Advancing Health Podcast

00:00:00:18 - 00:00:39:00
Tom Haederle
With similar missions, psychiatric hospitals and community mental health centers sound like they should be two peas in a pod. But in reality they're often siloed, working independently and not coordinating their efforts to meet patients needs. Butler, a renowned psychiatric hospital in Rhode Island, decided to change the equation - forging a close and cooperative relationship with the Providence Center, a community mental health center, and resulting in patient satisfaction rates that are off the charts.

00:00:39:02 - 00:01:06:03
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. For people experiencing severe and persistent mental illness, the goal is to treat and support them in their communities of choice. That's not necessarily a hospital. By closely coordinating their services and resources, Butler Hospital and the Providence Center are able to accommodate that objective and provide a more seamless continuum of services for patients.

00:01:06:06 - 00:01:29:10
Tom Haederle
In this podcast hosted by Rebecca Chickey, senior director of Behavioral health, Clinical Affairs and Workforce with AHA, Mary Marran, president and CEO of Butler Hospital, describes how the enhanced partnership between two mental health service providers has made a big difference. This podcast was recorded at the American Hospital Association's Annual Membership meeting in Washington, DC.

00:01:29:12 - 00:02:00:04
Rebecca Chickey
Thank you, Tom. And Mary, thank you for joining me today here at the American Hospital Association's 2024 Annual Meeting. So far, it has been just a phenomenal event, and we're going to add to it today with learning about Butler Hospital and its relationship with the Providence Center, a community mental health center. So, if I may, I want to start with asking you to describe what is that relationship between Butler, an internationally renowned psychiatric hospital, and the Providence Center?

00:02:00:07 - 00:02:02:11
Rebecca Chickey
Can you share and what was the journey to get there?

00:02:02:12 - 00:02:26:19
Mary Marran
Sure. Thanks. First, let me thank you for the opportunity to talk about our great work in Rhode Island. And it's an interesting story, quite frankly. The Providence Center joined Care New England, which is our health system that includes Butler Hospital - the psychiatric hospital I ran - about 5 or 6 years ago. At that time, they had their own CEO and president, and we moved them into the corporate shared services structure.

00:02:26:19 - 00:02:49:29
Mary Marran
It was a great way to support the great work of the Providence Center. Along the way, the president resigned, and ultimately I ended up stepping in as an interim to run the Providence Center. We tried to recruit a president for a period of time. We weren't really successful. So we decided for essentially now that I would run both the hospital and the center.

00:02:50:02 - 00:03:13:24
Mary Marran
And boy, what a privilege it's been. Because historically, and I think most people know this and it's not a bad thing, but community mental health centers hospitalization is a failure. The center is about days in the community. It's about supporting people with severe and persistent illness in their communities of choice. So when someone has to go into the hospital, truly that's considered a failure.

00:03:13:26 - 00:03:38:23
Mary Marran
I think what we've learned from the pandemic is there's so much need in our communities for the treatment of behavioral health services and our ability to partner and support each other with the unique services we bring, and combine those in a way that we fill the gaps, quite frankly, we're doing a great job with the transitions of care, particularly for the severe and persistently ill.

00:03:38:25 - 00:03:50:21
Mary Marran
So my ability to run both organizations and really connect the people that do this work, elbow to elbow, really does result in some tremendous outcomes, which I'll be happy to share with you.

00:03:50:23 - 00:04:07:10
Rebecca Chickey
Yeah, you teed that up so nicely because that's exactly where I was going to go next. As you say, there historically has been a silo or a big wall, often between community mental health centers and hospitals and sort of peering over the wall every now and then and going, what are you doing? And are you playing in my sandbox

00:04:07:10 - 00:04:40:11
Rebecca Chickey
sometimes. But more and more, I would say I've seen over the last 15 years or so, hospitals and community mental health centers coming together and specifically to have a full continuum of care because discharging patients from an inpatient setting can also be challenging, and that transition of care is a pain point often. So tell me what you have been able to do in care transitions that has really, I think based on the tone in your voice, strengthened the relationship between Butler and Providence.

00:04:40:14 - 00:05:06:04
Mary Marran
So, many things. But let me start with probably our first, most significant move, which was we've located one of our Act model integrated health home teams. So it's a sort of community treatment. We have a team that actually lives within the hospital, in offices that are, you know, maybe 50 yards from the inpatient units. What I love about this, it was my Providence Center staff who'd named the team.

00:05:06:10 - 00:05:38:13
Mary Marran
It's called Unity. It speaks to that coming in they understood that this is a job we need to do together. And actually, from people who meet the requirements for a sort of community treatment, there's about 300 people now served within that hospital based function. We actually are going to add a second team because the caseloads have increased. What it allows for is really both early identification of individuals who need this intensive community treatment and a warm handoff.

00:05:38:15 - 00:06:13:00
Mary Marran
Our staff can go...I should say my staff at the Providence Center because I have staff at the hospital as well...they can go right to the unit, meet the patient, talk to the patient about what the transition is going to look like, and move the patient right to the community services, keeping in mind that within the health home team, there are peer services, wraparound services that they will then plug in to, increasing the likelihood that the transition to the community will be successful, decreasing the likelihood that a readmission will follow, which is really important to all of us.

00:06:13:03 - 00:06:34:20
Mary Marran
So one example. The other example is we actually have a 24/7 call center at the hospital, and we cover the emergency line for the Providence Center. So if a client has a crisis in the community, they call Butler, we're able to engage the staff at the Providence Center, work first to divert, if possible, safely divert the patient.

00:06:34:20 - 00:06:54:21
Mary Marran
But if the patient needs to come in for any reason, we can get them into the emergency room, admit them if we need to, hold them till morning. Really connect them to the people they know at the Providence Center. Another great example is recently we were really struggling with folks who suffer from addiction. Come to our detox unit.

00:06:54:23 - 00:07:19:03
Mary Marran
Typically it's for alcohol use disorders, but they're our most frequent readmissions, are highest utilized hours. We were having trouble breaking that cycle. And this is what's changed at the hospital, is when we think of these transition issues, we first think about our partners at the Providence Center. What might we do with the Providence Center that can help with these transitions?

00:07:19:03 - 00:07:56:00
Mary Marran
Well, the Providence Center has a network of recovery centers, anchor recovery centers, and they have peers who help us in the EDs. They help us throughout the community. But at Butler, what we asked is, could you potentially bring peers to our unit before we try to discharge and see if we can't make that connection there? So it's only been about six months now, but we're starting to introduce peers on the detox unit to help navigate that transition by someone who has lived experience, which is one of our most powerful tools in the community.

00:07:56:00 - 00:08:26:03
Mary Marran
So that's another great example of the work that we're doing. The Providence Center has a huge challenge with individuals who are discharged from the hospital. We set up intake appointments yet high no show rate. So first intake at the Providence Center and it's not always people who are coming from Butler. The folks coming from Butler now, we do the intake right at Butler with the Unity team. Even if they may not need at level services

00:08:26:03 - 00:08:51:29
Mary Marran
we get them connected. They might need outpatient, they might need something else in the Center. But we're able to tie that handoff so that you do that quickly. You don't give opportunity for that person to leave and, you know, not be able to engage them in whatever service they need. So working with Butler to make sure that anybody coming from Butler, we try to increase the likelihood that they're going to engage and start treatment. Again,

00:08:51:29 - 00:09:17:06
Mary Marran
that unity relationship helps with that. We also work with the social service staff at Butler around individuals that they're sending that aren't necessarily going to go to Unity. And we really try to understand is the appointment time convenient? Transportation, all of those social drivers that might interfere and that tight relationship with Butler. We have a better rate of first appointment show rates.

00:09:17:09 - 00:09:35:29
Mary Marran
We struggle with some of the other hospitals. We're doing things to try to engage some of the other hospitals that refer. But with Butler, because of that tight relationship, we're really able to impact that no-show rate. It was pretty high. It was almost half, and we're overbooking, but still that miss. But it's that collaborative work where we brought that down.

00:09:35:29 - 00:09:43:10
Mary Marran
Now last week it looked like it was down to like 20% no show, which is, believe it or not, a pretty good no show rate for the community.

00:09:43:13 - 00:10:07:06
Rebecca Chickey
And that is incredibly significant. You shared so much. One of the things I want to compliment you on is everything you described seems like it is trying to treat the whole person. We were reminded yesterday in one of the sessions that only 20% of health can be managed or influenced by hospitalization, and that leaves a significant part for those of you who are not the math person, that leaves 80%

00:10:07:06 - 00:10:34:10
Rebecca Chickey
that's influenced by everything else that impact human beings on a daily basis. And so this partnership with the Providence Center helps you be able to better address that 80% and treat what's influencing their health. And it also sounds like, particularly those last two examples, that you provided relationships. The Surgeon General recently, within the last year or so, released a report on loneliness and how loneliness it really is becoming an epidemic

00:10:34:10 - 00:10:54:14
Rebecca Chickey
in many ways. It existed before the pandemic, but the pandemic has influenced it. And bringing those peers from the Providence Center into the detox unit, that allows them to have a relationship. And instead of when they're already going through a transition after discharge, trying to establish that relationship. So how brilliant. Thank you.

