D.
How do you actually use this concept of a health system to actually better recruit clinicians? I can tell you our parking is horrible here. So a number of our clinicians are happy to work at our other hospitals, where the operating room is a little bit more efficient, and the parking lot always has spaces. So how do you manage that with your health system?

00:06:59:24 - 00:07:24:28
Tom Priselac
Well, with regard to physicians being recruited here at Cedars-Sinai, first of all, it starts with what's the primary career interest of the physician being recruited? For those for whom their primary career interest is more research related. You know, the conversation there centers around things like access to diverse populations, which is now finally being recognized as how important that is on the on the research agenda.

00:07:24:28 - 00:08:09:01
Tom Priselac
And so, Los Angeles being one of the most diverse cities on the planet, we offer that kind of opportunity to academic physicians. And then secondly, with those physicians who have a more primary clinical orientation, the opportunity for the existence of the system, especially for the physicians who are providing the tertiary and quaternary services. The conversation really stems around how the existence of the system can facilitate the ability of Cedars-Sinai to be increasingly the place where more tertiary and quaternary services, which are of particular interest to that particular physician or surgeon, would be of most interest.

00:08:09:01 - 00:08:18:21
Tom Priselac
And so, there's an effort to try to align the purpose of the system with what the professional interest of the clinician or researcher involved.

00:08:18:23 - 00:08:47:02
Joanne Conroy, M.D.
How do you actually manage? And this is not uncommon for a new member hospital to actually look to the largest member of the organization to help them establish a new service or expand a service. Where are those decisions made in a health system? And there's got to be some investment because they're hard to stand up, and they're not always as maybe as efficient as it may be at a higher volume institution.

00:08:47:04 - 00:09:14:05
Tom Priselac
That process actually starts during the due diligence effort. And we try to take a very respectful approach with regard to clinical integration between Cedars-Sinai and the affiliates. We're very respectful of the capabilities and quality of the medical community and the local affiliate, and very consciously avoid trying to suggest that we're going to come in and fix a problem.

00:09:14:07 - 00:09:53:24
Tom Priselac
It's really a question of how can Cedars-Sinai and our clinical capability complement what already exists in the institution and builds on it for the benefit of that local community? By the way, you know, implementing that really gives emphasis to the importance of the individual who serves as the CEO of that affiliate organization, because that CEO has to have the kind of trusted and trusting relationship with their medical staff to be able to hopefully guide them through both an understanding and not just an acceptance, but a welcoming of the kind of relationship that I just described.

00:09:53:24 - 00:10:28:18
Tom Priselac
So, you know, and what we would typically do is our clinical leadership engaging with clinical leadership from the respective affiliate. And essentially, I guess you could call it going through an inventory. Before we actually proceed with the affiliation, there's a very clear understanding of where the priorities will be and how that would go about, how that might be executed via physicians that would be recruited here to Cedars-Sinai and then providing those services on some basis in the affiliate.

00:10:28:20 - 00:10:51:00
Tom Priselac
But in other situations, what we've done is we've taken the recruitment ability that an academic medical center has to be able to help those local communities be more successful in recruiting a more experienced and more capable physician or surgeon, depending on the specialty service involved.

00:10:51:02 - 00:11:21:29
Joanne Conroy, M.D.
You know, health systems, as we get larger, have a much broader community responsibility. And I know we are investing in transportation, housing, child care, really in a much broader footprint than necessarily one facility. What are the type of things that communities come to you and want your partnership on that actually benefit the broader health of the community?

00:11:22:01 - 00:12:03:12
Tom Priselac
One is the clinical capability. And so part of the strategic planning of the system is answering the question, how are we going to raise the clinical capability in each of the respective affiliates through whatever physician recruitment approach along the lines of what I just mentioned. So the clinical capability questions there, for some of the affiliates, being part of an organization that has the kind of balance sheet that the larger organization has, whether that's allowing the institution to be more cost effective and have better access to resources because borrowing costs might be lower, is maybe an example on that side.

