Advancing Health Podcast

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.

00:00:00:04 - 00:00:16:15
Tom Haederle
Welcome to Advancing Health. Advancing Health works to bring you podcasts that inform, inspire and enlighten. Please enjoy this encore airing of a great discussion about fighting hypertension through community collaboration.

00:00:16:17 - 00:00:42:06
Chris DeRienzo, M.D.
Hello again! I am Doctor Chris DeRienzo, the chief physician at the American Hospital Association. Joining me today is Anna Tharakan. She is the lead project manager on the closing the gap on hypertension disparities work at Duke. And Bradi Granger, who is a professor in the Duke University School of Nursing and a co-PI for that same project. Thank you both for joining us on the podcast today.

00:00:42:10 - 00:00:44:24
Chris DeRienzo, M.D.
I am so excited to get to welcome you here.

00:00:44:27 - 00:00:46:00
Anna Tharakan
Hi. Happy to be here.

00:00:46:07 - 00:00:48:00
Bradi Granger, Ph.D.
Thanks for having us today.

00:00:48:02 - 00:01:11:11
Chris DeRienzo, M.D.
Well, let's jump right in. You know, the community health needs assessments is a really broad, overview of both the assets and the needs within a community. I have known the community here in Durham, North Carolina, for nearly 25 years, when I started medical school in the early 2000s. But I'm really curious, you know, Duke Health has excelled in doing its CHNAs for a long time.

00:01:11:16 - 00:01:18:03
Chris DeRienzo, M.D.
Talk to us about how do you approach the CHNA and what kinds of things have you uncovered? Anna, we'll start with you.

00:01:18:05 - 00:01:47:06
Anna Tharakan
It's kind of kind of setting up what hypertension is present within our community. We see that despite the proven interventions that are currently present, over 50% of patients that are diagnosed with hypertension kind of have their condition controlled. And kind of specifically within Durham, we see that there's a prevalence of hypertension of almost 42%. So I think for us, those are kind of really some baseline statistics of really motivating us to kind of get out into the neighborhood and communities and reduce these hypertension disparities and improve overall population health.

00:01:47:08 - 00:02:13:18
Anna Tharakan
So kind of our approach was taking a quality improvement intervention to target these hypertension disparities via a telephone outreach program. So we partnered with the local FQHC or Federally Qualified Health Center and students based out of Duke Health to kind of deliver this telephone outreach. We aligned these functions essentially through student ambassadors, which were these students that conducted a structured telephone outreach to kind of help reach patients where they are.

00:02:13:19 - 00:02:36:21
Anna Tharakan
So over a series of 3 to 4 phone calls directly work with our patient cohort, which was around 300 patients, to help identify hypertension education. What are ways that we can help kind of work within their lifestyles - so maybe a touch hypertension care. We distributed free blood pressure cuffs. We helped them create smart goals and accountability partners. And then lastly also conducted a social needs assessment.

00:02:36:24 - 00:02:42:10
Anna Tharakan
Which was really just trying to identify what are other things that are kind of getting in the way of your hypertension and health.

00:02:42:12 - 00:02:59:18
Chris DeRienzo, M.D.
Let's pause there for a second because, wow. I mean, the level of depth that you are able to go to, is truly impressive. But bring this up, you know, to the 30,000ft view level for a moment, because I don't know how many of our listeners are familiar with the Durham community and specifically the role that Duke plays in that community.

00:02:59:19 - 00:03:11:21
Chris DeRienzo, M.D.
So can you give it just sort of the brief snapshot of when you're talking about, you know, over 40% of the Durham population? How many people are we really talking about? And when you're saying going into the community, what does that look like?

00:03:11:23 - 00:03:49:19
Bradi Granger, Ph.D.
I can pitch in here. Durham has about 300,000 people. And roughly, as Anna pointed out, we have a prevalence of hypertension of about 42 to 48% of the people in this county have hypertension. About half of those are uncontrolled or unaware. And so the third issue, I would say in Durham County, is the disparity in care that we've seen and the prevalence that the higher prevalence and the higher mortality and comorbidity that is associated with this chronic illness in the black population. Which that statistic is true throughout the South.

