Advancing Health Podcast

00;00;00;18 - 00;00;23;07
Tom Haederle
Every rural care provider in the United States can attest that finding, hiring and retaining clinicians across just about any specialty is getting harder and harder. In south central Washington state. Kittitas Valley Health Care, KVH, the only provider offering comprehensive OB-GYN services for many miles around, was suddenly faced with a huge problem. Within the space of about a year

00;00;23;08 - 00;00;37;27
Tom Haederle
its three full time OB-GYN specialists all decided to leave.

00;00;38;00 - 00;01;05;12
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Prior to 2022, KVH was delivering between 300 and 350 babies each year. Its six bed labor and delivery unit was the most in-demand service the hospital offered. In this podcast, we learn from the hospital's CEO how KVH kept its balance and its promise to area residents to preserve critical obstetric services

00;01;05;19 - 00;01;09;27
Tom Haederle
in the wake of the departure of several highly experienced clinicians.

00;01;09;29 - 00;01;22;18
John Supplitt
Good day. I'm John Supplitt, senior director of AHA Rural Health Services. And joining me is Julie Petersen, CEO, Kittitas Valley Health Care and Public Hospital District. Good afternoon. Julie.

00;01;22;20 - 00;01;23;20
Julie Petersen
Hello.

00;01;23;23 - 00;01;56;18
John Supplitt
For our listeners, Kittitas County Public Hospital District number one, also known as Kittitas Valley Health Care, provides care to Kittitas County and surrounding areas in central Washington state. KVH includes a 25-bed critical access hospital and provides care through clinics and specialty services in upper and lower Kittitas County. Julie, we're here to discuss how KVH has responded to a crisis to ensure continued access to obstetrical care in Kittitas County, Washington.

00;01;56;20 - 00;02;00;10
John Supplitt
How essential is obstetrics to your community?

00;02;00;12 - 00;02;22;10
Julie Petersen
We know from our latest Community Health Needs Assessment that admissions for women of childbearing age is our number one admission to our hospital. So this will include delivery as well as complications from deliveries and prepartum and postpartum issues. So it's not just an essential, it's a core service for our community.

00;02;22;12 - 00;02;39;03
John Supplitt
And I think I want to pull a thread on that because it's remarkable when I looked at your community health assessment and improvement plan, to see these conditions as being the highest source of admissions to the hospital for women of all childbearing ages, including teenagers.

00;02;39;03 - 00;03;03;04
Julie Petersen
Correct. And we staff a dedicated labor and delivery unit, a six-bed labor and delivery unit. We are a 25-bed critical access hospital. So our general medicine CCU population includes a number of different DRGs and conditions. But again, the number one major diagnostic classification that we have is those moms prepartum postpartum and the deliveries themselves.

00;03;03;04 - 00;03;25;28
Julie Petersen
And we deliver about 300 to 350 babies a year in Kittitas County. We have about 80% of the of the market of deliveries. And we're very, very careful in how we screen our moms. We know our limitations with our labor and delivery program. But again, that's 300 to 350 babies a year that rely on us to deliver them in Kittitas County.

00;03;25;29 - 00;03;27;24
Julie Petersen
We are the only hospital in the county.

00;03;28;00 - 00;03;44;15
John Supplitt
And that's a remarkable number. And I think we need to really get a sense of where you are relative to the other providers in your area with respect to location. You're in south central Washington to the south of you. The nearest city is Yakima.

00;03;44;17 - 00;04;05;00
Julie Petersen
That's correct. So any direction you want to go to deliver outside of Kittitas County, you're going to have to travel over a mountain range. You travel to Wenatchee, which is a mountain pass. That's about 40 miles. You can travel to Yakima, 35-40 miles over a mountain range or into the Seattle metropolitan area of the Cascades.

00;04;05;02 - 00;04;12;17
John Supplitt
And so recently, you've experienced significant disruption, disruption in your OB-GYN services. Tell us what happened.

00;04;12;20 - 00;04;43;23
Julie Petersen
Prior to 2022, we have worked with a pool of community providers, including those sole practitioners who retired in 2022. We also had an FQHC in our community that participated in our call and delivery program. And due to changes in the residency program and then just a tight OB market, that program has slimmed down in our community. But we have employed three OB-GYNs, and our community has been kind of the core of our model.

00;04;43;26 - 00;04;59;00
Julie Petersen
But in 2022, all three of those providers gave us notice that they would be leaving. Two of them continue to live in our community, but they travel to metropolitan areas to participate in labor programs in the large hospitals.

00;04;59;02 - 00;05;13;20
John Supplitt
Well, and again, I have to pull a thread on this because your model through 2022 was an employed service through your own OB-GYNs, which is remarkable to think that you were able to recruit them into the first place and that they were committed to the community for so long a period of time.

00;05;13;28 - 00;05;40;10
Julie Petersen
Right. And that that level of commitment, that market of being able to employ an OB-GYN who is responsible for their patients, 24/7 who disrupts their clinic life to go to the hospital to deliver a baby on the middle of a Wednesday afternoon. That market is harder and harder to draw to, and that is absolutely what we were trying to maintain in KVH, again with the participation of some great partners

00;05;40;10 - 00;05;47;29
Julie Petersen
in the FQHC and some private practitioners. But within the span of about 14 months, that entire model just came up hard on us.

00;05;48;03 - 00;05;55;19
John Supplitt
So you get punched in the gut as you see this attrition in your employed model of care. How did you respond to this crisis?

00;05;55;21 - 00;06;22;12
Julie Petersen
Well, the governing board, we are an elected board of five commissioners in Kittitas Valley. And they came out of the gate assuring the community and assuring our staff that we were going to remain in the OB business. So my charge was to make it happen. We'd already been recruiting to replace the traditional OB-GYN providers that we'd had in the past and we were not having very much success.

00;06;22;14 - 00;06;45;14
Julie Petersen
We did come across a family practice OB who has surgically trained, who's a key component of our program going forward. But after about 12 to 14 months of looking to backfill our OB-GYNs, we had no choice but to look outside for an outsource service, and we found a partner in OB hospitalist group or OBHG.

00;06;45;16 - 00;07;11;29
Julie Petersen
So again, I think the first thing we did was make the commitment from the governing board on down that we were going to continue to deliver babies in Kittitas County, and that's key, because one place where we're particularly strong is in our nursing program. We have an amazing group of labor and delivery, specialty trained nurses who have stuck through us, with us through this entire sort of meltdown in OB.

00;07;11;29 - 00;07;17;11
Julie Petersen
And the last thing we wanted to do was make ourselves vulnerable to losing those nurses.

00;07;17;13 - 00;07;26;23
John Supplitt
Well, and I'm going to share a couple of observations. First and foremost, this is a public district hospital and that the board is committed to delivering babies to this community.

00;07;26;27 - 00;07;28;09
Julie Petersen
That's absolutely correct.

00;07;28;09 - 00;07;31;11
John Supplitt
And that's at the core of your mission.

00;07;31;11 - 00;08;01;28
Julie Petersen
Right. That was never a question. And I think the way we see this is, again, our folks have been rigorous and determining who should deliver at KVH. We don't do high risk deliveries. And when you take 300 to 350 moms who can deliver in a safe hospital environment and put them on the road over mountain passes or 35-40 miles stretches, you take low risk, comfortable births, and you turn them into high risk births. That was not acceptable at my board.

00;08;02;00 - 00;08;25;25
John Supplitt
And then the other observation is, as we see hospitals drop obstetric services from their service components, I again reflect on the fact that as a public district hospital, your commitment to the community is at the core of what it is that you do. And in this particular, you're willing to take on this loss- leader in order to make sure that there's access to safe care to the women that live there.

