Advancing Health Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00:13:06:03 - 00:13:14:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00:11:33:20 - 00:11:42:01
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:27 - 00:00:17:08
Tom Haederle
Welcome to Advancing Health. When it comes to treating children's diabetes, the old saying that two heads are better than one has been put into practice with impressive results, as we learn in this podcast.

00:00:17:11 - 00:00:39:08
Tom Haederle
Hi everyone. I'm Tom Haederle senior communications specialist with the American Hospital Association, and really glad that you're along with us today. I'm going to start this podcast with a quote: "Prevention is always the way to go. If we can equip families with knowledge, support and community, we change health trajectories for life." So, those words are referring to childhood type two diabetes,

00:00:39:08 - 00:00:59:29
Tom Haederle
and they come from one of our guests today, Matthew Edwards, a certified diabetes care and education specialist at Children's Wisconsin Diabetes Prevention Clinic. And we're really pleased to also have Matt's colleague, Dr. Elizabeth Dabrowski, who is a pediatric endocrinologist at Children's Wisconsin, with us as well. So thank you again for coming on Advancing Health today. Really appreciate your being here.

00:01:00:01 - 00:01:13:09
Tom Haederle
A couple of years ago, when Children's Wisconsin opened its new diabetes prevention clinic, it seems like it decided to come at the problem a little bit differently than it has in the past. What can you tell us about that? Maybe Matt, if you take the first crack at that?

00:01:13:12 - 00:01:39:14
Matthew Edwards
Yeah. I think what we saw was a gap in our care. We had patients who had these comorbidities that were finding their ways to maybe our diabetes clinic or to our new kids clinic, but we were getting referrals from patients who maybe just had elevated BMI and not comorbidities to go along with it. And we just wanted to find a home for these patients before they ended up in those other clinics with the comorbidities.

00:01:39:17 - 00:01:45:02
Tom Haederle
So what was the treatment approach from the outset that was it was doing things a little more innovatively, shall we say?

00:01:45:09 - 00:02:06:00
Matthew Edwards
Yeah, we wanted closer contact points. There's several programs that have existed that showed more close contact with these patients leads to greater outcomes. And we knew we wanted to pair with our endocrinologist because their insight is just so helpful. We've got these other modalities of care that we can use now that are at our fingertips, that we can provide these patients with.

00:02:06:02 - 00:02:25:24
Matthew Edwards
And then we knew we also wanted to add some movement component with our physical therapist. That's really the piece that has been a little lacking in our program. And more recently, within the last two years, we've been able to refer a number of our diabetes patients and our prevention patients to physical therapy. And the relationship has been really great working with them.

00:02:25:26 - 00:02:38:29
Tom Haederle
Doctor Dombrowski, combining treatment for children's type two diabetes from endocrinologists and dieticians at the same time seems like a logical thing to do. Why wasn't it standard practice in the first place all along?

00:02:39:01 - 00:03:01:12
Elizabeth Dabrowski, MD
I think in part because usually by the time kids we get to the diabetes clinic, they already had type two diabetes, the horse was out of the barn. And we've been seeing, especially with the advent of GLP medications and new medications that were previously only FDA approved in adults are now FDA approved in children, some for weight and some for type two diabetes management.

00:03:01:19 - 00:03:33:09
Elizabeth Dabrowski, MD
We were seeing more referrals of kids for pre-diabetes or their labs were a little abnormal, but they didn't have diabetes yet. And we did not in standard practice have dietitians in our clinic. I think if we're looking at changing lifestyle they are the most important people to have with us. And then if we're looking at deconditioning and physical activity, that's why our physical therapists are wonderful, coming up with exercise regimens for kids that work for them, meeting them where they're at, teaching them a safe way to start.

00:03:33:11 - 00:03:40:06
Elizabeth Dabrowski, MD
And I think all of that's more important than what I can do. And so that's really why we tried to bring all these groups together.