00:10:54:17 - 00:11:15:06
Mary Marran
Well, and I think that quickly, the other thing that we've learned as a hospital, we've adopted service design from the Providence Center. We actually have an integrated health, an Act model team that we run at the hospital for the commercially insured who suffer from severe and persistent mental illness. We largely serve the Medicaid population from the mental health center.

00:11:15:06 - 00:11:38:28
Mary Marran
We modeled our service after the Providence Center and a lot of our transitional services with case management. These are lessons we've learned from the Providence Center. Social drivers. If we really want to appreciate social drivers, our community mental health centers have been doing this work forever, understanding that in order to actually get to care, you really need to help the individual with those challenges.

00:11:38:28 - 00:11:49:21
Mary Marran
Housing, transportation, food, insecurities, things that are barriers to care, and our mental health centers - and the one I have the privilege to run - have great expertise in that area.

00:11:49:26 - 00:11:56:07
Rebecca Chickey
Yeah, it's so important. Have you been able to track as a part of this any impact on patient satisfaction?

00:11:56:10 - 00:12:20:07
Mary Marran
In terms of the clients at the Providence Center, the patient satisfaction rates are off the charts. The connection to our staff, and quite frankly, our staff are so tightly tied to each other that experience for our clients is really highly regarded. So, absolutely, for those folks who are working with in transition, we're getting great satisfaction results.

00:12:20:08 - 00:12:21:10
Mary Marran
Yes.

00:12:21:12 - 00:12:22:19
Rebecca Chickey
How about the staff?

00:12:22:22 - 00:12:42:03
Mary Marran
Yeah. So it's interesting more and more. And it's a matter of routine now that when we're trying to solve a problem, I bring the teams from both the Providence Center and Butler together. And so at first you're sort of bumping around the table and it's Butler. It's the Providence Center. But now they do it themselves. They have a question.

00:12:42:06 - 00:12:54:12
Mary Marran
Workforce development. Another area where we're at the hospital mimicking some of the ladders, the professional ladders that we've developed at the Providence Center. And those things now are fluid, which is just wonderful.

00:12:54:14 - 00:13:14:11
Rebecca Chickey
That's so great. I had the opportunity last week to interview a community health worker, and I asked her why she chose that career, and at first she was hesitant. And then I said, well, what do you love about what you do? And she said, working with the people when they contact me and they say, you have a really helped me turn my life around.

00:13:14:13 - 00:13:21:01
Rebecca Chickey
And that's something that is invaluable. And she just got this big beam. So I expect that you see that as well.

00:13:21:01 - 00:13:49:27
Mary Marran
And it's not uncommon for me to receive an email sometimes through a staff member, sometimes directly from a client, from a patient at the hospital. And they're appreciative and delighted with the experience. And some of the best stories you're going to hear are from the folks who feel compelled to tell us about it, which is wonderful. And yes, we share that with our staff, and it's a moment where you can really underline how significant the work is that we're doing in this space in behavioral health.

00:13:49:29 - 00:14:08:24
Rebecca Chickey
So I'm going to ask the question around funding, because we all know that hospitals and health systems are being asked to do more and more with less and less. That's how it feels, particularly given Covid and the financial impact that that had. What have you seen in terms of the financial impact of this collaboration?

00:14:08:27 - 00:14:42:28
Mary Marran
I would say that what we're seeing is recognition that we cannot ignore this behavioral health crisis in front of us. So why forget when we did the podcast about the behavioral health short stay unit that I'm opening - entirely publicly funded. State/federal dollars, $12 million to permit me to open up this unit. The hospital has never seen that, but I believe people really understand that if we don't address this problem, it's going to affect us all in our economy, in the overall health of the population.

00:14:43:00 - 00:15:13:02
Mary Marran
The Providence Center is working right now with the state of Rhode Island, who has given us grant funds for workforce stabilization. So we did receive several million dollars to actually pay our staff market competitive rates, because everybody needs the talents of the folks doing the most difficult work in the community. So investment recognition by the state. Right now, the entire state is working on all of the mental health centers becoming CBHCs, so certified behavioral health clinics.

00:15:13:06 - 00:15:31:00
Mary Marran
And there's been a fair bit of grant funding from the state of Rhode Island to support us through that process. If all goes well, by October 1st, all of the community mental health centers that are licensed in Rhode Island will be CBHCs, and a couple other agencies are being added to that list. So in Rhode Island, could we use more?

00:15:31:02 - 00:15:43:28
Mary Marran
Absolutely. Are we struggling financially through this transition to CBHCs? Yes. But the state is, I think, really trying to do their part in helping us through that transition. We're very fortunate.

00:15:44:01 - 00:15:54:11
Rebecca Chickey
Now that's phenomenal. And it sounds like your state leadership has really gotten behind this and acknowledged the problem and not just talked about it, but actually stepped up and said, here's some funding.

00:15:54:15 - 00:15:59:07
Mary Marran
State and our federal delegation has been really active in helping us through this work.

00:15:59:10 - 00:16:05:19
Rebecca Chickey
That's great. Since we're here in D.C., yes, you may be going to the Hill to thank them or inform them.

00:16:05:20 - 00:16:13:17
Mary Marran
A nice thing about Rhode Island is they come visit us often. You know, we're small, 40 square miles. We do see our delegation. Awesome. And they've been wonderful to us.

00:16:13:19 - 00:16:38:01
Rebecca Chickey
That's phenomenal. So as I'm looking at time and wrapping up, you have shared a number of reasons for hospitals and health systems to be inspired by this community partnership. As you and I have talked about many times, there's not one solution to improving access to care. There's integration. There's reducing the stigma, there's technology, digital solutions. But community partnerships

00:16:38:01 - 00:17:06:04
Rebecca Chickey
I truly feel hit so many sweet spots because we're all caring for the same patients. And if you can coordinate that care across the continuum, particularly for individuals with chronic severe mental illness, it's just common sense. Although my son once said, mom, common sense is not that common anymore, and he has some common sense just by saying that, I'll say. But are there particularly 2 or 3 things you would say to inspire other hospital or health system leaders, too.

00:17:06:07 - 00:17:27:27
Mary Marran
I would say one, it's a great investment in terms of the time we put into these partnerships with our community providers. It quite frankly makes good sense clinically and good sense economically to really support those partnerships. I would also say there's a lot of work for us all to do, and the degree that we can collaborate together to get it done.

00:17:27:29 - 00:17:53:02
Mary Marran
And it's a rewarding process that quite frankly, we have to remind ourselves it's not competitive, it's cooperative. And the more we do that, the more patients we serve, the healthier they're going to be. And again, investment in behavioral health is really an investment in the overall health and well-being of your population. And lastly, there's a lot to learn from our community agencies and providers, health and human services providers like the Providence Center.

00:17:53:08 - 00:18:10:20
Mary Marran
They've been doing the work that we're talking about, being so important. Social drivers, taking care of those things that disrupt care, they know how to do it. We have a lot to learn from our community providers, and we should all lock arms with agencies like the Providence Center. The outcomes are pretty special.

00:18:10:23 - 00:18:33:16
Rebecca Chickey
Mary, thank you so much. Thank you for joining us here today. Really appreciate it. I'll let the listeners know there is a website on AHA.org/behavioral health. And if you scroll down on that page you'll see an icon and the words Community Partnerships. So if you click there you can listen and learn and read about other community partnerships.

00:18:33:23 - 00:18:45:19
Rebecca Chickey
Because this one is unique and each one has their own unique journey. But we can learn from all of them. So please consider taking a look at those resources. And Mary, just keep up the great work.

00:18:45:20 - 00:18:48:21
Mary Marran
Oh thank you. Thanks for the opportunity to talk about it.

00:18:48:23 - 00:18:57:05
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;19 - 00;00;42;23
Tom Haederle
John Bluford's distinguished career in hospital and health system administration has spanned more than four decades. He's been recognized as one of the most influential people in health care, and served as chair of the American Hospital Association in 2011. He's also the founder of the Bluford Health Care Leadership Institute, a professional development program that introduces talented minority undergraduate scholars to health care administration with the expectation that this pipeline of talent will ultimately help to eliminate health disparities among populations dealing with sustained hardship.

00;00;42;25 - 00;01;08;05
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. In this podcast, hosted by Joy A. Lewis, senior vice president of Health Equity Strategies with the AHA, Bluford describes how his institute trains promising young talent to assume leadership roles... the impact they've made...and how to deal with pushback in some quarters against DEI efforts in general.

00;01;08;07 - 00;01;14;25
Tom Haederle
This podcast was recorded at the American Hospital Association's Annual Membership Meeting in Washington, DC.

00;01;14;27 - 00;01;19;20
Joy A. Lewis
Good morning John. Thank you so much for joining me today. Is it fine to call you John?

00;01;19;20 - 00;01;21;02
John W. Bluford, MBA
Please do. Good morning to you.

00;01;21;02 - 00;01;46;10
Joy A. Lewis
Because I am sitting with the John Bluford. And this came together rather quickly, so I guess my timing was right. Thank you for carving time out of your busy schedule to join me in conversation today. Today's conversation is a really important one. We want to focus on how might we think about ways to create a diverse talent pool of health care leaders?

00;01;46;12 - 00;02;11;24
Joy A. Lewis
We know how important it is to have a diversity of thought, different perspectives weighing in, making decisions that then lead to better health outcomes for the patients and families and communities that we serve. So currently, you are the president, but also the founder of the Bluford Health Care Leadership Institute, which was established over a decade ago in 2013.

