Advancing Health Podcast

00:00:00:00 - 00:00:17:00
Tom Haederle
Welcome to Advancing Health. In this discussion, we learn more about the role of the chief medical and quality officer, an influential position in many hospitals and health systems that's been described as "a powerful cycle of leading people through change."

00:00:17:03 - 00:00:34:08
Chris DeRienzo, M.D.
I'm Dr. Chris DeRienzo, the chief physician executive for the American Hospital Association. And today, I am incredibly excited to be joined by Dr. Philip Chang. He serves as the chief medical and quality officer for Common Spirit Health. Phil, thank you so much for joining the series.

00:00:34:10 - 00:00:39:17
Phillip Chang, M.D.
Chris, delighted to be here. And good to catch up again.

00:00:39:19 - 00:00:52:22
Chris DeRienzo, M.D.
Likewise. Before we jump in, we've got a standard set of five questions. But, before we get into the questions, I always like to ask, tell us just a little bit first about yourself personally and about the health system that you serve. CommonSpirit Health.

00:00:52:24 - 00:01:30:19
Phillip Chang, M.D.
Absolutely. So, again, my name is Philip Chang. I'm the chief medical quality officer for CommonSpirit Health. And what I really love about CommonSpirit is the first and foremost it's mission driven. For me, if we were to geek out a little bit in the acute care side, for instance, we have small critical care access hospitals all the way to large academic hospitals with transplant and the whole works such as, you may know, Baylor St. Luke's, sort of the birthplace of in Houston, of advanced cardiac surgery and one of the premier liver transplant programs.

00:01:30:19 - 00:01:54:02
Phillip Chang, M.D.
But we also think that equally important to something as prestigious as Baylor St. Luke's, we have critical access hospitals where we anchor the community and the health they receive. So I'm very proud of that fact. My background, I'm a trauma surgeon by training. Sort of stumbled into quality safety. And the chief medical officer land.

00:01:54:04 - 00:02:18:01
Phillip Chang, M.D.
I think I think we'll talk about this a little more, but, I didn't grow up thinking "My gosh, I want to be a CMO." I sort of joined the medical staff and go, who's the CMO guy? But I gravitated towards that because I think many of us have, because the impact that we're able to make both is multifaceted and it's significant, right?

00:02:18:01 - 00:02:37:12
Phillip Chang, M.D.
And we think about patient impact, but we also think about medical staff impact. Now we call it physician well-being, which is also so important. But then the ability and the necessity to interface with the clinician administrators so that we can all work together - that that drew me to it.

00:02:37:15 - 00:02:56:21
Chris DeRienzo, M.D.
I was just going to get to that, actually, because you hit on something that is driving this, which effectively is so many of us wound up in leadership. It was less of an intentional journey. And, you know, we discovered in a paper that we wrote last fall that that effectively defines the leadership experience for college,

00:02:56:21 - 00:03:14:07
Chris DeRienzo, M.D.
you know, our vintage of chief physicians today. And it's the responsibility of folks like you and me and leaders and health systems across the country to try to make that difference. But in order to get there first, folks have to understand what job like yours actually look like. And yours is a pretty big one. So walk us through briefly a little bit,

00:03:14:14 - 00:03:20:28
Chris DeRienzo, M.D.
you know, your team at CommonSpirit. And what does a typical day look like for you as the chief medical and quality officer?

00:03:21:00 - 00:03:47:25
Phillip Chang, M.D.
We're looking at our team, and our team is obviously a number of very, very, strong experts in quality and safety, patient process improvement. But I also have a little liaison to interface with all of our chief medical officers. We have region, market, and then sites and how we work together. And the management structure is come in place.

00:03:47:25 - 00:04:14:17
Phillip Chang, M.D.
But I also have a, small but very mighty team of like minded clinicians, and they really push CommonSpirit to think through what the right clinical standards should be based on evidence based medicine. Obviously, we leverage all the experts within our organization. So that I like to think of as a continuous cycle. So we've got the data monitoring.

00:04:14:20 - 00:04:44:22
Phillip Chang, M.D.
We detect things that we believe we can improve on, bring it over to clinical standards, revise the standards, and then take it to the CMOs so they can help us execute. And that cycle continues. As you know, I'm fairly new at this role. It's now going on about ten months, nine, ten months. So I'm building some of these bridges and this collaborative sort of spirit. I like to think about not necessarily as the typical day. I'll tell you a funny story.

00:04:44:22 - 00:04:54:24
Phillip Chang, M.D.
So when I was operating a lot my kids knew if I'm there operating, you know, I'm at work. Now that's in the office, home office.

00:04:54:27 - 00:05:14:09
Chris DeRienzo, M.D.
Well sometimes you're there and sometimes you're in hospitals and sometimes you're in convention centers. I mean, I know your travel schedule looks, looks a lot like mine. But being ten months into the role, you know, I'm curious what you described as this very powerful cycle. And it becomes a flywheel of, of leading people through change.

00:05:14:12 - 00:05:20:06
Chris DeRienzo, M.D.
What is the biggest challenge that you're tasked with leading your teams through right now?

00:05:20:09 - 00:05:48:21
Phillip Chang, M.D.
Yeah, I think biggest challenge, and these are all fun challenges from my sort of vantage point. But we, we want to really think about how we redefine, how we measure what is high quality of care? But, you know, in addition to the traditional benchmarks that we all look after, right? There's, you know, CMS has health grades and the star ratings.

00:05:48:24 - 00:06:13:15
Phillip Chang, M.D.
I really think about what does it mean to CommonSpirit when we serve our community, what's right? And I'm not saying we're inventing new measures all the time and altogether. I'm saying that beyond the sort of overarching, okay, there are there are complications or there's, you know, patient safety indicators that we measure. What are other things that our patients might care about.

00:06:13:17 - 00:06:34:17
Phillip Chang, M.D.
And I know it is patient experience, but I also think it is a little bit of our promise to the patient to be able to deliver care at their level at their time, not our time. That paradigms got to shift, right? We used to be okay with the doctor will see you now. Now it's well, I'm ready for the doctor to come see me.

00:06:34:19 - 00:06:38:28
Phillip Chang, M.D.
And we really have to think that way because I think our patients deserve it and they expect it.

00:06:39:00 - 00:07:04:24
Chris DeRienzo, M.D.
One thing I've grown to appreciate deeply since I joined AHA about four years ago is that every health system serves a unique role in their communities. And the role that, you know, that you just described that a critical access hospital serves as an anchor in a very rural community, maybe only with a couple of patients inpatient every day  - is both the same and different from a role that, you know, a large center in Atlanta with a multi-tiered emergency department can serve.

00:07:04:26 - 00:07:43:20
Chris DeRienzo, M.D.
But defining that North Star and how you want your communities to experience it, that that's a big challenge. You describe a little bit of your pathway, to becoming a leader and becoming the CMQO at CommonSpirit. My path was similarly circuitous, as are many of our peers. And so I'm wondering if you can speak to either one person, or one experience that you didn't plan for, but that fundamentally helped you develop either the knowledge, the expertise or the experience based on that framework that we wrote about in the NEJM Catalyst that you needed to be successful doing what you do today.

00:07:43:23 - 00:08:12:07
Phillip Chang, M.D.
I was at the time an associate chief medical officer at University of Kentucky. I was, I was the perioperative medical director. The chief medical officer position opened up. It was primarily an internal search, or at least in the end all the candidates were internal. And we're going through a number of interview process, and I go, well, you know, I managed an operating room for five years, and if I could do that with that group of characters, I could do the hospital.

00:08:12:09 - 00:08:38:16
Phillip Chang, M.D.
And, I was asked a question during the during the process, and it was really about quality framed as why is the CMS, sort of quality measurement, why should we believe in it, you know, and, and tell us the nuances about it. And it took me aback and, fortunately I had the job despite me fumbling through that question, but I really doubled down.