00;08;25;27 - 00;08;49;29
Julie Petersen
And we see this service line also. At the core of this service line is labor and delivery and obstetrics. And that certainly is the biggest challenge in terms of continuing the service line. But it is bigger than that. We are a county of about 45,000 people, and we're a little bit unique in that we are growing as a sort of a long distance neighbor to the Seattle metropolitan area.

00;08;49;29 - 00;09;12;05
Julie Petersen
We are growing and we're holding our own in terms of age. So we're not aging the way some rural communities are. So long term, we need not only to be able to deliver our own babies, but we need to be able to take care of women generally in our community, the reproductive health needs of women, gynecological needs of women in our community are core to this as well.

00;09;12;07 - 00;09;25;28
Julie Petersen
And if you can't attract OB-GYNs, if you can't attract the nurses who care for women in the clinics in the hospital, you're going to lose your ability to take care of women generally, and reproductive health specifically.

00;09;26;01 - 00;09;43;00
John Supplitt
Julie, let's talk about the selection of OB hospital group as your agency to service this labor model. There had to be some research that went into that. There had to be some board buy-in and acceptance of this. Tell us a little bit about that process and how it went.

00;09;43;02 - 00;10;08;02
Julie Petersen
During the pandemic and initiating our research, one of the things that we learned is in a very short period of time, many, many hospitals had transitioned to a labor site model. And while it's largely an urban/suburban phenomenon, we saw some of it moving into the rural communities as well. So we looked for somebody who had experience in rural communities. And rural is different than urban,

00;10;08;02 - 00;10;33;24
Julie Petersen
they needed to be able to or willing. They needed to attract candidates who would work in a clinic setting, who would do general GYN surgery, and to that time as a laborist as well. So we needed to partner with someone who would be flexible, who would include our own dedicated staff, our family practice OB that I mentioned, our certified nurse midwife.

00;10;33;26 - 00;10;58;09
Julie Petersen
We had folks who we knew were really dedicated to our community, and we needed a partner who would build around them. So we worked with GBHG. They basically said, sat down with us and said, let's build some schedules. Let's see how we can make this work. And we settled on a three week a month rotation. When you were on call to deliver babies, that's all you do.

00;10;58;11 - 00;11;21;23
Julie Petersen
So again, delivering maybe a baby a day, that's not overly burdensome. It is a 24 hour commitment. But for seven days that's what you do. The next week you get off, you return to clinic work and just clinic work for the following two weeks. And that seems to have been an attractive model, not just for our own delivering physicians, but for OBGH as well

00;11;21;23 - 00;11;25;00
Julie Petersen
and they're having some success in recruiting to that position.

00;11;25;05 - 00;11;39;07
John Supplitt
Which is excellent news and I'm sure a relief to you. So this is how you're going to put this model into practice. How has the community received the message, or do they even understand the message that you're changing the model? Is it relevant to them?

00;11;39;09 - 00;12;03;08
Julie Petersen
You know, you lead with the fact that except in a rural community, people don't expect the OB they see in their clinic to deliver their baby in very many facilities anymore. So this is not new to people. It's new to Kittitas and to our population, but they were very much aware of it. And if they delivered somewhere else, that's probably the model that they had seen.

00;12;03;11 - 00;12;20;07
Julie Petersen
The thing we had to say over and over again is that we are committed to this. It's not going to be easy. We're not going to be able to do it overnight. But we have never been on divert for deliveries. So whatever it took to pull that together and keep that service intact, our board has been willing to make that commitment and do that.

00;12;20;07 - 00;12;26;03
Julie Petersen
And frankly, I think the community has come to believe us. They've seen how we've struggled, but they know we're in it.

00;12;26;06 - 00;12;38;17
John Supplitt
Nevertheless, Julie, it's a radical change in the way in which you've delivered OB in the past. I'm curious to know, given the importance of the nursing component, how has your nursing service responded to the change?

00;12;38;20 - 00;13;02;27
Julie Petersen
Labor and delivery nurses are the number one reason that we're seeing rural communities go out of the OB business. So while we have struggled with an OB-GYN component with first assist, of course have to have anesthesia available. You have to have someone there to take care of the baby as well. You have to have pediatricians or acute newborn providers and a cesarean section to take care of the babies.

00;13;02;27 - 00;13;27;02
Julie Petersen
So it takes a team. But our nurses are the bedrock of that. And we talk about labor and delivery. Eleven hours of labor and delivery is all about the nurse. The doc walks in and is there for a short period of time. Our nurses are dedicated. They have a lot of longevity, and they are just used to doing whatever it takes to get the job done, and that's what they've done for the last 15 months.

00;13;27;05 - 00;13;51;26
John Supplitt
So all these things considered, given the changes that you're planning - two questions. The first is what's the timeline for implementation? You really started this process back in 2022-2023. You've moved forward for the research. You made the decision to go to be with OB hospitalist Group in October of 2023. What's the timeline now for looking forward in terms of making this permanent?

00;13;51;28 - 00;14;23;06
Julie Petersen
We believe we will be fully staffed between our own providers and OBGH in July of this year. So it has been a long haul. We've been on the pediatric side of it. We've been building our acute newborn so that that's a very reliable group now. And anesthesia as well. So we feel like once we have weathered the storm of a lot of locums and short term locums, and we get our OBHG hospitalist on board, our own folks on board, we're going to be ready to go.

00;14;23;06 - 00;14;53;12
Julie Petersen
So July, August of this year. And again, a component of this and one of the ways that we make this affordable - and labor and delivery has always been a loss leader - but one of the ways we make this affordable is through this OB-GYN model is we do have built in GYN surgical time. So we're able now or we will be able to take care of more of the general gynecological needs of the women in our community than we've ever been able to take care of before.

00;14;53;15 - 00;15;05;17
John Supplitt
Well, and I think that that's the question, and that'll be the last question I ask. And that's the one that everybody wants to hear, is, how are you going to pay for this? How are you going to meet the expenses to make sure that this service remains viable moving forward?

00;15;05;20 - 00;15;34;24
Julie Petersen
So every schedule we've put together also includes that GYN surgery day. So our OB-GYN will be doing more surgery than are the ones that have been working 24 hours a day to deliver babies were willing to do. So GYN services will continue to increase. This, frankly, is a service that we have always look to our 340B savings to help support and like everyone else who delivers babies, we lose money on it

00;15;34;24 - 00;15;46;20
Julie Petersen
so we made a direct connection to those 340 B savings. So we keep a close eye on that as well. It is not going to be easy financially. We will struggle because of this. But again, we're committed.

00;15;46;22 - 00;16;05;27
John Supplitt
Well. And you raised some very important points is that none of these programs exist without the other. And 340B is essential to rural community hospitals across the country. It is the margin for many critical access hospitals and what you're suggesting, it's going to be pretty much the margin for you to be able to continue this OB service.

00;16;06;00 - 00;16;33;26
John Supplitt
I think I really, on behalf of all of our listeners, want to thank you and your board for the commitment to making sure that OB is available to the residents of your community. That they're not put at risk for unsafe deliveries, unhealthy situations, becoming unsafe because they have to cross a mountain pass. I think it's a huge commitment on behalf of your community and your leadership in making this happen to really implementing this practice and making it come so quickly

00;16;34;00 - 00;16;37;01
John Supplitt
given the crisis that you were confronted with just a few months ago.

00;16;37;07 - 00;16;38;25
Julie Petersen
Well, thank you. It's a privilege.

00;16;38;28 - 00;17;09;02
John Supplitt
I want to thank my guests. Julie Peterson, CEO of Kittitas Valley Health in Ellensburg, Washington, for sharing her important story and providing essential health services and reimagining OB to ensure continued care for the residents of Kittitas County. Your commitment is inspiring, and we'll be watching closely as you grow and evolve under this new model of care. I wish you every success in your effort and hope to learn more about how we can learn from your experience.