00:03:49:25 - 00:04:29:21
Bradi Granger, Ph.D.
And so we have a high proportion of minorities and underserved patients in Durham County. And we tend to focus on these first, as the risk in this group is much higher than the risk in the average population overall. So given that we started there, the clinics and the specific areas in the community where we could be most effective in improving overall health for the community were those underserved, like safety net clinics. And so across the county, we have our federally qualified health center, which Anna mentioned and our, my co-PI, Dr. Holly Biola, is there leading the effort there.

00:04:29:28 - 00:04:51:12
Bradi Granger, Ph.D.
And we've also worked together with the Duke Safety Net Clinic, the Duke Outpatient Clinic, as well as our broader population health clinics in the county. So though the work began at Lincoln, our federally qualified health center, we have reached out to try and scale the project across other areas in the community that represent underserved populations.

00:04:51:14 - 00:05:13:23
Chris DeRienzo, M.D.
Thank you so much for sharing that. You know, I moved to North Carolina 25 years ago, and in the other places I've lived, I never really had the level of appreciation that I have now for just how different a place like Durham County can look when you drive like eight minutes from the downtown core, because Durham, you know, with 300,000 people, there's definitely a downtown core and there's some high rises.

00:05:13:23 - 00:05:38:09
Chris DeRienzo, M.D.
And I mean, it's not, you know, like New York City's downtown, but it's definitely an inner city environment. But eight minutes away, you are in farm country. And so when you're talking about reaching a community, like you are going from a very urban feel to a very rural feel quite quickly. And so I know that community health workers have played a huge role in how you all have addressed this work through the project around hypertension.

00:05:38:12 - 00:05:47:11
Chris DeRienzo, M.D.
Tell us a little bit more about the role that you all are finding, community health workers playing and amplifying community outreach.

00:05:47:13 - 00:06:15:15
Bradi Granger, Ph.D.
We have a cohort of community health workers. The intent for that workforce is to really expand and extend the work that's done in a clinic, during a clinic visit with a primary care provider. The fact is that many of our people in the underserved area, especially, have so many social determinants, which Anna can expand on, that it's hard to fit the care that's needed within that short window of time of the visit.

00:06:15:18 - 00:06:38:21
Bradi Granger, Ph.D.
So this project has served to really engage health professions students like Anna as patient navigators to partner with these community health workers and literally give everyone more time to be able to provide the care, at the community level, that we want to do. So. So Anna can expand on exactly what that looks like.

00:06:38:23 - 00:06:59:24
Anna Tharakan
I think kind of as she pointed out, there was this huge not gap necessarily, we realized, but kind of this, this system that patients can't necessarily kind of getting the full time that they needed to just with the limitations of the system. And so I think what really community health workers, and in our case, students were able to really fill that gap was kind of being able to take that time with patients when they had it.

00:06:59:27 - 00:07:25:28
Anna Tharakan
Our first call with patients that students made was just sitting down with them being like, are you interested in kind of learning more about what hypertension means or how we can kind of implement some lifestyle changes, and can we do that on your time? I think that was just a really big portion of whether it was people that were working 2 to 3 jobs and only had availability at 8 p.m. or 9 p.m., I think that was kind of the really great gap that students could kind of fill, is kind of making sure outside clinic hours, where can we sit in and really impact and make a change.

00:07:26:01 - 00:07:54:02
nna Tharakan
And then on top of that, really kind of making it really personalized with that education that we gave them. Learning about the different things that they were kind of experiencing, what kind of struggles were specifically relevant to their lives, whether that was I'm struggling or trying to get groceries when I have to make sure to pick up my kids from preschool, or whether it's I'm taking care of two of my parents that are, kind of based in the hospital and kind of making sure that we were able to insert little pieces of advice, whether it's, hey, like, how about we try to get 30 minutes, you know, walk to your parent's house instead of,

00:07:54:04 - 00:08:05:06
Anna Tharakan
necessarily being able to drive there and really kind of instill small changes that they can make and really be their personal cheerleader and kind of instill in these small changes that can really make such a big difference in their blood pressure and hypertension.

