Advancing Health Podcast

00:00:00:20 - 00:00:29:13
Tom Haederle
Welcome to Advancing Health - and to the first Leadership Dialogue of the year - hosted by the American Hospital Association's 2025 Board Chair, Tina Freese Decker, president and CEO of Corewell Health. Today, two senior AHA leaders join Tina to discuss key issues in health care and how the AHA is working on many fronts to support hospitals and health systems so they can provide the best care to patients and communities.

00:00:29:15 - 00:00:56:10
Tina Freese Decker
Hello and thank you everyone for joining us today. In 2025, the American Hospital Association is all in in tackling the challenges that are facing health care today. I am looking forward to using this Leadership Dialogue series to highlight the incredible ways the American Hospital Association and our member hospitals and health systems are making health better. My name is Tina Freese Decker, and I'm the president and CEO of Corewell Health

00:00:56:12 - 00:01:23:05
Tina Freese Decker
and the 2025 American Hospital Association board chair. As we kick off this new year, I want to start by introducing you to a few amazing leaders within the American Hospital Association who will help us navigate the year ahead. The American Hospital Association is here to help remove those barriers so as hospitals and health systems, we can provide the very best care to our patients and communities.

00:01:23:07 - 00:01:45:04
Tina Freese Decker
So today, while we don't have all the time to meet the full AHA team, I'm so excited to introduce you to Stacy Hughes and Ashley Thompson, two fantastic individuals who lead the AHA's government relations and public policy work. One of the things that gives me the most confidence in our approach is when I listen and I talk with them.

00:01:45:07 - 00:02:02:23
Tina Freese Decker
So I thought it would be really beneficial for all of you, our members, to hear from them. So let's begin. So Stacy and Ashley, welcome. So glad to see you today. Let's start with some introductions and share what you do with the American Hospital Association. Stacy?

00:02:02:25 - 00:02:21:05
Stacey Hughes
Sure. Thank you for this opportunity. We're so excited about your year ahead and working with you. And we're really appreciative of having a chance to showcase a little bit about what our team is up to. But I'm Stacy Hughes. I'm executive vice president in the D.C. office and oversee regulatory policy, federal relations PAC, and some of our communication efforts.

00:02:21:08 - 00:02:25:06
Stacey Hughes
Have a great team here. And we're going to talk more about that. But that's my role here, Tina.

00:02:25:14 - 00:02:26:28
Tina Freese Decker
Thank you. Ashley?

00:02:27:00 - 00:02:50:00
Ashley Thompson
Thank you, Tina, so much for giving us this opportunity and for your leadership on the board in the past and especially this year as chair. I'm Ashley Thompson. I'm the senior vice president of policy here at AHA. I lead a team of about 24 very amazing, talented individuals. The work that we do is really on behalf of hospitals and the patients they serve.

00:02:50:03 - 00:03:10:11
Tina Freese Decker
As we think about the work ahead of us this year, I also want to learn more about what you and your teams are doing. So the American Hospital Association is a bipartisan organization, and we work with all lawmakers to advance the issues that mean the most to us as hospitals and health systems. So, Stacy, tell us about the team that you lead.

00:03:10:14 - 00:03:17:10
Tina Freese Decker
The depth of expertise and their balance and how your team is preparing for this new administration in Congress.

00:03:17:12 - 00:03:36:03
Stacey Hughes
Sure. And I couldn't be more proud to be honest with you. And I have to say, you know, I give Rick and others a such a shout out for the legacy, you know, Ashley says she's here 23 years, I'm starting year five. Boy, both what I inherited as a team that were here day one, and then how we've grown as people have, you know, rolled off or changed jobs.

00:03:36:05 - 00:04:01:12
Stacey Hughes
It is solid. We've got, you know, lobbyists that have all worked largely on Capitol Hill or they were deeply, deeply immersed in the issues that are critical to hospitals. I'll ask you to talk about the policy team that we work on together. We've got such currency politically with the lobbyists that are on the team. Our colleagues and my colleagues, Lisa Kidder, she's been here 20 years. Amy Kuhlman, there's no one better than Amy in terms of leading our lobbyist team.

00:04:01:12 - 00:04:24:17
Stacey Hughes
So both their experience actually on the Hill, writing bills, knowing all the member offices. You know, we cover every single office here, you know, House and Senate. That's a lot to say Grace over. In terms of preparing, obviously this is a unified town now, it's a Republican town. We had a bit of a sweep. So we're busy getting ready to look at how we frame our issues with a very specific audience.

00:04:24:19 - 00:04:44:10
Stacey Hughes
But in addition, Tina, as you know, this is a pretty sweeping election in terms of retirements. There are 14 new Senate freshmen between Republicans and Democrats. There are about 55 new freshmen House members. So a big part of what we're doing is educating them early and often. Lisa and Amy and others are putting together a 101 of hospital issues.

00:04:44:16 - 00:05:00:09
Stacey Hughes
They understand our field immediately and early, and be a resource for them. So everyone is readying for what is going to be. And then we'll talk more about what the year ahead, what the expectations are. But it's a lot. And we are excited that the team is ready, but they have great skills.

00:05:00:09 - 00:05:04:20
Stacey Hughes
And, couldn't be more proud to be collaborating with them and leading them.

00:05:04:23 - 00:05:14:25
Tina Freese Decker
And as you do that education, are our lawmakers interested in health care? Are they appreciative of the education, the orientation and the one on one that we provide? And when we show up.

00:05:14:28 - 00:05:31:24
Stacey Hughes
They are and, you know, we're in the process of so getting out some of our very specific every congressional districts or what that hospital footprint looks like, you know, who's in your backyard, how many jobs are you providing that community? What is your role in the economic engine of that community? What are you doing in terms of serving that population?

00:05:31:24 - 00:05:48:28
Stacey Hughes
And they are interested. I think that, you know, as you know, there are a lot of threats around the financing of hospital, particularly the burden on the federal government and debt. And so being able to bring it to life to them, what we're really doing with limited resources and our contribution to communities,

00:05:48:28 - 00:06:03:25
Stacey Hughes
they do appreciate it. And particularly the role we play in terms of our jobs and their district. But it takes time. You know, you really have to tell the story, go to make sure you invest in that time. You always want to know your members before you need them. And I think that's important.

00:06:03:27 - 00:06:16:00
Tina Freese Decker
Ashley, I'd like to ask you the same question. So share a quick overview with us of some of the issue areas of policy expertise that you have amongst your team members, and what's the one thing your team is gearing up for this year that you can share with us?

00:06:16:02 - 00:06:42:09
Ashley Thompson
Well, like Stacey, I am so proud of the policy team. Many of the individuals, I think there are 24 of them, have been here for a very long time. They are true issue area experts. They are smart, they are talented, they are motivated. And I will say that they really want to improve health and health care in America and get hospitals, the resources that they need to really care for their patients.

00:06:42:11 - 00:07:09:03
Ashley Thompson
We are kind of divided into four areas. So we have Medicare payment, coverage, quality and patient safety, and data and research are kind of the big buckets. But underneath them we tackle probably any issue that hospitals deal with. We have experts on AI, we have experts on prior authorization. We have experts on quality. So it's really a diverse group.

00:07:09:06 - 00:07:27:09
Ashley Thompson
I would say that it's really hard to pick the one issue that they're going to be dealing with this year. I think that there's probably four that are most important. And Stacey and I have been working on this together with others across the association. I think one of them is to protect Medicaid and its enrollees.

00:07:27:09 - 00:07:49:16
Ashley Thompson
I think the second one is to ensure what we call the marketplace premium tax credits continue after the end of this year. About 10 million people have gotten coverage due to those tax credits, and we don't want them to lose coverage. The third area is to make sure that hospitals are not subjected to site neutral payments.

00:07:49:18 - 00:08:09:12
Ashley Thompson
And then I'd say the fourth area is probably protecting 340B, which is the drug pricing program. So those are definitely on our radar. But it goes beyond that. There are so many issues, I think our advocacy agenda came out this week. I haven't counted there's probably 75 plus issues that we are actively working.