00;17;09;04 - 00;17;19;01
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;17;19;04 - 00;17;27;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;38;18
Tom Haederle
Some 57 million rural Americans depend on their hospital as an important source of care, as well as a critical component of their area's economic and social fabric. But many rural care providers have faced and continue to face a rocky road ahead. Attracting and retaining workers. Financial stresses. Dealing with complicated and sometimes conflicting regulations. These are among the factors that can jeopardize the ability of rural hospitals to provide patient access to care.

00;00;38;20 - 00;01;13;07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. AHA has made improving access to rural health a top priority. Our 2024 Advocacy Agenda for lawmakers and policy recommendations to government agencies lays out the groundwork for needed change to improve the system for patients. In this podcast, two AHA experts drill down into some of the specific steps needed to help essential rural health care providers stay solvent, healthy, and able to serve the patients and communities who depend on them.

00;01;13;09 - 00;01;20;19
Tom Haederle
The discussion took place at the 2024 AHA Rural Health Care Leadership Conference in Orlando, Florida.

00;01;20;22 - 00;01;49;08
Lisa Kidder
Good day. I'm Lisa Kidder, senior vice president, AHA advocacy and political affairs. I am joined today by my two colleagues, Travis Robey, vice president of political affairs, and Shannon Wu, senior associate director, AHA payment policy, two of the experts on rural health care. Welcome, Shannon. Welcome, Travis. We all know rural hospitals continue to experience ongoing challenges that jeopardize the ability to provide local access to care and essential services to their patients and community.

00;01;49;11 - 00;02;19;17
Lisa Kidder
Examples include workforce shortages, financial instability, overwhelming regulatory burden, just to name a few. AHA continues to work with Congress and the administration to enact policies or sometimes to stop policies to support these rural hospitals. Recently, we announced our AHA Rural Advocacy Agenda for 2024. I am going to talk to Travis and Shannon about the advocacy agenda and share with you some of the details as we drill down a little bit.

00;02;19;20 - 00;02;39;04
Lisa Kidder
Travis, let's start with you. As AHA continues to work with Congress and the administration to support these rural hospitals. We're also looking to support a public policy environment that will protect access to care, innovation and invest resources in new rural communities. Could you talk about those five areas, please?

00;02;39;07 - 00;03;02;11
Travis Robey
Absolutely. Our first priority in our updated rural advocacy agenda is commercial insurer accountability. It continues to be an issue that we hear as a top tier issue of concern for our members. Second is supporting flexible payment options. Third is ensuring fair and adequate reimbursement. Fourth is bolstering the workforce. And fifth is protecting the 340B program.

00;03;02;14 - 00;03;19;15
Lisa Kidder
Great. Thanks. I will dig into some of those issues here in just a minute. Shannon, as Travis mentioned, the number one he first mentioned and maybe even number one on our priority list this year is commercial insurer accountability. Can you talk a little bit about what's been happening with the administration and some of the actions they've taken to address this issue?

00;03;19;17 - 00;03;42;06
Shannon Wu
Sure. We've already seen some moves in the right direction from the administration, from last year and the beginning of this year. So first, we are carefully monitoring compliance and the recent Medicare Advantage rules that were finalized last year, which went into effect last month in January. Many of these rules hold plans accountable for covering services and for their marketing tactics, among other requirements.

00;03;42;09 - 00;04;05;10
Shannon Wu
So we're keeping a close eye on how this Medicare Advantage plans are complying with those rules for the upcoming year. Second, the administration also finalized just last month in January again, prior authorization rules that the AHA advocated heavily on. These will go into effect in the next few years and are really aimed at streamlining and reducing burden associated with prior authorization and at promoting greater transparency.

00;04;05;12 - 00;04;14;21
Shannon Wu
Of course, our work here is not done, and we continue to advocate for ways to reduce administrative burden and help our rural hospitals navigate through the changing Medicare Advantage landscape.

00;04;14;24 - 00;04;30;21
Lisa Kidder
Thanks, Shannon. It sounds like lots of good work is being done. Travis, let's talk about another issue that has getting a lot of attention in Washington, D.C. right now from both sides, both those who are for it and against it. Can you tell us about site neutral and what is happening right now in Congress on the issue?

00;04;30;24 - 00;05;02;18
Travis Robey
Absolutely. Hospitals and health systems play a critical role in preserving access to care for patients and communities throughout rural America. They've increasingly stepped up to fill the voids in care by reinvesting through access points like hospital outpatient departments. These sites of care are essential services in so many rural and low income communities across the country. Our emphasis right now is trying to push back on congressional efforts to impose site neutral payments, particularly for drug administration.

00;05;02;19 - 00;05;26;21
Travis Robey
But their longer term vision is far more expansive than that. And the impact on rural communities is particularly acute. We've recently put out data that shows that disproportionately rural patients access care at hospital outpatient departments. And we want to ensure that that access continues going forward by opposing the site neutral cuts.

00;05;26;23 - 00;05;33;17
Lisa Kidder
And, Travis, I hate to put people on the spot, but I'll put you on the spot. What do you think the chances are that Congress takes action this year on the issue?

00;05;33;19 - 00;05;59;18
Travis Robey
Well, right now we've got, in the short term, the March 1st and March 8th government funding deadlines that put us at risk on these issues. The hope is that we can stave off any pending cuts in that government funding package that's going to move in the next month, but then we'll still have the lame duck session of Congress in November and December, where this will be a top tier issue.

00;05;59;21 - 00;06;20;13
Travis Robey
So we need to make sure that our rural members and all of hospital leaders across the country are engaging with their legislators to make sure that the message gets delivered, that the current payment model is essential to maintain access to care, particularly given the financially vulnerable position of so many rural and safety net hospitals.

00;06;20;16 - 00;06;36;19
Lisa Kidder
Great. So that sounds like a call to action as well as an update. The next issue I know is one that really hospitals and hospitals really across the country are dealing with that definitely peaked during Covid. But can you talk about workforce challenges? So Travis, I'll send it to you. But then, Shannon, you may have thoughts as well of some of the issues you've worked on.

00;06;36;19 - 00;06;39;10
Lisa Kidder
So, Travis, why don't you go first and then you can turn it over?

00;06;39;12 - 00;07;06;10
Travis Robey
Yeah. This is a key area where there is the potential for possible bipartisan support over the coming months. The National Health Service Corps is up for reauthorization. We're also advocating for an expansion of graduate medical education residency slots. Over the last several years, we've seen investments in more GME slots after nearly a couple of decades where there had been a freeze on those slots.

00;07;06;12 - 00;07;33;21
Travis Robey
But there are also rural specific proposals, like the extending the Conrad state 30 program, which allows J-1 visa waivers for physicians who train in the U.S. to be able to stay here if they practice in an underserved or rural community. So there are a variety of key workforce provisions that are specifically focused on rural, but I want to highlight one additional area: the SAVE Act. That's focused on workplace violence,

00;07;33;23 - 00;07;58;17
Travis Robey
such a key issue for employees and administrators at hospitals to take this issue head on. We just had a very successful - almost 100 congressional staffers attend a briefing on this issue that really, I think, drove home to congressional staff the importance of this issue, and we're looking to make progress on that over the coming months as well. And that's a bipartisan piece of legislation in the House and the Senate.

00;07;58;24 - 00;08;35;20
Shannon Wu
Great. Well, on the regulatory front, we've been really focused on the proposed nurse staffing minimum rules that were released by the Centers for Medicare & Medicaid Services last year. We strongly oppose these rules. So while we agree that staffing is an integral part of providing safe, high quality care, we believe that the proposed rules from last year really are an overly simplistic approach to a complex issue and that, if implemented, would have serious negative consequences not just for nursing homes but across the continuum, especially with ongoing workforce challenges that are preventing hospitals and rural hospitals especially, from discharging their patients in a timely manner to subacute or post-acute places.