00:08:05:09 - 00:08:22:13
Chris DeRienzo, M.D.
I love that. Wouldn't we all benefit from having a personal cheerleader, especially when fighting, you know, a condition like hypertension, which is so seemingly innocuous because it's just a number on a machine. But we know that, that years and years and years of high blood pressure take its toll on nearly every organ system in the body.

00:08:22:15 - 00:08:40:14
Chris DeRienzo, M.D.
And again, being good project leads, I imagine you all are measuring countless kinds of metrics through this work. What is, one measurable impact that you can tell us about through this engagement of community health workers and really extending their reach, and not only into patients homes but into community based settings as well?

00:08:40:16 - 00:08:59:21
Anna Tharakan
I think the big one was just the impact that we had on their blood pressure. And then also just self-management. I think within our intervention this past year, we saw a average drop in the systolic blood pressure of those that participated of over 15mg mercury, which is just a really huge kind of drop when considering the intervention that took place.

00:08:59:23 - 00:09:18:29
Anna Tharakan
And I think another big one was this idea of self monitoring, kind of bringing the power to the patient, kind of being able to track with the free blood pressure cuffs that they were able to be provided, as well as a social needs assessment was kind of really putting that power of health back in their hands and showing that community health intervention led can produce really meaningful clinical outcomes.

00:09:19:01 - 00:09:21:19
Chris DeRienzo, M.D.
Spectacular. Bradi, anything you would add?

00:09:21:21 - 00:09:54:26
Bradi Granger, Ph.D.
The one thing I would add to that is the idea of the system integration that this project brings, whereby, to your point, hypertension really is a chronic illness, that the long term outcome is what we're after: reduction in stroke, reduction in chronic kidney disease and reduction in cardiovascular events. But those things happen so far from, you know, today's single measurement or even a couple of years worth of measurements of high blood pressure in an office visit, which is often mistakenly elevated anyway.

00:09:54:28 - 00:10:25:20
Bradi Granger, Ph.D.
So our real achievement, I feel like in addition to what Anna said about bringing the power to the patient to set their goals and really be able to be aware and to be responsible for changes and improvements in their health. We also really are trying to effectively connect a patient to the primary care provider team, including the community health worker and the community business organizations that help us serve patients outside of the formal system of health care delivery.

00:10:25:23 - 00:11:15:21
Bradi Granger, Ph.D.
These groups provide food, transportation, assistance with housing insecurity and all the things that are real barriers for patients managing long term hypertension. So solving for those things and tracking it as we have and making sure there's a closed loop on the referrals that happen, allows us to really measure the impact of this kind of project on some of our really important community outcomes, but also the policy implications for this project, which we're working on now with our North Carolina Department of Health and Human Services, and trying to make sure that the opportunity for us to expand healthy opportunities pilots from our Medicaid expansion initiative, trying to make sure that we have the evidence and

00:11:15:21 - 00:11:22:13
Bradi Granger, Ph.D.
the measurable outcomes to support new policies for expansion of those kinds of efforts in the community.

00:11:22:15 - 00:11:52:00
Chris DeRienzo, M.D.
Well, you all have certainly covered the waterfront. I mean, clearly, it takes it takes a team. And you've been able to connect to not just the acute care clinical team, but, the patient's family, community, teams all together in this web in supporting patients. And I'm curious. We've only got a minute or two left. If you had to give one piece of advice for health care team members in a community right now listening to this podcast who are just coming away from hearing your story and saying, I got to go do this tomorrow.

00:11:52:03 - 00:11:57:12
Chris DeRienzo, M.D.
What would your one piece of guidance be as they're preparing to take their first step?

00:11:57:15 - 00:12:08:15
Bradi Granger, Ph.D.
Our guidance would be communicate with your primary health care provider and let them know you're interested in joining our team as a patient expert in the hypertension Management program.

00:12:08:18 - 00:12:17:19
Chris DeRienzo, M.D.
Outstanding. Anna, what if you were giving advice to a hospital who is hearing the story? And they said, I want to be just like this project that they're doing, I do.