00:12:03:14 - 00:12:50:11
Tom Priselac
In some of the relationships the research capability of the institution and how that can facilitate the availability of clinical trials, especially in an area like cancer, which may be of more interest and need in one community versus another. And then finally, each of our institutions as not for profits, all have community benefit missions. You know, over time, one of the things that that we carry out is the integration effort on the community benefit side as much as anything else, to just make sure that as each of the institutions approach their individual community benefit missions, we're doing it in an aligned way and looking for the commonalities of what kind of community benefit activities would be

00:12:50:11 - 00:13:22:04
Tom Priselac
most impactful over the geographic footprint of the system. And the example I would give in that regard in Los Angeles today, we're all familiar with the challenge of homelessness - in America in general and certainly here in Los Angeles. And so in the area of community benefit work related to homelessness, whether it's grantmaking or programming that might go on in each of the institutions, and sharing information, sharing knowledge about best practices and what we have found to be the most effective strategies in that regard.

00:13:22:06 - 00:13:49:15
Joanne Conroy, M.D.
Yeah, you're right. You know, every single community just seems to have their own specific challenges. Talk a little bit about quality and patient safety. How do you, you know, bring people together and have them kind of co-create a quality safety culture? You know, I've said that the system is there. Its role is to monitor, but the quality is really kind of owned by the combined organizations.

00:13:49:15 - 00:13:56:04
Joanne Conroy, M.D.
So how have you kind of structured bringing people together and what do you think has been the most effective?

00:13:56:06 - 00:14:29:18
Tom Priselac
Yeah. So I guess I'd begin by reflecting the overall philosophy we've taken, which is the purpose of the system, is to assure the optimal success of each of the individual members. We're very much interested in strengthening and not disempowering the local hospital or the affiliate hospital, especially issues like quality. When we bring organizations into the system, part of that due diligence is to make sure we're satisfied it's already a high quality institution.

00:14:29:21 - 00:14:51:21
Tom Priselac
And the question is, how can becoming part of that system help make it better? We've taken the approach of in certain areas to pursue a more what I would call a shared services approach. And in others, we're using what we call a collaborative approach. And with regard to how we approach managing for quality, we use the collaborative structure.

00:14:51:26 - 00:15:31:00
Tom Priselac
What does that mean? What that means is that we've gone through a process of, on the one hand, identifying a set of common measures of what quality means across the system and making sure that each of the institutions have focused work that is addressing what those commonly identified quality goals are for each of the institutions, but also leaving room for the local institution to continue to pursue quality priorities that are relevant and unique to that particular institution.

00:15:31:02 - 00:16:00:25
Tom Priselac
We establish what I'll call a common language, a common platform for measurement, agree on how that measurement is going to take place, and then essentially we use the collaborative model and the knowledge sharing that goes on in the collaborative discussions among each of the management teams from the respective institutions to be able to advance the individual and therefore the collective performance of the system.

00:16:00:27 - 00:16:34:19
Joanne Conroy, M.D.
You know, you bring up a good point that, you know, you can't actually run it centrally. But one thing that is very evident when there's an issue is the resources when you can pull everybody from across the system to address an issue are incredibly powerful. I think we had an organization once that was going through a very rough Joint Commission visit. And I think on day two, half the system swooped in there to actually assist the team that was there and say, how can we help you?

00:16:34:22 - 00:16:51:15
Joanne Conroy, M.D.
And, you know, it's interesting you don't appreciate the power of the system until you actually need to use it. And it's often just all of a sudden, instead of having two people on your team, all the sudden you look behind you and you have 100. It makes people both confident and much more effective.

00:16:51:18 - 00:17:16:24
Tom Priselac
That's an example of what I meant earlier about systems bringing economies of capability or scaling capability within the institution. In a lot of the public policy discussions there's really a lack of appreciation, I think, from people outside of health care delivery about what that means and how that can enhance the ability of an institution to provide high quality care.

00:17:16:26 - 00:17:41:24
Joanne Conroy, M.D.
Well, Tom, I want to thank you for giving us some of your time today. We really appreciate your valuable insights and your expertise, and we wish you the best in retirement. But I have a feeling your dance card is going to be pretty full. Probably already is with people that want you to give them advice about, you know, building a health system that serves the needs of the communities.

00:17:41:27 - 00:17:43:27
Joanne Conroy, M.D.
Thank you Tom, again.

00:17:43:29 - 00:17:45:09
Tom Priselac
Thanks, Joanne.

00:17:45:11 - 00:17:53:22
Tom Haederle
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