00;02;11;27 - 00;02;33;03
Joy A. Lewis
And your program trains and mentors and prepares early careerists to occupy, to advance through into leadership roles in health care settings. And I guess in addition to how you're spending your time today, we should talk about your tenure. Your career portfolio, which includes...

00;02;33;03 - 00;02;33;12
John W. Bluford, MBA
It's been a long one.

00;02;33;12 - 00;02;36;09
Joy A. Lewis
I know! Spans over 50 years.

00;02;36;12 - 00;02;40;03
John W. Bluford, MBA
Oh, just about...not quite over 50, but we're getting there.

00;02;40;04 - 00;03;15;15
Joy A. Lewis
Okay. I want to be like you when I grow up. So, former president and CEO, president emeritus of Truman Medical Centers in Kansas City, Missouri. Prior to that, CEO of Hennepin County Medical Center in Minneapolis, Minnesota. So let's start there. Can you walk our listeners through your journey and I guess leading into this question around what were some of the conditions that you observed, you witnessed inside hospitals and health systems that you led?

00;03;15;21 - 00;03;24;25
Joy A. Lewis
And also, as a former chair of the AHA's Board of Trustees, that led you to create the Bluford Health Care Leadership Institute.

00;03;24;27 - 00;03;56;02
John W. Bluford, MBA
Thank you very much, Joy. It's a great lead in. And I would start by saying that these 45 plus years in the business have always been in urban settings. Large tertiary teaching hospitals that dealt with underserved patient populations. So that has been my story from day one. As an epidemiologist for the Center for Disease Control and the areas of Saint Louis, Missouri.

00;03;56;04 - 00;04;30;17
John W. Bluford, MBA
Pruitt-Igoe housing project, which is the first federally funded housing project in the country. And that is kind of where my orientation comes from. More recently as a CEO -and I've been retired for ten years -but I'll say recently as a CEO of two major academe training centers, I discovered that there was not a pipeline of diverse talent coming through graduate school programs for hospital administration.

00;04;30;19 - 00;05;13;20
John W. Bluford, MBA
How do I know that? Because I was a preceptor for several programs across the country between the late 80s and 90s, and I consistently got very talented scholars to come to my institution to fulfill their requirements for graduate school. But none of them were diverse candidates because they weren't in the pipeline. And the genesis of the program that's in place right now is a request that I made to the Hennepin County Board of Commissioners to give me some funding to go to Morehouse College and recruit an undergraduate student to come to Minneapolis and work with me for the summer.

00;05;13;25 - 00;05;14;20
Joy A. Lewis
Just one.

00;05;14;22 - 00;05;16;28
John W. Bluford, MBA
Just one. You got to start somewhere.

00;05;16;29 - 00;05;17;11
Joy A. Lewis
Yeah.

00;05;17;14 - 00;06;01;01
John W. Bluford, MBA
Right. And that one student stayed with me for two years while I was at Hennepin, followed me to Kansas City, Missouri, and ended up working for me for 17 years. So that project was very successful in one respect, but not a lot of players. Secondarily, because of the success of that one student and my love for doing that kind of work and mentoring, I did the same thing when I got to Kansas City, Missouri, and that has led me to go to primarily HBCUs, Fisk University, Spelman College, Morehouse, Florida A&M University, North Carolina, and A&T and Hampton University,

00;06;01;01 - 00;06;01;27
John W. Bluford, MBA
more recently.

00;06;01;28 - 00;06;03;20
Joy A. Lewis
Not Howard, my alma mater.

00;06;03;22 - 00;06;05;10
John W. Bluford, MBA
But it will be there next year.

00;06;05;11 - 00;06;06;11
Joy A. Lewis
Okay.

00;06;06;13 - 00;06;35;01
John W. Bluford, MBA
And solicit and recruit some very, very, very talented and smart scholars and convince them that health care is a good career path for them and go for it. That's one reason for the BHLI,  and the other is a wonderful experience that I had in the early 80s as a participant in Harvard University's mid-career programs. I was 31 years old at the time.

00;06;35;04 - 00;06;51;22
John W. Bluford, MBA
And that experience just exposed me to how the sausage is really made in health care. And I wanted to expose these young people to that type of experience. I could go on and on, but that gives you a little bit of the seeding of the Bluford Health Care Leadership Institute.

00;06;51;24 - 00;07;25;26
Joy A. Lewis
And again, the early beginnings, rooted in looking at expanding and providing exposure to those from historically underserved, marginalized communities and giving them an opportunity to even consider health care. Absolutely right. So if anyone visits your website for BHLI, they will see the Institute is described as an intense professional development program. Can you share a little bit more? What does that mean?

00;07;25;26 - 00;07;29;00
Joy A. Lewis
What does intense mean in this example?

00;07;29;02 - 00;07;52;21
John W. Bluford, MBA
Intense. It's a two-eek program, seven days a week. Each day, our scholars are picked up by an executive van or bus at seven in the morning, and their day ends 12 hours later, as the last couple of hours of the day, they're working on a case study that they will present to a community audience at the end of the program.

00;07;52;23 - 00;08;17;06
John W. Bluford, MBA
So intense, in my view, means first and foremost, looking for very serious scholars that want to be successful and hopefully in the health care field. The idea is that we are preparing them not for the next level, but the level beyond that. We want leaders, not mid-careerists.

00;08;17;08 - 00;08;27;29
Joy A. Lewis
And we know that there's typically this plateauing that occurs when you get to the midpoint. How do you then move into the more executive senior leadership roles?

00;08;28;02 - 00;08;58;17
John W. Bluford, MBA
So we have a very strong didactic experiential curriculum with leaders from the industry all over the country coming in and sharing their stories, their personal stories. People like Mr. Rick Pollack, for example, or Mr. Wright Lassiter, for example. I think we've had four past chairman of the boards from the AHA. Mindy Estes comes to mind. Kevin Lofton has been a couple of times.

00;08;58;24 - 00;09;34;14
John W. Bluford, MBA
Jeanne Wood has been. So they're get experience and wisdom from the top of the industry. That's number one. Number two, not only didactic and experiential learning, but we really focus on executive presence and what people call soft skills. I don't agree with that terminology. I think they are essential skills. And by that I mean presentation skills, language skills, appearance skills, self-awareness skills.

00;09;34;16 - 00;09;59;26
John W. Bluford, MBA
How to network skills. We drill that into each and every one of these scholars every day and all day. Even though we do have some social activities, but it's not a frat party. You're still on stage. So we have golfing outings, and we've done bowling before, and we go to the performing arts. And we tour a couple of museums in Kansas City, high end.

00;09;59;29 - 00;10;09;06
John W. Bluford, MBA
But we're constantly looking at our scholars and observing our scholars and how they interact with each other and others.

00;10;09;06 - 00;10;09;17
Joy A. Lewis
How they show up.

00;10;09;17 - 00;10;19;24
John W. Bluford, MBA
How they show up. Good point. And we don't grade on the curve. If we catch something that's out of order, we pull them aside and said, you might want to reconsider how you're doing that.

00;10;19;27 - 00;10;21;11
Joy A. Lewis
No partial credit, huh?

00;10;21;11 - 00;10;25;09
John W. Bluford, MBA
No partial credit. And I think that's very enlightening for these students.

00;10;25;11 - 00;10;33;08
Joy A. Lewis
That's helpful. To your point, there's the didactic component, the experiential component. But then there's the: how do you read a room?

00;10;33;11 - 00;10;55;16
John W. Bluford, MBA
Exactly. There are two things that I could have mentioned too: etiquette training, because part of the interview process is often how you perform at dinner or lunch. So we do that and we have speech coaches come in and really help on the presentation skills. So the underlying theme of that, sometimes it's not how much you know, but how well you can communicate what you know.

00;10;55;20 - 00;11;02;22
Joy A. Lewis
That's right. Very comprehensive. I don't know what you do with folks like me who are not morning persons. At seven a.m.?

00;11;02;22 - 00;11;06;09
John W. Bluford, MBA
They get on board real soon or they're left behind.

00;11;06;09 - 00;11;28;03
Joy A. Lewis
They don't have a choice, right? That's right. So a little bit more about, I get the goal here. To your point, it's not mid-career. It's preparing folks for those senior leadership roles. What's been the impact when you look back over the past decade since the inception of this program? Where have your scholars landed? What have they gone on to do?

00;11;28;06 - 00;12;00;08
John W. Bluford, MBA
I'm glad you asked that question. And that's the best question of the interview, because we can talk a lot about what is and what is and what we want to be, but what's the impact is the punch line. And we have been quite successful in our goal. Now remember, the goal is to train culturally sensitive, talented individuals to ultimately impact health care disparities among minority and vulnerable patient populations over the next two generations.

00;12;00;14 - 00;12;01;21
Joy A. Lewis
That's tall order.

00;12;01;23 - 00;12;34;23
John W. Bluford, MBA
That's a tall order. We've got time, and it's going to take time to get it done. And in that regard, in round figures, we've had 150 participants come through the program over the past 11 years, 11 or 12 years. We've had 120 internships that have resulted from those students coming through our program. Now, internships are fully paid summer internships after their two-week didactic experience in Kansas City.