00:08:38:19 - 00:09:14:05
Phillip Chang, M.D.
Okay. This is not something, at least at the time, that we have ever measured in the operating room. It was always a serious safety event, and it was all about volume through put, long time, turnover time, etc. so I really just put my head down and learned as much as I could and understand the nuances of it. And I think that's really helped me in my career, because a lot of what we're thinking about at CommonSpirit as well is how do we take a set of data's. You know, chief medical officer, chief quality officers, and I believe this is going around now.

00:09:14:12 - 00:09:42:13
Phillip Chang, M.D.
We're beginning to think of ourselves as sort of the CFO of quality measures, because we are presenting data in a coherent way to those who can directly impact and improve the unit that they are responsible for. And if you look at the CFOs charts, it's very clean, it's very standard because they have a shared common currency called US dollars.

00:09:42:16 - 00:10:05:04
Phillip Chang, M.D.
We are thinking through a lot of this in this, in this sort of fashion so that we're delivering usable information to our frontline, both ambulatory side, primary care service lines in the hospitals, obviously, and to say, okay, well, you are performing better than last year, but you're not performing fast enough compared to your peers inside CommonSpirit.

00:10:05:06 - 00:10:06:19
Phillip Chang, M.D.
So how can we help?

00:10:06:21 - 00:10:32:15
Chris DeRienzo, M.D.
You're all in. And you know, I love to geek out, Phil, and I love your analogy, in part because CFOs are accountable for the financial health of an institution, though they have very, very little direct ability to impact it. And to your point, chief medical officers and chief physicians have had the same kinds of accountability is often shared with other clinical leaders, but very, very rarely have all of the levers that they can directly pull to drive that change.

00:10:32:15 - 00:10:51:05
Chris DeRienzo, M.D.
Yeah. I'm curious, looking back at your career so far, is that the one thing that you wish that, that you had had learned earlier, or is there something else that that you wish you looking back at pre-associate CMO Phil, even, you know, trauma surgeon Phil. What one thing do you wish he knew that you know now?

00:10:51:08 - 00:11:14:21
Phillip Chang, M.D.
You know there's so many but I would say the one thing and to any sort of future CMOs is out there, take care of yourself. You know, for all of us, even though physicians are, you know, we take on a lot mentally and physically and, and, and I think it's not just for CMO, really, it's for any one of us who are giving ourselves, burning the candles for our patients.

00:11:14:27 - 00:11:20:15
Phillip Chang, M.D.
I think it's important to take a moment and spend some time with your family and take care of yourself.

00:11:20:18 - 00:11:39:29
Chris DeRienzo, M.D.
That is a spectacular note to end it on, Phil. And one that's again, I think when I speak to medical students and residents today, I tell them, you could not have picked a better time to be coming into medicine. First of all, we went through digital transformation over the last 25 years, and the electronic records that we're working in are much better than the digitized paper versions we started with.

00:11:40:05 - 00:11:56:11
Chris DeRienzo, M.D.
We're using AI enabled solutions at the points of physician and clinician experience, and we have a different appreciation for the negative axis of burnout and the positive axis of well-being. And crucially, folks like you are leading the way to do something about it.

00:11:56:13 - 00:12:04:24
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 - 00:00:18:20
Tom Haederle
Welcome to Advancing Health. An aging population. Nursing shortages. Overcrowded emergency departments. These all add up to an intense demand on acute care hospitals, where inpatient days are projected to rise by 9% in the coming decade.

00:00:18:22 - 00:00:40:20
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the American Hospital Association, and very pleased today to welcome Scott Edelman to our podcast. Scott is executive director of Burke Rehabilitation and he joins me today to talk about ways we can alleviate the growing stress on acute care hospitals.

00:00:40:23 - 00:00:43:24
Tom Haederle
Scott, thank you so much for joining me on Advancing Health today.

00:00:43:26 - 00:00:51:20
Scott Edelman
Oh, thank you so much. It’s just thrilled to be here. I listen to every podcast. And you know, they all serve a tremendous purpose.

00:00:51:22 - 00:01:09:05
Tom Haederle
Maybe we can frame this at the start by talking about acute care hospitals in general in terms of the demand for their resources right now and their ability to meet that demand. Where is the disconnect there? Are there more people that need their services than they really have the capability to deliver on?

00:01:09:08 - 00:01:33:03
Scott Edelman
So. let's just talk about the strategic role we play. The role we play is decompress acute care hospitals. We are a safety valve for acute care hospitals and improve the whole patient flow. One of the main contributors to the entire system right now is post-acute care. Where does someone go after a traumatic event? Burke, we have being 150 bed inpatient hospital,

00:01:33:06 - 00:02:02:03
Scott Edelman
we are seeing a shrinkage of IRF inpatient rehab facility beds in the tri-state area because of how busy the hospitals are, and they need to create capacity. So we become the safety valve. So it's a critical point that all acute hospitals that we have fantastic relationship with use us as a safety valve to remove and reduce the number of people in an emergency rooms that are in the hallway waiting for beds.

00:02:02:09 - 00:02:12:15
Scott Edelman
So to answer your question, I feel right now at 150 beds, we have enough beds. And when it becomes where we need more, we will petition the state for more.

00:02:12:18 - 00:02:21:25
Tom Haederle
So if a patient goes to an acute care hospital and is told we are really crowded, can't deal with you right now, they know to refer that patient to Burke?

00:02:21:27 - 00:02:47:12
Scott Edelman
So the rules to the game about being referred to an acute rehab hospital, you have to have a three day inpatient hospital stay. So a patient goes to White Plains Hospital for a traumatic event, a stroke. They're there 3 to 4 days, stabilized. Then they're referred to Burke, and then the journey continues. Another valve is a skilled nursing facility because they might be too sick for Burke or not sick enough.

00:02:47:18 - 00:02:51:21
Scott Edelman
But we're here to treat the patients in the right setting at the right time.

00:02:51:23 - 00:02:58:09
Tom Haederle
Doesn't Burke deal with some of the same capacity management and workforce challenges that many of the other hospitals do?

00:02:58:11 - 00:03:24:20
Scott Edelman
So right now, we don't have a capacity issue, right? So we're 150 bed hospital. Today's census is, I think, 142 so, you know, the myth that Burke is full or IRFs are full, I always tell the acute hospitals just refer the patient. Let us go through the clinicals. Let us go through the insurance approval. Right now because of the culture at Burke, we have one of the lowest turnover, employee turnover rates in the tri-state area.

00:03:24:22 - 00:03:42:04
Scott Edelman
We had made some changes to our compensation philosophy, to our retirement plan, to our medical plan, and we're seeing less than a 5% turnover. And as far as the Tri-State area that's seeing an RN crisis, we're almost fully staffed with RN's.

00:03:42:07 - 00:03:52:01
Tom Haederle
That is really impressive, because all we hear about today, of course, is workforce challenges. And it's so hard to recruit and train and keep people. But you're really, sounds like you're really doing it right.

00:03:52:04 - 00:04:14:08
Scott Edelman
Yeah. Tom, on the recruitment side, you know, we're always looking for the best and the brightest. You know, we want to hire a lot more physical and occupational therapists and speech because of our rapid and aggressive expansion plans. You know, we have 15 outpatient sites. I think the number is 50 that we need, but we're going to need a lot more qualified PTO, OT and speech therapists.

00:04:14:11 - 00:04:28:05
Scott Edelman
We have a great complement of physicians. We have one of the biggest teaching programs in the country. We have 20 residents and four fellows, and we train our physicians to go out and do amazing things.

00:04:28:07 - 00:04:47:13
Tom Haederle
Well, let's drill down into that a little bit. The hands on if I have the number right. I think I read that Burke Rehabilitation receives more than 200,000 patient visits each year in total across all of your facilities. I know you offer both hospital based rehabilitation and an extensive menu that you talked about at the beginning of our conversation.

00:04:47:21 - 00:04:58:14
Tom Haederle
An extensive menu of outpatient therapy programs. What is Burke doing differently in both of those settings to support and treat clinically complex cases more efficiently and more economically?

