Advancing Health Podcast

00:00:00:27 - 00:00:28:03
Tom Haederle
Welcome to Advancing Health. Being a doctor, both at the bedside and around the boardroom table often means channeling two different skill sets. And as we hear in this podcast, the successful physician leader must learn how to bridge the gaps in knowledge, exposure and experience needed to cross the bridge from clinical practice to leadership and master the art of social capital along the way.

00:00:28:06 - 00:00:55:14
Chris DeRienzo, M.D.
Hi everyone! Welcome to this episode of our podcast. I'm Dr. Chris DeRienzo and it is my true honor to welcome a long time mentor and friend to the podcast, Dr. Tom Lee. Dr. Lee is not only the chief medical officer of Press Ganey, he's the editor in chief of NEJM Catalyst. He's a practicing primary care doc. Got to know him many years ago through connections in the Asheville area.

00:00:55:16 - 00:01:05:24
Chris DeRienzo, M.D.
Tom is here to talk to us today about the intersection of social capital, and the AHA's physician leadership framework, which was just published. Tom, thank you so much again for joining us.

00:01:05:27 - 00:01:10:14
Thomas Lee, M.D.
I'm delighted to be here, Chris. And every time I talk with you, I learn stuff, too.

00:01:10:16 - 00:01:39:12
Chris DeRienzo, M.D.
Likewise, sir. As we get started, it would be good to note for listeners that the paper that I'm referencing, AHA's physician leadership framework - it was published in NEJM Catalyst earlier this year. We have links available to it and so you can read it at will, but at its core has been a challenge that we've wrestled with for some time. Which is there's a gap between, what we know it takes to be an excellent clinician, an outstanding bedside physician,

00:01:39:14 - 00:01:51:12
Chris DeRienzo, M.D.
and what it takes to become an outstanding physician leader. And Tom, that's a gap that you've explored for decades, not only in your research, but also as the editor in chief of NEJM Catalyst.

00:01:51:15 - 00:02:13:13
Thomas Lee, M.D.
Yeah. And these questions are interesting. I mean, they're core to our jobs. We have to actually deal with the situations were working hard is not enough, where it's not clear exactly what we should do. How do you figure out what we should do and how do we do it? That is the nature of the jobs of being a physician leader today.

00:02:13:15 - 00:02:36:21
Chris DeRienzo, M.D.
Working harder is something we've relied on for a long time in health care, and we've thought that we need a hero. And there are absolutely heroes in health care. But your construct of social capital is one that I think we should explore for listeners of the podcast, because the way it intersects with the bridges that we built in that framework, I think are not only interesting but important.

00:02:36:28 - 00:02:45:11
Chris DeRienzo, M.D.
And so perhaps you can just take a moment for listeners who aren't yet familiar with social capital to give them a sense of what it means and how do we develop it?

00:02:45:13 - 00:03:08:12
Thomas Lee, M.D.
Well, the concepts aren't really new or foreign, and they're going to feel very comfortable to everyone listening to this podcast. The different is framing it in a way where we approach it in a tough minded, businesslike way. You know, capital is anything that helps you improve. It helps you be better than your competitors, help you be better than yourself next year.

00:03:08:14 - 00:03:36:00
Thomas Lee, M.D.
Financial capital are the financial resources that enable you to do things you couldn't otherwise do. Human capital or the people with the expertise around you that help you do things you couldn't otherwise do. But social capital is how those people work with each other and with their infrastructure that enables you to do things you couldn't otherwise do. Social capital is based upon currencies like trust and respect and teamwork.

00:03:36:08 - 00:04:00:13
Thomas Lee, M.D.
These are things we're all for, but building them as opposed to just being grateful when we have them, that's what I'm suggesting we ought to all be doing. Getting tough minded like the CFO is about financial capital and building teamwork and trust in high reliability. I think we can do that work, and I don't think it will be annoying.

00:04:00:13 - 00:04:02:15
Thomas Lee, M.D.
I think it'll make our lives better.

00:04:02:17 - 00:04:28:20
Chris DeRienzo, M.D.
Not only make our lives better, but, but lead to better outcomes. In order to get there, though, that requires some intentionality. Relying on working harder is in some ways a simple answer, but reconfiguring a system to enable teamwork, to enable high reliability, I love the way that you frame that. It's like a book that I read recently by the person who founded Panera that that there are things that emerge from the system.

00:04:28:21 - 00:04:43:28
Chris DeRienzo, M.D.
Profits emerge from a high functioning system that is differentiated against other folks operating in that market. You describe teamwork and high reliability as secondary effects of high functioning social capital. Am I getting that right?

00:04:44:01 - 00:05:10:08
Thomas Lee, M.D.
Very much so. But to really have a great team...many of us have been on great teams and we know it took work to get there. It takes sacrifice, sacrifice of some of your autonomy to get there. It means having norms, behavioral norms and enforcement mechanisms for the norms so that if someone isn't being a good team member, they hear about it.

00:05:10:15 - 00:05:35:20
Thomas Lee, M.D.
We don't just say anything. I mean, just very recently, one of my colleagues was saying in the emergency department, you can see everything. You can see who's behaving like a jerk. And he said, do we say anything? And he said, hardly ever. But if you're being tough minded about social capital, you give your colleagues feedback. I know that's uncomfortable.

00:05:35:22 - 00:05:51:22
Thomas Lee, M.D.
But getting into that kind of culture where people give each other feedback on what will make us all better collectively for our patients and for the way we feel coming to work. That is what we're talking about here.

00:05:51:25 - 00:06:18:21
Chris DeRienzo, M.D.
And it's foundationally a different way of thinking than sometimes we would historically apply to physician training. I like to describe for folks that in the medical education world, we are taught to sit on top of a pyramid, and there's a whole lot of weight that sits on our shoulders. The order carries our signature. Our professional license is on the line for the decisions that we make, the patients and their families outcomes

00:06:18:24 - 00:06:50:01
Chris DeRienzo, M.D.
we are personally responsible for. And when that's the world that you've lived in for decades, and you envisioned the pyramid this way, it's pretty hard to invert it. Many folks do. But, it strikes me that leading teams in health care and the getting to the right side of the framework that that we described in our paper is fully grounded in that construct of social capital. That we have to realize that we may be an expert in the things in which we are expert, but that doesn't make us an expert in everything.