00;12;34;26 - 00;12;51;27
John W. Bluford, MBA
And those internships have been in 50 sites across the country. And the punch line is this: out of 121 students who've actually graduated from undergraduate school, because I interview them as freshmen and sophomores. So they're very young.

00;12;52;00 - 00;12;52;29
Joy A. Lewis
And you're doing the interviews.

00;12;52;29 - 00;13;22;08
John W. Bluford, MBA
And I do the interviews personally. Out of the 121 that have graduated, 100 of them are in health care space today, 83%. And the others are lawyers, and on Wall Street, they're doing well for their own personal careers. But 100 of them are in health care. So just give you an example, and this is a one hour interview in itself where some of these students are and more importantly, what they're doing.

00;13;22;11 - 00;13;49;24
John W. Bluford, MBA
And you can project what they're going to be doing in years to come. But we've got one of our scholars who was in our program in 2014. He is now the surgical specialty clinic director at Henry Ford Hospital. We've got another young lady. She's the pharmacy infusion manager at Emory Hospital's Winship Cancer Center, and she took me through a tour of this new facility.

00;13;50;02 - 00;13;52;29
John W. Bluford, MBA
It is really awesome. And she's in charge. 
00;13;52;29 - 00;13;53;12
Joy A. Lewis
And she's in charge. She's at the helm.

John W. Bluford, MBA
She's at the helm. And we've got another young lady, and I think you're going to meet her at your program in Kansas City later this summer. She's a deputy director for policy and human services for the governor of Kansas, and she's working on access to mental health and Medicaid expansion, which, as you know, is a big issue.

00;14;16;09 - 00;14;30;03
John W. Bluford, MBA
So we've got young people five, six, seven years in their career with no ceiling, doing meaningful and important work with good compensation.

00;14;30;06 - 00;14;35;22
Joy A. Lewis
That's critical. And, well, you started out with them getting paid internships. I noted that.

00;14;35;22 - 00;14;57;16
John W. Bluford, MBA
Absolutley. And they get paid for their two-week tenure in Kansas City as well. It's a $2,000 stipend because we realize while they're there they could have been working their summer jobs. So we want to be competitive to get the best students. And the best students are being paid for their time right now. Let me tell you a little bit about these sites.

00;14;57;18 - 00;15;30;17
John W. Bluford, MBA
I mentioned 120 internships, 50 different sites. The American Hospital Association membership and its leadership has been very valuable connectivity for us because we're placing our students in their institutions. So we've had students at Duke University, Johns Hopkins, Atlantic Health in Morristown, New Jersey, Advocate Atrium have taken a lot of our students. Truman Medical Center's my old stomping ground.

00;15;30;18 - 00;16;03;23
John W. Bluford, MBA
Obviously, it's taking a lot of students University Health and Cleveland, several Blue Cross Blue Shield programs across the country. Saint Luke's Hospital, Dr. Estes' old place, has taken several of our students. Aeon on a long term consultancy..so it just goes to show that networking and the loyalty and concern among my colleagues in the field are paying dividends as well and helping us do this.

00;16;03;23 - 00;16;35;20
Joy A. Lewis
Amazing, amazing impact. So when you started this Leadership Institute again in 2013, the environment was quite different, the external environment. And so what we're looking at right now are some serious - as my CEO Rick Pollack likes to call them - motivated adversaries with deep pockets who are waging a war against anything that smells or looks like diversity, equity, inclusion.

00;16;35;22 - 00;16;55;08
Joy A. Lewis
So again, we're in a very different place today. How are you thinking about the existing world that you're training these young folks to show up in? How are you preparing them to be successful with all the headwinds in the midst of these anti-DEI efforts?

00;16;55;13 - 00;17;47;15
John W. Bluford, MBA
That's a great question, and perhaps one difficult to answer, but it's easy for me. One, we started before these anti-DEI and affirmative action related mentality surfaced and as such very narrowly focused on teaching, mentoring, coaching, and perhaps more importantly, sponsoring the scholars in our program. And that sponsorship, that coaching, that teaching was very specifically directed toward dealing with health care disparities in America, specifically among minorities and underserved patient populations. Rural America, the different pockets that need the support.

00;17;47;17 - 00;18;21;12
John W. Bluford, MBA
And we wanted to make sure they were culturally sensitive to the issues of socioeconomic determinants, etc., which I now favor the public policy determinants of health, and be laser focused on that and eliminating the disparities. So we don't talk a lot about DEI or anything. We talk about disparities, socioeconomic determinants, and how you can position yourself to get in a decision making role to make a difference.

00;18;21;14 - 00;18;33;15
Joy A. Lewis
And the disparities have been there. They have a long tail, to your point, well-documented. So keeping a focus on the elimination, not the reduction, the elimination of those disparities.

00;18;33;15 - 00;18;34;07
John W. Bluford, MBA
Zero.

00;18;34;20 - 00;18;47;29
John W. Bluford, MBA
And we hope that we've given them enough time frame over the next two generations to make a difference. I certainly don't want my grandson's children to experience some of the same disparities.

00;18;48;00 - 00;19;02;05
Joy A. Lewis
Correct, correct. And I like the break down. You've done a really good job of distinguishing between mentoring and sponsorship, for example. Those two tend to get conflated and we know they're very different.

00;19;02;07 - 00;19;27;27
John W. Bluford, MBA
I think many of us who've had the pleasure of serving in this industry were helped quite a bit by someone that was in those positions that we wanted to get to. And it's not unusual for me to pick up the phone and call a colleague of mine and say, you know, Joy Lewis has been in your operation now for four years, and I understand she's doing well.

00;19;27;27 - 00;19;29;24
John W. Bluford, MBA
We want to see some growth in her career.

00;19;29;27 - 00;19;30;11
Joy A. Lewis
Right.

00;19;30;13 - 00;19;31;17
John W. Bluford, MBA
Yes.

00;19;31;19 - 00;19;51;13
Joy A. Lewis
Makes sense. Appreciate that. So we're coming up on time here. But I want to ask. It would be foolish to have someone of your stature sitting here and not solicit some piece of advice from you to these young scholars. What is it that you wish someone had told you?

00;19;51;15 - 00;20;23;20
John W. Bluford, MBA
You know, I've had such a positive journey, and I wish someone would have told me about what an opportunity and blessing it's gonna be to help and serve the community in which I work. It's hard work, but the work is twice rewarding when you see the results. That's a very powerful statement. And I tell everyone, at least in my case: never had a job.

00;20;23;23 - 00;20;42;08
John W. Bluford, MBA
It's always been a mission, not a job. And that's how I've gone about my work. Compensation and those kinds of things have always been secondary. And I tell people all the time, if you're going in it for the money, then do something differently. But if you go in it and do well, get your money.

00;20;42;10 - 00;21;13;09
Joy A. Lewis
That's powerful, John, and very compelling. This notion of you're in it because it's your cause to make lives better at the end of the day. So I can't thank you enough for your continued leadership. You lay the mantle down in terms of CEO-ship roles a decade or so ago, but you continue to add to that almost 50 year legacy that we referenced earlier, really impressive and impactful career that you've had and continue to have for many of us who are in the trenches here.

00;21;13;09 - 00;21;20;00
Joy A. Lewis
So it's great to be in community with you and to have this conversation. And thank you for your time.

00;21;20;05 - 00;21;22;03
John W. Bluford, MBA
Thank you for inviting me.

00;21;22;05 - 00;21;23;20
Joy A. Lewis
Absolutely.

00;21;23;23 - 00;21;32;03
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:13 - 00:00:24:07
Tom Haederle
Changing demographics and financial pressures pose challenges for hospitals, especially those in rural communities, to maintain obstetric services. In the last five years, more than 300 birthing units across the country have shut down.

00:00:24:09 - 00:01:06:18
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Despite today's many challenges, some hospitals are implementing creative strategies to maintain necessary obstetric services for their communities. San Luis Valley Hospital in rural central Colorado is cross-training its clinical staff and partnering with community stakeholders to keep serving their community. Julia Resnick, AHA's director of Strategic Initiatives, recently spoke with Monica Hinds, an RN and director of Emergency Services and Obstetrics and Stephanie Posorske, a certified nurse midwife, about their approach to maternal care for the San Luis Valley community.

00:01:06:20 - 00:01:15:02
Julia Resnick
So, Monica, Stephanie, thank you both so much for joining me. Let's start with some background about each of you and San Luis Valley Health. Monica, I'll start with you.

00:01:15:04 - 00:01:40:14
Monica Hinds, R.N.
I am new to nursing. I've been a nurse for about ten years. This is my second career. and I attribute my nursing drive to OB, actually. When I had my kids, the OB nurses here at San Luis Valley Health were awesome, and I felt like that's what I wanted to give back to the community. So that was a little bit about myself.

00:01:40:16 - 00:01:58:11
Monica Hinds, R.N.
I have been overseeing the OB department for the last 4 to 5 years, I think is when I took over. I was, originally, an emergency room nurse. Became director of the emergency department, and then just sort of, fell into the OB leadership position as well.

00:01:58:14 - 00:02:03:02
Julia Resnick
So can you tell me a just a little bit about the community that is in the Valley?

00:02:03:04 - 00:02:22:28
Monica Hinds, R.N.
Alamosa is the central hub of the Valley. We do service several communities throughout the area, the San Luis Valley. And we are the only location that does labor and delivery. And so everyone does come to us, or they go outside of the valley for their OB needs.