00;08;35;23 - 00;08;43;26
Shannon Wu
So we are currently awaiting the final rule and in the meantime, have supported legislation that would prohibit the agency from finalizing those proposed requirements.

00;08;43;28 - 00;08;56;06
Lisa Kidder
Great, thanks. Going to turn to Travis again for an issue that has perennially gotten a lot of attention. And this is the 340B drug pricing program. Travis, I know that there's some interest in it right now on Capitol Hill. Can you bring us up to speed?

00;08;56;09 - 00;09;22;15
Travis Robey
Yes. The House of Representatives has had some hearings on this issue, trying to make changes that we think are problematic for the program. There's also been some legislation, a draft legislation put forward by some of the members of the Senate who have been champions of the 340B program. We're currently evaluating that to provide comments as they continue to refine that legislation moving forward.

00;09;22;18 - 00;09;43;28
Travis Robey
But I think the key message is that we want to make sure that all 340B hospitals are reaching out to their legislators to continue to explain the importance of the 340B program, how it ensures that you can stretch scarce federal resources further, and particularly for our rural members, how important it is to maintain access to care in your communities.

00;09;44;00 - 00;09;56;18
Lisa Kidder
Great,thanks. And just in the last couple of minutes, let me open it up to you. I know this is a question we sometimes ask our CEOs, but you know what's keeping you up at night? What's the unfinished business of rural health care that you'd like to see tackled? Shannon?

00;09;56;21 - 00;10;19;18
Shannon Wu
Well, I'll just continue on the 340B theme. And I want to mention here, obviously the AHA continues to oppose any efforts to undermine the 340B program, but in particular contract pharmacies. And we know how important that is for rural communities. So we know that there are still legal actions pending in the federal courts. And much of that action has moved to the states, which the AHA is very supportive and poised to help states in protecting access to contract pharmacy.

00;10;19;18 - 00;10;24;06
Shannon Wu
So that is something that we continue to monitor and continue to be engaged on for this year.

00;10;24;09 - 00;10;25;18
Lisa Kidder
Thanks, Travis. Anything from you?

00;10;25;25 - 00;10;46;01
Travis Robey
It really is site neutral for me. That's the issue that I think is front and center in Congress right now. There are certainly important provisions, like extending the Medicaid DSH cut moratorium that is essential for protecting the financial stability of the field. But I think right now, the number one threat to the hospital field are site neutral payment cuts.

00;10;46;03 - 00;11;02;07
Travis Robey
And that's what keeps me up at night, concerned that at a time of continued financial challenges for the field, that Congress might unwisely try to pass that legislation. So again, one last call to action on that. Please continue to reach out to your legislators on that issue.

00;11;02;10 - 00;11;14;20
Lisa Kidder
Great. Thank you so much to both of you. Lots of hard work being done. And again, thanks, Travis and Shannon for all your help. I am Lisa Kidder, and thanks for listening. This has been an AHA Advancing Health podcast.

00;11;14;22 - 00;11;23;02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;14 - 00;00;31;10
Tom Haederle
E Pluribus Unum - that's Latin for "out of many, one" - is the traditional motto of the United States and printed on the dollar bill. Out of many, one is also the goal for independent hospitals and their boards who merge into larger health systems and may face the challenge of maintaining safety and quality standards that are no longer just their own.

00;00;31;13 - 00;01;06;07
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Valley Health System serves a sizable patient population in Virginia. It was formerly six separate hospitals, all of which were governed independently by their boards. In this Safety Speak series podcast hosted by Sue Ellen Wagner, vice president of Trustee Engagement and Strategy with AHA, we hear how Valley Health System rearranged its governance system to overcome the hiccups of its growing pains and ensure that patient safety standards were kept up across the board.

00;01;06;09 - 00;01;18;26
Sue Ellen Wagner
Thank you Tom. Joining me for this podcast is Harry Smith, board chair of Valley Health System in Virginia, and member of the committee on Governance. Welcome, Harry, and thank you for joining me.

00;01;19;03 - 00;01;20;27
Harry S. Smith
Thank you, Sue Ellen. Happy to be here.

00;01;20;29 - 00;01;26;18
Sue Ellen Wagner
Great to have you. So can you tell us a high level overview of your health system?

00;01;26;21 - 00;01;58;29
Harry S. Smith
Be happy to. Valley Health System, and I've been involved with it and its largest subsidiary, Winchester Medical Center for 22 years. In two more years, I will retire. I will have termed out of Valley Health, and as a career banker, I have found health care to be - as a friend of mine said one time - you're performing God's mission. And I don't know of any organization in the world that does what hospitals and health care systems do to care for our population.

00;01;59;01 - 00;02;29;24
Harry S. Smith
So when I first started this journey 20 some years ago, I was on the Winchester Medical Center board, which is about 83% of the economic engine, the patient base of our system. We had five other hospitals. We did have a system, Valley Health System. We serve nine counties and a city in the northern part of Virginia. And some people will know it as the panhandle of West Virginia.

00;02;29;25 - 00;03;00;21
Harry S. Smith
So in addition to Virginia laws, rules and regulations, we also deal with West Virginia. So Valley Health System started back in the late 90s as starting to pull together a loose confederation of like-minded small hospitals to become a regional hospital. Over the years, 2 or 3 that we thought might come into that system actually sold to a for profit system, and that was their decision.

00;03;00;23 - 00;03;35;06
Harry S. Smith
So we ended up with the Winchester Medical Center, which is Level II trauma, to critical access hospitals and then three rural hospitals. It's been fun looking at this growth of this eclectic system of several different types of delivery in two different states. We realized early on, though, that we were somewhat disconnected, even though we had this holding company called Valley Health, we still had its board in six different hospital boards.

00;03;35;08 - 00;04;04;06
Harry S. Smith
And principally they were responsible for their hospital, their operations. They had their own president. For the most part they did some of their financial and some of their accounting, but a lot of that was at the system level. But they were really principally responsible for quality. And so I became more involved and then was on the hospital board at Winchester Medical Center and the Health System Board, I started realizing how complex this was.

00;04;04;09 - 00;04;39;01
Harry S. Smith
It should be more efficient, and we should be able to provide even better quality for our community. And how could we do that? And first is ask questions. One of the first questions I asked of our CEO was how many quality meetings? How many board meetings do you go to in a month? And it was astounding because remember, we had a quality hospital board meeting for each one of those, plus the system, and he was attending all of those, and each one was handling quality at a high level, but with its own standards.

00;04;39;04 - 00;05;09;03
Harry S. Smith
You can't take six hospitals that used to be independent and overnight, put them all under one system and say to their executive team and to their board, you are no longer independent. So that took a process of moving more functions to the system, which we started really with finance and then audit. They then were principally quality. Then it was, we've got to standardize quality.

00;05;09;03 - 00;05;41;12
Harry S. Smith
So Valley Health System hired its chief quality medical officer to system level. And then started working with the individual hospital presidents and their vice presidents of medical affairs to begin that process. As it started, we still were meeting a lot and I'm not sure really moving the needle as positively as we wanted with quality. So we then visited several systems, worked with consultants on how do we do this better?

00;05;41;15 - 00;06;06;29
Harry S. Smith
And what we came up with, what we did was Valley Health System then became the sole member of all of these separate hospitals. So we then evolved into one board, Valley Health System, which is the sole member of the six hospitals with one board. So early when they were independent hospitals, you had a lot of attention to quality, because that's pretty much what they did.