00:06:50:03 - 00:07:13:00
Thomas Lee, M.D.
Well, you know, instead of picturing pyramids, but I encourage our audience to think about is think about social network diagrams, you know, web of nodes. Some people right in the middle of things, connected to everyone. Some people just on the edges, you know maybe loosely connected, if at all. And the truth of the matter is, we're all in social networks.

00:07:13:03 - 00:07:43:27
Thomas Lee, M.D.
And social capital means making those social networks more effective, making them stronger, making the connections real among everyone and making them compelling. And then spreading the right norms and values across those connections so that the team can be more effective. And so the teams can interact so that the organization can be more effective. It is real work, but it's cool work, actually.

00:07:43:29 - 00:08:06:16
Chris DeRienzo, M.D.
It can be fun. And, you know, it strikes me that for a long time physician leaders have somewhat informally relied on that social capital to accrete some of the knowledge that it takes to move from outstanding practicing physician to outstanding physician leader. I'll give you one example. I don't have an MBA or an MHA. I learned about EBIDTA from my CFO.

00:08:06:18 - 00:08:28:16
Chris DeRienzo, M.D.
EBIDTA, which for those who don't yet know, is, a commonly used finance abbreviation for earnings before interest, depreciation, taxes and amortization. And when I was in my first C-suite level role as a physician leader, that CFO sat down with me every month and walked their income statement and our balance sheet. So I not only accreted knowledge

00:08:28:16 - 00:08:52:07
Chris DeRienzo, M.D.
and in the framework we describe sort of three gaps. There's a knowledge gap, but then there's an exposure gap. We have to get exposed to how that applies in a hospital and health system. And then ultimately, in order to be able to own that skillset, we need some experience in being accountable for it. And for me, my CFO was a node in that network who was willing to sit down and share with me enough -

00:08:52:13 - 00:09:02:04
Chris DeRienzo, M.D.
I'm never going to refinance bonds - but I know enough now to be a competent operator. And you're exactly right. That is a outcome of social capital.

00:09:02:06 - 00:09:41:29
Chris DeRienzo, M.D.
And I think that the framework that you recently wrote about, breaking down the types of work it takes is a great framework. And, I admire your clear thinking. And it's so much more sophisticated than the advice I was thinking about, which is telling the audience, go watch the TV show The Pit and, the HBO show about the emergency department and watch how over the course of season one, the 15 episodes, the relationships, they get stronger and stronger among the people down in the emergency department together where people are ready to do whatever it takes.

00:09:42:06 - 00:10:11:19
Thomas Lee, M.D.
They're not thinking about their job description. They're doing whatever it takes. They're actually building social capital, including the part where they're sitting on a park bench sharing beer from a cooler in the next to the last episode of the season. So even though they make a big joke about Press Ganey in the first ten minutes and despite that start, it's a fantastic show that captures something what leaders in who are physicians can do and should do.

00:10:11:21 - 00:10:32:12
Chris DeRienzo, M.D.
And that's the kind of experience that I think we are accustomed to clinically having. Some folks have shared, you know, it gets lonely because you're used to - when you're a neonatologist like me, a primary care doc like you, an ER doc, a trauma doc, you know, you get this team camaraderie that builds when you go through those kinds of really hard things together.

00:10:32:16 - 00:10:55:01
Chris DeRienzo, M.D.
It's a different kind of a team when you're sitting around the health system CEO's table, because frequently you're the last doctor left at the party, unless the CEO also happens to be a doctor. And it takes a different degree of intentionality to find ways to connect and as you pointed out, crucially, to build some informal opportunities to relate to each other as people.

00:10:55:04 - 00:11:29:17
Thomas Lee, M.D.
Well, you know, actually, I've an article that'll be coming out soon with Dr. Ale Quiroga, a physician who's the CEO at Children's Mercy Hospital in Kansas City. And what we write about is how the way clinicians think it may be very appropriate for the kind of management challenges that we face in health care today. Because clinicians like us, you know, we're used to complex situations where the right thing to do may not be clear, but we try things and we get some data and we modify things.

00:11:29:24 - 00:11:58:15
Thomas Lee, M.D.
And, you know, we iterate. We're constantly gathering information. Now, that kind of approach to complex patients, for example, that may be more the right thing for complex problems like overcrowded hospitals, overcrowded emergency departments flow through a system more so than complicated management strategy. You know, complicated tasks. There's many people must do many things, but it's pretty clear everyone's got a job,

00:11:58:15 - 00:12:17:10
Thomas Lee, M.D.
do your job. You need those kind, that kind of approach. But it only takes you so far with the kind of complex challenges we have today. So I do think that thinking like a clinician, Ale and I have an article coming out very soon making the case: yeah, we need to do that more in our management life too.

00:12:17:12 - 00:12:43:01
Chris DeRienzo, M.D.
I look forward to reading that. And if anything, Tom, looking back over the papers you've written, many have a degree of foresight that one historically might one only apply to Nostradamus. And I'd like to close on one of those quotes. And this was from ten years ago. You wrote in New England Journal of Medicine that we believe "social capital is likely to be even more important than financial capital in the era ahead.

00:12:43:04 - 00:13:01:15
Chris DeRienzo, M.D.
After all, one can go to the bank to borrow money, but there is nowhere to go to borrow trust, teamwork, reliability, and the desire to innovate and improve." You said that ten years ago. It feels just as relevant today, but I wanted to give you just a chance to share with listeners a closing thought.

00:13:01:17 - 00:13:31:08
Thomas Lee, M.D.
Thanks. Chris and I do still feel that way, and even more so. Because I'm not naive about money, but I know the limits of what money can do. You can get money from the outside, but you can't get teamwork and trust and high reliability and safety. You know, you've got to build that from the inside. And our organizations are not going to differentiate themselves from other organizations on the basis of who can borrow the most money.