00:12:17:22 - 00:12:32:15
Anna Tharakan
I think it's just showing that it's possible to kind of get intervention like this off the ground, and it really can make a real big difference in patients lives. And so kind of putting a focus on community health workers and kind of connecting back to that primary care, as Dr. Granger said, is a really important component.

00:12:32:17 - 00:12:50:25
Chris DeRienzo, M.D.
You have done tremendous work. Obviously connecting all the way back to the community health needs assessment. What it lifts it up, how you connect that to a project, building in the approach that brings community health workers into the fold, and then obviously bringing patients and family members into the fold with you. We could not wish you more luck in the work that you're doing.

00:12:50:25 - 00:12:55:27
Chris DeRienzo, M.D.
And again, couldn't think of a better story to tell. Any closing thoughts before we say goodbye?

00:12:56:00 - 00:13:03:26
Bradi Granger, Ph.D.
I think thanks for your support and for the dissemination of efforts like this and the impact it has on our community. Thank you.

00:13:03:28 - 00:13:07:09
Chris DeRienzo, M.D.
Couldn't say it better myself. Thank you both so much.

00:13:07:12 - 00:13:15:23
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 - 00:00:18:12
Tom Haederle
Welcome to Advancing Health. As health care evolves to meet the needs of patients today, providers are finding that breaking down barriers between disciplines, scrapping separate medical training programs in favor of an integrated approach is improving access to care.

00:00:18:15 - 00:00:59:05
Elisa Arespacochaga
This is Elisa Arespacochaga, group vice president at the American Hospital Association. We know that practiced well, health care is a team sport, yet we still maintain very separate training programs that can sometimes reduce that ability to build team muscle early. I'm very excited to share with you today my conversation with our two guests, Dr. Jeremy Fish, founding director of the John Muir Health Family Medicine Residency, and Dr. Pilar Corcoran-Lozano, Behavioral Health Core faculty and supervising psychologist of the Co-Training Program, about how they've not only integrated physical and behavioral health in their residency clinic to improve access to care, but how they've integrated the training programs to truly build teams

00:00:59:05 - 00:01:04:12
Elisa Arespacochaga
from day one. So first of all, thank you so much for joining me and sharing your story.

00:01:04:15 - 00:01:05:21
Jeremy Fish, M.D.
Thanks for having us.

00:01:05:23 - 00:01:07:06
Pilar Corcoran-Lozano, PsyD
Thanks for having us.

00:01:07:08 - 00:01:22:28
Elisa Arespacochaga
Dr. Fish, I'm going to start with you. As a family medicine physician, you started down this path. You've been a residency director. You thought about, okay, how can we make this better? What made you say, you know what we need? We need clinical psychologists and we need to train them here.

00:01:23:01 - 00:01:43:01
Jeremy Fish, M.D.
Yeah, well, it's been a long journey because I practiced for many years in a county based health system. We did have some behavioral health folks in the residency that I trained at over at Contra Costa. And what I learned was, there's a whole lot of care that I'm not a real expert at providing. And yet the need is constant.

00:01:43:04 - 00:02:10:00
Jeremy Fish, M.D.
And I found myself virtually getting kind of quasi-psychological support and behavioral health support, in ways that I felt very ineffective. And I really didn't find that comfortable for me because I really enjoy as a family physician, being able to help people across a full spectrum of needs. And yet I found there often we fell short. So I had some exposure to the model of behavioral health folks being in primary care during my training.

00:02:10:02 - 00:02:32:19
Jeremy Fish, M.D.
Family medicine is unique in that way in that we have behavioral health faculty who are actually teaching us. When I came to John Muir, we really wanted to do something even more advanced. And the reason for that is that I really felt this was a need that was there every time I was in clinic. And so that the residents, every time they're in clinic and they need that help, I wanted them to have that support.

00:02:32:21 - 00:02:54:03
Jeremy Fish, M.D.
And so when we set out to establish an advanced primary care practice in our residency program, the first initiative I really had was to fully establish a partnership with the Behavioral Health Educational Program. And that's how I met Dr. Corcoran-Lozano. She was one of our first students to come in to that early iteration of our program.