00:02:23:05 - 00:02:26:21
Julia Resnick
Got it. And what kind of pregnancy care does your hospital provide?

00:02:26:23 - 00:02:44:24
Monica Hinds, R.N.
We pretty much do everything. Because even if we cannot manage the patients here, we make sure that we get them to that higher level of care. So we do have the C-sections, we do induce, we do have a local midwife that does deliver outside that we do support as well for her needs.

00:02:44:27 - 00:02:52:06
Julia Resnick
And tell me a little bit about the community stakeholders and partners that you work with, both for prenatal care and postpartum care.

00:02:52:08 - 00:03:11:07
Monica Hinds, R.N.
So we do have valley wide. They are also part of our labor and delivery department. They do manage their own patients. Do their own deliveries, do their postpartum care as well. And then we do have our ObGyn clinic here that, manages our patients for our hospital.

00:03:11:10 - 00:03:24:28
Julia Resnick
So turning to you, Stephanie. I know that there are a lot of challenges faced by rural communities, especially in terms of maternal care. So can you talk about some of the challenges, that expectant and postpartum moms are facing in your community?

00:03:25:00 - 00:03:49:18
Stephanie Posorske
So, interestingly enough, I think that social media has changed this significantly in the last ten years in the sense that everybody knows what's out there, and then what's that availability here? So they're, you know, they want to know, like, can I have an epidural? And yes, they totally can. And being able to meet those needs.

00:03:49:18 - 00:04:19:25
Stephanie Posorske
I think that we do a really good job of finding the niches that are really important. For example, women really worry about being able to have a lactation consultation. And while we don't have a specific lactation counselor, that that's just what they do. I'm our hospital's lactation counselor, on top of being a certified nurse midwife, so that we can still meet those needs without, you know, having to expend our resources.

00:04:19:27 - 00:04:41:08
Julia Resnick
Got it. And, you know, every day we're hearing about more OB units closing down unlimited access in rural communities. But you all are some of the rare ones who are managing to keep yours up and running and serving your community. So can you tell me about what strategies you're implementing that's able to keep your maternity unit open and thriving?

00:04:41:11 - 00:05:05:18
Monica Hinds, R.N.
We are seeing a decrease in, deliveries per year as well. And to be able to make our department managable as far as financial, we've really had to think outside of the box on what we're going to put on that unit. So we have expanded our unit to that surge overflow unit. We have implemented pediatric patients on part of our unit.

00:05:05:21 - 00:05:26:00
Monica Hinds, R.N.
We do some post-surgicals that are not Ob-Gyn related on our unit. So we really have grown our OB nurses into well-rounded nurses that do everything. And so we give them a lot of credit for the knowledge that they've had to obtain over these last few years just to be able to care for our patients in our community.

00:05:26:03 - 00:05:29:02
Julia Resnick
That's really wonderful. Stephanie, anything else you want to add?

00:05:29:04 - 00:05:57:03
Stephanie Posorske
Yeah, I think that there has come a lot of flexibility and changing our expectations of what works for people, and that that's what like all these units that have been able to stay open have had to do...is that we've had to become more flexible as an employee, but also the employer has had to become more flexible on what meeting the needs of everybody's situation so that we can keep this resource available.

00:05:57:05 - 00:06:17:14
Julia Resnick
That's great and wonderful that you're all willing to be so adaptable as you're trying to make your way through this. So besides clinical services, we know that a lot of rural women are also experiencing challenges around behavioral health, such as substance use, and other issues related to social determinants of health. So how are you addressing those issues in your community

00:06:17:16 - 00:06:20:29
Julia Resnick
especially for pregnant and postpartum women?

00:06:21:01 - 00:06:44:19
Stephanie Posorske
I think I can answer that. So I prescribe Suboxone, which is for people that use opiates. And on top of that, like being a great resource for people that use opiates so that they can hopefully get off opiates, it also opens the door for all avenues of people knowing that we're open to doing that and what we can do to help.

00:06:44:21 - 00:07:08:00
Stephanie Posorske
I think we really want to get out there this idea of like, we want you to come in, we want you to get care. Despite all of these challenges, whether it's for behavioral health or because you use some substance, we want to be the doors are open because this is an opportunity for us to capture people that are using

00:07:08:03 - 00:07:20:18
Stephanie Posorske
and it's when they're going to be most motivated to make a change in their lives. And so keeping that door wide open is the best way to do that and hopefully is working.

00:07:20:21 - 00:07:22:17
Julia Resnick
Monica, anything you want to add?

00:07:22:19 - 00:07:48:27
Monica Hinds, R.N.
So I would really like to add we do depression screening on all of our patients - no matter if they're observation patients or inpatients, postpartum in the middle of their pregnancy - just so we can try to catch these patients early enough to be able to give them the resources that they need. We have also really focused on our social determinants and making sure that we're asking those hard questions of patients, you know, do they need some help with housing?

00:07:48:27 - 00:08:06:16
Monica Hinds, R.N.
Do they need transportation? Is food a difficulty for them at this point in time? And we have great care coordination that actually will follow up on all of those patients prior to them being discharged to make sure that they're providing them the resources in the community that they need.

00:08:06:18 - 00:08:29:09
Julia Resnick
And yeah, I think you're both really getting at this idea that, like, these are sensitive questions and sensitive topics for people and keeping that door open so that they feel comfortable coming to you and asking for the support they need is just so crucial. So we always love stories that can really bring this to life. Do you have any stories from your hospital or patient stories, that can help bring to life the work you're doing?

00:08:29:12 - 00:09:02:03
Stephanie Posorske
I have a patient. She's had a baby already. Her and her partner have had times where they've used either fentanyl or opiates. And that door has stayed open to them, despite their not always being as compliant as we would like them to be. But they continue to come see us. Another provider in my clinic sees her husband so that we are both taking care of both of them and their substance use.

00:09:02:05 - 00:09:25:18
Stephanie Posorske
It's just lovely for them, like to have their baby, and for us to be continuing to work on this medical problem that they have. And it's not black and white and it's not it's not super easy. But every time they bring that little baby in and that they're still together and that they're still coming is exactly why that that door has to stay open.

00:09:25:21 - 00:09:34:08
Julia Resnick
Absolutely. And clearly the motivation is there. Yeah. And it's wonderful that you embrace them. Monica, any stories from your world?

00:09:34:10 - 00:09:58:00
Monica Hinds, R.N.
I don't have any specific patients. I mean, we do see when those those patients come in that have that substance use and and we're able to, you know, get them the resources that they need and be able to get them reunited with their baby, even if they aren't able to leave with them at discharge. But to be able to help them get that custody back.

00:09:58:02 - 00:10:06:07
Monica Hinds, R.N.
We see it, you know, not daily, but we see it a lot. It warms our heart that we can help those patients get back with their babies.

00:10:06:09 - 00:10:17:15
Julia Resnick
That is wonderful. So for other rural hospitals that are considering different creative avenues for providing maternal care, what advice do you have for them? What have you learned along the way?

00:10:17:17 - 00:10:56:10
Monica Hinds, R.N.
I'm going to say that you have to listen to your staff. It's been very difficult making that transition from just being a labor and delivery nurse and moving into other fields. It's definitely a lot easier with the newer nurses that are coming out, because that has expectations set forth on employment. But for those those experienced labor and delivery nurses, taking that time to listen to them, about their concerns and what kind of education that they need to make sure that they feel comfortable in providing the care to patients that they haven't cared for, you know, since nursing school, probably.

00:10:56:12 - 00:11:05:03
Monica Hinds, R.N.
So just stopping and listening to concerns is something that I feel that we can really learn throughout this transition.

00:11:05:05 - 00:11:05:27
Julia Resnick
Stephanie?

00:11:06:00 - 00:11:25:09
Stephanie Posorske
I mean I think that's really important. And like listening to your staff is how we will make changes together and not be like get all that pushback. And just like the adaptability like we talked about, we have to all be adaptable. We had to be adaptable in the sense that we brought these patients to our unit,

00:11:25:12 - 00:11:46:09
Stephanie Posorske
that we sometimes have some med surge patients on our unit. But depending on what's going on on labor and delivery, we have to be able to change that. And I think all of our expectations have changed, and we've all learned to evolve with the situation. And that's the true heart of nursing and medicine is that we have to be able to evolve and change based on the patient.

00:11:46:09 - 00:11:54:15
Stephanie Posorske
But big picture: How we evolve and have adapted and changed for our unit as a whole has been really how this has worked.

00:11:54:18 - 00:12:09:22
Julia Resnick
That is an incredibly powerful message that I think we all need to to take in to the work that we do, that, you know, the world changes and we need to change along with it to make things work. So to wrap up, what's next for you all? And SLVH's is work in maternal health?

00:12:09:25 - 00:12:12:06
Monica Hinds, R.N.
I'll let you go first, Stephanie.

00:12:12:09 - 00:12:35:18
Stephanie Posorske
Well, you know, I mean, Monica knows that I always have all kinds of ideas and some of them work and some of them don't. But we, you know, we all move forward and with our ideas and, you know, like, I'd like it if we had nitrous is an option for our patients. And I think we're totally on the brink of getting that. We want to meet to the need of everybody

00:12:35:21 - 00:12:53:28
Stephanie Posorske
which is a wide variety of people really here. And so finding ways that keep us safe and financially feasible, but also our meetings and needs and make us also feel like maybe we aren't as Podunk as sometimes we think, even.