00:13:31:14 - 00:14:05:10
Thomas Lee, M.D.
They're not going to differentiate themselves on the basis of who has the best AI. You know, you've got to be competitive and all these things. But where will differentiate ourselves is how we work together. That will enable us to hold on to great employees, and that will enable us to hold on to our patients as well. So I really think that focusing on social capital, how we work together, that is every bit as strategic and really more so than financial capital issues alone.

00:14:05:12 - 00:14:21:19
Chris DeRienzo, M.D.
You know, health care is and will always be a uniquely human experience. And in the words of Tom Lee, you can buy things, but you can't buy trust. You've got to build it. Thank you so much for spending time with us on the podcast, Tom. It is it is really one of the honors of my career.

00:14:21:21 - 00:14:30:02
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.

00:00:01:00 - 00:00:28:18
Tom Haederle
Welcome to Advancing Health. Western Wisconsin Health recently put a lot of care, planning and resources into expanding its maternal care services for the rural population it serves. Was it successful? Well, the hospital CEO jokes that she took on a little bit of market research herself by having her own child at the hospital and checking out the experience from a patient's point of view.

00:00:28:20 - 00:00:54:01
Julia Resnick
Hi, I'm Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association. I'm so excited to be here today with Eilidh Pederson CEO of Western Wisconsin Health. Today we're going to discuss rural maternal health. As many rural hospitals are shutting their labor and delivery services, some are doubling down. Eilidh’s hospital is one of the ones that's expanding their maternity care for their community and for their patients.

00:00:54:03 - 00:01:06:15
Julia Resnick
And Eilidh has a special connection to share. So let's get right into it. Eilidh thank you so much for joining me for this conversation. To kick things off, can you tell me more about your hospital and the community that you serve?

00:01:06:17 - 00:01:35:06
Eilidh Pederson
Yes. Thank you, Julia, for having me. Thank you to the AHA. My name is Eilidh Pederson. I'm the CEO with Western Wisconsin Health, and we are Critical Access Hospital in Baldwin, Wisconsin. We serve a rural community and we serve as a safety net hospital to both our community and to our region. We employ about 500 people and offer a full breadth of service, focusing on a holistic approach to health care and meeting patients where they are.

00:01:35:08 - 00:01:39:15
Julia Resnick
Fantastic. And tell me more about your family and raising your family in Baldwin.

00:01:39:18 - 00:02:11:19
Eilidh Pederson
So now I have four kids. Very excited to share my pregnancy journey with you with my most recent baby. She was the latest addition to four kids. Two boys, two girls. And I absolutely love raising a family in Baldwin. I think there's nothing better than raising your children in a rural community. Having an opportunity to really get to deeply know people, both people with whom you're raising children at the same time, but also meeting and getting to know people who use and benefit from your hospital services.

00:02:11:21 - 00:02:37:27
Eilidh Pederson
I personally love that opportunity to meet patients in the grocery store, at the local football game, or my family at our hockey games, or big hockey players. And so that opportunity to get to know people outside of just when they're sick and when they're in the hospital, when they're feeling their best out in the community, I think is the absolute best thing about serving as a leader in a rural hospital and living in a rural community.

00:02:38:00 - 00:02:43:29
Julia Resnick
That's so special that you get to see your patients when they're healthy and out of the hospital and back to their day to day lives.

00:02:44:02 - 00:03:07:22
Eilidh Pederson
Yes, yes. I think it also is really what contributes to the quality of medicine and rural communities. There's nowhere to hide if something doesn't go well, if there is displeasure about a service, you're going to hear about it again at the grocery store, at the football game, at church, at the hockey game. And that high level of accountability translates into quality outcomes.

00:03:07:22 - 00:03:13:06
Eilidh Pederson
So it makes a difference to, to live and work in the same community.

00:03:13:08 - 00:03:20:20
Julia Resnick
Absolutely. So tell me about what maternity care is like in your community, all the way from prenatal care through postpartum care.

00:03:20:22 - 00:03:50:12
Eilidh Pederson
So all things encompassing, maternal and child health are really a staple in our hospital. We've made a conscious decision that these are foundational programs to us. So we offer prenatal care, through midwives, certified nurse midwives, obstetricians and family medicine physicians with obstetrical care as part of their training and their service. So the prenatal journey starts there. Patients have an option to see any of those providers.

00:03:50:12 - 00:04:12:28
Eilidh Pederson
It's their choice. Part of our very focused approach to medicine here. Patients are in control. They lead their own show. We're here to support and care for them. So the prenatal care journey starts there, and we see patients through anti-partum visits, and we see for them through their ultrasounds. All of their lab work is done within our hospital.

00:04:13:00 - 00:04:36:10
Eilidh Pederson
And then there's the birth experience that happens in our labor and delivery unit. We are now a seven bed obstetrical care unit where we deliver patients, either vaginally or through C-section. And then once those patients are born, we're there to be serve as their medical home. So on the pediatric side, we have two pediatricians. One specializes in developmental pediatrics.

00:04:36:10 - 00:05:00:23
Eilidh Pederson
So for our patients who have developmental needs, we have onsite pediatric care for patients in need of those services. We have a pediatric nurse practitioner. And then we have family medicine providers who also meet the needs of our pediatric patients. And we really want to be that wraparound service for a patient's life span. So through the birth through childhood and all the way throughout all stages of life, we want to be here for our patients.

00:05:00:28 - 00:05:11:18
Julia Resnick
And it's one thing to talk about pregnancy care in the abstract. It's another when you are the hospital CEO who's getting your pregnancy care at your own hospital. So can you talk about that experience?

00:05:11:21 - 00:05:35:27
Eilidh Pederson
It is just an absolute joy to have my own child at this hospital. One of the things that we do here for all patients is we sign kind of a quasi birth certificate. It's not an official birth certificate, but it's a welcome to the world. We put the baby's footprint on it. It's one of my favorite parts of the job is I get to personally sign all of those welcome to the world, through our hospital.

00:05:35:28 - 00:05:58:01
Eilidh Pederson
And so it was really special and fun too. I had my own baby, and I got my own certificate that I signed welcoming my baby into the world. Being able to experience prenatal care here, I went the midwifery route and had an absolute wonderful experience through prenatal care, sharing and the joys of practice with that personalized approach of a nurse midwife.