00:02:54:06 - 00:03:21:15
Jeremy Fish, M.D.
It was initially a kind of mix of LMFTs - license and marriage and family therapists, as well as PsyD students. We eventually, under the leadership of Dr. Heidi Joshi, who was a PsyD expert,  who had a lot of experience with building PsyD programs that we fully went into the PsyD level program because in many ways they are the highest level skilled across all payers.

00:03:21:16 - 00:03:45:01
Jeremy Fish, M.D.
They can also bill all payers. And so that really kind of solidified that what we needed to do was really build the leaders of the future for primary care behavioral health integration. And so when we established a program at John Muir, that has now become our model of co-training in this way. Because we also found, you know, when we're young, when I was younger, I was more open to a lot of different things.

00:03:45:03 - 00:04:06:12
Jeremy Fish, M.D.
And I just think using the youthful energy and the desire, I think the Gen Z and you know, millennials, they really enjoy team-based training. They like to rely on other professionals so I think it really also provided the opportunity for getting the relationships developed early in training, where then they would have an expectation of working with behavioral health folks in their careers.

00:04:06:14 - 00:04:34:22
Elisa Arespacochaga
I love that. Dr. Lozono, can you tell me a little bit. From your perspective, you're coming from a training program that often isn't co-located with family medicine, residency, or physician residency programs. How did you, get to this path - as Dr. Fisher mentioned, you were one of the early students - but how did you help bring in your own students and adjust them to the workflow of a traditional physician residency?

00:04:34:24 - 00:05:04:22
Pilar Corcoran-Lozano, PsyD
Behavioral health providers, mental health providers and family physicians, they're trained in silos. Like we learn about a specific discipline, for example, by reading about it, by seeing videos. And so a big part of my own training was having the opportunity to be in a learning environment that really fostered teamwork, which this residency did. And so it allowed me to be vulnerable.

00:05:04:23 - 00:05:15:25
Pilar Corcoran-Lozano, PsyD
It allowed me to kind of rely on other team members. It allowed me to know the limits of my own knowledge, so that way I could rely on another discipline.

00:05:15:27 - 00:05:37:29
Jeremy Fish, M.D.
Yeah. And I think as you mentioned, really establishing a culture of learning and health care, we are always learning, but we don't necessarily do it in a conscious way. And learning to be team members is really tough. I think the key word to use there was making yourselves vulnerable. It is hard to make yourself vulnerable within your profession.

00:05:38:02 - 00:06:06:08
Jeremy Fish, M.D.
It is even more challenging to make yourself vulnerable across professions. And early on, we had some challenges. And yet, Dr. Corcoran-Lozano saw enough in that to come back. She first came as a doctoral student, returned as a postdoctoral student, and then became a faculty member and now a supervising faculty. So she's a perfect example of the evolution of the comfort that people get over time in doing this.

00:06:06:09 - 00:06:07:20
Jeremy Fish, M.D.
But it's not easy.

00:06:07:23 - 00:06:29:14
Pilar Corcoran-Lozano, PsyD
It's not easy. And it appears, and maybe it seems simple, to just be able to like work as a team. Like that sounds wonderful and great. And really, it's a huge cultural shift of putting two different disciplines that are trained vastly different and then putting them together and telling them, support this patient.

00:06:29:16 - 00:06:57:26
Elisa Arespacochaga
What I love about the work that you've done with this integration, and Dr. Lozano, I'm going to ask you to talk a little bit about this, because I know this is obviously from the behavioral health side a huge need. Not that there isn't a need for access to care from every angle, but especially behavioral health needs. How is this integration really driving that ability for all the patients you see in clinic to have access to not only the physical health support they need, but the mental health support they need?

00:06:57:28 - 00:07:19:12
Pilar Corcoran-Lozano, PsyD
So one thing that we actually offer in clinic is what is referred to as warm handoffs. And so these are we have one of our behavioral health providers sitting in the same exact room as the medical learners, the medical residents. And so we have our ear open and we're listening to things that are related to possibly behavioral health.

