Advancing Health Podcast

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.

00;00;00;17 - 00;00;35;07
Tom Haederle
According to the World Health Organization, behavioral health conditions among older people are often under-recognized and undertreated, and the stigma surrounding these conditions can make people hesitant to seek help when they need it. West Virginia based Broaddus Hospital, a critical access hospital that is part of the Davis Health System, has created Senior Life Solutions, an intensive outpatient program designed to fit the needs of patients 65 and older.

00;00;35;10 - 00;01;10;10
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Although the overall population of Broaddus Hospital's rural community has decreased over time, the population of older adults has steadily increased. What wasn't increasing, however, was the availability of behavioral health services for this population. Recognizing that there were many older community members who needed help managing depression, anxiety, social isolation and grief, the team at Broaddus Hospital decided to get to work to create a treatment program that address their unique needs.

00;01;10;13 - 00;01;33;24
Tom Haederle
In this podcast, hosted by Jordan Steiger, senior program manager of Clinical Affairs and Workforce with the AHA, she is joined by two leaders who share how this hospital-based program has benefited not only patients who seek care through their program, but the community overall. Dana Gould is CEO, Broaddus Hospital, and Donetta McVicker is program director of Senior Life Solutions with Broaddus Hospital.

00;01;33;27 - 00;01;45;09
Jordan Steiger
Dana and Donetta, thank you so much for being with us today on our AHA Advancing Health podcast. We're really excited to talk to you today and to hear your perspective about some of the work that you've been doing.

00;01;45;12 - 00;01;46;19
Dana Gould
Thank you for having us.

00;01;46;21 - 00;01;52;04
Jordan Steiger
So tell us a little bit about Broaddus Hospital and the community that your hospital is in.

00;01;52;06 - 00;02;12;08
Dana Gould
It's a critical access hospital, 72 bed facility. We have 12 acute care swing beds as well as a 60 bed nursing home. We're located in Philippi, West Virginia, a pretty rural area. And so this is a nice facility to have here in our small community.

00;02;12;10 - 00;02;21;14
Jordan Steiger
It's great. And you know, how many communities does your hospital serve? Is it just in your town or does it kind of serve a bigger, rural population?

00;02;21;16 - 00;02;30;27
Dana Gould
We serve our surrounding counties there, about five different surrounding counties that we serve, in addition to Barbara County, West Virginia.

00;02;31;00 - 00;02;53;22
Jordan Steiger
You know, that's really nice to hear. And I think something that other, you know, rural listeners can resonate with, you know, serving that big population, that big, area, you know, in your community and not just the people that may be live next door to you, but also the people that kind of live just in your region. And, we know that a lot of communities really depend on the work of rural and critical access hospitals to get care.

00;02;53;22 - 00;03;07;00
Jordan Steiger
So, we're really excited to learn more today. What are some of the common, you know, kind of like population health issues that face your community, especially related to behavioral health and substance use?

00;03;07;02 - 00;03;29;11
Dana Gould
Well, we do our annual community  - not annual, and we do it every three years - our community health needs assessment. And so for the last several years when we've completed that, we've found that behavioral health is one of the areas of greatest need in our community. We also have a pretty large percentage, around 20 some to 22% of population

00;03;29;11 - 00;03;49;25
Dana Gould
that's over 65 years of age. And we're finding that even though the population of our county has decreased or remained relatively flat, the population of those 60 and 65 or older, have has increased. So, there is of an increasing need for behavioral health in our community.

00;03;49;27 - 00;04;16;29
Jordan Steiger
I think that leads us into exactly what we're here to talk about today. So, your hospital has a really strong, geriatric, intensive outpatient program. And I think that's really unique and something that our listeners are going to be really interested in just because, as you mentioned, a lot of communities I think, are kind of facing that same issue of aging populations and maybe not having enough care in the area to help them with their behavioral health issues.

00;04;17;02 - 00;04;28;27
Jordan Steiger
And it sounds like what you've done has really enhance the quality of life for the older adults and their families in your community. So I'd love if you could tell us a little bit more just about your program.

00;04;29;00 - 00;05;00;12
Donetta McVicker
Okay, I guess I will step in there. My name is Donetta McVicker. I am the program director here at Senior Life Solutions at Broaddus Hospital. Senior Life Solutions is an outpatient behavioral health program here at Broaddus Hospital. It's designed to meet the unique needs of older adults, typically 65 and older, who are experiencing issues such as depression, anxiety, or other mental health challenges associated with the changes that accompany the aging process.

00;05;00;14 - 00;05;08;00
Donetta McVicker
Our services include group therapy, individual therapy, family therapy, and medication management.

00;05;08;02 - 00;05;16;02
Jordan Steiger
That's great. Can you tell us more about maybe some of the skills that patients learn? Maybe in group therapy or individual therapy?