00:05:58:04 - 00:06:22:09
Eilidh Pederson
Then, through the labor experience to a nurse midwife by my side, we expanded our hospital a year and a half ago, and to be able to be in a room that we worked hard to bring on site for patients in need. Was great to see every aspect of that design come to life as a patient, to see firsthand why we built it that way.

00:06:22:12 - 00:06:38:11
Eilidh Pederson
All of the funds that we raised to bring that to life. Again, just to experience that firsthand was great. And nothing beats the joy of welcoming a child into the world. And to get to do it in my hospital is beyond words, how special that was.

00:06:38:13 - 00:06:42:26
Julia Resnick
Being a patient in your hospital, how did it make you think about care differently?

00:06:42:28 - 00:07:14:10
Eilidh Pederson
You know you have more vision as an administrator on what you think that care journey should look like. Of course you do that in partnership with physicians, providers, nurses, all of the, caretakers who are closest to the work. And that vision you hope you plan, you prepare that that aligns with reality. And so I joke that this was one way to do market research to determine, okay, did all of that planning go according to plan and a real life experience?

00:07:14:10 - 00:07:33:16
Eilidh Pederson
And I will say, for the most part, it did. It went exactly as we planned and prepared that it should, with few exceptions, and I'm happy to share those exceptions. But it was great to see that vision that we had, that plan of care come to life and to experience that as a patient. I'm thinking, you know, okay, this is what should happen next.

00:07:33:17 - 00:07:41:25
Eilidh Pederson
This is what we plan for. This is what it should look like. And really in every aspect, it it basically did, which was wonderful to experience firsthand as a patient.

00:07:41:28 - 00:07:47:13
Julia Resnick
Yeah. What were those exceptions and how are you thinking about changing things based on those?

00:07:47:15 - 00:08:05:22
Eilidh Pederson
You know, you can't predict some of these things, but I was glad to see how it played out. So this was a unique birth experience and that there was a storm coming when I went into labor. And, my midwife who is as great of a midwife as she is, storm tracker said, “okay, Allie, I need you to be prepared.

00:08:05:24 - 00:08:21:27
Eilidh Pederson
There's a storm coming. I think it's going to hit about 10 p.m..”And that's right around the time when your baby is going to be born. And I said, Sarah, how do you know this? I know you're a great midwife, but how do you also track storms? And she said, “in my spare time, I track the weather and I know there's a storm coming.

00:08:21:27 - 00:08:41:23
Eilidh Pederson
And so we need to prepare you.” Sure enough, I was ready to push at 10 p.m., right? At that time, all of the power went out in the hospital. We had a huge storm. Indeed. Power went out. We were on backup generator power. And so it was this dual thought, I need to have this baby right now.

00:08:41:23 - 00:09:03:00
Eilidh Pederson
And I'm also very curious to see how our emergency preparedness planning is going to work in this moment. Minutes before the power went out, the team moved everything to the red outlets, which are the outlets that make sure that when generator power comes on, all of the monitors and equipment still works the way that it should. They did this quietly, discreetly.

00:09:03:00 - 00:09:32:17
Eilidh Pederson
I, of course, knew what they were doing. My husband had no idea, which is what you want. It happened seamlessly. It was clear that our emergency preparedness planning went the way that it should. Everything functioned. Indeed, when the power went out a few minutes later and was able to safely and healthily deliver my baby girl in the midst of a storm with no power, only operating on generator power, the team knew the emergency preparedness policies training was effective.

00:09:32:20 - 00:10:03:21
Eilidh Pederson
The power was out until the next morning at 7 a.m., so we had a full evening of without, regular power. The hospital was still able to deliver many babies that night. The other unique thing about the experience that I thought about differently as a patient is when our OB rooms are full, which they often are because of the need in the community, we have to move patients to either a triage room or, to, a postpartum care room.

00:10:03:23 - 00:10:30:20
Eilidh Pederson
And we do this routinely. And as we plan for this, you know, I thought, okay, well, this won't be a big deal to families. They'll understand. We've got a patient coming in who needs a labor and delivery room. But as I experience that as a patient, I saw firsthand the challenges of moving everything. You know, the new baby, the partner, all of the mountains of things you have, and doing that at 3 a.m., was not an ideal time.

00:10:30:22 - 00:10:41:00
Eilidh Pederson
And so I saw firsthand that we can probably do that in a better way. So the market research continued with how do we interact with our patients better when those needs arise?

00:10:41:03 - 00:10:57:03
Julia Resnick
That is such a helpful learning that I think you can only realize by being in it. So I want to talk about rural maternal health generally. So many rural hospitals are being forced to close their labor and delivery services. While you all seem to be expanding, how do you do that?

00:10:57:05 - 00:11:27:07
Eilidh Pederson
We've made an investment and a commitment to sustaining rural obstetrical care. Despite all odds. We've really taken it as our personal mission that when others close, we have to be there for those communities in need. How do we do that? Number one, quality of care. That's the foundational aspect of this training, making sure that we know our patients needs because of that relationship, to be there to deliver the best care possible.

00:11:27:10 - 00:11:55:03
Eilidh Pederson
We have a 4% C-section rate. So clearly that foundational level of quality care rings true. Number two is workforce making sure that we have a diverse, sustainable workforce to meet the varied needs of our patients. And that's why we employ certified nurse midwives, obstetricians, family medicine physicians with OB, so we can have a variety and enough caregivers to meet the needs of our patients.

00:11:55:06 - 00:12:19:02
Eilidh Pederson
And then number three is advocacy work that needs to continue so that our government partners, our community partners, know the challenges that we endure and know how they best can support rural hospitals to stay open. And our minds, those are the keys to success. And that's our daily mantra. And how do we do this? How do we keep our doors open and do it well?

00:12:19:05 - 00:12:28:07
Julia Resnick
And as labor and delivery departments around you are closing their services, how are you adapting to meet not just the needs of patients in Baldwin, but in the communities that are around you?