00:07:19:19 - 00:07:48:10
Pilar Corcoran-Lozano, PsyD
And we are a resource for people. And so being in that room allows us to have same day visits with patients. Many times in this setting, we are the first face related to mental health or behavioral health that a patient may interface. And so there's definitely stigma still related to mental health and behavioral health. And so lessening that stigma might just be like, hey, would you like to talk to Dr. Pilar?

00:07:48:12 - 00:08:13:04
Pilar Corcoran-Lozano, PsyD
She can come in and kind of meet with you same day, can be very beneficial. And so one is we're addressing those needs. So we're lessening the barriers, the stigma related to mental health. As well as, where in that visit we might teach something to that patient. We may talk a little bit about therapy or resources, give them a skill that they can take home with them.

00:08:13:06 - 00:08:30:14
Pilar Corcoran-Lozano, PsyD
And we can also schedule same day. Before they leave, they already have an appointment with a mental health provider. They might have met that mental health provider already, so that already lessens the kind of the fear, maybe, that might be like, who am I going to be meeting? So...

00:08:30:17 - 00:08:52:16
Jeremy Fish, M.D.
Yeah. And if I might add to that, because I think it just really is the centerpiece. It took us nearly two years to come up to a joint agreement that warm handoffs would be the key priority, in part because it really brought up that almost everything involved, you know, where is the privacy there? And in a stigmatized industry, privacy is paramount.

00:08:52:18 - 00:09:15:19
Jeremy Fish, M.D.
Right. So you're taking people who have to come in very quickly in a few minutes. Are they going to do it inside the same room that the doctor was there? Or are we going to put the patient in a different room? So you've got to go, you know, there's workflow issues that have to be addressed. And it was very challenging for them to come in with only a brief like, what do I do in a few minutes to establish rapport?

00:09:15:21 - 00:09:47:07
Jeremy Fish, M.D.
That kind of that's a real primary care challenge, because often in behavioral health, you're spending weeks to months developing that trust. And so what's enough trust in just a few minutes? And that's we found bringing them into the room right away and then addressing the workflow needs, was vitally important. Because if you look at a traditional primary care setting, you're talking about maybe 10% of patients will actually make their first referral to a behavioral health practice

00:09:47:12 - 00:10:17:09
Jeremy Fish, M.D.
that's not integrated inside of the practice. I mean, it's just profoundly different, the follow through, right? And so we really wanted to achieve in the in the realm of 90 to 100% of that first visit. And so it took us a couple of years to come to a joint agreement on that. And once we did that, that really established for the residents and the faculty to see the behavioral health folks as a really readily available resource, that help them relieve their stress.

00:10:17:13 - 00:10:42:15
Jeremy Fish, M.D.
Not only is it better care for the patients, it's actually the mental and behavioral well-being of the physicians improves and the staff in the practice. Because the sense of efficacy, we're doing good work. We're actually helping people because people with unmet mental and behavioral health needs can make very unusual demands on a practice. And, and have behavioral issues that can be very stressful to a practice.

00:10:42:19 - 00:11:00:27
Jeremy Fish, M.D.
So having professionals who really know how to help us manage that is extraordinarily effective. And we saw that particularly during Covid, where there were high levels of distress going on. We were so grateful having the behavioral health folks there to help us do the assessments and make sure we could actually do the right thing for these patients.

00:11:00:29 - 00:11:18:25
Elisa Arespacochaga
You know, absolutely. And I think my last question that I want to ask you both to comment on, and I'll start with you, Dr. Fish. You're building an army of residents who think now full spectrum family medicine is not just, you know, family medicine plus OB, it's family medicine plus behavioral health plus OB plus being part of a team.

00:11:18:27 - 00:11:30:05
Elisa Arespacochaga
What lessons are some of your residents telling you they're taking away into their careers? And, you know, now you've graduated a couple of classes. They're starting to demand these things in their attending positions.

00:11:30:08 - 00:11:55:07
Jeremy Fish, M.D.
Yeah. And there's a there's a tension with that because definitely we've gotten feedback from our residents, how essential it is, how much they enjoy the partnership that they develop, particularly with the co-learners. They consider them fellow residents, right, that they are part of our residency training program. And so those relationships and the depth of those relationships give our residents a great deal of confidence in the care of patients that they have.