00:03:40:08 - 00:03:53:28
Tom Haederle
So from a young patient's point of view, what is the hospital experience like when they when they come to Children's? If you could maybe walk us through a typical day, the kind of care they get, who they're seeing, what kind of advice they're getting, what would that look like?

00:03:54:00 - 00:04:19:02
Elizabeth Dabrowski, MD
So the way our clinic is set up, they'll be seen by endocrinologist first. That hospital is actually very kid friendly. My kids actually really enjoy their visits here. And so we'll see them. We'll get a general idea of history, medical problems, family history, all of the general stuff you talk with your physician about. And then we'll talk a little bit about diet and exercise, what the patient's goals are, what their concerns are and why they're there.

00:04:19:03 - 00:04:34:07
Elizabeth Dabrowski, MD
I don't like to focus on weight. I don't like to focus on a number I like to see. What are your goals as your goal? To be able to play like one of my little kids, he wants to be on the football team, and they told him he cannot be on the football team where he's at right now.

00:04:34:07 - 00:04:39:20
Elizabeth Dabrowski, MD
And so, okay, how do we get to that goal? And we'll meet my goal in the background at the same time.

00:04:39:22 - 00:04:46:16
Tom Haederle
It sounds like you're really making a point to stay away from any negative messaging about their condition or like you say, weight or anything else like that.

00:04:46:18 - 00:04:47:27
Elizabeth Dabrowski, MD
Correct? Yes.

00:04:48:00 - 00:04:55:24
Tom Haederle
What kind of diet advice are kids hearing and are they hearing it for the first time? Maybe you know something that they should have been hearing all along.

00:04:55:26 - 00:05:13:21
Matthew Edwards
Yeah, I think absolutely. A lot of times our patients are hearing our message for the first time because I think it goes beyond that. Typical eat healthy, more fruits, more, more vegetables kind of messaging. We really individualize our approach for our patients. When the dietitian hops into the visit, they'll do what's called the 24 hour recall

00:05:13:21 - 00:05:34:04
Matthew Edwards
where we get a sense of what this patient's day looks like. Are they eating breakfast, lunch, dinner? Where are those meals happening and what are the portions or typical foods look like? And we also do talk a great deal about physical activity. We'll talk about sleep. We'll talk about hydration. We'll talk about stressors or other things that might impact their food choices or food decisions, their health environment.

00:05:34:06 - 00:05:54:07
Matthew Edwards
We often cover social determinants of health, access to healthy foods and healthy fruits, vegetables, those kind of things. And so it's much greater than just kind of healthy eating. It's how do you take some knowledge and apply it to a glucose environment or a blood sugar environment to help your body stay in regulation?

00:05:54:09 - 00:06:09:25
Tom Haederle
Does it ever feel like you're fighting an uphill battle? And I only ask that because, you know, there is so much - I think we all admit this - there's so much sugar and garbage and junk in the typical American diet that it's very difficult, I would think, to wall off, you know, especially a young person from those influences.

00:06:09:25 - 00:06:11:28
Tom Haederle
So how do you handle that part of it?

00:06:12:00 - 00:06:31:02
Matthew Edwards
It's extremely difficult. I think it's important to meet the families where they're at. Maybe not every meal is ideal, but could we have an optimized snack or an optimized meal at certain times of the day? Can we focus more on satiety or filling foods? Maybe not changing the foods that are on their plate, but what is that composition look like?

00:06:31:02 - 00:06:44:06
Matthew Edwards
Can we decrease the amount of less filling foods like grains and increase the filling foods like proteins, fruits and vegetables or fibrous foods? And it's just really meeting the patients where they're at and individualizing their approach.

00:06:44:09 - 00:07:03:02
Elizabeth Dabrowski, MD
I think a big part also is the family approach. And so I'm not asking my patients to do anything that I don't already do in my house. And I'm also, you know, if Mom and dad aren't doing it, the child is not going to do it. And so one of our big things is juice. My personal take, no one needs juice.