00:08:09:14 - 00:08:34:21
Tina Freese Decker
And we're so appreciative of kind of highlighting the main areas that we need to focus on, but then understanding that as hospitals and health systems, we're not all alike and there are different issues that come up that we need to navigate as we move forward. Again, what I am so proud of is your team, both of your teams, really have the expertise and the experience to help tackle this and guide us as members as we move forward.

00:08:34:23 - 00:08:56:08
Tina Freese Decker
You know, there's also a much broader team at American Hospital Association that's supporting the work of our field  - from legal to communications to the quality of patient safety, field engagement. There's so many people that are ready to assist our members. So let's talk a bit about how our members and our leaders and our hospitals and our health systems might work with the American Hospital Association on those issues.

00:08:56:11 - 00:09:13:02
Tina Freese Decker
So, Stacy, can you tell us how your team engages with the members? And this time not the members of the Capitol Hill, but it's like hospitals and health systems. How can our hospital and health system leaders get more involved in advocacy efforts, and why is that important?

00:09:13:05 - 00:09:31:26
Stacey Hughes
Sure. Well, first and foremost, you know, our teams are constantly working with our members. I know Ashley would say the same, whether it's policy or federal relations. And that's just in the everyday, just grind of learning how to address issues and learn from them in terms of what we actually advocate for, that's an ongoing thing. But to your point, there are a lot of different ways that we work with members.

00:09:31:26 - 00:09:51:09
Stacey Hughes
One is through our government relations officer network. Certainly we work through our allieds, all the 50 state hospital executives, and is a huge partner for us in terms of our advocacy. But in terms of your of a hospital health system, main thing you can do is get to know your delegation. You know, I know you guys do this both obviously with your state, representatives and your state elected officials.

00:09:51:09 - 00:10:07:20
Stacey Hughes
But on the federal side, really getting to know them and telling that story often. And also, don't be afraid to go to them and let them know when you have a problem. You really want to get them invested in your success. And it doesn't take much. And I think we all, going through Covid, we saw how much everyone does stand up.

00:10:07:20 - 00:10:25:00
Stacey Hughes
They recognize the importance of making sure we have a sustainable, functioning hospital network and health systems. And so being sure to take that leap, give your member a call, get to know the staff and being willing to advocate. I mean, I will say, you know, we put out these advocacy alerts and, we try to be judicious.

00:10:25:00 - 00:10:45:00
Stacey Hughes
We don't want to say "hair on fire" every day, but we do have a lot of challenges coming, Tina, as you know, in terms of all the pressures to address some of the deficit issues, mandatory programs like Medicare, Medicaid are the top drivers of the deficit and spending. So we have a lot coming up. But we really say when we do give a call to action, we really need it.

00:10:45:00 - 00:11:00:21
Stacey Hughes
And in particular, if you know you have a member of Congress or senator that is uniquely positioned on committees of jurisdiction as well as leadership, you want to make sure there no daylight between what you're doing, what your needs are, and what they understand in terms of their education.

00:11:00:24 - 00:11:11:25
Tina Freese Decker
Great advice. Thank you so much, Ashley. Similarly, are there examples of member engagement that you can speak to that have been particularly successful or impactful in influencing policy development?

00:11:11:28 - 00:11:38:24
Ashley Thompson
Yeah, I actually think that one of the reasons why AHA is so successful is because of our policy development process. I think it's very unique. Through our committees and our regional policy board meetings, we touch probably 550 CEOs or C-suite leaders three times a year. And we bring to them, you know, our committees, our grouped by kind of type of hospital, whether you're rural or post-acute or whether you're behavioral health.

00:11:38:26 - 00:12:02:26
Ashley Thompson
And then our regions are just what it says. We divide up by region and they weigh in on policy development. So they weigh in on what should we do about physician payment, what should we do about health care affordability? What should we do about the increase in medical debt? What should we do about X, Y, and Z? And it's a really a thoughtful, like iterative process.

00:12:02:29 - 00:12:39:24
Ashley Thompson
We also have strategic leadership groups. We also have task forces that we staff on certain issues, whether it's principles or whether it's health care, the future. You know, what should we do about workforce issues? So we really rely on everyone to weigh in. And of course, our board of trustees. So we rely very heavily on our board. And thank you again for your chairmanship of it to help direct the association, to direct our policy positions, to direct what recommendations we come up with, and often to direct our strategy of how to achieve what we want in terms of outcomes.

00:12:39:24 - 00:12:59:11
Ashley Thompson
And so I do think that AHA, and particularly probably the policy team given the work that we do, has a lot of connections and we really rely on that and we want to hear from our members and we want them to be active and engaged, because the more they communicate with us, the better we can represent them on Capitol Hill or with the administration.

00:12:59:13 - 00:13:28:16
Tina Freese Decker
I completely agree, and one of the most impactful, stories that I have is when I took one of our lawmakers through our mental health area and just highlighted what we are doing well, but what we need their support in. And then you could see that happen with bills came up and things needed to be impacted. And so I'm sure that there are stories like that in every part of our organizations and our membership about how that personal touch is so incredibly important as we drive forward.

00:13:28:16 - 00:13:37:27
Tina Freese Decker
All right. Are there any last comments, or thoughts on the year ahead that would be most helpful for you and your teams that you want to share with us?

00:13:38:00 - 00:14:02:21
Ashley Thompson
I think it's going to be a very challenging year. I know that the AHA is going to be really working hard on behalf of our members, and I think that the team at is very motivated to do so. Very similar to employees in hospitals, or the staff in the hospitals. I think that we tend to rise when there's a crisis and we rise to that occasion.

00:14:02:21 - 00:14:24:08
Ashley Thompson
And whether it's Covid or whether it was going to be repeal and replace of the ACA a few years ago, several years ago, or whether it's the Change Health care cyber event, I really think that AHA is here to serve its members, to get them through those hard times and to put them on a trajectory in the future.

00:14:24:08 - 00:14:35:13
Ashley Thompson
And I want our members to know that this the staff team at AHA is really committed to doing so, to really making sure that you have the resources that you need in order to care for your patients.

00:14:35:15 - 00:14:44:00
Stacey Hughes
Yeah, so well said. I would just add, you know, we think about the year, reflecting back between Change Healthcare, OneBlood supply in Florida and Baxter.

00:14:44:03 - 00:15:04:12
Stacey Hughes
And that was just weeks ago, if you really think about it in terms of the need for the association with your leadership and others, Tina, to really jump in and problem solve quickly and mitigate those types of issues. But I'll just say going into the year, I think I've kind of beaten that drum a little bit. But you know, we are, as Ashley said, we are working so far, the policy team and others to bring forth data.

00:15:04:18 - 00:15:22:11
Stacey Hughes
One of the ways that we win these battles is being able to tell a story with very specific data. We've got some pretty difficult issues, one of which is extending the ACA subsidies, I think Ashley mentioned. Knowing what that looks like to your hospital. How does it affect your bottom line? How does it affect patients? How does it affect the insurance coverage?

00:15:22:11 - 00:15:45:18
Stacey Hughes
I think that's true for Medicaid. So when we put all this stuff together, really would encourage everyone or field to take that information and help tell the story and amplify as much as we can. We'll do all the work for you in terms of making sure that we get you guys what you need to be able to understand the implications of some of these policies, but really just, welcome everyone's ability to engage with their members of Congress.

00:15:45:18 - 00:15:49:10
Stacey Hughes
So, that's my final note, I would say, Tina, in terms of the year ahead.

00:15:49:13 - 00:16:12:15
Tina Freese Decker
That's perfect. So thank you so much for your time today. And I really enjoy working with you and working with your teams. As you both said: the AHA teams are all in, we're ready to go. We're excited, we're passionate. This is you know what gets us up in the morning moving forward. And we need that partnership with our member hospitals and health systems to make sure we have the data and the stories and the connection there.

00:16:12:18 - 00:16:33:05
Tina Freese Decker
So it really takes this whole ecosystem to come together to make an impact and to make an impact for policies, the regulations that are coming forth, most importantly, so we can do an even better job taking care of our communities and improving health. And so we're so grateful for all the work that you and your teams are doing at the American Hospital Association.