00:12:28:09 - 00:12:48:24
Eilidh Pederson
The thoughts that we have as we work to adapt to the changing landscape and the ever growing needs, goes back to what I shared earlier. Number one workforce. We need more caregivers and providers to do this work. And the number two is increasing our space. Just a year and a half ago, we doubled the size of our labor and delivery unit.

00:12:48:24 - 00:13:10:06
Eilidh Pederson
And we're already pushing up against those limits. I personally had to move as a patient because we had more patients coming in to deliver. We need more space. And that's why as part of our five year strategic plan in this hospital, we intend to add yet again, more space, more clinical space to meet the needs of our growing region.

00:13:10:08 - 00:13:29:01
Eilidh Pederson
I think we do this and can do this well because we're local, we're independent, we're very accountable to our community. And it highlights why it's so important for rural, independent hospitals to stay open, because they keep these things at the heart of their work, keeping labor and delivery open.

00:13:29:03 - 00:13:54:25
Julia Resnick
Absolutely. And it's just such a powerful story for how you can have rural medicine really serving the needs of the community and providing high quality care that even the CEO or be willing to have her baby at. And listeners, I've met that baby and she is adorable. So congratulations on your new little one. Thank you so much for the work that you do every day for your community, and I just really appreciate you sharing your story with our listeners.

00:13:54:27 - 00:13:57:12
Eilidh Pederson
My pleasure. Thank you for having me.

00:13:57:15 - 00:14:05:26
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.

00:00:01:01 - 00:00:27:01
Tom Haederle
Welcome to Advancing Health. Behavioral health resources are in especially short supply in many rural areas of the country. Sutter Health in Northern California is committed to dramatically expanding access to behavioral health services for rural residents. And as we hear in this discussion, it's game plan goes beyond just constructing new facilities.

00:00:27:03 - 00:00:54:14
Rebecca Chickey
I'm Rebecca Chickey, the senior director of behavioral health at the American Hospital Association. And it is my honor, truly, today to have two speakers for this podcast. Dan Peterson, who is the CEO of Behavioral Health Services, as well as the CEO for Sutter Center for Psychiatry at Sutter Health; and his colleague, Dr. Matthew White, who is the chair of the behavioral health service line at Sutter Health.

00:00:54:17 - 00:01:26:11
Rebecca Chickey
Welcome to both of you, and thank you for being willing to share your time and expertise on how Sutter is expanding access to behavioral health in rural communities. Before I launch my first question to you, though, I just want to set the stage for the listeners who may not know the severity of accessing services in rural communities. 65% of rural counties do not have a psychiatrist, and 70% of rural counties have no child and adolescent psychiatrist.

00:01:26:13 - 00:01:50:29
Rebecca Chickey
And for nearly two decades now, suicide rates have been consistently higher in rural America compared to urban America. So just to level set, how important it is that Sutter is doing this work. As we start, could you give the listeners a sense of what is Sutter Health, you know, what's its clinical footprint? And, Dan, I'll pitch it to you.

00:01:50:29 - 00:01:53:26
Rebecca Chickey
And, then Dr. White, please weigh in.

00:01:53:29 - 00:02:21:14
Dan Peterson
Yeah. So Sutter Health is a large, integrated health care system. We're really geographically focused in Northern California, but we cover the breadth of services across our footprint in Northern California. We have 23 hospitals. We have 57,000 employees, 6,000 physicians, clinicians, and our medical groups, almost 6,000. And so we're really quite a large health system, but we are also quite geographically diverse, right?

00:02:21:15 - 00:02:41:00
Dan Peterson
We have hospitals and clinics everywhere from downtown San Francisco, right in the middle of the city, all the way up to Crescent City, a small town up on the Oregon border, eight hours north. We have a number of rural hospitals, critical access hospitals and rural health clinics that we're very proud to support.

00:02:41:03 - 00:02:48:02
Rebecca Chickey
And for the listeners who may not be health care experts, per se, can you describe a little bit of your critical access hospital?

00:02:48:09 - 00:03:16:19
Dan Peterson
Yeah. Thank you. A critical access hospital is just a designation for a hospital that is essentially a sole provider in a community. You have to meet certain geographic distance requirements from other hospitals. And really, by definition be in a rural area. I was actually the CEO at Sutter Lakeside Hospital in rural Lake County several years ago, about 8 or 9 years ago, serving in a community living in a town of Lake Park, with just a couple thousand people there.

00:03:16:25 - 00:03:45:24
Dan Peterson
And it's really meaningful care provided in those communities, because you really are the provider that those residents have to depend on. Many of them simply cannot travel. Either can't afford to travel, don't have the means to travel or logistically because of the needs of their care, cannot travel long distances in order to reach another provider. So the communities really depend on these providers in the rural communities to do - not just to be there - but to do a great job for them.

00:03:45:27 - 00:04:03:00
Rebecca Chickey
Well, and I can tell there's a piece of your heart that is clearly committed to rural communities. Sutter has recently made investments to expand behavioral health services in two rural areas in California. Can you tell me about that? Let the listeners know what you're doing and why?

00:04:03:02 - 00:04:27:08
Dan Peterson
Yeah, I'll start with some of our capital investments and then maybe Matt can talk about some of the programs. We have recently announced we're building more infrastructure in these rural communities. That's an important piece of what we have to do. So, we are going to be building some additional office buildings, about 18,000ft² of additional office buildings for primary care and urgent care up in Crescent City on the Oregon border.

00:04:27:10 - 00:04:57:24
Dan Peterson
We're also really excited to announce something called an empath unit, which is a crisis care unit, for individuals in a behavioral health crisis immediately adjacent to our emergency department there in Crescent City. It'll be a 3,000 square foot facility really designated for behavioral health crises. We're also building an additional medical office building on Lake County at our lakeside hospital, another 7,000ft² or so, about a $5.5 million investment in that community.

00:04:57:27 - 00:05:19:03
Dan Peterson
And this coming summer, we'll be opening another rural health clinic in Los Banos actually, just outside of Modesto. We have a rural hospital there, and we're excited to open a new rural health clinic there, which does tie into our behavioral health strategy as well as we're really looking programmatically to embed these services in our primary care offerings at all these communities.

00:05:19:03 - 00:05:26:03
Dan Peterson
And Matt, as a psychiatrist, can probably talk a little bit better about that. The strategy behind that and why that really works well.