00:07:03:04 - 00:07:19:06
Elizabeth Dabrowski, MD
It is not a healthy option. And so if  - the kid you're buying juice and the kid's drinking the whole bottle in two days - let's just not buy it anymore. I had one little kid. I must have seen him last October because I told the mom my approach to Halloween candy and all of that. And the next visit, I saw him.

00:07:19:06 - 00:07:34:17
Elizabeth Dabrowski, MD
I was like, oh my gosh, you're doing so well. Why did you change it? She's like, well, you mentioned how you just limit the snacks in your house to a few days a week, like the really sugary things, you still get them, but it's limited. And she's like, that's all we did. It's not that simple all the time, by any means.

00:07:34:17 - 00:08:05:28
Elizabeth Dabrowski, MD
But that one just stuck out because I was like, oh, I didn't even realize I was helping there. But, I think meeting them where they're at, trying not to make anything off limits because then you're going to limit, limit, limit and then overdo it. And so just like Matt said, talking about portions, talking about how much carbohydrates versus protein and all of that, or when you're talking about snacks, kids who are having chips three times a day, oh, like maybe replace one with a fruit and one with salted popcorn or something a little better, but maybe not what we all see

00:08:05:28 - 00:08:09:13
Elizabeth Dabrowski, MD
as great. It still makes a big difference overall.

00:08:09:16 - 00:08:29:19
Tom Haederle
And I imagine in some cases you're really working not just to change an individual's behavior, but that of their family or their peer group or whoever or whoever they're spending time with. In the first two years the program served approximately 200 children, and not one of the program's participants went on to develop a type two diabetes diagnosis, which is remarkable.

00:08:29:22 - 00:08:32:21
Tom Haederle
Did you anticipate such a record of success?

00:08:32:23 - 00:09:06:19
Matthew Edwards
I don't think so. It's been really hopeful to see that kind of results. Now, the one caveat I can put on that result is that there may be patients that have been lost to follow up, that we don't know if they've now experience a diagnosis of diabetes. So I want to just put that out there. But I would say that, you know, we see so much success in this program for those patients that really invest in the long term follow up plan with this kind of clinic. Because again, the more contact points we have with the patient and with the family, the better the results that we're seeing.

00:09:06:21 - 00:09:30:23
Elizabeth Dabrowski, MD
We really created the clinic to fill a need. And we just I went in with zero expectations. I really wanted to see what would work for families. We have these kids getting referred to a lot of subspecialists, a lot of different places. And when we're looking at causes of excess weight and all of that, there's a lot of social determinants of health that go into that that may limit their ability to come to appointments or to miss that much work to go to appointments.

00:09:30:26 - 00:09:44:25
Elizabeth Dabrowski, MD
So seeing how much we could bundle things in one appointment or add some virtual touchpoints or things like that where kids weren't missing as much school, parents weren't missing work, we were hoping to get more of those touchpoints in. So it looks like it's helping.

00:09:45:02 - 00:10:03:25
Tom Haederle
Yeah. You must be encouraged by the success you've seen so far. It's wonderful. Any final thoughts about maybe what your peers, another health system or hospital could take away from your experience so far in terms of your patient population, what you've seen work? What would you say to somebody, another hospital, say, that's considering doing something similar?

00:10:03:27 - 00:10:27:06
Elizabeth Dabrowski, MD
I'd say don't take no for an answer. If you see a need that's there for patients, you just keep asking and asking and asking until you get what you think is best for them and until you get the care from external sources and dieticians, physical therapists. We're talking about getting some other people into our clinic to serve some of those other needs our patients may have.

00:10:27:09 - 00:10:30:13
Elizabeth Dabrowski, MD
I'd say just keep chipping away until you get the "yes."