00:16:33:08 - 00:16:50:11
Tina Freese Decker
I know that it's going to be a tough year but with the focus and the energy, I think we can accomplish a lot of things. So thank you so much. To all of our members listening in, thank you so much for joining us today. And we'll be back next month for another Leadership Dialogue conversation.

00:16:50:13 - 00:16:58:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:01 - 00:00:20:00
Tom Haederle
Welcome to Advancing Health. Coming up in today's episode, a conversation with Englewood Health about the rise in the use of opioids since the pandemic. We'll talk about what providers can do to decrease their use and what Englewood Health is doing right now by way of prevention. Your host is Rebecca Chickey, senior director of behavioral health services with the AHA.

00:00:20:03 - 00:00:30:27
Tom Haederle
She's speaking with Lauren Savage, director of Population Health, Englewood Hospital, and Dr. Vinnidhy Dave, director of palliative medicine, Englewood Health Physician Network.

00:00:30:29 - 00:00:57:04
Rebecca Chickey
Dr. Dave and Lauren, thank you so much for being here with us today to talk about this incredible topic. The opioid crisis during Covid did nothing but escalate, unfortunately. And the more creative the suppliers of opiates and synthetics become, I think the more challenging your job, our role in helping individuals with opioid use disorder, the more challenging it becomes.

00:00:57:04 - 00:01:24:27
Rebecca Chickey
So I'm delighted to, first of all let the audience know Englewood was a Foster McGaw Prize finalist. They were acknowledged and presented with this award at AHA's Leadership Summit in 2024. The prize was for a much broader perspective. They have really done a lot of work around all of behavioral health and improving access. But today we want to focus in on opioid stewardship.

00:01:25:04 - 00:01:48:05
Rebecca Chickey
And I'm going to break this down in a number of ways. My first question to you is that I'd like you to provide some statistics. What are the driving factors that really allowed you to say this is a problem? This is a challenge, and we have to focus on it. So can you start there? Everyone knows what's going on in their community, but they don't know what's going on in yours.

00:01:48:08 - 00:02:06:16
Lauren Savage
Yeah. I mean, I can start and Dr. Dave, feel free to add to the conversation. I think you said it best, Rebecca. This is a problem in everyone's community, and nobody is surprised by the concerns that we're seeing. We do use our community health needs assessment to better understand our community and their needs.

00:02:06:18 - 00:02:34:16
Lauren Savage
In the 2016 and 2019 Community Health Needs Assessment, the need for behavioral health increased tremendously. And at that point, we knew we needed to do more. We also were seeing it in within our own patient population, within our community. And there was also a very generous family that donated to the hospital. And so in 2018, we were also able to open the Gregory P. Shattuck Behavioral Care Center.

00:02:34:18 - 00:03:12:07
Lauren Savage
And this center is dedicated to behavioral health and to substance use. The Shattuck family lost a family member to substance use. And they were clear that part of this center should be focused on our treating our patients and our community on substance use, as well. And it was through the Shattuck Center that we were also able to form an opioid stewardship committee, so that we were really able to get a group of dedicated providers, mostly disciplinary team at our hospital, to come together to talk about the epidemic, to learn, you know, what's happening in our community amongst our patients, and to begin to address it.

00:03:12:09 - 00:03:32:08
Vinnidhy Dave, D.O.
I would say from the physician side of things, you know, my background is internal medicine. And then I trained in palliative care. For years we always, you know, thought about surgeons as the ones that were giving opioids first to patients. But there's been data over the last few years showing that hospitalists and internist were actually the ones that were exposing patients to opioids

00:03:32:08 - 00:03:54:12
Vinnidhy Dave, D.O.
first from the hospital side. So, I think that's where my interest came in, was really how do we work on decreasing the use of opioids in the hospital? How do we decrease the amount of patients we're sending home with opioids? After I read this article in the New England Journal medicine, where it was showing that internists were probably the ones that were exposing patients to opioids first, before surgeons and surgeons have done better job with the last few years.

00:03:54:15 - 00:04:13:12
Rebecca Chickey
So a couple of things. One, I heard in terms of key success factors, Lauren, that you said is when you identified the need, you had the data, you replicated it, you shared it, you then found a generous philanthropist to be able to provide you with the funding and the backing that you needed, but then you also created a committee.

00:04:13:13 - 00:04:36:09
Rebecca Chickey
So this was not being done in isolation. And that really leads me to my next question. One key part if I understand your program correctly, one key component is around prevention. And it is in terms of what are some alternatives to opiates as well as what are best practices around prescribing privileges?

00:04:36:11 - 00:04:58:15
Vinnidhy Dave, D.O.
This is where my kind of work has been with the team and the task force, is really creating what a lot of hospitals are now calling out alternatives to opioids, in the emergency room when we started it and then we started in on the floors in the hospital as well to provide it to our internists hospital as surgeons for normal pain, things that we commonly see.

00:04:58:15 - 00:05:19:17
Vinnidhy Dave, D.O.
So in the emergency room we've created a protocol for back pain, kidney stone pain, headaches, intractable abdominal pain that's not surgical. And there's an order set in our Epic system where we put in non opioids that can be given for those types of pains. So you would just type in alto and in that let's say back pain comes up.

00:05:19:17 - 00:05:45:17
Vinnidhy Dave, D.O.
And then under back pain there's options of steroids, muscle relaxants, anti-inflammatories, reminding providers that have been trained for years just to go to opioids automatically when someone's in severe pain that these are all the other options we have. And sometimes, you know, as physicians, sometimes when you're in the E.R. you're seeing 40 patients it's hard to remember. But now when you type in pain and your alto pops up and now you see back pain, you can check off these things.

00:05:45:19 - 00:06:23:20
Vinnidhy Dave, D.O.
It makes it easier for the providers. And then, of course, we've done a lot of education with the providers. We've done education with the doctors on the floors in the E.R. Most recently now we're working on pain protocol or pain order set, where basically what a lot of hospitals have done for insulin, where there's long acting insulin, short acting insulin, how to check sugars more frequently so that you run into less problems with hypo and hypoglycemia is now we have a whole pain order set that is smart and it uses like if someone has kidney function issues, a liver function issues, certain medications will automatically not pop up so that patients won't accidentally get

00:06:23:20 - 00:06:41:26
Vinnidhy Dave, D.O.
like an ibuprofen if they have kidney issues. This will be the only way to order opioids. They can't just give someone oxycodone. They want to give them oxycodone, they have to go to the order set and the order that has your non-opioids there, your opioids there. So you're always actively thinking about other options to give than just automatically going to opioids.

00:06:41:29 - 00:06:50:00
Rebecca Chickey
Absolutely. Thank you for that. I may come back to you here with a question, but I want to give Lauren the opportunity to jump in a little bit as well.

00:06:50:03 - 00:07:10:28
Lauren Savage
I think we always say this in our department, but we will never have enough providers to provide the treatment needed for the need of our community. So we really have focused a lot on prevention. So a lot of what Dr. Dave is saying in terms of limiting opioid initiations and leveraging our electronic medical record to provide better care.

00:07:11:01 - 00:07:34:24
Lauren Savage
He's gone out and done lots of trainings. We've done some targeted trainings to certain providers who need that further education, but we've also done training for our patients when they are prescribed opioids. So, any time a patient is prescribed opioids at discharge that are provided, automatically provided educational materials to better understand what they're being prescribed and how to not, you know, misuse that prescription.

00:07:34:26 - 00:08:00:07
Rebecca Chickey
I should share with you. We worked with the CDC, AHA worked with the CDC probably about five years ago now, but I think it is still very on point and helpful. We have a two-pager that we can provide to families and patients. So not just the patients, but letting the family know what are some of the signs and symptoms if they start to see you know, perhaps abuse of the opioids if they do go home with them.

00:08:00:09 - 00:08:22:18
Rebecca Chickey
So my next question is, I think you've also developed a screening tool for OUD, probably, much broader, but for all substance use disorders, particularly given the statistics that you just said, Dr. Dave, regarding, you know, what happens upon admission and discharge. So can you tell me a little bit about the screening tool and how you baked it into your EHR?