00:04:58:16 - 00:05:30:27
Scott Edelman
Great question. So on the inpatient side, in 2025, we treated 3,300 inpatients. On the outpatient, it was over 200,000. What we're doing differently is making sure that we add the right services and can support those services. And I'll give you an example. A year ago, we added inpatient dialysis to our programs here at Burke. Prior to that, if you need an inpatient rehab and you are on active dialysis, you wouldn't be able to [be] admitted.

00:05:30:29 - 00:05:51:28
Scott Edelman
Last year, we admitted over 100 patients that needed rehab and on dialysis. We've added TPN, total parental nutrition. We're looking ahead - disorders of consciousness. We want to make sure that if there's a neurological or traumatic event, the entire country knows that Burke is the right place to get better.

00:05:52:00 - 00:06:09:21
Tom Haederle
Well said. And it's just so impressive, the sheer breadth of the different services and therapies that you offer. Which kind of leads me to the next question. What kinds of care or medical procedures seem the most promising in terms of delivering care in new ways that that do put less stress on acute care hospitals?

00:06:09:24 - 00:06:40:18
Scott Edelman
Right. So what we're seeing is neurological diagnosis are on the uptick. We're seeing a lot more strokes, especially in young people. And a lot of hospitals aren't equipped to deal with stage one or trauma one. And what we're doing in our Montefiore Health System is making sure from any initial diagnosis that we have everything in the health system, from your first admission to your discharge to home for continuum of care and follow up.

00:06:40:20 - 00:07:02:19
Scott Edelman
We're seeing a lot less orthopedic admissions because they're going more to skilled nursing facilities or to home. And as a product of this, Tom, 90 of our 150 beds are focused on neurologic conditions, and we might have to expand that more of our 150 beds. We do a lot of transplant patients. We do a lot of cardiac.

00:07:02:19 - 00:07:26:17
Scott Edelman
We do pulmonary patients. Our patients' average length of stay is 14 to 15 days. Once they check in to our beautiful 61 acre campus, they really get settled in, understand what recovery is. Three hours plus hours of therapy per day. We also do ancillary therapy that's not really required of an acute rehab. We do neurological music therapy.

00:07:26:20 - 00:07:32:06
Scott Edelman
We do pet therapy. And this is all to help the patients get better.

00:07:32:09 - 00:07:47:07
Tom Haederle
It struck me that maybe one of the secrets to your success so far has been what patient needs are, where they're moving. As you pointed out, we're seeing growth in this area, some declines in that area. You're really just sort of tracking what's going on in health generally in this country, isn't it?

00:07:47:10 - 00:08:07:06
Scott Edelman
I think you hit the nail on the head, but it all starts with the patient. Everything we do is focused on how can we get the patient back to maximum functional recovery. When we look at a product or service, it doesn't necessarily have to have direct ROI, return on investment, but it has to speak to patient quality, patient safety.

00:08:07:10 - 00:08:28:04
Scott Edelman
How do we get patients back home, back to the life they love and how after discharge do we stay connected, right? So it's constant follow up in phone calls and being part of the Burke family. We actually, all patients that are admitted, we give a card on admission and says, “Welcome to the Burke family.” We want to keep everyone connected.

00:08:28:07 - 00:08:41:15
Scott Edelman
We’re nationally recognized, U.S. News and World Report. We're on Newsweek's list of best physical medicine rehab centers in the country. We're also - our employees voted us best places to work. That has to say volumes.

00:08:41:18 - 00:08:57:00
Tom Haederle
It really does. I guess I would conclude then, and you've touched on some of these things already, but what advice would you have for your peers out there? You know, in the in the health care field who look at Burke and say, “my gosh, you're just doing so many things right. We'd like to follow their example.” What would you share?

00:08:57:06 - 00:08:58:23
Tom Haederle
What are your thoughts about that?

00:08:58:25 - 00:09:23:14
Scott Edelman
So Tom, I would go twofold. On the clinical end, listen to the acute care hospitals challenges. Help with reducing length of stay. That is what acute hospitals want to hear. It's better for the patient. It's better for the hospital. It's better for everyone. In addition, don't be afraid to swing big and fall hard. Not everything is going to work, right?

00:09:23:18 - 00:09:44:09
Scott Edelman
When we did our strategic plan, we threw spaghetti at the wall and see what stuck. Right? And we had 53 initiatives. Not every one of them are going to be home runs, Grand Slams, but we're hoping some base hits there. And leadership is everything. I start and end my day on the patient units, talking to patients and families and employees.

00:09:44:12 - 00:10:00:09
Scott Edelman
Sometimes you could find me at the front desk welcoming visitors. You could find me at the admissions center welcoming new patients. It's really all about presence, visibility and being humble and caring about your organization and the people we serve.

00:10:00:11 - 00:10:13:18
Tom Haederle
That is just a great summation of everything that you guys are doing right. Thank you so much for what you do on behalf of your patients. Thank you for your time joining me on Advancing Health today. And best of luck in everything you're doing and good luck in the future.

00:10:13:20 - 00:10:16:12
Scott Edelman
Thank you. It's been my pleasure and thrill.

00:10:16:15 - 00:10:24:26
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.

00:00:00:09 - 00:00:21:15
Tom Haederle
Welcome to Advancing Health. March's Leadership Dialogue podcast explores how a collaboration between Rutgers Health and RWJ Barnabas Health is unleashing the power of AI - carefully and methodically - to improve patient safety and reduce clinician burnout.

00:00:21:18 - 00:00:44:23
Marc Boom, M.D.
I'm Marc Boom. I'm the president and CEO of Houston Methodist and the chair of the board of the American Hospital Association. So I want to continue this thread of our discussions this month. We're going to focus on innovation in patient safety. All hospitals and health systems we know put safe, high quality care first for their patients. And for decades now, we've been using innovation to improve outcomes.

00:00:44:23 - 00:01:06:27
Marc Boom, M.D.
And we know that we've seen really dramatic improvements. But we also know we can never be complacent. We need to continuously work to advance safety and quality, because we have a sacred responsibility to keep our patients safe at every single step, whether it's our physicians or nurses who are at the bedside or leadership shaping systemwide decisions. We always have the same goal, which is be safe, deliver safe care.

00:01:07:03 - 00:01:26:26
Marc Boom, M.D.
And innovation is a critically important tool in making that happen. And thankfully, we have a lot of new tools that help that happen. So, for example, small wearable devices that can monitor vital signs in real time and send updates directly to nurses, giving nurses more time at the patient's bedside, patients more time to recover and less sleep interruption.

00:01:26:29 - 00:01:53:17
Marc Boom, M.D.
Adopting innovative approaches is really, as I said, critically important, but it sometimes feels pretty challenging. And so I'm very excited to have a guest with me today who is expert and really doing exactly the kinds of things I was just talking about. So please join me in welcoming Amy Rockman. Amy is the director of the Artificial Intelligence Center of Excellence, which is a system wide collaborative initiative between RWJ Barnabas Health and Rutgers Health.

00:01:53:23 - 00:02:14:06
Marc Boom, M.D.
Amy, welcome. So, Amy, I want to begin by asking you to share a bit more about the partnership. I understand that your mission is to dedicate responsible development and integration of artificial intelligence to improve patient care and also a goal of reducing clinician burnout. So tell us a little bit about how it came to be and why it's notable for the work you're doing.

00:02:14:09 - 00:02:37:05
Amy Rockman
Thank you so much Dr. Boom. So we started this center and this group a few years back. So forward thinking leadership was really seeing the potential of these powerful AI tools. And so what we created is essentially an AI focused learning health system. So that's a system between our university and our health system in which research is informing practice and practice is

00:02:37:05 - 00:03:11:04
Amy Rockman
then again informing research. And so the idea between these two structures and bridging them together for the center is to bring those research experts, together with our everyday heroes, real clinicians in the health system, practicing medicine so that we can better inform the tools that we're introducing and how they can really drive change throughout our hospitals. So we brought together these two different sides of the health system and the university, and we did it with AI because it really requires this next level focus.