00:05:26:05 - 00:05:27:26
Rebecca Chickey
Dr. White, you're up.

00:05:27:28 - 00:05:51:12
Matthew White, M.D.
First to expand, on the Empath unit a little bit and then talk about some other ways in which Sutter is supporting behavioral health in these rural communities. As Dan articulated, Crescent City is up in the far, far north coast of California, and it's really pretty much an island in a very rural community. So if you're in a behavioral crisis, you end up in our emergency room there more often than not.

00:05:51:14 - 00:06:15:10
Matthew White, M.D.
So Sutter recently got some state funds to build a specialized kind of crisis care unit, a crisis stabilization unit. But an empath unit is really a particular type of crisis stabilization unit. It's designed differently in a more therapeutic way. It doesn't have the bright lights of an emergency room. It tends to have chairs rather than gurneys. It's really just a much more soothing environment.

00:06:15:10 - 00:06:31:26
Matthew White, M.D.
And it's shown to have significant reduction in hospitalization rates and reduced length of stay. So we're really fortunate to be able to leverage a state grant opportunity to kind of provide a place for folks in crisis in that area can go to get more therapeutic relief than the current state.

00:06:31:28 - 00:06:52:15
Rebecca Chickey
So it sounds much more patient centered for someone who is in a psychiatric crisis compared to an emergency department, which, as you articulated, can be loud, with lots of lights and lots of activity. You really are being able to deliver patient centered care in a different way. Is there an average length of stay? What is the time period?

00:06:52:15 - 00:07:16:25
Matthew White, M.D.
Usually it's significantly less than 23 hours, so that the average length of stay in an emergency room in these rural communities can be literally days sometimes, because if you need to be in a hospital, there's very few resources around. So people can spend several days sometimes waiting to get a hospital bed and then travel six hours to the nearest hospital. Because empath units are more therapeutic

00:07:16:25 - 00:07:26:15
Matthew White, M.D.
actually, if folks don't end up getting hospitalized quite as frequently and didn't get the care they need right then and there, instead of going a long, long distance after a long stay.

00:07:26:17 - 00:07:36:21
Rebecca Chickey
If that's not patient centered care, I don't know what it is. I know that Sutter has been the driving force behind some of these initiatives, but have you had engagement or worked with community partners?

00:07:36:24 - 00:08:00:03
Matthew White, M.D.
Yeah, the empath unit is a perfect example. It actually started a number of years ago where our community benefits liaison had been working with local behavioral health and local tribal entities, because it's been a long identified problem. And they actually got some early seed grant funding a number of years ago to sort of plan for something like this empath unit.

00:08:00:06 - 00:08:25:03
Matthew White, M.D.
So when this larger grant opportunity came along last year, which was prioritizing projects that were kind of, quote, "shovel ready, ready to go because of the existing kind of groundwork that Sutter had done, working already with the local communities and hoping and planning for one of these empath units. It was a project and a grant application that really rose right to the top and got funded because again, some of that community work that had already been happening.

00:08:25:06 - 00:08:28:21
Rebecca Chickey
Dan, anything you'd like to add about the community partnerships?

00:08:28:24 - 00:08:54:28
Dan Peterson
One of the things that I have loved about working in rural communities is you have an opportunity to truly rally everyone in the community around something, right? Because there just aren't that many people to rally. And so it is logistically possible to bring together all the stakeholders, you know, to bring together multiple interested parties, multiple interested organizations, and get them all physically at the same table and co-develop some of these ideas.

00:08:55:05 - 00:09:16:00
Dan Peterson
It's an ideal scenario in many ways. I think sometimes we think of the rural communities as having challenges and difficulties because that's true. But on the other hand, there are some of these advantages where you truly can bring the whole community together and come up with a dream and a vision as a community in a way that is far more difficult in a metropolitan area.

00:09:16:02 - 00:09:43:10
Rebecca Chickey
I so concur. I grew up in rural Alabama, in a community of about 30 homes, so everyone knew everybody. The local police officer, you know, of the tiny little town seven miles away, used to come on my mother's grass. I mean, her primary care physician was right down the street. And so the support system and the ability to identify needs and then come together and collaborate to meet those needs, it's truly unique in rural communities.

00:09:43:13 - 00:09:50:24
Rebecca Chickey
Beyond the empath unit, can you share how center is working to expand access to care in rural areas in California?

00:09:50:27 - 00:10:11:17
Matthew White, M.D.
There's a couple ways, actually a number of ways. As Dan mentioned earlier, finding a psychiatrist or even a therapist is so challenging in this environment. So one of the initiatives Sutter has been leveraging virtual opportunities and tele-psychiatry, and one such way is through embedding primary care into pay for help using a nationally recognized model called collaborative care.

00:10:11:20 - 00:10:37:13
Matthew White, M.D.
And so we've been able to stand up collaborative care using a virtual provider. So this is where a primary care physician can get support and access to a therapist for the patient and psychiatric support for help medication management through Content Health, our virtual partner. Additionally, in Los Banos, which Dan mentioned earlier, Sutter has recently hired some nurse practitioners to serve patients in their rural health clinic.

00:10:37:15 - 00:11:05:19
Dan Peterson
One of the reasons that this model is so successful - at Sutter Health we've embraced this collaborative care model - is because it really allows our clinicians to work at the top of their license, and it allows us to maximize our clinician workforce, right? There are only so many psychiatrists out there, and there are only so many psychiatric nurse practitioners and advanced practice clinicians, it's like clinical workforce especially in rural areas is difficult to come by.

00:11:05:21 - 00:11:34:15
Dan Peterson
Recruitment is difficult. There are many rural communities that you just can't find a dedicated psychiatrist to come move to that rural community, but by embracing other care models that sort of allow these clinicians to come in and consult on the care of the patient and allow the primary care doctor to continue to be the prescribing clinician but with the support of a psychiatrist, those models really lend themselves towards virtual support, which is very helpful in the rural communities.