00;06;07;01 - 00;06;34;17
Harry S. Smith
Now it's one big board, not in each community, even though there's some community representation. How is it going to handle quality in a community that might be 70 miles away? That brought through the standardization process. And we did that at the Valley Health level, kind of just doing what we used to do, but now instead of 6 or 7 boards, it's one. Still wasn't working as well or as efficient as we thought.

00;06;34;19 - 00;06;57;27
Harry S. Smith
We then decided to form what we call QMAC. It's the Quality Medical Affairs Committee, which has the full authority of the board. The system board meets six times a year. Credentialing occurs more than six times a year. And we said the hospitals have to exist for credentialing. You just can't disband a hospital. It has to have a board.

00;06;57;28 - 00;07;37;20
Harry S. Smith
Well, its board is the Valley Health Board because it is a sole member-owned hospital. So representatives then of each hospital, their vice presidents of medical affairs, their lead administrators, their chief nursing officers, key physicians serve on the QMAC, Quality Medical Affairs Committee, which has the full authority of the board. And it meets monthly, and it has full authority to do credentialing to review all quality indices, KPIs and we then at the Valley Health Board, when we meet that six times a year, will open

00;07;37;20 - 00;08;03;00
Harry S. Smith
our meeting, will have a consent agenda. And let me go back, if I might, because in one of this morning's presentations talked about the board's priorities as days and days and years and years ago, it may well have been finance. I think we all understand our number one priority is quality, and we have taken a lot of the normal duties and responsibilities.

00;08;03;02 - 00;08;28;22
Harry S. Smith
Even the monthly financial report and the quarterly. And that's in a consent agenda now. So we don't have a long formal presentation on finance. So we save our time and our time is saved really at reviewing quality, educating the board on quality, but also taking time to educate. Our last meeting, we talked a lot about artificial intelligence and its impact on systems and quality and physicians

00;08;28;22 - 00;08;58;02
Harry S. Smith
and don't be afraid of it because it's just a tool. You still will have humans making those decisions. So I then chair the board. We'll go through the consent agenda of those items that used to take an hour or more. We then open the sole member meetings, and that's where the quality report flows up to our system. The chair of our quality committee and the chief medical officer for the system will make that presentation.

00;08;58;04 - 00;09;21;20
Harry S. Smith
And all this information is in our board package, and we have what we call an S-bar. You'll see the report. But then if you want literally the other 200 pages to go with that report, you can pull that up. That committee is populated, as I mentioned, from all of our hospitals are critical care. Our clinical administrators, our physicians assistants, nurse practitioners, chief nursing officers.

00;09;21;22 - 00;09;52;22
Harry S. Smith
So it's very well represented. And that's where the deep dive occurs. That's where the sausage is made. We at the system level who aren't on that committee have to have a very high level of trust, which we do, and have given that committee, again, full authority to act on the board for our quality initiatives, including credentialing. So I know I'm rambling, but just to give you an idea of what this committee does and then how we review it.

00;09;52;23 - 00;10;28;25
Harry S. Smith
So our QMAC committee reviews credentials. Our staff executive committee, which some would call their medical executive: committee minutes and reviews. Our performance improvement committee: harm scorecard quality scores, patient experience scores. They'll have special reports. They'll hear from our VHMG, which is our Valley Health medical group. That's the employed physicians. We have our entity presidents. There will have information that comes at a little bit of recruiting, is epic working as we would sentinel events, serious safety events.

00;10;29;01 - 00;10;59;21
Harry S. Smith
Again, this is for all six hospitals coming to one group. As I mentioned credentialing, we have advanced practice providers involved in that. We hear a report from each department: cardiology, emergency medicine, family, etc. Review in depth the Performance Improvement Committee which again includes harm patient experience. The annual quality plan which they review first recommend to the board. The board will review it, discuss it,

00;10;59;21 - 00;11;31;11
Harry S. Smith
at times we tweak it. That will become the annual plan of quality for our system. They look at falls, wrong site surgeries, lab issues, patient access, wound care. All of this happens on a monthly basis. You couldn't expect a board of 14 to 16 to really have that depth and level of knowledge to review every month, the thousands of hours that go into the details to come to that committee on a monthly basis, which typically meets for two to 2.5 hours.

00;11;31;14 - 00;11;40;23
Harry S. Smith
So they have figured out how to get this information. And what underlies that information is a tremendous amount of detail.

00;11;40;25 - 00;12;08;18
Chris DeRienzo, M.D.
Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the AHA’s chief physician executive and a champion of the AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

00;12;08;21 - 00;12;40;18
Chris DeRienzo, M.D.
We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1500 other hospitals already involved, visit aha.org/patientsafety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the AHA's Patient Safety Initiative.

00;12;40;20 - 00;12;47;13
Chris DeRienzo, M.D.
Remember, together, we can make health care safer for everyone.

00;12;47;15 - 00;12;56;00
Sue Ellen Wagner
So that QMAC is a way to keep quality at that local community hospital level, and then weave it right up to the top to the system.

00;12;56;06 - 00;13;29;09
Harry S. Smith
Absolutely. I'm not sure I'll say it's our challenge, but our opportunity now and this has been a ten year endeavor. But QMAC really in the last four years has come of its own to where the data, the conversation, the presentation, that's all very, very good. We still have some pockets though, where we could have better standardization of delivery of quality throughout our various entities, including our employed physicians.

00;13;29;11 - 00;14;02;12
Harry S. Smith
That's really the drive right now. We started in 2017 on a journey called High Reliability Organization, which is comprehensive, expensive in the short run, but will be very beneficial in the long run. And it's a journey that never ends. I think I've mentioned to you before, this really came from the Navy. And what does that mean? It means what happens 100% of the time should happen, and what shouldn't happen 100% of the time doesn't happen.

00;14;02;14 - 00;14;24;12
Harry S. Smith
And that's not easy to do. But if that is your goal, if that is your mission, if you know that you want to do everything right. If you don't, you correct it, you learn from it, and then you have to have those standards across the system that everybody is operating in the same manner. And that's where we're finding still a little bit of some variables.

00;14;24;15 - 00;14;49;26
Harry S. Smith
The last thing they look at, and the most important thing that QMAC back presents to our board then would be our dashboard, our KPIs. This is approved. Our quality plan annually originates from this committee representing all of those constituents I mentioned earlier. Comes up to the board and is presented twice. Once - okay, here's what we think. You all chew on this for a month or two.

00;14;49;27 - 00;15;14;26
Harry S. Smith
We're going to come back and then receive formal board approval for our quality plan. In the last three years, the board has made a few tweaks. They never have just blindly accepted the QMAC report and quality plan. An example would be the mortality index. We were doing really, really very well on that. Because we were doing so well

00;15;14;28 - 00;15;33;22
Harry S. Smith
QMAC folks in executive management recommended, because the hurdle was already pretty high, that we should continue that for the next year. Board members said, we think you need to raise that. You've already obtained this level. And they go, yeah, but this is a great level when you look at peer. Yeah, but we think you can do better.

00;15;33;25 - 00;15;35;06
Harry S. Smith
And they exceeded that.

00;15;35;11 - 00;15;37;11
Sue Ellen Wagner
Commend you for that. That's amazing.

00;15;37;14 - 00;15;58;23
Harry S. Smith
Thank you. And they did accept us. So currently we are looking at and this is where we had to tweak the mortality index. We look at whole house infection. We used to just look at sepsis. They made the change. I asked our quality medical officer, tell me what this whole house infection is. And he goes, well it's a new indices that CMS is looking at.

00;15;58;25 - 00;16;21;07
Harry S. Smith
And sepsis. We've got a pretty good handle on that in our system now. So we're now looking across the whole system i.e. the whole house at all infections not just sepsis. If we would see sepsis crop up, then we certainly would put a shining light on that and give that more attention. We are looking average length of stay.