00:08:22:21 - 00:08:50:12
Vinnidhy Dave, D.O.
So we've implemented the opioid risk tool, which is probably the most studied one out of what we have right now. And it's implemented into our EHR, where anybody can put the phrase in: dot.org.key or dot.risk. And it pops up and it's also part of our preoperative screening as well. So in the preoperative area, if someone is tagged to be high risk, then they're referred to a pain management provider so that we can follow them

00:08:50:12 - 00:09:08:09
Vinnidhy Dave, D.O.
postoperatively if there's any concerns. We've done education with the residents and the hospitals about using this tool. So if they do start someone on opioids in the hospital, they're able to understand what risk factors the patients have. And then we've shared this with our outpatient providers as well, because we have hundreds of primary care doctors that are part of our network.

00:09:08:09 - 00:09:13:07
Vinnidhy Dave, D.O.
So they can use that as well when they're prescribing opiates to their patients.

00:09:13:09 - 00:09:15:29
Rebecca Chickey
Lauren, what would you like to add?

00:09:16:01 - 00:09:36:03
Lauren Savage
Yeah. So in addition to the opioid risk tool, we've also implemented a screening tool in our emergency room. So I'm going to go back to my point of prevention. And if we can screening individuals and earlier determine whether or not they have a substance use concern, we can provide them the correct resources and connect them to the appropriate level of care.

00:09:36:06 - 00:09:59:14
Lauren Savage
So all individuals who come to our emergency room, I believe it's 18 and up. We are screening for all substances, opioids included. And any patient who screens positive will receive counseling by one of our emergency room doctors, by our social workers. And if needed, a social worker will make a referral for that patient for additional services.

00:09:59:16 - 00:10:22:07
Rebecca Chickey
I have to admit, one of my biases is that that's the wave of the future, to screen for psychiatric and substance use disorders for every admission, it's somewhere between 1 in 4 or 1 in 5 admissions to the hospital has  - and is probably much higher than that in the emergency room - has a comorbid psychiatric or substance use disorder.

00:10:22:15 - 00:10:44:05
Rebecca Chickey
That is not, as you said, they're presenting diagnosis or the presenting reason for their admission, but it's there nonetheless. And we should always take the opportunity to identify and treat, if needed. And also, you know, that happens sometimes to improve outcomes and shorten length of stay. And anyway, I could speak on that for hours. I won't here.

00:10:44:12 - 00:10:51:17
Lauren Savage
You are correct though. It's about 20% of the individuals we are screening have a positive screen for substance use.

00:10:51:19 - 00:11:14:05
Rebecca Chickey
As we begin to bring this to a close, let me ask you this key important fact. What's the impact then, for all this work, for creating the center, for implementing the screening programs, for doing the training, for changing the culture, quite honestly? For using technology to help in decision-making process. What's the impact you've seen?

00:11:14:07 - 00:11:39:23
Lauren Savage
One impact I can share. I think you touched it when you just said changing the culture. Englewood Health has really recognized that 20% of the patients that we've screen in the emergency room are in need of additional counseling and support. So, just two months ago we have now opened an outpatient addiction medicine office so that we are more easily able to treat the patients that we identify within our own system.

00:11:39:26 - 00:12:01:14
Vinnidhy Dave, D.O.
And I can follow what Lauren said. I think, you know, we've seen a huge difference just from the hospital side, from our providers, from our residents when you know, they're ordering, I'm seeing less opioids being ordered if we're ordering opioids. Even the nurses are sometimes questioning it or they'll ask me on the side like, is this appropriate? So there's this huge culture shift that we've seen with education.

00:12:01:16 - 00:12:23:21
Vinnidhy Dave, D.O.
And I think making the providers feel comfortable using other medications and not feeling like they have to go to an opioid first, that it's kind of a domino effect throughout the program. And, you know, we're seeing outpatient providers, inpatient providers really trying to make sure that they're only using the opioid when they feel it's really appropriate. And it's not the first thing that they're going to do in terms of treatment.

00:12:23:23 - 00:12:55:18
Rebecca Chickey
That's phenomenal. What would you say are two key success factors that allowed you to do this? Was it a champion like Dr. Dave stepping up and saying, we've got to do this, and I'm here to be a team player to make it happen. Obviously, I think earlier you mentioned, a wonderful philanthropist that allowed you to have the funds to do that. But what are a couple of key success factors that the listeners would need to know about to implement something similar in their own organization?

00:12:55:21 - 00:13:17:15
Lauren Savage
I think for our stewardship, it really was a collaboration of different disciplines coming together and recognizing the role that each of us plays in this process. Because it was all of us working together that we were able to implement all of these workflow changes and utilizing our electronic medical record and the education of our providers and the education of our community.

00:13:17:18 - 00:13:21:07
Lauren Savage
It required all of us to work together to achieve the goals we set forth.

00:13:21:09 - 00:13:44:05
Vinnidhy Dave, D.O.
I was thinking the same thing that Lauren said. I think it's really getting the providers in different areas to really bring this together and make it move forward quickly, whether it's, you know, someone from IT, whether it's you know, someone from social work, whether it's ER doctor, the chief of anesthesia, you know, chief of medicine, chief of psychiatry, and then, you know, Lauren making sure these meetings happen on top of it.

00:13:44:05 - 00:14:05:16
Vinnidhy Dave, D.O.
and we're making sure we're planning for it beforehand. And then making sure we have a plan for the next one, and really, I think, a point person and then being able to get the right people together to implement it, and then everyone being passionate about it. Everyone on the team was excited about, we want to try to do this, and we want to try to reduce opioids and we want to try to, you know, get better care for our patients.

00:14:05:19 - 00:14:40:09
Rebecca Chickey
Awesome. Well, thank you so very much for your willingness to share your time and your expertise. I'm hoping that this podcast, along with other work that AHA has done and that you have done, will inspire others to go on this journey for this very, very important clinical disease and disorder. And I again say congratulations on being one of AHA's Foster McGaw Prize finalists, and I will point the listeners to AHA's resources on opioids at AHA.org/opioids.

00:14:40:11 - 00:14:48:22
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:20 - 00:00:26:24
Tom Haederle
Welcome to Advancing Health. Today we bring you the final segment in a podcast series featuring four leaders from San Diego-based Scripps Health, who discussed the need for business and clinical contingency plans to sustain patient care in the wake of suddenly losing all technology, as happened to Scripps Health after a dangerous cyberattack nearly four years ago. Your host is John Riggi, AHA national advisor for cybersecurity and risk. And his four Scripps Health

00:00:26:24 - 00:00:43:09
Tom Haederle
guests are Chris Van Gorder, president and CEO, Todd Walbridge, senior director of corporate information systems, Shane Thielman, chief information officer, and Gerry Soderstrom, chief audit, compliance and risk officer. Let's join them.

00:00:43:11 - 00:00:55:22
John Riggi
Chris, maybe I could start with you. What concerns you most about this continued evolution of ransomware and that we're seeing in the increased frequency and severity of attacks?

00:00:55:24 - 00:01:16:28
Chris Van Gorder
I think there's a couple of things. One is communication. Basically, the answer is don't. That was very difficult. I was just meeting with a reporter, you know, before we did this podcast. And he was a reporter that was pretty angry at me during the course of our cyberattack and after, because I'm a pretty transparent individual. Our organization is a major community resource.

00:01:17:01 - 00:01:39:26
Chris Van Gorder
And it was pretty frustrating for me to be told by every lawyer, internal lawyers, the external lawyers, the insurance company lawyers - that because of subsequent issues down the road, mostly the class action lawsuits that are sure to follow, that everything and anything we said would clearly be used against us. And I wasn't even able to communicate that to reporters until this morning.

00:01:39:28 - 00:02:03:09
Chris Van Gorder
And he certainly understood the issue because there's been a lot more cyberattacks, of course, since ours took place. So we had to, I mentioned earlier, hire a communications company that assisted us with crisis communication. I remember one day I was I insisted on making a statement and it took, I think, about 25 people in two different organizations an entire day to write one paragraph that I was permitted to share.

00:02:03:16 - 00:02:28:09
Chris Van Gorder
And the reason again for that is because the concern about regulatory agencies ultimately using that against us. Certainly the class action lawyers. And I think that's a real problem, because there have been a number of attacks since. And we're willing to reach out and offer our assistance. But there's a concern there that, you know, even though we were doing everything under attorney client privilege, every contract we made, everything went through our legal office.