00:11:34:17 - 00:12:06:22
Dan Peterson
And second of all, it helps you sort of maximize the impact of the workforce that you do have available. And so then, you know, we look at places like Los Banos where we haven't been able to bring in a psychiatrist for that model, but we have had success in recruiting a psychiatric nurse practitioner or some of the other areas where we're able to find some therapists and they just need some support, or we have a strong core of primary care doctors, but they just need some support from a psychiatrist. Embracing different types of models like that really just helps logistically embrace the challenge of recruitment in those areas.

00:12:06:25 - 00:12:32:15
Rebecca Chickey
So it sounds like from this approach, you are meeting the patients where they are, you're better supporting the staff, the clinicians that you do recruit practicing at the top of their license. I've seen some studies in integration that show that integrated care or collaborative care not only improves patient satisfaction, but workforce satisfaction. It can reduce stigma, which can be great in rural communities.

00:12:32:17 - 00:12:56:26
Rebecca Chickey
It has just an abundance of positive outcomes. So thank you for taking it there. Dan, Matthew, thank you so much for being here with us today. And for sharing your experiences and your innovative ideas on how you're improving access to behavioral health services in rural communities. And before I go, I'd like to remind everyone that November 20th is National Rural Health Day.

00:12:56:29 - 00:13:06:01
Rebecca Chickey
Be sure to check out the links in the show notes below for a wide variety of resources that'll allow you to participate in this important awareness day.

00:13:06:03 - 00:13:14:09
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.

00:00:01:00 - 00:00:21:06
Tom Haederle
Welcome to Advancing Health. Homes built before 1978 did not have the prohibition against the use of lead based paint that's in place today. Let's hear what one proactive city is doing to protect its residents against this environmental danger.

00:00:21:09 - 00:00:50:03
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the American Hospital Association. Thank you so much for joining us today. We've all heard the phrase "get the lead out," meaning get moving, pick up the pace. But in Cleveland, Ohio, those words have a more literal meaning. Our two guests today will talk about the massive effort to reduce and eliminate lead poisoning in the city's population, especially among kids who are four times more likely to have elevated levels of lead in their blood than the national average.

00:00:50:05 - 00:01:03:04
Tom Haederle
So joining me to talk about this effort are two experts from Cleveland Clinic. Vickie Johnson, executive vice president and chief community officer and pediatrician Dr. Roopa Thakur. Thank you both for joining me on Advancing Health today. Appreciate you being here.

00:01:03:10 - 00:01:05:02
Vickie Johnson
We're glad to be here.

00:01:05:04 - 00:01:21:12
Tom Haederle
Well, Vicki, maybe we can start with you to bring this into focus. A lot of people may assume that the problem of lead poisoning is a thing of the past. Why is the problem of exposure to lead in the environment so acute in Cleveland, to the point where it's become Cleveland Clinic's top priority for community health?

00:01:21:14 - 00:01:59:12
Vickie Johnson
It is our number one public health priority, because 90% of Cleveland's homes were built before 1978, which means that lead is in the paint in the homes. And as the home deteriorates, it's likely to poison those children living in the homes. So we talk about this as a public health crisis with a housing solution. So often the solution isn't very clear on so many issues, but this is one where we know where the problem is, and we have an ability to partner with others to address it.

00:01:59:14 - 00:02:08:29
Tom Haederle
Is it a matter of the deterioration of the paint itself as time goes on that releases more and more lead into the environment or into the atmosphere? Is that what's going on?

00:02:09:01 - 00:02:34:13
Roopa Thakur, M.D.
Yes, exactly. So, paint deteriorates over time, especially in areas of high friction. So if you think about a door frames, window sills, areas where you're opening and closing a lot, areas that are tread on a lot. So porches and decks are a common source in Ohio. But as the paint chips or rubs off, it creates lead dust that then settles on the floor or settles on the carpet.

00:02:34:15 - 00:02:40:24
Roopa Thakur, M.D.
And then our little ones, who are playing on those floors pick up that lead dust and either inhale or ingest it.

00:02:40:26 - 00:02:49:05
Tom Haederle
So it's really everywhere. And Dr. Thakur, what is the effect of high levels of lead exposure on the human body and particularly in children?

00:02:49:07 - 00:03:09:18
Roopa Thakur, M.D.
Yeah. So we think about our little ones, especially at one and two years old, because that's when their brains are actively growing. We know from the CDC that even the lowest levels of lead exposure can damage the brain and nervous system, can slow growth and development, and can lead to learning and behavior problems. So it can definitely prevent children from getting to their full potential.

00:03:09:27 - 00:03:20:15
Roopa Thakur, M.D.
But we also can see - because lead affects every single organ system in the body - we might see bone problems, we might see kidney problems, liver problems, heart problems as an effect of lead poisoning.

00:03:20:17 - 00:03:31:22
Tom Haederle -
Are the effects less dramatic on full grown adults? If somebody moves into a house, you know, in midlife that happens to be a house built before 1978, are they at the same level of risk or not so much?

00:03:31:24 - 00:03:41:03
Roopa Thakur, M.D.
We definitely can see health effects in adults, but because the brain has kind of fully grown by then, the effects are different. We don't tend to see those same lifelong effects.

00:03:41:05 - 00:03:54:28
Tom Haederle
I know that Cleveland Clinic recently pledged $55 million to the Let's Save Cleveland Coalition and the United Way of Greater Cleveland. How will these funds be used to address the problem of lead exposure in people's homes? What's the plan for the money?

00:03:55:00 - 00:04:22:19
Vickie Johnson
So it's been about three years since we've made that commitment. And we worked with the Lead Safe Coalition to identify the greatest need. So the dollars primarily are allocated to remove the lead from the house. Primarily. But we also have other initiatives such as workforce development, marketing evaluation. We have a budget for that. And most excitingly, we have a budget for childcare centers.

00:04:22:26 - 00:04:39:08
Vickie Johnson
Once we got involved in the coalition, we thought, yes, kids live in homes, but also little ones who go to childcare spend as much time during the week there as they do at home. And that's when we launched the Let's Save Childcare Center initiative.

00:04:39:10 - 00:04:46:09
Tom Haederle
Are these grants that people have to apply for, or how would they go about getting some of that available money to do the clean up?