00:12:54:00 - 00:13:10:08
Monica Hinds, R.N.
Yeah. And I would definitely agree with what Stephanie is saying. We we do try to stay up with the times, but making sure that we are providing that safe environment for our patients and for our staff as well, and giving them those opportunities to continue to learn and grow in the field.

00:13:10:10 - 00:13:27:00
Julia Resnick
Well, it's clear how dedicated you all are to your patients and your community and really making sure that door stays open to them. So I just want to thank you for the great work that you're doing to to support moms in your community and really appreciate your taking the time to talk with us today about your work.

00:13:27:01 - 00:13:28:15
Julia Resnick
Thank you so much.

00:13:28:17 - 00:13:29:24
Stephanie Posorske
Thank you for having us.

00:13:29:26 - 00:13:31:28
Monica Hinds, R.N.
Yeah, thank you for sure.

00:13:32:01 - 00:13:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:25 - 00:00:33:19
Tom Haederle
Being a new parent is challenging in the best of circumstances, but it's even harder for expecting and new moms struggling with social and behavioral health needs. And living in a rural community means that the resources available to support new parents may be limited. The first 1,000 days from pregnancy to age two offers a crucial window of opportunity to create brighter, healthier futures.

00:00:33:21 - 00:01:17:00
Tom Haederle
Welcome to Rural, a yearlong series devoted to rural hospitals and health systems in America. I'm Tom Haederle with AHA Communications. St. James Health Care in Butte, Montana, now part of Intermountain Health, is designing care around new moms who need the extra support not just during pregnancy, but during the first two years of the baby's life. At this year's AHA Rural Health Care Leadership Conference, Julia Resnick, director of strategic initiatives at the AHA, spoke with April Ennis Keippel, community health director, Montana/Wyoming Market at Intermountain Health, and Joslin Hubbard, social worker at Intermountain Health at St.James Hospital, about how their first 1,000 Days program provides wraparound services for at risk new moms.

00:01:17:03 - 00:01:25:18
Tom Haederle
They were joined by Lacey Starcevich, a former program participant who shares her powerful journey to build a healthy life for herself and her family.

00:01:25:21 - 00:01:42:25
Julia Resnick
April and Joslin and Lacey, thank you so much for recording this podcast with us. We're here at the AHA Rural Health Care Leadership Conference. I'm really pleased to have all of you. So to kick things off, let's get a little background on your health care system. So can you tell us about Intermountain Health, St.James Hospital, and the community that you serve?

00:01:43:02 - 00:01:44:27
Julia Resnick
April, do you want to kick things off?

00:01:45:00 - 00:02:12:19
April Ennis Keippel
Sure. So we are a part of a large system, Intermountain Health, that includes hospitals in Montana, Colorado, Utah, clinics in Nevada as well. And St. James is located in southwest Montana. It's a community of about 35,000 residents, is a level three emergency department and really provides services for all the surrounding counties, which are primarily rural counties.

00:02:12:21 - 00:02:15:12
Julia Resnick
Anything else you both want to add about the hospital and your community?

00:02:15:12 - 00:02:30:04
Joslin Hubbard
Butte is a really proud community. It has a long history of mining and people are proud to be from Butte. They help each other out. They come together to support one another. And it's just a beautiful place to live.

00:02:30:07 - 00:02:44:00
April Ennis Keippel
And Butte was known as the richest hill on earth at one point and at one time was the largest city between Chicago and San Francisco in its heyday. So rich history in the community.

00:02:44:00 - 00:02:58:01
Julia Resnick
That is quite a history. And I love that piece about community because I think that's really what we're here to talk about. And our focus today is really on maternal health. So, Jocelyn, can you talk at all about the maternal population that you're serving and where your patients come from?

00:02:58:07 - 00:03:23:00
Joslin Hubbard
Yeah. So most of our patients live in Butte or Silver Bow County. We do serve the women from the surrounding counties as well. Our payor mix at our hospital is, you know, around 85% Medicare and Medicaid. And we have women primarily of Caucasian descent. And we serve ages, you know, teen age to later maternal - advanced maternal age, they call it.

00:03:23:01 - 00:03:26:06
Joslin Hubbard
So but just a really great mix of.

00:03:26:09 - 00:03:33:27
Julia Resnick
And even though most of your patient population does identify as white, are there any disparities that you've identified between like different subsections?

00:03:33:29 - 00:03:53:15
April Ennis Keippel
So a lot of the disparities we see in our community health needs assessment are actually related to socioeconomic status. Individuals living in poverty across all health outcomes have poorer outcomes. So anyone 200% or less of the federal poverty level just scores worse on a number of health outcomes.

00:03:53:18 - 00:03:58:29
Joslin Hubbard
April, Do you know what population of our patients fall within that 200% below poverty level?

00:03:59:04 - 00:04:05:24
April Ennis Keippel
The residents, I would say about 20% of overall residents. So one in five are below the poverty level.

00:04:05:27 - 00:04:19:22
Julia Resnick
Got it. And when you're thinking about these new parents in your community, are there any particular challenges that you've been seeing them experience? I know you touched on their socioeconomic status of needs, but in terms of behavioral health and how those challenges are impacting them.

00:04:19:24 - 00:04:46:18
Joslin Hubbard
So we have limited resources for our behavioral health and substance use. So those definitely impact our patients' access to care. When we're talking our socioeconomic struggles, it's even transportation to those appointments. It's housing, working with women and families. It's hard to talk about getting to appointments when they're not sure where they're going to live, you know, or stay that night or how they're going to get to that appointment.

00:04:46:21 - 00:04:53:07
Joslin Hubbard
You know, we have to take in all of that into consideration when we're dealing with people with substance and mental health needs.

00:04:53:10 - 00:05:01:00
Julia Resnick
Absolutely. So we're really here to talk about the Meadowlark Initiative. So can you talk to our listeners about what that is?

00:05:01:03 - 00:05:28:08
April Ennis Keippel
I can maybe start and then you can fill in as needed. So the Meadowlark Initiative is funded through the Montana Health Care Foundation. And it's really focused on providing intensive case management to the most at-risk patients prenatal and then following through til the second year of life. So, really helping to guide and support both prenatally and then also postnatal.

00:05:28:10 - 00:05:30:07
April Ennis Keippel
What else would you add, Jocelyn?

00:05:30:09 - 00:06:05:15
Joslin Hubbard
Yeah, so the initiative initially was funded by the Montana Health Care Foundation, but St.James has continued that, recognizing the need and the importance of this work. And so our program was the first 1,000 Days, which is from conception to age two, recognizing that it is the most critical and crucial time in human development. And when the brain develops, you know, it's just really using that care coordination piece to kind of bridge the gaps between those services, whether it's housing, food issues, transportation, mental health, substance use and the clinic or the hospital and how to connect patients when they come in for prenatal care with those outside resources, and then to continue to be

00:06:05:15 - 00:06:12:02
Joslin Hubbard
a resource and a support for them as they not only through their pregnancy, but as they embark on parenthood.

00:06:12:04 - 00:06:22:08
Julia Resnick
That's amazing that you have such a long perspective on it and not just, you know, a specific part of pregnancy or postpartum. So who are you partnering with or coordinating with to bring this all to life.

00:06:22:14 - 00:06:46:16
Joslin Hubbard
In terms of community resources? Yeah, Perfect. Yeah. So we have lots of you know, we partner with all of our resources in the community, whether that's private therapists. We partner with our Southwest Montana Community Health Center to provide mental health services as well as primary care following delivery. You know, our mental health centers and parenting agencies in the community as well.

00:06:46:18 - 00:06:53:24
Julia Resnick
So talk me through it...like someone finds out they're pregnant: how do they get enrolled in the program? Like, what happens next? What does that look like?

00:06:53:26 - 00:07:15:00
Joslin Hubbard
The hope is that they would seek prenatal care and come to an appointment. And at that appointment they would be screened for social determinants of health. So we would be screening for transportation issues, food insecurities, housing, as well as mental health and substance use. We would also be screening the partner or whoever is supportive of that woman in pregnancy.

00:07:15:02 - 00:07:28:25
Joslin Hubbard
So that we can really help the whole unit. And then they would meet with a care coordinator. And that care coordinator then would connect with resources and help identify needs, provide education, and then support throughout the pregnancy.

00:07:28:27 - 00:07:32:27
Julia Resnick
It's wonderful. And are there any stories you can share that can really bring this to life?

00:07:33:04 - 00:07:43:25
Joslin Hubbard
Well, I'm fortunate to have Lacey here today. Lacey was one of our moms in our program, and I think that she can speak to her story better than I could ever.

00:07:43:27 - 00:07:46:05
Julia Resnick
Great. Lacey, over to you.

00:07:46:07 - 00:08:11:12
Lacey St.arcevich
I'm Lacey. I just, on the 22nd of February, recently celebrate five years clean. I originally attended my first prenatal appointment actively using drugs. I was screened and obviously made the requirements for the program. At the time, I was homeless and still using. I left that first prenatal appointment not sure if I was going to get clean or not.