00:02:28:16 - 00:02:52:11
Chris Van Gorder
Once we start communicating to another organization that's going through this, they may in fact not be protected from the information that we share. And so I'm unable to even share our experience with our colleagues that are facing cyberattack for fear of class action lawsuits. So I think in the end, the government really does have to take a look at, you know, setting standards, in my opinion, just as we have standards in hospitals for virtually everything we do.

00:02:52:14 - 00:03:17:15
Chris Van Gorder
You know, the Joint Commission and our state health departments and CMS, survey us to make sure that we are, in fact, compliant. And if an organization is compliant, in my opinion, they should be held free from future regulatory and class action lawsuits. And in so doing, we can actually share the information more freely and communicate and help each other during these attacks, instead of being silent and not being able to do so.

00:03:17:16 - 00:03:42:19
Chris Van Gorder
I was advised initially not to talk to the FBI, not to release all the data that we had that could have been helpful in the investigation. And I chose because my law enforcement background and because of my relationship with the FBI, which started long before the cyberattack, that we had an obligation to the country, to the health care industry, and to our own organization and community to share as much information as we possibly could

00:03:42:19 - 00:03:48:07
Chris Van Gorder
and that's what I insisted on doing, despite legal recommendations otherwise.

00:03:48:09 - 00:04:13:03
John Riggi
Thanks for that perspective, Chris. Again, you understood because of your dedication of your life to service and law enforcement and health care, how important it was not only for you as an organization to cooperate with the federal government, but to help prevent other attacks, as you said, to help warn the nation. Folks, I'll just point to public law 116, 116-321, which the AHA helped get passed in January 2021,

00:04:13:06 - 00:04:35:10
John Riggi
that does provide a measure of regulatory relief, if you can, as Chris said, demonstrated adherences to basic cybersecurity protocols. But the missing element, as you said Chris, is there's no civil litigation protection there, especially when it comes to the impact that he attacks. Todd, maybe I could go back to you, based on your investigative background, to wrap this question up.

00:04:35:15 - 00:04:49:03
John Riggi
Where do you see ransomware going, especially where we have this kind of hybrid threat, nation/state involvement, this murky world. Where does criminality end and really intelligence operations or terrorism begin?

00:04:49:06 - 00:04:55:22
Todd Walbridge
The benefits that Scripps provided to the United States intelligence community were immense. I don't think the intelligence community realized

00:04:55:22 - 00:04:57:27
Todd Walbridge
the damages that can be caused

00:04:57:27 - 00:05:09:12
Todd Walbridge
to a community through a ransomware attack when you hit a hospital. And we were able to, at a high level, let the United States intelligence community realize the impact of an attack on our hospital system.

00:05:09:14 - 00:05:11:25
Todd Walbridge
And as Chris opined previously, that

00:05:11:25 - 00:05:13:10
Todd Walbridge
people can die as a result

00:05:13:10 - 00:05:28:03
Todd Walbridge
of systems being offline. So I think the United States government needs a combined approach. And that was one of the things that we were able to do with Conti, where it's not just the FBI, it's the FBI and the intelligence community, whether that's the CIA, the NSA, and even working with

00:05:28:03 - 00:05:30:16
Todd Walbridge
cybercomm for offensive capabilities.

00:05:30:21 - 00:05:37:18
Todd Walbridge
Defending is going to be a cat and mouse game. We've seen some of these groups go after other industries, get out of the health care industry,

00:05:37:21 - 00:05:39:23
Todd Walbridge
only to find some of these other industries tightening

00:05:39:23 - 00:05:42:05
Todd Walbridge
their security defenses and returning

00:05:42:05 - 00:05:45:06
Todd Walbridge
back to the health care industry, because health care equipment

00:05:45:06 - 00:05:47:21
Todd Walbridge
that touches the internet is really hard to defend against.

00:05:47:23 - 00:05:50:10
Todd Walbridge
when you have a vast array of devices

00:05:50:10 - 00:06:03:23
Todd Walbridge
that touch the internet, from imaging machines to IV drip machines to just computers. Your average business has servers and desktop computers and laptops that they have to secure. It's different from securing medical devices that touch the internet.

00:06:03:26 - 00:06:07:15
Todd Walbridge
So this sort of attack on a hospital system is always

00:06:07:15 - 00:06:16:04
Todd Walbridge
going to be beneficial to a ransomware actor unless we start to take away their incentives or unless we're able to impose some sort of consequence on them.

00:06:16:06 - 00:06:16:21
Todd Walbridge
And some of those

00:06:16:21 - 00:06:22:01
Todd Walbridge
consequences require the U.S. government to punch a little bit further than the FBI can.

00:06:22:03 - 00:07:05:24
John Riggi
Yeah. Understood, Todd. Again my role, you know, from years at the Bureau counterterrorism, we've got to increase risk and consequences for the bad guys and use all of U.S. government's capabilities, both military and intelligence capabilities, to degrade the bad guys' capability to attack us utilizing those offensive cyber operations. Chris and Shane, to that point, you know that I, on behalf of the AHA - all of us here at AHA have been very vocal in the media and with Congress and with policymakers that these attacks against hospitals not only threaten the hospital as an organization, they threaten the patients within the walls of the hospital, and they threaten the safety of the entire community

00:07:05:24 - 00:07:21:03
John Riggi
that depends on the availability of that hospital. And ultimately, these are truly threat to life crimes. Chris, maybe I'll go back to your - I think you touched on this a little bit. Could you elaborate a little further on how ransomware attacks affect patient care?

00:07:21:05 - 00:07:43:05
Chris Van Gorder
Well, we've been calling them cyberattacks and ransomware attacks. These are terrorist attacks, and they have the potential of killing just as much as a bullet or a bomb could. And it's not just the patients that are in the hospital. Remember, when you go on diversion, you're bypassing people who need emergency care and they have to go elsewhere in the community for that, which cost time and time could be lives.

00:07:43:06 - 00:08:05:02
Chris Van Gorder
So these are very significant threats to our country, our communities and our patients. And I know there's a, you know, expectation that somehow hospitals just make themselves safe. But I think that you've heard through the expertise of the people on my team and Todd, internal and external expertise is that there's no 100% way to protect yourself 100% of the time.

00:08:05:04 - 00:08:26:28
Chris Van Gorder
And so the key now is for our country to step up and help support its medical and health care industry with expertise and resources, if necessary. If this is important to them as much as it is to all of us, and frankly, to go after our adversaries who are in fact, international terrorists. We have done that before in response to 9/11 and elsewhere.

00:08:27:00 - 00:08:53:20
Chris Van Gorder
This is no different. Every single one of these attacks across the country - every time my heart breaks when I see another hospital victim of a cyber incident - most of those are ransomware attacks with flat out criminals and terrorists that are taking advantage of the health care system. And we need, I think, to do a better job. And certainly for regulators and legislators to be far more understanding about hospitals as a victim and not the bad guy when there's an attack.

00:08:53:22 - 00:09:10:18
John Riggi
Totally agree, Chris. We are not going to win this battle, this war, on defense alone. There's got to be an equally aggressive offensive side to this as well. Shane, what are your thoughts on that? How did this ransomware attack impact patient care from your perspective?

00:09:10:20 - 00:09:44:10
Shane Thielman
Yeah, Chris has touched on a few significant observable impacts to our community. I actually sort of see this as an exercise each time that a cyberattack is announced on a hospital or health care system as really an exercise in resilience of our clinical community and those that are providing patient care. The mission doesn't change. The tools and the access to data and information are vital to delivering high quality and safe care.

00:09:44:12 - 00:10:10:18
Shane Thielman
But what ends up happening in the absence of access to information that's expected or anticipated when someone shows up for their shift, is an incredible amount of ingenuity and a focus on each and every patient, and ensuring that the care is of equal quality and is delivered in a safe and effective way. I think as much as we talk about the impact patient care, we have to consider the clinical community and the impact on the community as well.