00:03:11:12 - 00:03:29:28
Amy Rockman
When you're bringing in and integrating these powerful artificial intelligence tools, there are so many things to think about from a safety perspective. There's safety and security, of course. Then there's validity and reliability of the tools. And that's with a lot of the technologies that you're bringing in. But AI introduces this whole new layer, since there's so much about it that we still don't understand.

00:03:30:00 - 00:03:53:14
Amy Rockman
So explainability for example, and transparency, interpretability of the tools. All of this we're still learning as AI is coming out. AI is looking at these huge sweeping statistical associations. And it's so incredibly powerful. It's able to do incredible speed, accuracy, so many changes that come with the tools, but we need to be able to understand them, validate them, evaluate them.

00:03:53:21 - 00:04:15:28
Amy Rockman
So there's actually a whole AI product lifecycle that we started to follow. And the Coalition for Health AI has really created this in detail, and it fit very closely with our work and how we think about how do we determine which area of our health system would most benefit from a tool right now? How do we then identify a tool?

00:04:16:00 - 00:04:40:13
Amy Rockman
Is it going to be homegrown internally, the university, or is it going to be vendor acquired and introduced? Then once we introduce it, there's a whole integration process of integrating it both technically into your infrastructure and into your clinical workflow. Then you need to monitor it, fully evaluate it, identify gaps, and the process restarts. So as we're following this AI lifecycle at each step there's a lot to think about.

00:04:40:14 - 00:04:57:10
Amy Rockman
And so it's not just so much that you need to think through. It's how interdisciplinary the work truly is. So how many people you really need on the team to be able to think through this in the most impactful way and in the safest way for our patients.

00:04:57:12 - 00:05:11:17
Marc Boom, M.D.
I hear that. It sounds like you're extremely intentional on how you're approaching this. I mean, you're not just sort of waiting for things to come to you. You're sitting there saying, what are the problems you want to solve? And how might we build something ourselves or go to look for a solution? Is that correct?

00:05:11:20 - 00:05:32:02
Amy Rockman
It's actually incredible how there's multiple different wavelengths coming together to make a lot of these decisions. And so a lot of it starts from our KPIs and drivers and risks and thinking through, you know, first we started introducing, for example, administrative tools as they were low, much lower risk. And there's still a lot of high reward even for patient safety, right?

00:05:32:02 - 00:05:50:03
Amy Rockman
If you're able to catch a lot of those documentation issues, you're able to address those. You have better documentation for your patient, you have a better patient history. So we introduce some of these low risk tools first and then started introducing the more high risk tools. We also we started introducing it by again looking at you know, those KPIs - 
00:05:50:03 - 00:06:11:19
Amy Rockman
those drivers, our verticals, our horizontals. But as we're doing that, we're building these interdisciplinary teams. And as we're doing that, we're starting to learn from the teams and really get a deeper understanding of how the AI tools we started to introduce are affecting the clinical environment. And so now we're getting a grassroots input as well. And so the decision making is really, really thoughtful.

00:06:11:25 - 00:06:17:00
Amy Rockman
It involves a great number of people and a great interdisciplinary effort.

00:06:17:03 - 00:06:34:04
Marc Boom, M.D.
So I knew a lot of people would like to follow your lead and do things on his own. Can you walk me through an example of something you've tackled, and how big is the core personnel versus interdisciplinary team versus getting to the grassroots? Would you walk me through kind of an example of something that's worked and how that has been put together.

00:06:34:06 - 00:06:53:06
Amy Rockman
We've introduced dozens of tools at this point, and some of them really have taken these incredible team efforts. So I'd love to give you an example of one. And so I think the AI enabled Clinical Deterioration Index is an off the shelf EPIC tool that we introduced into RJW Barnabas Health. And we introduced it starting with a small pilot.

00:06:53:08 - 00:07:20:15
Amy Rockman
And it required a large interdisciplinary team of providers, administrators and tech experts who are really working, coming together on a weekly basis at one point to really review, as you introduced this tool. And so let me share what the tool is. It is a early warning system for clinical deterioration, flagging a patient for potential deterioration 24 hours before the deterioration is expected.

00:07:20:17 - 00:07:41:00
Amy Rockman
And so we all know that earlier intervention in many of these cases is essential. And so it's really a game changer to be able to have that much warning and be able to make a change and actually impacts the care. And you can impact the care in different ways. In our health system, we chose to impact the care by moving that person to the ICU in advance.

00:07:41:00 - 00:07:58:06
Amy Rockman
Other health systems have made different choices. But you have a choice people can make, and that's what matters. You can really respond sooner. And so in order to do this, though, and to make it work, a lot of thought needed to go into it. Because even though these products, many of these products, they're off the shelf, they should be easily implemented.

00:07:58:08 - 00:08:17:14
Amy Rockman
They might be easily implemented into your technical infrastructure if you have EPICF, for example. But that does not necessarily mean they're easily implemented into your work streams and your workflow. And so when we first implemented it, there was so much to think about as far as who is getting the flag? It's a rapid response team. How are we adjusting this team?

00:08:17:14 - 00:08:38:03
Amy Rockman
How is that getting to the providers? And then we're looking at constantly the sensitivity and specificity because we're getting false warnings. You know, we want to ensure we're not missing warnings. And so how do you adjust the algorithm when the algorithm is a complete black box? Most of the algorithms that we get, even when they're data analytics focus, we don't know everything about it because it's proprietary.

00:08:38:05 - 00:09:00:28
Amy Rockman
But in AI it's truly a black box in many of these situations. We don't know all how it's getting to the answers that it is. And so we need to create our own interpretability layer or explainability layer, if you will, to really try to understand. And so when we did that, we started to stratify and we started to see that there are different proportions in our population and in the population to which this was initially trained.

00:09:01:00 - 00:09:20:21
Amy Rockman
And so we can make some adjustments. We made some adjustments for hospice, for example, when we removed some of the stratum and we found that we could adjust it and really get it to an ideal sensitivity and specificity. Where now the 24 hour flags were so meaningful that we saw an over 18% reduction in in-hospital mortality.

00:09:20:23 - 00:09:35:29
Marc Boom, M.D.
Wow. That's very impressive. So that really meets that noble goal of what you're talking about with this. So when I've read up on your center and I think you already give us an example, but give us a little more around an inside of a living laboratory. What do you mean by that exactly?

00:09:36:01 - 00:09:56:04
Amy Rockman
Yeah. So we're, you know, exploring the world, and we're doing this work right in that real world health care setting. And so if you think about how we're moving research from bench to bedside, most of the work really is focused on that bedside space of integrating directly into the health care system. But as I mentioned, the AI life cycle earlier, right,

00:09:56:04 - 00:10:17:12
Amy Rockman
comes back to the bench. It comes back to homegrown at certain points. But it's a living lab because we're doing a lot of this evaluating and studying and all of this work together, interdisciplinary work in that real world space. And so what ended up happening is that we brought these interdisciplinary teams together to integrate into the workflow.

00:10:17:16 - 00:10:39:10
Amy Rockman
We also brought the interdisciplinary teams together to evaluate afterward as part of that lifecycle. And as we started bringing these different expertise and areas together, naturally, a research hub formed. And so you started to have everyone that I just mentioned who's in the health system trying to integrate and look toward those dashboards and those analytics and really make adjustments in the clinical workflow.

00:10:39:12 - 00:10:58:22
Amy Rockman
And now we're also introducing engineers and computer scientists and statisticians who are going to look even a little bit deeper from a research perspective. Now that we've fine tuned to a certain degree, let's look even deeper and really study and validate and ensure that we really know what we saw isn't due to confounders. What we saw is real, right?

00:10:58:23 - 00:11:15:28
Amy Rockman
That 18% drop is a real value that we're seeing, and that we took off line into a lab and studied it further. Once we have findings from that, which currently for the 20th Ethical Deterioration Index, we have a publication here under review with NEJM AI where we looked into all of those indicators.