00;05;16;04 - 00;05;53;14
Donetta McVicker
Yeah, absolutely. Our therapy sessions occur in small groups and are facilitated by our licensed therapist. Patients typically attend group sessions three days a week, at first, and then they titrate to two or one day per week as they progress through the program. The program usually uses various skills to support patients in achieving their personal therapy goals, such as mindfulness, grounding skills, progressive muscle relaxation, self-care, social and communication skills.

00;05;53;16 - 00;06;18;01
Jordan Steiger
That's great. And you know, I know, one thing that we talked about when I initially learned about your program is that you've seen maybe that there's been an increase in, you know, socialization of the older adults in your community from meeting each other in this program. And can you talk about maybe some of kind of the positive byproducts that have come out of having this kind of group therapy setting?

00;06;18;04 - 00;06;49;19
Donetta McVicker
Our patients typically experience a lot of isolation and loneliness. So once they engage in the program, they meet new people who are experiencing similar issues that they are currently experiencing themselves. So they relate with one another, and they become friends. A lot of times, once they're discharged, they still remain in contact with the people that they met in group.

00;06;49;21 - 00;07;12;19
Donetta McVicker
They've created these relationships with the other clients, and they will call each other on the weekends, or they'll arrange an outing and have coffee together or something like that. And that really increases their socialization and, really improves, some of their mental health issues.

00;07;12;21 - 00;07;33;13
Jordan Steiger
I think that is an incredible thing to highlight here because obviously, you know, we're looking for in a program like this, you know, positive clinical outcomes, reduced depression, reduced anxiety, things like that. But, you know, really having that decreased loneliness and socialized relation, especially in older adults, I mean, we know that that has so many positive mental and physical health outcomes.

00;07;33;15 - 00;07;37;20
Jordan Steiger
So I think the fact that you're providing that in your community is such a great thing.

00;07;37;22 - 00;07;39;20
Donetta McVicker
Yeah, absolutely I agree.

00;07;39;22 - 00;07;59;24
Jordan Steiger
So one thing that we know is on everyone's mind across the country, whether it's, you know, small critical access hospital or a big health system is workforce. And having the right workforce available in the community and in the hospital to fulfill and, you know, continue programs like this. So who do you need to be successful in this program?

00;07;59;24 - 00;08;06;28
Jordan Steiger
Do you have, you know, a psychiatrist? Do you have social workers? Tell the audience a little bit more about who's on your team.

00;08;07;01 - 00;08;27;13
Donetta McVicker
Yeah. Our program is made up of multidisciplinary cast or, staff. We have a registered nurse. We have a licensed social worker. We have a psychiatrist and other clinical staff that support the patients such as CNAs and things like that, NAs.

00;08;27;13 - 00;08;42;06
Jordan Steiger
I think that multidisciplinary approach is always helpful in behavioral health and, you know, gives our listeners an idea maybe what it would take for them, you know, to put something like this in place, knowing that they're going to need lots of different people, lots of different moving parts to kind of make this a success.

00;08;42;08 - 00;08;43;02
Donetta McVicker
Yeah.

00;08;43;04 - 00;09;08;06
Jordan Steiger
So one thing I know, we hear a lot about and, you know, the behavioral health world in general, and especially with aging adults and rural communities is stigma. You know, stigma around seeking care, stigma about actually admitting that you need help with your mental health. is this something that you found to be true, when you're seeing people coming into your geriatric IOP program?

00;09;08;09 - 00;09;33;19
Donetta McVicker
Yes. Of course. You know, one thing that we tell our patients or anyone considering the program is that there is no shame or stigma in providing good self-care. Mental health care should be no different than physical health care. There are nearly 58 million adults aged 65 and older living in the United States, yet we continue to lack services specifically for that population.

00;09;33;21 - 00;09;52;08
Donetta McVicker
Unfortunately, the aging process does not come with an instructional manual. However, our program helps to provide resources and the tools, both emotionally and socially, to be better equipped on ways to overcome some of these challenges that often accompany this journey.

00;09;52;10 - 00;10;10;20
Jordan Steiger
I love what you said about aging doesn't come with the manual. I think that's, you know, something to keep in mind, you know, here and nobody knows exactly how it feels as people are getting older. It's a really great thing I think, that you have something in your community to provide some structure and provide some guidance.

00;10;10;20 - 00;10;32;14
Jordan Steiger
And, like you said, there is no stigma. There should be no stigma around seeking care, especially when it can improve the quality of your life as much as you've seen for your patients. So that's really, really great. Speaking of that, how has your geriatric IOP program positively impacted your patients, families and community?