00:11:55:07 - 00:12:16:19
Jeremy Fish, M.D.
So they're very appreciative of the fact that they're very comfortable doing testing, like PHQ9 and how to how to use that sort of assessment around a depressed patient to determine what to do, that there are alternatives to medications, because we face this all the time, where patients through stigma don't want to take medicines either, because that medicine means they have a disease they don't want to have.

00:12:16:22 - 00:12:40:06
Jeremy Fish, M.D.
They don't want to necessarily acknowledge that they're depressed or anxious. And so having alternative treatments for those patients where they can work through cognitive behavioral therapy or some other mechanism, really helps broaden the comfort of our residents. So there's lots of things we can do for people who are struggling with these challenges. And they tell us, you know, if we were not to have this, they can't imagine what that is like.

00:12:40:06 - 00:13:03:23
Jeremy Fish, M.D.
And so then when they're going on to their careers, this has created a attention point in the in the systems that they've gone on to work and where they are saying, hey, Dr. Fish, I'm at this new place that will go unnamed and I can't even get a psychiatry consultation. It's just really hard. And so now I'm using all the skills, but I'm worried I'm going to burn out, because everybody's sending me their behavioral health patients.

00:13:03:23 - 00:13:21:00
Jeremy Fish, M.D.
And I said, yes, this is part of the symptoms. And this is part of why we do leadership development is we want you to learn how to work within your system to say, hey, this does work because there's a lot of, misinformation out there. Because it's challenging to do this, a lot of health administrators will say, oh, it can't be done.

00:13:21:00 - 00:13:38:22
Jeremy Fish, M.D.
We tried that in, you know, 2004 and it didn't work. There's a lot of that in health care. And I understand that. When something takes two years to get it working well, it's hard for a health system to have that kind of patience to get there. So there's a lot of misinformation that this can't be done.

00:13:38:22 - 00:14:00:05
Jeremy Fish, M.D.
And so part of our mission is to help people understand it can be done and then part of our training for our residents is you need to be that leader who goes to the meetings and says, here's something we could do that I've seen, because when you've have a lived experience of something, you're a much more persuasive and compelling narrative giver on the value of it.

00:14:00:08 - 00:14:03:19
Elisa Arespacochaga
Dr. Corcoran-Lozano, I would love to hear your last thoughts on this.

00:14:03:21 - 00:14:30:24
Pilar Corcoran-Lozano, PsyD
I think it actually goes down to the need. There's the need for patient care. However, since we're talking about a residency clinic, we're talking about folks that are in training and there's a need there. There's a need that I am sitting across from a patient in an exam room, and they have feelings and they're crying, and they just got a new diagnosis.

00:14:30:24 - 00:14:54:18
Pilar Corcoran-Lozano, PsyD
Or maybe they're having a difficult time taking their medications every day. And that can be medications for anything. And so they're sitting there struggling perhaps like how do I communicate with this particular patient? How do I talk to them about medication adherence or asking about what are some of the reasons or barriers for them not to take their medications?

00:14:54:18 - 00:15:20:18
Pilar Corcoran-Lozano, PsyD
And that's just one example. And so we're here for that need to help support and teach these residents. They're able to have these difficult conversations with patients. They're able to actually treat the whole person, right? Because they, they recognize - and something that we really kind of stress here - is that we have this thing that is in between our head and our body, and that is referred to as a neck.

00:15:20:21 - 00:15:39:19
Pilar Corcoran-Lozano, PsyD
And that is because we are our mind and body are connected like we are all whole people and we're complex. And so it's really about meeting the needs of the learners and the patients. And so also teaching the next generation of psychology trainees on how to do that.

00:15:39:21 - 00:15:59:28
Elisa Arespacochaga
Absolutely. Well, I want to thank you both for joining me today for sharing about your program. I love the work that you have put into not saying yes in the face of maybe a few too many no's and continuing to push to bring together the care you knew needed to be provided as a team sport in your clinics.

00:15:59:28 - 00:16:02:06
Elisa Arespacochaga
So thank you both for joining me.

00:16:02:08 - 00:16:10:18
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.