00:11:16:00 - 00:11:32:26
Marc Boom, M.D.
You're impacting patient care and patient safety, and at the same time studying it and having the discipline to really make sure that it is indeed your interventions that are doing that and then sharing it with the rest of the world. So we can all move the needle forward. I mean, it's really wonderful the way the way you all do that.

00:11:32:26 - 00:11:37:18
Marc Boom, M.D.
So give me a couple other examples of some things you're working on these days.

00:11:37:21 - 00:11:57:07
Amy Rockman
Yeah, there's so many different tools and technologies out there and there's so many different areas where we're really trying to expand and understand this technology further. So we also introduced some different platforms that are ambient AI, which is really popular right now because it makes such a difference in our ability to practice medicine with our patients.

00:11:57:07 - 00:12:01:12
Marc Boom, M.D.
Yeah. You can count me as a fan. I use it in my primary care clinic, I love it.

00:12:01:15 - 00:12:19:28
Amy Rockman
That's great. Exactly. If you can have a tool that can record your conversations so that you can interact with the patient directly, then it's a game changer. And now they're even, you know, they're advancing so rapidly, able to take those notes and actually input it into the system for you. Now your documentation is potentially even better than before.

00:12:20:01 - 00:12:37:29
Amy Rockman
But with all these tools as we're introducing them, you really do need to think through those strengths and limitations. That's where that living lab model really comes into play. Because as we're introducing this, you can't take human in the loop out of that one, right? So at the moment you have your, you know, your analytics, your bridge, all of your different vendor products

00:12:37:29 - 00:12:58:06
Amy Rockman
that can do this ambient technology. When you get your notes back in your practice, you need to review it, right? It's like you got a trainee, right? Who's working on it. And they're great and they're amazing. But if you don't review those notes fully, something will get missed potentially. And that impacts the patient safety ultimately. So making sure human in the loop is there, especially as we move toward more advanced AI types.

00:12:58:06 - 00:13:17:23
Amy Rockman
And so there's a couple different ways that we're doing that. One is that as we start to build these homegrown technologies, we're moving toward agenda AI. And so now the AI is not only generating content, the AI is taking autonomous action potentially. And so human in the loop has become more important than ever. And ensuring that where that's needed, the human the loop is still there.

00:13:18:00 - 00:13:41:00
Amy Rockman
And there isn't a problem of overreliance, right? And that we're trying to reduce bias in the algorithm by reviewing thoroughly from a traditional practice perspective as well. Then there's also, again, as mentioned earlier, the explainability and transparency of the products themselves. And so we are trying to understand better because some of these tools are so powerful that we're introducing them due to the changes that we're seeing.

00:13:41:00 - 00:14:00:06
Amy Rockman
So we see, you know, that 18% drop in mortality and it's worth introducing that tool, right? But we also want to know how the AI is getting to the answers that it is. And so we're starting to think through in our AI learning lab, how do we actually make these tools more explainable. And starting to work with the vendors on how explainable is this tool and can we get there?

00:14:00:09 - 00:14:10:03
Amy Rockman
Do we only have post-hoc methods or we're looking at heatmaps? Do we have ante-hoc methods where the AI can actually show me its work, the same way that you would ask a person, a trainee or resident to show theirs.

00:14:10:06 - 00:14:20:18
Marc Boom, M.D.
I often hear that part of what AI is doing these days, nobody really totally understands in terms of some of that black box. So that that I imagine could be a little bit of a challenge, what you described there.

00:14:20:21 - 00:14:21:01
Amy Rockman
That's right.

00:14:21:09 - 00:14:26:07
Marc Boom, M.D.
If you could tackle something, what's the big something you'd like to tackle coming up?

00:14:26:10 - 00:14:47:24
Amy Rockman
There are so many different opportunities here. And this area is moving so fast. Everything is moving so quickly at lightning speed, and there's so little that we know at the moment. Right? We don't know, for example, there's not a lot of information about how this impacts your ROI when you first go to choose a tool. There's not a ton of information about how it might affect your patient population as you go to pick this tool.

00:14:47:28 - 00:15:05:03
Amy Rockman
All of these, you know, you need to some degree take a leap of faith and you need to invest in these tools. But these tools are the way of the future. And as we've seen, they're so incredibly powerful. And so I think one thing that we're working on is how do we maximize the strengths of these powerful tools while minimizing the limitations?

00:15:05:08 - 00:15:25:15
Amy Rockman
Right? And in many ways, it's both dual about how it's designed and how it's used, right? So we're introducing, for example, AI chat bots or for using automated response technologies. Speaking to a chat bot would seem like it's more empathetic, for example. Right. Because it never tires, or speaking to a chat bot that seem less empathetic because it feels like a robot, right?

00:15:25:15 - 00:15:41:02
Amy Rockman
Right. How the tool is designed and how that tool is used make such a difference? Same with the elements, right? So Open Evidence was released not so long ago, and it's a super powerful large language model to be using the clinical setting. But it really depends what prompts are entered into that.

00:15:41:08 - 00:15:42:07
Marc Boom, M.D.
Yeah. Input matters.

00:15:42:07 - 00:15:59:08
Amy Rockman
Yeah, exactly. Prompt engineering is an entire study of itself now. And what kind of you're going to use - is it going to be one shot or zero shot? You know, is it going to be structured? So training the next generation of providers to understand how to use these tools properly is a huge area for us. And how do we think through that.

00:15:59:08 - 00:16:26:03
Amy Rockman
How do we essentially ensure to the best of our ability that the tools are being used in a way that does minimize bias, that does minimize over reliance? MIT just came out with your Brain on ChatGPT study showing what a big cognitive debt you're seeing if there is overreliance on the tool. And so we're trying to avoid that by now educating the next generation on how to use this. By educating decisions that are in the hospital at this moment and are starting to get these tools.

00:16:26:03 - 00:16:44:18
Amy Rockman
And I will say that we've managed through this center, through this structure to drum up a lot of excitement about these tools. So we're seeing a lot of the providers are coming to us eager to get more and more and more of the tools. And so that's great. That's a great place to be. People are very interested in working on these interdisciplinary teams together, which is really important.

00:16:44:21 - 00:17:00:19
Amy Rockman
But so the key now is to ensure that every time we adopt one of these tools, we've thought through the process, we've thought through that AI life cycle. We've thought through how the providers are going to interact with it. How are you going to use it? We've thought through how is it designed. We have a sense of what the bias is for this tool.

00:17:00:22 - 00:17:22:24
Amy Rockman
Do we have a sense of what the explainability level is for this tool? And so we know to the best of our ability what we're acquiring and integrating into our health system. And we have an expectation of this powerful tool. What will be the change, the transformation we'll see? And then the super fun part for me with my epidemiology background is we're monitoring it and we're ensuring that that really happens.

00:17:22:26 - 00:17:38:12
Marc Boom, M.D.
Again, I'll say I love how structured and thoughtful you are and how you're liking it all of that, and now education as well. I mean, I know you have many residents. This is bringing up the next generation of physician residents, as well as obviously nurse trainees and others, which is great. Well, let me ask you one closing word.

00:17:38:12 - 00:17:55:21
Marc Boom, M.D.
If you had some closing thoughts to the colleagues who are watching this, you know, you all have a very impressive center. Not everybody is going to be quite as far along, but we're all on this very fast moving train. What would you say to those individuals about how to embrace change, how to invest in innovative technologies? What would be some key messages?

00:17:55:24 - 00:18:26:21
Amy Rockman
Absolutely. So communication is key and being honest, showing the excitement and potential of these transformative applications. But being practical about it, it's not always going to be easy. You're not going to see that transformation potential right away. I think some of the ambient technology is a great example of that. It also required a lot of tweaking before people felt like the output was to the same level as their own notes, and that they would take it without drafting, taking more time than if you just had written them on your own.