00;16;21;08 - 00;16;48;04
Harry S. Smith
We think that is important, which ties a little bit into and we still have operating margin. And then last is engagement. Employee, outpatient, inpatient, ED - critically important to us. What people think about us, how do they feel about our quality. And we take that seriously. These are our major dashboard KPIs. And really only 20% of that is finance.

00;16;48;06 - 00;16;59;23
Harry S. Smith
You might say a little bit of length of stay is tied to finance. And I will tell you, a decade ago, 60% would have been financial indicators. Now it's 20%.

00;16;59;25 - 00;17;02;10
Sue Ellen Wagner
And the rest is quality or most of it.

00;17;02;13 - 00;17;27;15
Harry S. Smith
Most is quality. And again, working through that socially, politically and again when you're realigning boards and duties and we're wanting to get to a point where you never will get. And that's 100% perfection. But if that's your goal and if you can continue to improve on that goal, tweak it as you get there, then I think we've done our job.

00;17;27;17 - 00;17;47;15
Sue Ellen Wagner
Absolutely. Wow. So you've really described a great case example for other systems to follow and other hospitals. You're still keeping that quality local, but your reduced the number of meetings that boards have to go to. And that system is still seeing what's going on across all of your six hospitals. That's great.

00;17;47;17 - 00;18;12;27
Harry S. Smith
We are. We have independent trustees. The chair of QMAC has to be a trustee. Now we're lucky this happens to be a physician. So that's great. We have a trustee who is a nurse, actually dean of a nursing school who had been a practicing nurse. She is on that. So we have independent nursing validation. We then have several independent trustees who do not have a medical background.

00;18;13;00 - 00;18;33;08
Harry S. Smith
And we now require that members of the board who are not members of QMAC mandatorily have to attend at least one meeting a year. Because in one of our surveys a couple of years ago, members said they weren't sure that we were meeting our quality commitment. Those on the committee were going, what?

00;18;33;10 - 00;18;37;05
Sue Ellen Wagner
So you just weren't transferring the information more broadly.

00;18;37;08 - 00;19;13;20
Harry S. Smith
And we were bringing it up to the system board, but we were bringing it up through, you know, a monthly meeting report, but some probably weren't going to that S-bar or reviewing those 100 or so pages. Nor should they. They were newer learning how to trust this. Is it really working as we think it should? One way to get that is to have the experience of attending that meeting at least once during the year, to really see what these very dedicated professionals are committing to and doing, to continue to strive to improve quality, to again that 100% level.

00;19;13;22 - 00;19;37;27
Sue Ellen Wagner
It's a very important step to make sure that all your board members are knowledgeable about what's going on and understand. And I also think it's pretty phenomenal that you've modified the way your consent agenda is done, and you're talking more about quality. We talked earlier at the AHA Annual Meeting at our Age Friendly and Quality and Patient Safety program, how it's so important to have quality be front and center of your board members.

00;19;38;00 - 00;19;52;06
Sue Ellen Wagner
Any other words of wisdom for other boards in terms of what they should be focusing on, on quality and patient safety, or how they get buy in to make some changes to their board structure and how they should be talking about quality and patient safety.

00;19;52;08 - 00;20;19;27
Harry S. Smith
I think the first is don't be shy that you don't know everything. You may not have a background in health care. That's where I think most of the apprehension might be. You have to be comfortable in giving up the perceived local control. You have to develop what your community, what your structure that will work for you and it.

00;20;19;29 - 00;20;49;01
Harry S. Smith
And I would say this would be more for those trustees that don't have that quality level of background. It's okay to ask a question. I mean, I'm a banker and I've started this years ago going, how many meetings do you attend and why are we spending so much time on this and why are we doing that? Getting involved in organizations like the American Hospital Association, attending meetings, listening to peers best practices.

00;20;49;03 - 00;21;14;08
Harry S. Smith
It really does help with efficiency, effectiveness. And it's okay to ask that question. It might not work for everyone. That's okay, but you can improve what you're doing in every single instance and circumstance in every part of this country if you just aren't comfortable with the status quo and just ask why, how, and maybe we can do things better, we found that you can.

00;21;14;10 - 00;21;19;06
Sue Ellen Wagner
Well, I think you've provided some great insights for our listeners, and I want to thank you for joining me.

00;21;19;13 - 00;21;20;24
Harry S. Smith
Thank you, Sue Ellen.

00;21;20;26 - 00;21;29;05
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;14 - 00;00;24;21
Tom Haederle
The reality of today's health care workforce is this demand outstrips supply. So every health care employer knows it's more important than ever to support their people and give them good reasons to stay not just surviving, but thriving.

00;00;24;23 - 00;00;53;05
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. For rural health care providers, especially, building and sustaining a strong and vibrant workforce that can meet the community's needs is paramount. In this podcast, recorded for the ages 2024 Rural Health Care Leadership Conference, we learn how the use of team steps and other tools has made a big difference for one rural system in Washington state, says today's guest.

00;00;53;13 - 00;00;57;08
Tom Haederle
The well-being of our team is foundational to everything we do.

00;00;57;10 - 00;01;19;05
Elisa Arespacochaga
Hi, I'm Elisa Arespacochaga vice president for clinical affairs and workforce, and today I'm joined by Brandie Manuel, chief patient safety and quality officer at Jefferson Healthcare in Port Townsend, Washington. We're talking about supporting the current health care workforce so that they can move from surviving to thriving. So, Brandie, let's start with tell me a little bit about yourself and your role at Jefferson.

00;01;19;08 - 00;01;39;26
Brandie Manuel
Thanks. I am a registered nurse. My background and I have been with Jefferson Healthcare for about 11 years. I started there as the Director of Patient Safety and Quality, and my role has evolved over time, and my interest in workforce development and supporting our workforce really goes back to wanting to provide the best patient outcomes for our community.

00;01;39;26 - 00;01;44;07
Brandie Manuel
And that's hard to do when you don't have an engaged team to take care of them.

00;01;44;09 - 00;02;12;06
Elisa Arespacochaga
Absolutely. So you're at a rural organization, but you still have to coordinate care across a huge area with a number of different partners across the continuum, some of which may be a boat ride away, some which may be several hours in a car away, all of which have an impact on the well-being of your team. So how do you coordinate some of that work to make sure that all the good you're doing for your own team continues to spread across that continuum?

00;02;12;09 - 00;02;36;00
Brandie Manuel
I think it has to do with how well we are collaborating with our external partners, as well as how well we're managing the work internally. So we've developed relationships with our paramedics. We have developed a community peer medicine program to look at fall prevention in older adults, and then we also work collaboratively with several of our partners, both across the water and even right next door.

00;02;36;02 - 00;03;02;02
Elisa Arespacochaga
That's great. So your organization, you've really understood that during the pandemic, you've really needed to help your own team thrive, because there weren't a lot of other people you could bring in. Tell me a little bit about how you really leveraged some of the work around teamwork. I know you were a big proponent of TeamSTEPPs and team training, which I am as well, but how did you leverage that work to really help your organization thrive?

00;03;02;05 - 00;03;23;07
Brandie Manuel
I think for us, we started TeamSTEPPs several years before the pandemic, which was fortunate because the tools and strategies really helped as we were navigating through that. So implementing and hardwiring things like huddles, briefs and debriefs, making sure that there's role clarity on the team and just really helping our teams use those tools to operate at the highest level that they could.

00;03;23;10 - 00;03;44;27
Brandie Manuel
Became critical during the pandemic, especially when you didn't know everybody that you were working with. We went from knowing every face in the hallway to having travelers, which we had never done before, and hiring new faces that were now covered by masks and no benefit of real social interaction outside of work. So having strong team skills and communication became pretty important.