00:04:46:11 - 00:05:13:13
Vickie Johnson
Absolutely. Yes. There are grants and there's also incentives. As you can imagine, even when resources are available, it takes time to educate the public that the funds are available, that there's an issue that can be resolved. In many cases, we're talking about a landlord and not necessarily a homeowner. So it's different in terms of how you need to engage with those different populations, the homeowner versus the landlord.

00:05:13:20 - 00:05:39:16
Vickie Johnson
Resources are available as incentives. If you apply for Let's Save Cleveland dollars, which is a grant, then there's an incentive available for you just to get utilization increase so that we can address the issue. This is a sense of urgency, and we want every child in the city of Cleveland, you know, for us, as a beginning. We also collaborate with partners on a county level.

00:05:39:16 - 00:05:46:28
Vickie Johnson
But we want every child to live in a lead safe environment for the reasons that Dr. Thakur explained just a moment ago.

00:05:47:01 - 00:05:56:03
Tom Haederle
In terms of what actually needs to be done, is it painting over that original layer of dangerous paint, or does it physically have to be stripped from the wall and replaced entirely?

00:05:56:05 - 00:06:30:10
Vickie Johnson
It's both. So in Cleveland, we have two different approaches. It's making a unit lead safe, which is encapsulating. Yes, you can paint over with the special paint and we can wrap an area that has paint with aluminum or vinyl, if you think about outside a home. And we can also replace and tear out, which is more lead free than let's say, can you put a brand new deck on the porch as opposed to scraping, painting, which you would then have to repeat every couple of years?

00:06:30:15 - 00:06:47:20
Vickie Johnson
So it's two different approaches. It really depends on the state, the current state of the unit as to which method is best. We believe that lead safe is best for the immediate. And then when we can make units lead free as well.

00:06:47:22 - 00:07:09:09
Tom Haederle
A question for both of you. The immediate goal, of course, is to improve the environment and make it healthier, and especially for young kids who are still developing. What are some of the other benefits that we realize from dealing with this problem in terms of health care, lost earnings, societal costs that that have spiraled, I guess, because of the prevalence of lead in the city's homes?

00:07:09:11 - 00:07:43:27
Roopa Thakur, M.D.
So there's actually been a study done by Case Western Reserve University a few years ago that looked at the downstream effects of lead poisoning in our community's children. And what they found was that when you look at the dollars spent on various therapies that those children require over time, if you look at the public benefit spending on some of the services that those patients require as they become adolescents or young adults, many of them deal with homelessness, unemployment, they have several mental health issues and ADHD that can affect their ability to be to remain employed.

00:07:43:29 - 00:08:03:24
Roopa Thakur, M.D.
And so when we think about the long term spending on those public benefits as well as then, you know, there is a subset that is at higher risk for incarceration or juvenile detention, and we look at the spending there. Their data showed that each dollar invested in lead poisoning prevention can have as much as $220 return on investment.

00:08:03:27 - 00:08:17:06
Tom Haederle
Wow. That's impressive. Dr. Thakur, I wonder, is there any reason to think that there will ever be an effective treatment for the damage caused by chronic lead exposure? Or will prevention always remain the best solution?

00:08:17:09 - 00:08:36:01
Roopa Thakur, M.D.
Prevention is our best option. As far as we know, there is no cure for lead poisoning. Once it's happened, we can try to mediate results as best as we can with the therapies that we can provide, such as occupational, physical or speech therapy. But there's no way to reverse the damage that's been done.

00:08:36:03 - 00:08:56:01
Tom Haederle
Sobering message. Final question for both of you. And I know this is not a box checked, this is not a done initiative. But what you've learned so far, and what Cleveland Clinic's experience has been in helping the city deal with this problem. What advice would you have for other health systems across the country that may be looking at the same problem?

00:08:56:01 - 00:08:58:24
Tom Haederle
And also considering, you know, how do we tackle this?

00:08:58:26 - 00:09:27:06
Vickie Johnson
This work takes a long time, and we need to be patient with the results that we hope for. For example, Cleveland has over $100 million available with all of the investors. It's not just Cleveland Clinic. They're other partners that are involved. And so we thought for once, money resources was not an issue. So we just thought that people would run in and take advantage of these resources.

00:09:27:06 - 00:09:50:20
Vickie Johnson
And in a couple of years and five years, we thought our problem would be fixed. And that is not the case. That's not the case. In fact, only a small percent of the resources overall for the Let's Save home piece of it - not testing, not screening, not marketing, not evaluation. A a small percent of the resources have been utilized.

00:09:50:24 - 00:10:19:00
Vickie Johnson
We're still trying to educate the population on the danger of lead poisoning and we're taking different approaches to deal with this. Knocking on doors, going to war club meetings, working with the faith community, childcare centers, state, county, city, public housing, you name it. Everyone is trying to address the issue. There are over 400 members in the coalition.

00:10:19:02 - 00:10:39:14
Vickie Johnson
And when I say members, these are representatives of organizations. So we have thousands of people who are working together on this policy, government. We're trying and we're not satisfied with where we are today, but we're all committed to stay until we accomplish our goal.

00:10:39:17 - 00:10:47:25
Tom Haederle
It sounds like the takeaway message here is there's also a big messaging dimension to this whole initiative that people have to pay attention to.

00:10:47:28 - 00:11:08:00
Roopa Thakur, M.D.
I'll add to that as well, that, you know, Vicky's talking about partnerships. When we think about what we knew about lead poisoning in Cleveland 15 years ago, compared to what we know now, a lot of that required breaking down barriers between all the different silos that we're working on this separately. So our public health departments had the data.

00:11:08:03 - 00:11:16:25
Roopa Thakur, M.D.
We knew clinically what was happening with our patients. But to bridge the gap, to understand well, where is the lead coming from? It takes a lot of people working together.

00:11:16:27 - 00:11:33:18
Tom Haederle
Well, thank you so much for helping shed some light on a very serious problem that is probably more widespread than most people are aware of in other cities as well. Thank you so much again for being on Advancing Health today, and best of luck in this important work you're doing as you work to improve the health of the people of Cleveland.

00:11:33:20 - 00:11:42:01
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.