00:18:26:23 - 00:18:48:19
Amy Rockman
Right. So being really practical about that, but being supportive and excited. This is the first generation of these tools, right? We really put the investment into this. You'll see, as they continue to grow just more and more powerful to support our workforce. And that's a key piece of communication too, and the messaging is that AI is here to support and enhance our workforce, not to replace it.

00:18:48:21 - 00:19:04:03
Amy Rockman
And it has been enhancing it. You can tell it as you talk to a lot of the providers who are using it, they're excited. It's meaningful. There's change happening that makes them feel like they can have the joy of work back again. It makes them feel like they can really take care of their patients in a way that felt like it was gone for a while.

00:19:04:09 - 00:19:09:07
Amy Rockman
And these tools are there to make that difference in medicine.

00:19:09:09 - 00:19:31:12
Marc Boom, M.D.
I love that. You know, at Houston Methodist, we have kind of two overarching principles around new innovation in the work we do. And one is obsessive focus on the needs of our patients, the communities we serve. And then a close second is improve the lives of the people caring for those patients and connect them to the things human beings can do, you know, take away some of the drudgery and other things that prevent it.

00:19:31:13 - 00:19:51:12
Marc Boom, M.D.
Sounds like we're on a very similar page. So anyway, thank you, Amy, for your time today. What you're doing is really, really very impressive, very inspiring. And I know you all are already making a difference in people's lives. I can't even imagine as this promulgates across the field profession, you know, we all share that goal of keeping patients safe, keeping people at the center ready to do so.

00:19:51:12 - 00:20:01:09
Marc Boom, M.D.
Thank you again. Thank you, everybody, for finding time to listen. And I will be back in another month for another Leadership Dialog conversation. Thanks so much.

00:20:01:12 - 00:20:09:23
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 - 00:00:19:27
Tom Haederle
Welcome to Advancing Health. The American Hospital Association will hold its first Healthier Together conference in Dallas May 12 to 14. And while there, attendees will get to see an amazing local organization in action working to improve health with the city's underserved population.

00:00:20:00 - 00:00:52:18
Nancy Myers
Hi everyone. Welcome to the American Hospital Association's Advancing Health podcast. I'm Nancy Meyers, vice president of leadership and system innovation here at AHA. And I'm joined today by two great colleagues, Venita Owens, who's president of Baylor Scott and White's Health and Wellness Center, and Andrea Hays, who's manager of marketing and public relations for that organization. This May, the center is going to be hosting attendees of the Healthier Together conference in Dallas, Texas, for a community immersion experience.

00:00:52:21 - 00:01:12:03
Nancy Myers
So we're going to be talking in today's podcast about the center's key initiatives and discuss the impact of their programing across their community. Venita, I'd like to start with you. Tell us about how the Baylor Scott and White model of care stands apart in supporting and empowering the community that you serve.

00:01:12:06 - 00:01:50:22
Venita Owens
Hello, Nancy, and thank you for having me. The Baylor Scott White Health and Wellness Center model of care stands apart as a unique model of care by providing tools for individuals who are empowered to take care and charge of their health and their health outcomes. Our model of care is a unique one in that it brings together clinical care through our family health clinic, nutrition and chronic disease education, which is provided by registered dietitians and community health workers and physical fitness, which these classes are taught by trained professionals.

00:01:50:24 - 00:02:03:02
Venita Owens
We feel that bringing these three elements together work to make an individual well. And these services are provided free of charge to an uninsured and underinsured population.

00:02:03:04 - 00:02:31:18
Nancy Myers
I love that, you know, taking that whole person approach through the way that you've organized care and services at the center and truly advancing people's health is a team sport, right? So I know that you collaborate with community organizations in the greater Dallas region, like Bonton Farms in your work. Can you tell us a little bit about that collaboration and others like it that really are making an impact for your patients and your community?

00:02:31:20 - 00:02:58:20
Venita Owens
Absolutely. We collaborate with over 100 community organizations. We focus on health, and we allow our community partners to focus on their areas of expertise. It takes a village working together to address the social determinants of health in underserved and uninsured populations. Our goal is to support this community in their journey to becoming well.

00:02:58:23 - 00:03:10:17
Nancy Myers
Great. Andrea, I want to get you in on this conversation. Can you share a meaningful change that you've seen in the community as a result of the services that you offer through the center?

00:03:10:19 - 00:03:36:28
Andrea Hayes
Absolutely. Thank you for having me here today. And thank you for bringing this conference to, to the city of Dallas. A couple stories that like to, to talk about and just stories about our members. And one overarching story that I'd like to tell is about our model's reduction in ED utilization and inpatient admissions. So, we did a five year study based on all of our programs and services that we do.

00:03:37:00 - 00:04:03:07
Andrea Hayes
And we found that we had a 37% reduction in emergency department visits. And a 21% reduction in inpatient admissions at the hospital. And so what we're doing on the community level is helping to keep our members well, and not actually, you know, into the hospital emergency room, but getting care where they need it on the community level.

00:04:03:09 - 00:04:29:14
Andrea Hayes
One of the stories about a patient who was 64 years old, with elevated A1C and elevated blood pressure. And so we integrated them into our programs. One is our diabetes self-management education program. And then also, along with a farm standard and medical nutrition therapy, and then in four months their A1C was reduced to 6.2%

00:04:29:14 - 00:04:49:05
Andrea Hayes
and then they also lost 10 pounds. So that's an amazing testament to the programs that we have here and how it's improving the health of our community for each individual patient. And we customize the services, we meet them where they are on their journey and help them along the way. And we give them the tools to be well.

00:04:49:07 - 00:05:20:06
Nancy Myers
That's great. And I really like how you're using both that quantitative data around health outcomes and health care utilization, but you're also keeping it real by talking to folks about what's important to them and really bringing their goals and successes into the outcomes that you're tracking. Anita, back to you. So we are excited that we will be bringing the Healthier Together conference to Dallas in just a couple of months from this conversation that we're taping.

00:05:20:09 - 00:05:26:10
Nancy Myers
What can conference attendees expect to see and experience when they come to see the center?

00:05:26:12 - 00:06:01:27
Venita Owens
Well, we're excited about having the conference attendees also. And what they can expect is to observe a day in the life of a Baylor Scott and White Health and Wellness Center community member. This will include doctor's appointments, chronic disease education sessions, cooking demonstrations, fitness classes, and the purchasing of fresh produce from our farm stand at cost. Conference attendees will be able to participate in some of these activities and interact with the community members and our staff.

00:06:01:29 - 00:06:31:14
Nancy Myers
One of the things that we are really focused on as we bring this conference to Dallas and we'll be bringing it to other cities in the years to come, is making sure that everybody who attends walks away with learnings that they can take back to their own organizations and to their own communities and patient populations. What are attendees going to be able to take back to their own place of work after attending a site visit at the center?

00:06:31:17 - 00:06:58:20
Venita Owens
We hope attendees will feel the passion and commitment that we feel on a daily basis. This is a very hands on model, very hands on approach, and caring for the underserved population requires that. So we're hoping that they will take away that we are working to improve the health of these communities one person, one family, and one community at a time.

00:06:58:23 - 00:07:18:01
Andrea Hayes
We're just excited to be able to feature what we do and let people see what's going on in our community. And it's just amazing to actually see our model in action, and we want them to take that back. And certainly we know that it's scalable. And so we want to showcase that this can be done in other communities.

00:07:18:03 - 00:07:40:28
Nancy Myers
Thank you for that. I want to as we come to the end of our time here thank you both again. First and foremost, for sharing your expertise with us. Most importantly for the work that you're doing every single day to really improve the health of the people who've entrusted their care to Baylor Scott and White. I'm really looking forward to seeing you in Dallas.

00:07:40:28 - 00:07:53:25
Nancy Myers
To those of you who are listening in, please check out our conference website and make plans to join us in person as well. And thanks to all for the work that all of you are doing every day in your communities. Be well.