00;03;45;00 - 00;04;09;15
Elisa Arespacochaga
And for those who don't know, TeamSTEPPs really is a rubric to take that team of experts and make them an expert team. And I love that definition, because it really is about how do you get everybody on the same page quickly? Tell me a little bit about what's up next in your plans and how you're going to sustain some of the improvements you've made in terms of really helping your teams gel and supporting them in their well-being?

00;04;09;17 - 00;04;28;21
Brandie Manuel
Yeah, we've just restarted TeamSTEPPS in person, so we did the updated curriculum, a new master trainer course in the fourth quarter. We have some new trainers coming in, and we're introducing the training as a hybrid option. So both kind of for people who've already taken it and want a refresher, but also for those who it's brand new for.

00;04;28;23 - 00;05;00;17
Brandie Manuel
And then looking at how we can embed those tools and strategies into our daily work even more than we have already, as well as our onboarding and sort of training that in addition to the work that we're doing to introduce those same tools and strategies to our medical directors and our medical staff leaders and head down the path of providing leadership tools and training for our physicians who are in leadership positions, maybe for the first time, and kind of introduce them to some of the same things we have done for our directors, managers and supervisors.

00;05;00;19 - 00;05;19;07
Elisa Arespacochaga
That's great. I know you've got a lot of different wellbeing sort of threads that are woven throughout. Can you just make that connection a little more? And I know you, you believe it. It's why you do this work. The connection between the well-being of your team and your your title. Chief patient safety and Quality Officer.

00;05;19;10 - 00;05;43;08
Brandie Manuel
The well-being of our teams really is foundational to everything we do. And for us, our mission really is to hold the trust of our community. And that starts with the people who are caring for them when they walk through the doors. So it really is personal, and it really is important that we are taking care of each other first and that our team as a whole is engaged in well and enjoying the work that they're doing.

00;05;43;11 - 00;05;47;29
Brandie Manuel
So we feel like that's really the first piece to then taking great care of our patients.

00;05;48;02 - 00;05;52;22
Elisa Arespacochaga
Absolutely. Especially since most of your patients are your your neighbors.

00;05;52;25 - 00;05;54;28
Brandie Manuel
And in some case, our coworkers.

00;05;55;00 - 00;06;15;27
Elisa Arespacochaga
Absolutely. All right. So let me wrap up with the question about what advice would you give to leaders who are looking to address organizational well-being, who may be thinking, there's too much, there's too much I've got to do to make this, to change our culture, to move our work. What are some of the things that you tried that really helped?

00;06;15;29 - 00;06;49;23
Brandie Manuel
I think starting small and really recognizing that you're probably already doing some of the things already. So things like rounding on your team, rounding with purpose, starting with some of the tools that they teach in team steps, which I am just I've seen the evidence, but I've also seen it work for us. So spending some time getting to know the people if you don't already, getting to know the people that you work with, getting to hear what matters most to them, it may surprise you and spend more time being out and experiencing what it is that they're seeing every day.

00;06;49;25 - 00;06;59;24
Elisa Arespacochaga
Brandi, thank you so much for both the work that you do and the care you're taking of your team. I think it's a wonderful opportunity, and I know you're continuing to spread it to the next generation.

00;06;59;26 - 00;07;01;12
Brandie Manuel
Thank you for having me.

00;07;01;14 - 00;07;09;24
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;33;02
Tom Haederle
Henry Ford Health operates 46 medical centers, along with more than 250 clinic locations throughout Michigan. That's serving a lot of people, with too many locations to provide integrated physical and behavioral health services at each and every one. Nonetheless, Henry Ford has perfected a system of providing those services to many who may need them, regardless of where they are.

00;00;33;05 - 00;00;59;00
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. A Henry Ford patient who may benefit from the services of a psychiatrist or social worker - in addition to a medical clinician - can usually access them online and interact with an integrated care team. Henry Ford has focused on putting behavioral health resources into many of its clinics, able to serve patients of all ages.

00;00;59;03 - 00;01;16;24
Tom Haederle
In this podcast hosted by the AHA’s Rebecca Chickey, senior director of Behavioral Health, Dr. Cathy Frank, who chairs psychiatry and behavioral health services with Henry Ford, shares how its virtual team approach and patient tracking registry benefits patients from every corner of Michigan.

00;01;16;27 - 00;01;45;02
Rebecca Chickey
Thank you Tom. It is indeed an honor to be here today with Dr. Catherine Frank. I call her Cathy. She is as he indicated, the chair of psychiatry and behavioral health services at the Henry Ford Health in Detroit, Michigan. Cathy, thank you so much for being willing to share of your time and expertise as it relates to the many, many years of integrating physical and behavioral health care at and across the Henry Ford Health System.

00;01;45;05 - 00;01;58;15
Rebecca Chickey
So I want to start and ask you to tell us, the audience, the listeners, about the origins or drivers of Henry Ford's integration work. In other words, the when, the why and the how.

00;01;58;17 - 00;02;26;28
Catherine Frank, M.D.
Thank you for the invitation, Rebecca. You know, collaborative care and what we call behavioral health integration at Henry Ford, is a very scalable population health intervention. And that's been something that Henry Ford's been invested in for quite some time. The driver when we started this way back when was to improve quality and access and ensure that our population remained healthy.

00;02;27;01 - 00;02;53;19
Catherine Frank, M.D.
We were also very invested in those early years in suicide prevention and knew even at that point in our evolution as the pioneers of zero suicide, that screening and access were really essential to safe care and suicide prevention. So back in 2001, we really had co-pair, meaning that we put some of our behavioral health people in primary care offices.

00;02;53;21 - 00;03;17;15
Catherine Frank, M.D.
Then we got to a different evolution of putting an advanced practice nurse in the primary care, sort of a teaching model that would sit with primary care docs, help with diagnosis, help with treatment. But what we found is, on a scale that was such a slow process, we'd probably be 20 years before we went to all of our clinics.

00;03;17;18 - 00;03;47;06
Catherine Frank, M.D.
So in 2017, we really transformed our model, to similar to what it is today. We are strictly virtual. We have many, many clinics. And the idea from a access point of view, financial point of view, we couldn't possibly put a behavioral health clinician in every one of our clinics. But with virtual, and this was long before I heard the word Covid,

00;03;47;09 - 00;04;15;28
Catherine Frank, M.D.
we could be very, very nimble and be where the patient and the primary care wanted us to be. At current, we have three varieties of behavioral health integration. We have that with adult primary care docs, aligned with about 285 adult primary care docs. We have a pediatric collaborative care model, and we have a collaborative care model for perinatal patients.

00;04;16;00 - 00;04;39;13
Catherine Frank, M.D.
We hope before the end of 2024 to have one that also addresses substance use care, so that we're really hitting the types of problems that not only affect our patients, but stymie primary care docs and really want to be able to help them and help the patients where they're out at that time.

00;04;39;15 - 00;05;07;28
Rebecca Chickey
First of all, congratulations on being such an early adapter or adopter of integrating physical and behavioral health care. It also helped, as you mentioned, I suspect it helped greatly when the Covid pandemic began and you already had in place a very sophisticated virtual telehealth delivery system for mental health needs. And perhaps it, allowed you to respond more quickly.

00;05;08;01 - 00;05;38;12
Rebecca Chickey
That's an a value of integrating physical and behavioral health at a virtual level that many people probably hadn't even addressed or thought of. We hadn't experienced such a pandemic and hopefully never will again. We will see. But I have a couple of questions to dig a little deeper into what you shared. You mentioned now that it's virtual, and obviously with the workforce shortages, you couldn't possibly have a behavioral health clinician be available in the multitude of clinics that comprise Henry Ford.