00;10;32;17 - 00;10;37;14
Donetta McVicker
I actually have a few testimonials if I may be permitted to read some of them.

00;10;37;20 - 00;10;38;23
Jordan Steiger
Absolutely.

00;10;38;28 - 00;11;06;21
Donetta McVicker
All right. So I have: "Since retirement, I needed to reassess who I am and how I occupy my mind. I found the direction and the support with this program." Another client wrote, "I lost my grandchild and found myself in a dark place. I didn't know how I would make it through without the support that I needed. With the help of this program

00;11;06;21 - 00;11;38;00
Donetta McVicker
I have made friends and found ways to celebrate her life." And then lastly, one client stated, "I have learned a lot about myself and how to cope with my current health conditions." So as you can see, there are many different ways that patients have experienced an increase in their knowledge of themselves, of their, newly occurring health conditions, which seems like once you're 65 or older, those seem to be more rapidly occurring in their life.

00;11;38;02 - 00;12;04;23
Donetta McVicker
And then, you know, losing a loved one seems to happen more frequently in the ages of 65 and older. And unfortunately, it doesn't just stop with the spouse or a friend or a relative or something like that. What we're seeing a lot here is they're losing their adult children or even their grandchildren to things like substance abuse and accidents and things like that.

00;12;04;23 - 00;12;30;07
Donetta McVicker
So we're seeing a lot of grief in our program. It's really nice that, you know, that testimony about losing her grandchild. It's really nice to hear that we were able to help her really change her perspective on that grief and flip it around to say how she now has found ways to celebrate that life instead of mourning the loss of that individual.

00;12;30;10 - 00;12;51;19
Jordan Steiger
Yeah. I mean, we know that community is such a powerful tool in addressing grief. And, I love that you brought in some patient perspective and you know, testimonial. I think that really kind of brings to life the importance of this program in your community. And I'm sure our listeners are also going to be really impacted by those testimonials as well.

00;12;51;22 - 00;13;09;01
Jordan Steiger
So as we kind of wrap up our conversation today, if there is another rural or critical access hospital out there who, you know is hearing the work that you're doing and hearing your story and is like, wow, I would love to have something like that in my community. What advice would you give them as they were getting started?

00;13;09;03 - 00;13;38;27
Donetta McVicker
You know, honestly, I would start off and say, take a look around your community. Do you have resources readily available for your most vulnerable populations? The aging process has a host of challenges. So the population often experiences things like grief and financial struggle, isolation, loneliness, chronic health conditions, and just an overall lack of support. A program like Senior Life Solutions can help accommodate those needs.

00;13;38;29 - 00;14;02;25
Donetta McVicker
I know that through our program, it didn't take a whole lot to get started here. It's a small staff. Like I said, we have a registered nurse, a CNA, a licensed therapist, and a psychiatrist. And with that small multi-disciplinary staff, we're able to, you know, do really big, important things for our clients.

00;14;02;28 - 00;14;20;18
Jordan Steiger
That's great. And I think, you know, the message that it doesn't maybe take a lot to get this off the ground, I think is important. And, you know, of course it's going to take effort to start a new program or something like that. But I think the payoff from what you've said is totally it's worth the work, right, to provide those services to your community.

00;14;20;21 - 00;14;25;20
Jordan Steiger
Dana, any closing thoughts from an administrative perspective?

00;14;25;23 - 00;14;52;11
Dana Gould
Sure. Financially, the program has been beneficial for us. Since we are a critical access hospital, our reimbursement is, at least for Medicare, is primarily based on our cost. So this allows you to be fully reimbursed for the cost of the program because the majority of the patients are Medicare patients and then also assist with some of the allocated costs that that go to the program.

00;14;52;15 - 00;15;01;11
Dana Gould
Some of your overhead costs can be allocated and reimbursed. So financially, it is a very good program for critical access hospital.

00;15;01;14 - 00;15;22;24
Jordan Steiger
That's great. That's really important to mention I think, because of course we can't avoid that conversation talking about the finances and how to keep these programs running. So I'm glad that it has been a financially viable program for you and that it continues to be successful. So thank you both so much for sharing your insights with us today.

00;15;22;27 - 00;15;31;19
Jordan Steiger
I think that our members at the AHA really going to learn a lot from this conversation, and we really appreciate that you took the time to share with us.

00;15;31;22 - 00;15;40;03
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;01;03 - 00;00;23;00
Tom Haederle
Health care providers coast-to-coast have seen a significant rise in the past several years in the demand for behavioral health services. Broadly speaking, behavioral health encompasses those things that affect overall well-being, including mental health issues and substance use disorders. Many hospitals and health systems want to fully integrate behavioral health treatment as a core part of patient centered care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00;22;00;13 - 00;22;08;23
Tom Haederle
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