00:07:53:28 - 00:07:54:21
Venita Owens
Thank you.

00:07:54:24 - 00:07:56:15
Andrea Hayes
Thank you.

00:07:56:18 - 00:08:04:29
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:00 - 00:00:22:11
Tom Haederle
Welcome to Advancing Health. For many hospitals and health systems, a relatively small number of patients rely heavily on the emergency department for their care. Hear how University of Utah Health is taking a different approach, using intensive primary care to support patients navigating complex medical and social challenges.

00:00:22:14 - 00:00:51:26
Julia Resnick
Hi everyone. I'm Julia Resnick, senior director in the Division of Health Outcomes and Care Transformation here at the AHA. Today we're here to talk about care delivery transformation, particularly primary care transformation. I'm happy to be joined today by three outstanding leaders from University of Utah Health. Joining me are Dr. Peter Weir, chief population health officer, Dr. Erica Baiden, medical director of the intensive outpatient clinic, and Kerri Burns, behavioral health lead also at the intensive outpatient clinic.

00:00:51:28 - 00:01:06:25
Julia Resnick
Thanks to the three of you for joining me, let's jump right in. I'd love to learn a little more about what led University of Utah Health to create the IOC and what gap in traditional primary care are you trying to address? Peter, why don't you kick us off?

00:01:06:27 - 00:01:40:25
Peter Weir, M.D.
So the way the concept started was we have at the University of Utah, a internal insurance component to our health system, which is the University of Utah Health plans. And you'll hear us refer to them as UUHP, University of Utah Health plans. And they manage a Medicaid. It's called the Medicaid ACO Accountable Care Organization for the state. So the state delegates a portion of the Medicaid population to our health systems insurance side to help manage that population.

00:01:40:27 - 00:02:08:04
Peter Weir, M.D.
And so I went to them about nine, ten years ago and said, do you have a small group of people within your Medicaid population that are really, really hard to care for because they appear to over utilize? Go to the ER frequently and get admitted to the hospital frequently? And of course, like any group that manages a large population of people, there's always a small percent of people utilizing services at a really, really high rate.

00:02:08:06 - 00:02:29:29
Peter Weir, M.D.
So it was pretty easy to identify who they were. And then the idea was is it possible to create a clinic and hire the right people to provide services to help address the issues that might be leading to the overutilization? And I say it that way in a way that has a little ambiguity to it, because we didn't know how to do it or what we were doing

00:02:30:00 - 00:02:38:00
Peter Weir, M.D.
honestly, when we first got started. And there was a lot of lessons learned. But that was sort of the original conception of the idea and how it got started.

00:02:38:03 - 00:02:44:19
Julia Resnick
So that makes a lot of sense. And I'm really curious about, you know, when you're intentionally designing primary care like that, what does it look like?

00:02:44:21 - 00:03:03:25
Peter Weir, M.D.
Yeah, so initially we went into it with a very strong medical model, which is a very physician-centric way of thinking, which is this is all medical, right? In my head, I used to think this is going to be a medically fragile patient population, like people with heart failure that was really hard to treat and things like that.

00:03:03:27 - 00:03:25:08
Peter Weir, M.D.
But as we began bringing people into the clinic, our social worker at the time said to me, the first ten people we brought in, all ten had had significant childhood abuse, both physical, verbal, like neglect, like a really, really rough childhood, lots of trauma. And I thought, this is what I said to her, actually. Wow, what a coincidence.

00:03:25:09 - 00:03:49:14
Peter Weir, M.D.
And she said, no, it's not a coincidence at all. And so what we realized by selecting for like, high ER visits, what we were doing, we were beginning to select for a population of people that had needs that extended way beyond medical needs. They were social needs. They were behavioral health needs. They were, in some cases, substance use problems, in some cases precarious housing.

00:03:49:16 - 00:04:23:21
Peter Weir, M.D.
But what really bound our patients together was this idea of having had significant trauma that led to like difficult, challenging coping strategies and skills. And it led to this kind of frequent use of the ER and hospital. Kind of stumbled into that. I honestly, we didn't foresee that we had to slowly begin to hire the right people. And I want to have Kerri step in if I could, hiring people that could address those issues, which they're not like typical things that health system would address. This isn't a typical set up.

00:04:23:21 - 00:04:29:24
Peter Weir, M.D.
It's quite customized to the needs of this population. Kerri, do you want to maybe expand on that?

00:04:29:27 - 00:04:55:27
Kerri Burns
Yeah. I mean, I think we look at not only do these folks have, high medical needs, which causes a certain amount of trauma, but also their social situations, like Peter spoke about. So a lot of times we have them, their high medical needs. So they go to the ED because they don't have the right coping skills to say, what can I do and what can I do not to go to the ED?

00:04:55:29 - 00:05:27:11
Kerri Burns
What can I do to solve my problem without rushing to the ED because that's the only thing they know how to do. They just want it fixed. And with us working with them to improve their coping skills and improve resources in their lives, they can come up with better choices, hopefully after a certain amount of time, and then they can bring down their ED use and hopefully expand their coping skills and strategies and work through some of their trauma.

00:05:27:13 - 00:05:45:11
Julia Resnick
I imagine that to meet the medical and social and emotional needs of your patients at the IOC, you need to be very intentional about how you're structuring your care teams. So can you talk a little bit about how you're thinking about that and who the different health care providers are that are on those teams and what that looks like?

00:05:45:13 - 00:05:47:09
Julia Resnick
Erica, let's hear from you.

00:05:47:12 - 00:06:11:25
Erica Baiden, M.D.
In order to create this kind of team, we also have to understand that first, it started with health care leaders and our health insurance planning a UHP to have this innovative way of reframing how we care for this vulnerable population. And the team that we have is very integrated with medical support, behavioral health or therapists, care managers and medical assistants, and our front desk.

00:06:12:00 - 00:06:46:15
Erica Baiden, M.D.
Each of the people on this team have a way of building rapport, trust, and care for these vulnerable patients that have very specific care seeking patterns that are leading to their utilization. What we found with this framework, or method of delivering care for this population is that there's a lot of fear and uncertainty behind their utilization, and it takes the right people to sit and be patient and unpack all those layers that drove them to this utilization pattern.

00:06:46:15 - 00:07:07:27
Erica Baiden, M.D.
And so though we have people with different credentialing, there's something inherent within the team that we were able to hire and put together that has this beautiful and innate ability to just see people and I mean see people through that surface, that utilization and really get to the heart of the matter .

00:07:07:29 - 00:07:17:15
Kerri Burns
And if I could just add, we have a small team, but it's really important that we're all on the same page once we figure out what's driving our patients.

00:07:17:17 - 00:07:38:27
Kerri Burns
For instance, Erica and I have a patient that we figured out not too far in after they came to the clinic, that when she feels pain, her mental health declines. And so we had to come up with strategies to help her realize, you know, yeah, I'm having pain. How do we deal with that? Because she would be in pain.

00:07:38:27 - 00:07:49:08
Kerri Burns
And then all of a sudden she was suicidal. So us, all giving the same message, all helping her in the same ways is really important.

00:07:49:10 - 00:07:53:15
Julia Resnick
What's it like working as a provider on the sort of interdisciplinary team?

00:07:53:17 - 00:08:18:22
Erica Baiden, M.D.
Medically, I don't know how to practice any other way without this interdisciplinary team. We learned how to lean into the skill sets of our different team members in order to see the whole person. Because if we're just seeing it from the lens of the medical condition, we're going to miss so much of what's really driving the utilization for this particular person or what's that underlying concern that they have.

00:08:18:25 - 00:08:31:09
Erica Baiden, M.D.
So again, as Dr. Weir said, in the beginning, it was very medical provider or medical-centric, but we've moved towards this more holistic, patient centered, integrated approach.

00:08:31:12 - 00:08:46:08
Kerri Burns
And as a clinician, oh, man, I know way more medical things than I ever wanted to know working in this clinic. But it's been nice. And to be able to see the correlation between medical issues and behavioral health issues.