00:10:10:20 - 00:10:38:08
Shane Thielman
And so we really have heroes. They're heroes when we're not dealing with cyberattacks, but they are elevated even more in the midst of addressing a significant outage that's caused by a cyber event. And so I really think that as much as we talk about patient care, I don't think that our clinicians get up when they are dealing with a cyberattack and think differently about the mission that they are serving on behalf of the organization.

00:10:38:09 - 00:11:19:05
Shane Thielman
And I think in many ways, we need to be thinking about how do we create the safeguards for them to practice and deliver care in the best way that they can under duress and under challenging circumstances, and then ensure that after the fact that we have mechanisms in place to continue to care for our care providers in a way that allows them to work through that very stressful event and the effects of that stress on them individually, so that once we're back to, you know, restoration of all of our systems and to a degree back to normal, that we don't forget about the effect that's also had on our clinical community.

00:11:19:07 - 00:11:39:19
John Riggi
That's a great point. Clinical staff, as you said, our frontline health care heroes have so much to deal with. And then to try to continue providing care without technology is just immense, especially during Covid. Along those lines, we've talked about the attack, the impacts. Let's talk a little bit about resiliency and recovery now. And then Chris, I'll go back to you and then over to Gerry.

00:11:39:21 - 00:12:04:06
John Riggi
So in the face of this attack, how was your organization prepared to continue to deliver care without technology for an extended period? When I do many, many presentations across the country, I talk about the need to prepare not just business continuity, but clinical continuity plans to sustain a loss of technology during ransomware attacks for up to 30 days or longer.

00:12:04:10 - 00:12:07:21
John Riggi
So, Chris, maybe I could start with you on this.

00:12:07:24 - 00:12:32:06
Chris Van Gorder
Yeah, again, we relied on our frontline people to identify whether or not we could continue taking care of patients, and if not, we would transfer those patients. In the case of radiation oncology patients that needed to have therapy every single day, we were not certain that we could do that. And so a number of those patients ultimately were referred to outside radiation oncology centers so that they could continue their therapy.

00:12:32:08 - 00:13:00:12
Chris Van Gorder
There were other practices that we were able to continue. There were some x rays and other devices that continued to be used, but not necessarily connected to the electronic health record or to our PACs system or those types of things. And so everything had to be done more manually. I mean, literally with physicians, you know, and others going to the old imaging reading room and with the radiologist, you know, a surgeon, radiologist, and maybe other clinical staff, reading the X-ray and then going back and being able to take care of those patients.

00:13:00:15 - 00:13:24:25
Chris Van Gorder
Certainly only emergent and urgent cases, continued elective cases were put off, obviously, until we were back up and operational. But you think about blood banks, lab work, all the enormous amount of paper that has to be generated so that when we do go back up  - and this has been touched on by Shane and Jerry already - that, you know, our business continuity program, you know, and people are looking right from day one.

00:13:24:27 - 00:13:41:00
Chris Van Gorder
And so what are we going to do with this with all of this paper? How are we going to ultimately get it back into the electronic health record and into our business billing systems, so that in fact, we would be able to have income coming in. Understand payroll, Kronos, all of those systems that we used for payroll were down.

00:13:41:01 - 00:14:05:24
Chris Van Gorder
And so we had to come up with HR, people with a methodology to continue to pay our employees and track time or, in the end reconcile payments to employees that we continued to make after the fact. I recall one of our older physicians was thrilled that the electronic health record was down and loved it being on paper, but we discovered that our residents didn't know how to write prescriptions on paper because they never had to do that before.

00:14:05:24 - 00:14:27:01
Chris Van Gorder
And so those were kinds of things that we had to manage as we did. And of course all along thinking, how are we ultimately going to comply regulations, where Gerry came in and really handled, you know, our operators, our health information people lab and others worked for literally months on reconciling and bringing back that information.

00:14:27:06 - 00:14:49:01
Chris Van Gorder
By the way, handwriting became a big issue because we moved away from handwriting, and now we couldn't read patient names on a lab report or couldn't read the order properly. And so there had to be a whole process set up to reconcile when you couldn't understand the information. And literally I remember going in and there's dozens and dozens of people that are reconciling all of this handwritten information.

00:14:49:04 - 00:15:12:08
Chris Van Gorder
In the end, how many, you know, records were exposed and how are we going to manage the notifications? And that required - and Jerry can elaborate on this, you know, - literally outside companies going through a huge amount of data and information, reconciling duplicates and triplicates and all of those types of things identifying the number. Well, people were frustrated, calling us in on a regular basis

00:15:12:08 - 00:15:35:05
Chris Van Gorder
going, was my information exposed? Our doctors, they were getting little hacks at home, had nothing to do with this, assuming all of a sudden that had to do with the ransomware attack and therefore Scripps had to be responsible for that. And in the end, setting up outside call centers so that there were enough people to take the calls and internal staff to be able to handle the issues that were coming up that the call centers couldn't handle.

00:15:35:07 - 00:15:47:15
Chris Van Gorder
And then ultimately, the notifications, that whole process that took place. I mean, literally, we're talking about three and a half weeks, but we're talking about, well in excess of a year to manage all of these pieces appropriately.

00:15:47:17 - 00:15:54:13
John Riggi
Thanks, Chris. Jerry, if you could further elaborate on all of those recovery process and those issues that you had to deal with.

00:15:54:16 - 00:16:19:21
Gerry Soderstrom
You bet. The recovery, as Chris mentioned, has a very long tail. Addressing the privacy requirements alone was a significant and I would say, as Chris noted, a Herculean effort. You have to look at all of the documents or any piece of information that may have been accessed by the threat actor, and make sure that you properly notify the patients who are impacted. Now

00:16:19:24 - 00:16:43:10
Gerry Soderstrom
again, you know, one of the benefits for us at Scripps was that the threat actor never got into our electronic health record. They never got into Epic. However, most organizations put a significant amount of operational data, right, on their different storage areas around the company. So in our case, it was on our network servers. So those network servers had daily census.

00:16:43:13 - 00:17:02:12
Gerry Soderstrom
And so the type of information was pretty limited, right? It may have had a patient's name. It may have their physician's name. It may have had their location or their time for the procedure or the treatment. And that was it. But that alone gave rise to a notification requirement that we need to have under HIPAA and any organization has.

00:17:02:12 - 00:17:23:01
Gerry Soderstrom
And again, as most of you are aware, if it's over 500, then you've got additional requirements and responsibilities that you need to attend to. This isn't just a single document with a single patient name. It could be a spreadsheet with hundreds of patients' names. And so you need to go through all of those and understand what is the required notification to each of those patients?

00:17:23:03 - 00:17:52:12
Gerry Soderstrom
How are we going to do that as timely as possible? We need to demonstrate right to ourselves, to the public and to the regulators that we met the expectations that we have for the community that we serve each and every day. I was going to mention, you know, as we went through the recovery, our focus was and always is, even when all of our systems are online, is to focus on supporting our patient care, supporting our physicians, our clinical teams, right to do the work that they do each and every day.

00:17:52:15 - 00:18:13:17
Gerry Soderstrom
But as Chris mentioned, there's also the business of health care. And that business of health care is also making sure taking care of them means paying them. And so, as Chris mentioned, when our systems were down and our internet connections and our network connections between systems were no longer working because Active Directory was impacted, so we're no longer able to communicate as easily internally

00:18:13:24 - 00:18:40:04
Gerry Soderstrom
and those business systems didn't communicate with anyone, we needed to find alternative ways to deal with that. And so one of the pieces that I'd also just encourage people is to set up those different teams that are available to support that ingenuity that's happening on the fly to make sure that those legal considerations, the privacy considerations, compliance considerations, all of those other things are being addressed in real time so that we can deploy that.

00:18:40:06 - 00:19:04:03
Gerry Soderstrom
I think Shane talked about the importance of bringing back online those clinical systems that were prioritized, that are required for delivering the patient care that we needed to. And so there were a lot of people that said, I want the payroll system up. Well, the payroll system was important in that we needed to pay our employees, and we did that, but we needed to prioritize other systems ahead of that

00:19:04:04 - 00:19:32:24
Gerry Soderstrom
once we were able to find a way to meet payroll. There are certain things, right, when you run a business that are not options. One is for us delivering safe, high quality patient care, and the other one is paying those individuals that do that work. But it is a long tail, you know, having to address the class action lawsuit, having to address your privacy requirements both at the state and federal level, and making sure that you're doing those notifications takes an enormous amount of work.