00:08:11:17 - 00:08:26:09
Lacey St.arcevich
Not even sure if I wanted to keep Bradon. That's my son's name. He'll be five in August, actually. So with the help of Jocelyn and the Meadowlark Initiative, I was able to connect with these resources and get help. And today I'm present for my children.

00:08:26:12 - 00:08:32:02
Julia Resnick
That's amazing. I'm just so glad you're here to share your story and that you've been involved in the program since, is that?.. Yes.

00:08:32:03 - 00:08:41:09
Lacey St.arcevich
Yeah. So anything I can do to help? There are just so many mothers out there who are in the same position I am. And it's an unfortunate situation. But with things like this, we can try to lower that number.

00:08:41:12 - 00:08:46:06
Julia Resnick
And I'm sure having contact with you helps them feel less alone and that, you know, there is a light at the end of the tunnel.

00:08:46:12 - 00:08:50:19
Lacey St.arcevich
You know, there's nothing more therapeutic than another addict helping another addict.

00:08:50:21 - 00:09:03:09
Julia Resnick
Wonderful. And I know that, you know, we have a great personal story of the impact of this work, but have you been measuring what the impact is on the women that are in the program? Yes. Yes, we have. Is there anything you can share?

00:09:03:11 - 00:09:06:28
April Ennis Keippel
If I look at my notes...I don't know off the top of my head.

00:09:07:00 - 00:09:31:28
Joslin Hubbard
We have found that women who participate in this program are more likely to have consistent prenatal care. They're more likely to take their child home at delivery. And that means from a lower involvement of the Child Protective Services Removals, women have better health outcomes to higher birth weights, lower complications, less hospital stays that are involved in the care as well.

00:09:32:01 - 00:09:44:24
Joslin Hubbard
And a lot of that's probably attributed to the more consistent prenatal care, as well as changing a lot of their lifestyle and ensuring that they have the food and resources that they need,  as well as you know, hopefully not using substances.

00:09:44:26 - 00:10:01:19
Julia Resnick
So to wrap us up, I love your words of advice for other rural hospitals that are really thinking about what they can do to improve their maternal and child health outcomes. What have you learned along the way that you can share with them? And Lacey, you'll have a slightly different version of that question.

00:10:01:22 - 00:10:30:04
Joslin Hubbard
You know, when we're dealing with rural, it's hard to find people to fill spots, right? And I think the most important thing is that we realize that this is just has to be someone who cares and who understands the community and the resources out there and who can show understanding and love and kindness to patients. There's not a magic wand. This is hard work, but it's, you know, it's done in partnerships and relationships that are built not only with the patient but with the community.

00:10:30:07 - 00:10:40:10
Joslin Hubbard
And, you know, just really taking time, stepping back, understanding what the needs of your community are and, you know, just addressing it one day at a time.

00:10:40:13 - 00:10:41:21
April Ennis Keippel
Well said.

00:10:41:23 - 00:10:43:26
Julia Resnick
Very well said, April.

00:10:43:28 - 00:11:10:09
April Ennis Keippel
I don't know if I could really add anything more to that. I think it just in looking at having a connector and a go-to person, I think is probably the most important thing so that there's a single point of contact that can help move forward any of the needs and make connections. And I'm not sure that that always would need to be a particular type of training to do that work.

00:11:10:10 - 00:11:22:25
April Ennis Keippel
So I think in a rural community you could customize it to really fit what you have available. But the key piece would be just to have that single person who can really help be the connector.

00:11:22:27 - 00:11:41:11
Julia Resnick
That human connection piece really just came out strongly in both of your answers. And Lacey, from being on the participant side of this and, you know, having been one of the moms in the program, what do you wish that hospitals knew about working with new moms who might need additional social or emotional support?

00:11:41:13 - 00:11:59:16
Lacey St.arcevich
We just need, you know, a setting that's not judgmental. We do not have a village. And programs like this help us create that village, and that sets us up for success. They help me create my family. They help not only me get clean and deliver a healthy baby, but my husband followed ensued because they provided us the resource to be able to do that.

00:11:59:19 - 00:12:00:22
Julia Resnick
It's wonderful.

00:12:00:25 - 00:12:16:03
Joslin Hubbard
I just wanted to call out Lacey. You know, not only does she have Bradon, but she now has a two year-old, Parker. She's married, has bought her own home, and is a role model for other women in our community and just so proud of where she is.

00:12:16:06 - 00:12:20:06
Julia Resnick
I'm so glad we can lift up your story and share it with the world.

00:12:20:09 - 00:12:21:03
Lacey St.arcevich
Thank you.

00:12:21:05 - 00:12:30:07
Julia Resnick
So, Lacey, Joslyn, April, thank you so much for joining this podcast. I look forward to seeing your presentation later today. And just congratulations on the fantastic work you're doing.

00:12:30:09 - 00:12:30:22
Joslin Hubbard
Thank you.

00:12:30:28 - 00:12:31:27
Lacey St.arcevich
Thank you.

00:12:32:00 - 00:12:40:12
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and read us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:18 - 00:00:29:28
Tom Haederle
Ransomware and other cyber attacks directed against hospital and health system information networks have not slacked off in 2024. As you might imagine, cyber security experts are in great demand in the health care field these days, and their consensus opinion is that third party risk is a huge reason hospitals continue to be hit.

00:00:30:00 - 00:00:54:03
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Hospitals and health systems work very hard and have invested a lot of time and effort into protecting their systems and data. But hackers continue to squirrel their way in. Third party technology and solution providers are often both at the point of the attack and the source of technical vulnerabilities.

00:00:54:06 - 00:01:09:01
Tom Haederle
In this podcast, part two in the series hosted by John Riggi, the AHA's National Advisor for Cybersecurity and Risk, we hear more from two cybersecurity experts from Providence about what their organization is doing to protect itself.

00:01:09:03 - 00:01:28:27
John Riggi
We have Adam Zoller, the chief information security officer from Providence, and we also have Katie Adams, the cybersecurity director for clinical technology services at Providence. Katie, turning to medical devices. Why is it so difficult to keep medical devices current from a cyber perspective?

00:01:29:00 - 00:02:00:06
Katie Adams
It's a great question, John, and I think there are several reasons. It's a really complex question with probably a complex answer. But, you know, when you think about a medical device, most of this equipment is actually touching a patient and can be directly in use 24 hours a day, seven days a week. So from a traditional cybersecurity lens, when we think about things like patching or operating system upgrades, becomes difficult to find a time when that device is actually available to make some of the cybersecurity upgrades that are required to keep that device current.

00:02:00:09 - 00:02:28:27
Katie Adams
From a financial standpoint, this medical equipment is extremely expensive. You know, we have medical devices in our environment that can be upwards of two and three million dollars. And even just the cost to upgrade that equipment can be as high as $200 - $250,000 just to lift the operating system of the device itself. And for a nonprofit organization like Providence that runs on extremely thin margins, the financial challenge of keeping this equipment current throughout its life becomes very complicated.

00:02:29:00 - 00:02:52:18
Katie Adams
You know, when you think about these devices, they're in our environment much longer than traditional IT equipment. We have medical devices that, you know, like an MRI or an X-ray or some of this other fixed equipment that may be in our environment for ten or 15 years. And throughout that time, from a software standpoint, you know, Microsoft is rolling out updates that are happening much, much more quickly than that.

00:02:52:21 - 00:03:14:20
Katie Adams
And so it becomes challenging to keep the device current from a cybersecurity perspective for as long as it's current from a clinical perspective. I think in addition, the fact that this is all regulated equipment, you know, that's managed by the FDA means that our vendors have to go through pretty significant rigor when they're updating or upgrading the operating systems associated with these devices.

00:03:14:20 - 00:03:28:27
Katie Adams
And so that process also just really slows down the time to market for when we can get the latest and greatest version of these devices. So there are a number of challenges that make it really difficult to keep medical devices current from a cyber perspective.

00:03:29:00 - 00:03:53:10
John Riggi
Thank you, Katie. Even though your answer was fairly concise for a very, very complex issue, you really touched on a couple of key areas. So on the one hand, we have this paradox. The devices themselves are built pretty good. They're built to last 15, 20 years, except the software subsequently becomes outdated. And we have this issue of legacy technology where the devices work as designed.

00:03:53:13 - 00:04:15:26
John Riggi
They take images, but it's the software package because at the time they were designed, these principles of secure by design were not in place. And often the manufacturers will..of course...their response may be, well, it's time to buy a new device, even though this one's working fine. The other issue you touched on about the patching, you know, I just want to expand on that a little bit.

00:04:15:27 - 00:04:41:13
John Riggi
Often the hospitals are criticized for not patching in a timely manner. And I hear this from government after attacks. You know, my response is, just as you said, Katie, I said we can't just roll out a patch from across the enterprise that touches medical devices. They have to be tested. We have to make sure that when the patch is deployed, it does not cause a malfunction in the device that affects patient safety.

00:04:41:13 - 00:05:09:00
John Riggi
We have to find a time to take these devices offline. So thank you for summarizing a very complex issue and giving some context for the difficulties and challenges. Adam, back over to you. From from a regulatory standpoint, what changes would you like to see to address this issue nationwide? In terms of third party risk, the challenges we face in having third parties often comply with what we're asking

00:05:09:00 - 00:05:16:09
John Riggi
on the cybersecurity front. HIPPA says we're responsible, but how do we make the third parties responsible as well?