00:08:46:10 - 00:08:56:27
Julia Resnick
And for patients, what does it look like and feel like to receive care at the IOC? And do you have any patient stories that you can share that really illustrate what it's like to get care there?

00:08:57:00 - 00:09:27:02
Erica Baiden, M.D.
One of our patients who came from a history and a childhood of neglect, a parent with severe mental illness, a habit of picking partners that were not always kind to her, but she was always seeking to find her needs met, but not in ways that they were perfectly being met. And so one way that she coped was to use the emergency department, because that was a time where she was alone.

00:09:27:06 - 00:09:51:16
Erica Baiden, M.D.
She didn't have to care for her kids. She had the attention that she needed. And in those few hours she was cared for. There was space held for her to get that rest, to get that care. But we've been able to work together in an integrated fashion to really understand and help her understand. When you feel this way, where is the best place to get your support or just to even acknowledge and validate?

00:09:51:17 - 00:09:57:24
Erica Baiden, M.D.
Yeah, we know this is hard. We know you're overwhelmed and sometimes it just takes that pause.

00:09:57:27 - 00:10:18:27
Julia Resnick
Such a wonderful example of, you know, going from just realizing that they're, you know, a frequent utilizer of the ED to really understanding where that comes from and trying to get at it. At the root of their - what is clearly not just a medical issue, but an emotional issue. And that's incredible that you have a clinic that is built just for people like that.

00:10:18:29 - 00:10:23:03
Julia Resnick
Peter, can you talk about the operational and financial model for the clinic?

00:10:23:05 - 00:10:48:28
Peter Weir, M.D.
The first part of this that's key is having a payer partner willing to do this work together. And we've had a great relationship with our own University of Utah health plans. They've been a fantastic partner, extremely supportive. And without them, none of this would exist. And you're exactly right. You need a novel payment mechanism to reward this type of work because it doesn't fit in a fee-for-service world.

00:10:48:28 - 00:11:09:04
Peter Weir, M.D.
So if anyone's listening like, oh, this sounds really cool, I'm going to do it. You literally cannot do it in a fee-for-service manner. At least I can't figure out how you do it. We don't even come close to our fee-for-service reimbursement to cover our costs. So there has to be a value based payment or an alternative payment model or something else to incentivize the care coordination, the mental health piece.

00:11:09:04 - 00:11:29:03
Peter Weir, M.D.
We also do a lot of oral health integration, which we haven't talked about. But that's another key component is working with our School of Dentistry colleagues to aid in the oral health problems our patients suffer from, which is often frequent and significant. But I have to say, just if people are listening, curious about this. It isn't easy to find, like the payment model to do this.

00:11:29:03 - 00:11:45:17
Peter Weir, M.D.
It's this negotiation, this back and forth. And then there's also this interesting thing where you can look at the data in different ways. So the data is the data, but then how you look at it and how you analyze it in terms of impact is also somewhat subjective in terms of how people want to do it and depends on their assumptions and things.

00:11:45:17 - 00:12:07:08
Peter Weir, M.D.
So there's always a back and forth. But essentially what we do, just to give people an idea, we do the fee for service billing to get as much of that part of it done as we can, and we try to kind of optimize our billing side of things. And then there's incentives for like quality and HCC coding, which for all of you out there that are familiar with this world, that's kind of inherent.

00:12:07:10 - 00:12:30:12
Peter Weir, M.D.
But there's also then money that goes towards the care coordination we provide, which we have to document in our medical record system in terms of time spent as well as an incentive to reduce ER rates and hospitalization rates. We've tried to look at the total cost of care, but our census is small, it's 150 people. And the variability of year to year looking at total cost is like, it's a mess.

00:12:30:12 - 00:12:52:00
Peter Weir, M.D.
It's really hard to do. So it's easier looking at utilization patterns. And I'll say one more thing that’s really complex that people wouldn't...might not think of right away is, sometimes that your reduction doesn't happen until year two. It doesn't happen in the 12 month cycle. And so insurance companies kind of look at the world through a 12 month window, and we have to get them to like think a little bit broader.

00:12:52:00 - 00:13:08:15
Peter Weir, M.D.
And luckily we do have people in our health plans that have a clinical backgrounds, just nursing and are willing to have a broader view that this is more complicated and you have to look at it through a lens that, you know, incorporates a little bit longer time frame than you would maybe in a traditional setting.

00:13:08:18 - 00:13:27:15
Julia Resnick
You raise a really important point that, you know, we're talking about people who have a lifetime of trauma and medical conditions. You're not going to change all of that in one year, and it requires patience and ongoing engagement, to get to that point. But to Kerri and Erica, you know, you're serving this patient with really complex medical and social needs.

00:13:27:18 - 00:13:32:28
Julia Resnick
And so how do you measure impact? How do you know that you're on the right path?

00:13:33:00 - 00:14:04:23
Kerri Burns
We have to look at - I call them like small wins in the regular therapeutic community. You will see a patient for, you know, 6 to 8 visits and you give them coping skills and they have goals and then they transition out of therapy. That's not how we look at things in our clinic. We look at things like, oh, they were, you know, hospitalized for suicidal ideations ten times last year, and now they've only been hospitalized once.

00:14:04:25 - 00:14:05:28
Julia Resnick
Erica.

00:14:06:00 - 00:14:30:28
Erica Baiden, M.D.
It's about movement to stability. When we first meet a patient, they're often in a state of maybe something is chaotic. There's several unmet needs. And it's just that longitudinal effort of moving them from one space of stability to another. And again, like Kerri said, it's the small wins that we look at every day. Did they show up for this appointment?

00:14:31:00 - 00:14:58:02
Erica Baiden, M.D.
Have they been able to build a community even as a lot of our patients are socially isolated, and that's something we don't get to talk much about in a typical health care setting. But they've been able to establish community. They find a space of safety outside of their home. Sometimes we become their point of contact when something significant happens, or they become acutely destabilized and they find solace within our clinic walls.

00:14:58:02 - 00:15:05:18
Erica Baiden, M.D.
And so there's so many definitions. It's not typical, but it's what the patient needs at that time.

00:15:05:21 - 00:15:32:15
Peter Weir, M.D.
One other small thing, I think is a helpful framework to think about impact, which is the way over the years we've seen it work, typically is it starts with building trust and rapport. And then that slowly leads to engagement with their health and their health concerns. And then sort of the last to move is the utilization. So like if you look at it just through a utilization lens, that's a blunt way of looking at it.

00:15:32:15 - 00:15:52:08
Peter Weir, M.D.
And it's actually a late effect. It starts with trust. And like the term that we use internally is "trust is our currency." It's everything. What we're doing, when we look through the claims data is finding people and inviting them in. And they often start off very skittish and like they're testing us. They test a little bit at a time, a little bit here, a little bit

00:15:52:08 - 00:16:14:08
Peter Weir, M.D.
there. Like, “is this thing for real? You guys really that interested and invested in me?” because they've been burned so many times and also retraumatized so many times. So we have this very trauma-informed care model that really gently begins to build that trust back up again. And to me, like, that's how it all starts and you have to build off of that.

00:16:14:11 - 00:16:37:14
Julia Resnick
That is profound and so important for everyone listening. So I want to thank all of you for being here, for the work that you do, to serve patients in your community. It's truly inspiring, and I hope that our listeners can pull out some tidbits from what you're doing to apply in their settings, so that everyone can receive that kind of holistic, person centered primary care that your patients are able to.

00:16:37:16 - 00:16:41:07
Julia Resnick
So thank you for all that you do and for sharing your expertise with us.

00:16:41:10 - 00:16:59:04
Peter Weir, M.D.
Yeah. Thank you very much for having us. It's really near and dear to us. So it really feels good to be able to share that with others. And if anyone is interested in connecting with us, we'd also be happy to connect. We're at the University of Utah and we're pretty easy to find online, so please look us up if there's a follow up.

00:16:59:06 - 00:17:07:17
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.