00:19:32:24 - 00:19:55:17
Gerry Soderstrom
And as Chris said, I even maintained the log because there was no shortage of individuals that were convinced - whether it was our patients, our own employees, physicians that we work with - that somehow their information was caught up in this. I think, you know, the world continues to evolve. I think every week or once a month, all of us get notified that our information was compromised somewhere.

00:19:55:19 - 00:20:09:00
Gerry Soderstrom
But again, you're always thinking of what's happening in the moment. So I maintained a log and I made sure and scrubbed that log to see if there was any instance that was connected. Fortunately, we did not identify any connections to our event.

00:20:09:02 - 00:20:29:15
John Riggi
Thank you for that. Gerry and Chris, thank you and your team for your leadership and courage to come forward and tell your story. I have no doubt you will help defend health care in America against these type of attacks. And I also want to thank, of course, all our frontline health care heroes for everything you do every day to care for our patients and serve your communities.

00:20:29:18 - 00:20:38:18
John Riggi
On behalf of the American Hospital Association, this has been John Riggi, your national advisor for cybersecurity and risk. Stay safe everyone.

00:20:38:21 - 00:20:47:02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:16 - 00:00:24:06
Tom Haederle
Welcome to Advancing Health. Coming up in today's episode, a conversation with Boston Medical Center about the launch of its Health Equity Accelerator Program and the difference it's making to expand access to behavioral health services to historically underserved communities. Our host is Rebecca Chickey, senior director of behavioral health services with AHA.

00:00:24:09 - 00:00:55:21
Rebecca Chickey
It is my honor today to be joined by three speakers from Boston Medical Center Health System. BMC Health System is a Foster McGaw Award winner. Their equity accelerator program has improved access to behavioral health services for historically marginalized and underserved communities. And so today, the three speakers that I am so lucky to be here with are Dr. Thea James, Trina Martin Cherry, and Dr. Christine Crawford.

00:00:55:24 - 00:01:10:16
Rebecca Chickey
So first I'm going to kick it over to Dr. James, VP of mission and associate CMO and the co-executive director of Health Equity Accelerator Program. So, Dr. James, can you lay a little bit of foundation for this?

00:01:10:18 - 00:01:53:11
Thea James, M.D.
Sure. And thank you for the privilege to be here today. Back in 2020, there were, many people across multiple sectors who were coming out with, I would say commitment to equity statements. And at our institution, our leaders, our CEO and our CEO at the time decided that we were not going to do that. And mainly because, you know we serve a population that is predominantly I would say about 70% identify as Black or Latino.

00:01:53:13 - 00:02:23:21
Thea James, M.D.
And also three quarters of our patients are government insured. And so that just sets a picture only to state that there are many sort of structural barriers and systems that they face that often make it impossible for them to prioritize health. You know, they're making rational decisions because they're prioritizing survival, I would say. But, you know we continue with prioritizing clinical excellence and innovation and that type thing.

00:02:23:24 - 00:02:46:10
Thea James, M.D.
And so we have created many innovative programs that have been disseminated across the country. And so when people were coming out with commitment to equity statements in 2020, our leaders just didn't want to be a part of that. Instead, they made a decision to look inside our own house so that we could better understand some of the structural reasons that were preventing our patients from thriving.

00:02:46:13 - 00:03:15:17
Thea James, M.D.
And we looked at the outcomes data for Boston. And what the leaders said is that we have been doing this work for decades, and it has had no impact on the outcomes data. It's highly predictable who's going to do what. So, we looked inside our house, across the entire enterprise, looking in operations, looking at clinical inpatient, outpatient research, education, human resources, even things like public safety.

00:03:15:19 - 00:03:42:07
Thea James, M.D.
And of course, we found things. What they did was to bring together about 80 leaders and also to divide us up into equal groups that cover those areas I spoke about, including the types of things that impact beyond health, things like economic mobility, which is a clearly root cause for why people are not able to prioritize their health.

00:03:42:09 - 00:04:04:19
Thea James, M.D.
And so each workgroup was led by an executive. And, there was a great deal of accountability put into it. There were dashboards. We had to report out every month. And I had a two-hour roundtable. It was quite intense. And we identified the clinical areas where there were highest rates of disparities and also some other areas.

00:04:04:26 - 00:04:20:27
Thea James, M.D.
And we were charged with closing gaps over the next 12 to 24 months. And we had to identify which gaps we were going to work on. One of the things we wanted to do was to sort of challenge conventional wisdom in the ways in which people actually go about this work.

00:04:21:00 - 00:04:50:17
Rebecca Chickey
Dr. James, thank you. You just described why you named to this program, the Health Equity Accelerator. You didn't want to just identify where the disparities were, but to accelerate the implementation of closing the gap of addressing and reducing those health disparities. So thank you for bringing that message home. I also heard you say, I think, that often when people get into this work, they have a need or a tendency to boil the ocean.

00:04:50:20 - 00:05:16:06
Rebecca Chickey
There are so many disparities that we can address. But yet you went through a process of identifying some key specific health disparities and populations that needed those gaps closed, and do so with an operational approach compared to a research approach. Now, I'm sure there's a lot of research that went on because I've seen some of the data that's come out of the work that you have. But you rolled up your sleeves and were pragmatic.

00:05:16:08 - 00:05:20:22
Rebecca Chickey
Was there anything I just said that was incorrect? Keep me, keep me honest here at the end!

00:05:20:24 - 00:05:44:25
Thea James, M.D.
No. It's correct. That's something I think important that I left out is: two very different approaches that have made this become such a proof of concept. It's what has enabled us to -we think - it has enabled us to have dramatic gap closures and in record time, I would say, is that, number one, when we look at data, we interpret it back to the root cause.

00:05:44:28 - 00:06:15:13
Thea James, M.D.
And that was the work we did in decision to incision when the ObGyn department created a model or an algorithm for addressing unplanned, urgent C-sections. So one is interrogating data back to the root cause, not being afraid to discover what you discover. And the second half of that is using the subjects of the data to interpret it, to tell you what it means, and partner with them to create solutions.

00:06:15:14 - 00:06:35:15
Thea James, M.D.
So usually when we look at data, you know, we sit down together and we come up with what these data mean. Even when people are writing papers about disparities or whatever, they sort of write conclusions based upon what they think the data mean. But not everyone has the lived experience of the subjects of the data. The data subjects -

00:06:35:18 - 00:06:45:20
Thea James, M.D.
we work with them to add context to what the quantitative data means and also again, partnering with us to create solutions.

00:06:45:22 - 00:07:29:24
Rebecca Chickey
Thank you, Dr. James. And that's a really nice segue to our next speaker here today, Petrina - or Trina, as she prefers to be called - Martin Cherry, who's the vice president of community engagement and external affairs at BMCHS. I'm going to turn to you, Trina, to say, can you speak a little bit to where behavioral health and this work fits into the overall mission for BMHS, but also, as Dr. James was just saying, the subjects of the data, that lived experience is so important in really understanding how to make a bigger impact and, unless I'm mistaken, all of the subjects in there lived in your communities.

00:07:29:26 - 00:07:40:25
Rebecca Chickey
And so the value and the importance of looking at the social determinants of health having an impact on the community health as a whole. I turn to you, Trina, to share some of that journey with us.

00:07:40:27 - 00:08:15:20
Petrina Martin Cherry
Hi, Rebecca. Thanks again for having us. And, thank you for your question. And I think to answer the base of that is that we don't see the community as subjects. Like, they are a community with a lived experience that we could not do the work without having them, and what their daily experience is at the table to really help us understand that. At BMC we have an amazing history of having an incredible amount of trust with the communities we serve, because historically, they've seen us as being an institution that is there for them in a multiple amount of ways.

00:08:15:20 - 00:08:55:24
Petrina Martin Cherry
We often come out of our campus into communities, and we show up for them in a way that's real to them. We have authentic partnerships with community-based organizations, so we think it's really important to make sure that when we are like planning a program through our health equity accelerator - maternal/ health, behavioral health, whatever it is - making sure that we are working with community health centers, community based organizations, that we are using our community advisory boards to ask the questions about what we are doing, are we doing it right, where we need to flex, and when we hear back from them, we pivot.