00;05;38;14 - 00;05;49;26
Rebecca Chickey
Can you define for the listeners, what do you mean when you say a behavioral health clinician? Is it a licensed clinical social worker? Is it a psychologist? Give a little more detail there if you could.

00;05;49;28 - 00;06;20;13
Catherine Frank, M.D.
So in the classic collaborative care model is really a team approach. So we have the patient. We have the primary care physician. We have some type of clinician. For us it's usually a social worker. And that's paired with a psychiatrist who's a consultant. So in real terms, primary care doc says gee, my patient has some mental health concerns.

00;06;20;16 - 00;06;56;10
Catherine Frank, M.D.
We gear, as most people do, our interventions to people with mild to moderate illnesses and usually the type of illnesses that primary care docs often see, particularly depression and anxiety. So once a primary care doc makes a referral, the social worker in our case, although some systems use nurses or a psychologist, sees the patient virtually and then the cool part for mental health is then that social worker presents the case to a psychiatrist.

00;06;56;13 - 00;07;24;18
Catherine Frank, M.D.
They consult, they talk about it on diagnostic and treatment recommendations, and then that goes in writing. Or if it's urgent by phone call to the primary care doc. And when medication is indicated, the primary care doctor and is coached then becomes the prescriber of choice. The other key to the success of behavioral health integration is that there's a registry.

00;07;24;20 - 00;07;57;15
Catherine Frank, M.D.
So often in a traditional medical or psychiatric clinic, patients may get lost to follow up. But there is a registry that we track patients over time. We also use very well established scales like Patient Health Questionnaire 9 or GAD 7. So we track them. We may talk to them weekly. We may see them x number of times for further evaluation.

00;07;57;17 - 00;08;24;18
Catherine Frank, M.D.
So we never lose track of our patients. we know where they're doing and we know how they're doing. I think one of the things that is a little bit different about Henry Ford, some collaborative care models do that consultation only. We do that. Plus allow up to eight visits of virtual psychotherapy if it's indicated. So in that initial evaluation, we're helping with the diagnosis and treatment plan.

00;08;24;20 - 00;08;37;18
Catherine Frank, M.D.
We're also deciding if that patient needs to be triaged and seen in a more specific psychiatric clinic, or whether they're appropriate for that mild to moderate model with their primary care doc.

00;08;37;20 - 00;09;06;11
Rebecca Chickey
Thank you. That makes it much clearer. And it also highlights the full continuum of integrated care since you offer up to eight visits and never lose track of the patient. That's great. Can you also share for the listeners what have been the impact of this? Obviously I think through having access to virtual mental health and substance use disorder care, you have improved the access to care.

00;09;06;14 - 00;09;26;08
Rebecca Chickey
But can you speak to what's the impact been in terms of on patient outcomes or staff satisfaction, or the return on the investment that you had to make in order to hire the additional clinicians and set up the virtual technology and maintain it? Would love to hear how this has played out in real time.

00;09;26;11 - 00;09;53;22
Catherine Frank, M.D.
Since it started, we've seen about 9200 patients in this specific program. All of them that were referred had a PHQ-9 of greater than five, meaning that they had some illness of some sort. If we look at the statistics, we look at full remission. Again, a lot of these patients start in this model and then go on to longer care.

00;09;53;23 - 00;10;25;01
Catherine Frank, M.D.
But if we look at their treatment time in this model, about 60% reach full remission meaning the PHQ was less than five. And if we look at response defined as their PHQ-9 went down at least by 50% at the minimum, it's more than 50%. So again, some of these patients start here and then are transferred. Some complete care in the model and so forth.

00;10;25;04 - 00;11;03;04
Catherine Frank, M.D.
And about 82% of those patients had some form of psychotherapy, usually up to eight sessions. So we found that patients truly felt that was a value added to our model. We certainly seen as we follow these cases over the years, a decrease in frequency, certainly of emergency room visits of inpatient psychiatry and actually inpatient medical and fewer primary care visits. Because often these patients are not coming with, you know, I just have malaise,
00;11;03;04 - 00;11;31;05
Catherine Frank, M.D.
I'm tired, I'm not sleeping. And when there is a mental illness that's diagnosed and treated, a lot of those visits are no longer needed for that. So it's been a very positive experience. In terms of the financial angle of things there have been a number of studies showing that it least breaks even or usually makes money for most systems.

00;11;31;07 - 00;12;04;26
Catherine Frank, M.D.
And again, I think you have to look at the financial in a very broad term. So there is how much we get back from CPT codes or from copays and how that is against the salaries we pay people to provide this care. But there's also the fact that, again, if you're looking at population health and management, you're saving on fewer ER visits, fewer unnecessary hospitalizations or visits.

00;12;04;28 - 00;12;41;01
Catherine Frank, M.D.
One of the things that was a big boom shortly after we switched to virtual, is that CMS created billing codes for collaborative care. Now, I will say that not all insurers reimburse for them, and that's a real need nationally, but it certainly allowed us to collect appropriate reimbursement for that. Our social worker for example, bills for an evaluation, bills for psychotherapy, if it's appropriate. In our state

00;12;41;02 - 00;13;15;15
Catherine Frank, M.D.
Blue Cross Blue Shield has been a huge proponent of collaborative care in the state of Michigan. They have probably about 27-28 quality improvement projects in Blue Cross, and one of them is promoting collaborative care. And so we get also as a system value-based reimbursement from Blue Cross, because they're supporting us as better care. And if you add up all those things, we certainly profit from this

00;13;15;18 - 00;13;26;04
Catherine Frank, M.D.
financially. But the main profit is our patients stay well, get better faster, have less morbidity and mortality from their illness.

00;13;26;06 - 00;13;52;19
Rebecca Chickey
Phenomenal. So as we wrap up today's podcast, if you had to say three things to the listeners, why should you go on this journey to either begin your organization's own first steps to integrate physical and behavioral health, or to go to the next level, much as you mentioned at the beginning. Expand that integration as you hope to do with substance use disorder care.

00;13;52;22 - 00;14;00;02
Rebecca Chickey
What are those three points that you want to hammer home so that before we know it this has expanded across the country?

00;14;00;04 - 00;14;45;03
Catherine Frank, M.D.
Well, it's hard to keep it to three, but I would say that one of the things we knew before Covid, and we certainly know after Covid that mental illness has increased dramatically. You know, 2023 was the highest rate of suicide ever in the United States, more than 50,000. So with the increased prevalence of mental illness paired with a shrinking workforce in terms of psychiatrists and psychologists and psychotherapists, collaborative care provides a model that not only improves access, but also interventions that lead to decreased morbidity and mortality.

00;14;45;05 - 00;15;13;11
Catherine Frank, M.D.
Secondly, it sort of explains the obvious. And by that I mean primary care physicians have always been the main providers of mental health care in the United States. But prior to collaborative care, we really weren't helping them in that respect. There was a disincentive, really, to ask people about their symptoms because there was nobody to really help them manage those symptoms.

00;15;13;13 - 00;15;43;04
Catherine Frank, M.D.
And the partnership of psychiatry and primary care helps correct that and provides that support. I think that behavioral health integration lastly, is a treatment option that decreases stigma and really helps reduce health care disparities. It allows us to do that in a way that traditional psychiatric clinics may not do.

00;15;43;04 - 00;16;21;05
Rebecca Chickey
To all the listeners out there, I think she just made the case quite clearly and passionately as to the value of integrating physical and behavioral health. So thank you, Dr. Frank, for sharing of your time and expertise today. For the listeners, if you go to www.org/behavioralhealth, on that landing page, you'll see a section dedicated to resources for the field on other systems, other resources on how to take that first step to integrate care.

00;16;21;07 - 00;16;23;05
Rebecca Chickey
Please check it out.

00;16;23;08 - 00;16;31;18
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.