00:05:16:12 - 00:05:42:21
Adam Zoller
Yeah, I think and that's a great question. And I can I want to piggyback my answers to that question. Because there's several pieces to that that need to be unpacked. I want to piggyback that on what you and also what Katie said previously. So I'd say, you know, overall, if we're looking at the regulatory landscape and you compare regulations like PCI to HIPPA, I think there's a fundamental misalignment in our priorities.

00:05:42:23 - 00:06:10:26
Adam Zoller
When you look at the regulations of, again, HIPPA compared to PCI and PCI is regulations for payment card industry protection of credit card details are more stringent than HIPPA IT controls. And, you know, I'm never one to really advocate for more regulation, but I do think there needs to be some higher level of accountability in the health care sector at large for adhering to industry best practice as itertains to cybersecurity controls.

00:06:10:28 - 00:06:37:27
Adam Zoller
So I guess to sum it up, it's hold us accountable, but make sure that as you hold us accountable, hold our third parties and suppliers accountable to the same regulations, because I find myself oftentimes at odds with the third parties that we do business with, having conversations with them about why their products or their services, their processes don't adhere to cybersecurity best practice, and how it introduces unnecessary cybersecurity risk to us in our patient care journey.

00:06:38:00 - 00:07:04:08
Adam Zoller
I shouldn't have to have those conversations with third parties. They should just be held accountable to regulations that hold them accountable from their regulators to adhere to those. I would also say regulations can't be at odds with modern IT practices. What I mean by that is oftentimes third parties push back on my conversations with them - and Katie's as well - to say, you know, we we are demanding that they adhere to modern IT security practices.

00:07:04:08 - 00:07:22:16
Adam Zoller
But then the third parties will oftentimes point back at the FDA certification and say, we can't do this because the FDA certified this device. And if we make this change that you're requesting, it's going to break that certification. The regulations can't be at odds with modern IT security practices. I'd also say that the accountability models are out of alignment.

00:07:22:18 - 00:07:55:10
Adam Zoller
Many third parties are publicly tradable companies. We're a not for profit company. Any time a company is beholden to shareholders and makes a choice to cut costs or to manage costs to hit their quarterly numbers at the expense of security best practice - and again, I'm not going to point the finger at any particular company - but I would say, you know, if there are publicly traded companies that are looking at cutting costs and hitting quarterly numbers versus, you know, investing in security best practice, that's going to lend itself to some additional regulatory scrutiny against those companies.

00:07:55:13 - 00:08:34:23
Adam Zoller
And I would also say something that I think we've hinted at through this conversation. Third parties have made a conscious choice to develop on commercial operating systems and commercial software. This commercial software and these commercial operating systems have lifespans that are far shorter than the devices that those pieces of software and those operating systems reside on. So, if it is true that these third parties are going to sell us and they will continue selling us these devices, running third party commercial software, then the device itself should either have a life span that matches the software that runs on that device or the vendor should be held accountable through regulation, keeping the software on that

00:08:34:23 - 00:08:59:24
Adam Zoller
device up to date through the entire acceptable lifecycle of that device. So if, for example, Windows software runs for seven years on a seven year lifecycle, and that device is designed to be in my ecosystem for 20 years, then I want to see a plan from that vendor that will upgrade that device at no cost to me to keep that software that the vendor chose to develop on secure and up to date through the entire lifecycle of that device.

00:08:59:27 - 00:09:18:20
Adam Zoller
And I think there should be regulation mandating that vendors can't sell devices that have either end of life or out of date software to customers. We've had issues in the last two or three years at Providence where major vendors have tried to sell us medical devices running end of life software, end of life operating systems.

00:09:18:20 - 00:09:21:17
Adam Zoller
And to me, that's just flat out unacceptable.

00:09:21:19 - 00:09:48:29
John Riggi
I appreciate that, Adam. You know, again, couple of comments on your wide ranging commentary, which I absolutely agree with. So, you know, and there's this misperception when vendors will say, no, we need FDA approval to upgrade here for security and so on. It's not accurate. The FDA website has a specific page devoted to explaining what security patches would need updates and which don't.

00:09:48:29 - 00:10:13:25
John Riggi
If it does not affect the function, the security patch does not affect the function of the device, you do not need FDA approval to implement that patch. And the FDA's made that very clear. Law passed last year, called the Patch Act provides that for all new technology where applications for new medical devices submitted after October 1, must include a lot of what you said, Adam, secure by design.

00:10:14:02 - 00:10:42:17
John Riggi
What is the plan to disclose vulnerabilities? What is the plan to update the systems and provide some type of support for the device over the lifetime of that device when comes to security? But that's only for new technology, for new applications submitted October 1. We have a massive legacy technology cybersecurity issue. Katie, since we're talking about your area, let's go over to you and give you a chance to also discuss with us.

00:10:42:19 - 00:11:05:03
Katie Adams
I would just add on to what Adam said. I mean, I think first and foremost, what we're asking for from our vendor partners is to really take cybersecurity seriously. This can't be an afterthought in the development of medical devices where they're so focused on the clinical aspect that they forget to include cybersecurity as part of the design of this equipment. That needs to be upfront as part of the initial innovation and design of the device.

00:11:05:03 - 00:11:10:04
Katie Adams
And so we need them to really work with us to help protect our patients and keep them safe.

00:11:10:06 - 00:11:46:06
John Riggi
Yeah. Thank you, Katie. And Adam, you did allude to their profit orientation on a lot of these companies, which we support, right? That's what makes this country great, capitalism, but not at the expense of security and patient safety. And ultimately, we as end consumers, as organizational and individual consumers have a choice. And I think we need to exercise that choice to impose market pressure on those third parties that do not have sufficient security to to let them know we can make a choice.

00:11:46:06 - 00:12:11:17
John Riggi
If we have that choice, we have public voices. We have regulatory voices that to help drive market forces where security becomes not an expense but a revenue driver for them. It becomes the selling differentiator perhaps, for some of these cybersecurity firms. Adam, over to you here for our last thought here. If you could make an ask of third party vendors around this issue, what would it be?

00:12:11:21 - 00:12:14:14
Adam Zoller
I don't have just one ask.

00:12:14:16 - 00:12:17:22
John Riggi
Given the fact we have limited time. Let's go ahead.

00:12:17:24 - 00:12:41:12
Adam Zoller
Yeah, a few things. I think. Number one, what Katie said: build security into your devices and software from the ground up. Know I shouldn't have to come to you as a third party and say, hey, institute this modern security practice in your device or software. Number two, if you're using commercial software operating systems, let us manage them like we do all other commercially developed operating systems, devices, etc. on our network.

00:12:41:12 - 00:13:08:15
Adam Zoller
And that includes things like scanning them for vulnerabilities, installing modern endpoint detection and response technology on the devices. Modern asset inventory mechanisms. Let us manage these devices as we do every other Windows or Linux device on our network. Hire, train and retain a security team. I can't tell you how many incidents that we've had over the last two three years where a third party gets hit by a ransomware attack and they don't have a full time security person at all.

00:13:08:17 - 00:13:36:21
Adam Zoller
Next, I'd say align your business practices with security best practices. For example, we had an incident, an issue a couple of years ago where a third party we were working with, a major third party was storing remote log on credentials in their instance of Salesforce. And obviously doesn't align to best practice. And then lastly, I would say don't show up to meetings with me or with Katie and refuse to cooperate on security best practice or don't show up to the meetings and play ignorant to security practices.

00:13:36:23 - 00:13:42:25
Adam Zoller
For me, patient health and safety is my number one priority and it should be your number one priority too, as a vendor.

00:13:42:27 - 00:13:47:06
John Riggi
Thank you for that, Adam. Katie, we'll give you the last word here.

00:13:47:08 - 00:14:03:20
Katie Adams
Man, it's hard to add on to that. I think Adam covered it pretty thoroughly. I would probably just go back to the partnership, right? We're in this together, and to deliver safe care to our patients requires not only Providence and our our health care partners and health care system, but the help of our vendors as well.

00:14:03:20 - 00:14:14:26
Katie Adams
And so rather than looking at medical device cybersecurity like a revenue stream, I would ask that they partner with us to really deliver the best possible care, safe care to our patients.

00:14:14:29 - 00:14:43:01
John Riggi
Thank you, Katie. And as I close out here, perhaps a word to our third party vendors. Please understand we have a choice in cybersecurity cells. This is a very, very serious responsibility for all of us here to protect patient safety and their data. But again, protecting patient safety is our number one concern. Pending cyber regulations, cybersecurity performance goals, specifically targeting hospitals

00:14:43:04 - 00:15:08:22
John Riggi
the AHA has a loud voice. We are also recommending any regulation that applies to us, especially around third party risk management to hospitals, must apply to the third parties as well. So Katie and Adam, thank you again for joining me today. Thank you for what you do every day as network defenders to care for our patients, serve our patients, defend them from all these varied cyber threats.

00:15:08:24 - 00:15:21:09
John Riggi
And thank you to all our frontline health care heroes for everything you do every day to care for our patients and serve our communities. This has been John Riggi, your National Advisor for Cybersecurity and Risk. Stay safe everyone.

00:15:21:11 - 00:15:29:22
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.