00:08:56:01 - 00:09:26:24
Petrina Martin Cherry
We understand that you can't invite the community to the table and ask them for advice and guidance and when they give it to you, you don't move on it. And so that's one of the things that I really, really love about BMC. We take the advice of those with lived experience and pivot when necessary. In terms of the work of health equity accelerator and the work we're doing in behavioral health, I think that it is important that we have those relationships with anchor institutions in the city of Boston and in the Commonwealth.

00:09:26:27 - 00:09:53:04
Petrina Martin Cherry
So anchor institutions like community health centers, I mentioned those already, but also the Boys and Girls Clubs, the YMCAs, Boston Public Schools. We've been there. We partnered with them and other things so that when we, you know, wanted and needed to set up critical services to make critical services and behavioral health available, there was trust there where it made them more willing to say yes and to partner with us.

00:09:53:06 - 00:10:26:14
Petrina Martin Cherry
One other really great example about us reaching out to community, getting their feedback and then actually stepping in and doing something about some of the issues that we heard: In Roxbury, which is an incredible city in Boston where the life expectancy is I think about a 23-year life expectancy gap from the south end of Boston to Roxbury, which is literally about two bus stops, and there's a 23-year life expectancy gap.

00:10:26:18 - 00:10:46:09
Petrina Martin Cherry
We spend a lot of time working in that community, talking to them, asking them what it is that they need, how we can, you know, close the gaps on some of these things. And one of the things that we heard back was that they wanted more access to healthy food. They wanted more availability for black businesses to thrive in that area.

00:10:46:09 - 00:11:16:06
Petrina Martin Cherry
And so Boston Medical Center invested well over $1 million in a black owned grocery store. And so this is one of the things that really helped us to win the Foster McGaw Award, our work with Nubian markets. The investment in that neighborhood with that particular business has been just incredible. So not only is it a beautiful grocery store with amazing fresh fruits and vegetables, it's also a halal butchery.

00:11:16:11 - 00:11:40:18
Petrina Martin Cherry
It's also an incredible cafe where folks can get foods that are delicious but also healthy, prepared by a chef who has been featured in Bon Appetit. And it goes to show that no matter what zip code you you're in, you deserve the best food. You that deserve the best health care. You deserve the best opportunities to thrive.

00:11:40:21 - 00:11:58:24
Rebecca Chickey
Trina, that was fantastic. We got into health care to help other people, right? And if we're not listening to those people and what their needs truly are, we're missing opportunities to help. Dr. Crawford, I'm going to kick it over to you now to, share some of the experiences and inspire others to go on this journey.

00:11:58:26 - 00:12:13:17
Christine Crawford, M.D.
Yeah. What we know to be true is that the patient to receives their care at Boston Medical Center, whether it's primary care, ObGyn care, whatever type of care it is - at the heart of their ability to take care of their physical health,

00:12:13:24 - 00:12:56:06
Christine Crawford, M.D.
we also have to address their mental health. Because we have fantastic providers: nurses, nurse practitioners, physicians here who are working tirelessly to improve the physical well-being of our patients. But what we know as a hospital, what we know as a system, is that we really have to pay special attention to the mental health needs of this patient population while being mindful of the unique mental health needs of this specific population, just given their vulnerabilities and historically, what it is that they've been through, and the fact that access to mental health supports not only in the city of Boston, but also across the country is quite limited.

00:12:56:13 - 00:13:29:06
Christine Crawford, M.D.
And so I've always appreciated how invested in this hospital, this hospital system has been in finding ways to improve access to mental health services for this highly vulnerable population. Not only are we invested in mental health supports within the physical walls of the hospital, and thinking about our psychiatric hospital that we opened a couple of years ago, that's providing inpatient level of care for our sickest individuals who are living with psychiatric symptoms,

00:13:29:12 - 00:14:11:05
Christine Crawford, M.D.
but we're also looking at ways in which we can increase access while out in the community. And so having the opportunity to work in some of our community health centers, such as Codman Square, where they see a large number of primary care patients and the overwhelming percentage of those patients are also living with mental health conditions. And so a number of our psychiatrists, not only do they see patients here at Boston Medical Center, but they're also providing care out in the community within these community health centers. Which is fantastic because there are so many barriers that make it challenging for people in the community to come over to our hospital, even though we're not

00:14:11:05 - 00:14:47:05
Christine Crawford, M.D.
that far away. But it's a very complicated city to navigate, just given the way in which the city was designed because of historical practices way back when that made it such that public transportation posed significant barriers for people to come into the city, into our hospital to get care. The other wonderful thing is that there have been a number of schools, not only in the city of Boston, but across the country, that I've reaped the benefits of having mental health clinicians and specific mental health support within the schools.

00:14:47:05 - 00:15:18:13
Christine Crawford, M.D.
Since we know that kids are spending a large part of their lives inside of schools, it's a really important place to provide psychiatric care, to provide mental health care so that we can meet the kids where they're at. So here at Boston Medical Center, we have partnered with the Boston Public Health Commission, which has a number of mental health clinicians who work in health centers that are embedded in a number of middle schools and high schools all throughout the city of Boston.

00:15:18:16 - 00:15:45:05
Christine Crawford, M.D.
What's truly unique about these social workers and these licensed mental health clinicians is that they are hired to be in the schools to only provide therapy. Other social workers who are hired by the Boston Public Schools are hired to do therapy, to provide counseling, but they're also doing cafeteria  duty. They're also doing school bus duty. They're doing the field trips.

00:15:45:05 - 00:16:15:27
Christine Crawford, M.D.
They're doing a whole bunch of other things and filling in all these different gaps that we see in a lot of the schools, because it's been so hard to retain people in the school buildings. But these clinicians, all they do each and every day is provide therapy. One hour therapy to students inside of the school. What parents need to do at the beginning of the school year, they sign a permission form that grants the kid access to all of the services within the health center.

00:16:15:29 - 00:16:49:03
Christine Crawford, M.D.
Some of those services include mental health services. So what's absolutely beautiful about this program is that if a student happens to develop some mental health needs, they can go straight down to the health center. Pair up with one of the clinicians and not have to talk to their parents about it. Get special permission. It's fantastic. The other thing, too, is that these clinicians document all of their notes, all of their encounters in our medical record system at Boston Medical Center.

00:16:49:06 - 00:17:24:18
Christine Crawford, M.D.
So we have the capacity to communicate, these clinicians, to communicate with their primary care providers at Boston Medical Center, as well as other providers. So everyone is looped in to all of the needs of this one individual child who spends the majority of their time in school. And being a psychiatrist, I meet with these clinicians monthly to supervise them to discuss challenging cases, and to identify if there are any potential students who would benefit from medication management and as an easy referral to my clinic.

00:17:24:20 - 00:17:49:12
Christine Crawford, M.D.
And so the fact that we are investing the resources to connect these licensed mental health clinicians, these social workers who are providing therapy in school such that they are documenting in our medical system, closing the loop, making it such that we're filling this need is absolutely wonderful. And not a lot of health systems are thinking outside of the box in that sort of way,

00:17:49:12 - 00:17:50:02
Christine Crawford, M.D.
and BMC is.

00:17:50:24 - 00:18:14:14
Rebecca Chickey
Wow, that is phenomenal. The ability to have those notes integrated into the EHR so that it goes to their primary care physician. The fact that the licensed mental health clinicians working in the school are able to focus on that one purpose, then the fact that that distraction doesn't happen in this case is just so phenomenal.

00:18:14:16 - 00:18:36:17
Rebecca Chickey
Thank you so much for sharing your time and expertise here today, for being innovators. You've inspired us and inspired the listeners. I'm going to challenge all of the listeners to help get your dream in terms of accessing mental health services. Regardless, there should be no wrong door. And thank you so much for the work that you do.

00:18:36:18 - 00:18:42:26
Rebecca Chickey
Keep up the great work. You brought joy in my heart and I hope others today as well.

00:18:42:28 - 00:18:51:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.