00:10:30:16 - 00:10:35:10
Tom Haederle
Great advice. Matt, any final thoughts? Anything we haven't discussed so far that you want to touch on?

00:10:35:12 - 00:10:59:14
Matthew Edwards
Yeah, I just have one analogy that I do want to really sneak in here. And just to highlight the benefit of a prevention clinic. It's something that I remember from being an intern, during my internship. And one of the mentors that I had at the time said, prevention is like a bridge over a river. And that bridge is broken and people are crossing the bridge and they're falling into the river and they're heading downstream.

00:10:59:16 - 00:11:24:28
Matthew Edwards
Now, our diabetes clinic is the river. We're pouring in tons of resources and tons of effort to relieve this metabolic syndrome. But I just think about the benefit of preventing people from going into that river and having to struggle and having to pour all those resources in. To me, that's what our prevention clinic is, is where we're preventing them from going into the river and turning that life trajectory around.

00:11:25:00 - 00:11:39:14
Tom Haederle
Well, that's a wonderful image to end our discussion on. Thank you so much. I appreciate your time this afternoon and your excellent work on behalf of your patients. It's really inspiring. So thanks again for appearing on Advancing Health and good luck continuing with your great work.

00:11:39:17 - 00:11:40:08
Matthew Edwards
Thank you.

00:11:40:10 - 00:11:41:13
Elizabeth Dabrowski, MD
Thank you.

00:11:41:15 - 00:11:49:26
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:28 - 00:00:23:27
Tom Haederle
Welcome to Advancing Health. Philanthropic support of a hospital or health system can support tactical investments that will impact a community for years to come. In today's podcast, we hear how CommonSpirit Health leveraged its donor support to create a plan that helps unlock other investments that continue to drive the mission.

00:00:24:00 - 00:00:51:12
Sue Ellen Wagner
Welcome to Advancing Health. My name is Sue Ellen Wagner, vice president of trustee services with the American Hospital Association. Very happy to have with us today leadership from CommonSpirit. Specifically, we have Daniel Morissette, senior executive vice president and chief financial officer. And Nancy Bussani, executive vice president and chief financial officer and president of the Common Spirit Health Foundation.

00:00:51:15 - 00:00:54:15
Sue Ellen Wagner
Dan and Nancy, very happy to have you with me today.

00:00:54:18 - 00:00:56:00
Daniel Morissette, MBA
We're thrilled to be here.

00:00:56:03 - 00:00:57:13
Nancy Bussani
Thank you, Sue Ellen.

00:00:57:16 - 00:01:15:23
Sue Ellen Wagner
Philanthropy can have a huge impact in helping a hospital or a health system achieve its mission of caring for patients, while also supporting operations. What role is philanthropy playing right now in health care? And can you talk about what is happening at Common Spirit?

00:01:15:26 - 00:01:46:20
Daniel Morissette, MBA
Thank you so much for that question. I guess to I can summarize it briefly first by saying it plays a huge role in helping us achieve our strategic capital and operational objectives. And so the money that we receive from our various philanthropic sources really does make a dramatic impact on funding our mission and doing the strategic initiatives that we have ongoing of providing even cash flow support to some of our important endeavors.

00:01:46:23 - 00:02:05:22
Daniel Morissette, MBA
And as you know, in today's health care environment, it is I can't recall a time where it's been more challenging, just from a pure operation standpoint. So, at CommonSpirit, Nancy'll go into this some, CommonSpirit has made just a dramatic effect on our various communities.

00:02:05:24 - 00:02:32:06
Nancy Bussani
Well, thank you, Dan. And I know our goal when we raise funds is to make sure they really make a difference for the health system. Last year we raised about $360 million, which was really in a very challenging environment where there was some volatility in donor sense of how they want to give. And we did it in an environment where we had to streamline, where we really had to look at how do we make sure that we're as efficient as possible.

00:02:32:06 - 00:02:56:03
Nancy Bussani
So we have we had a return on investment about $5.25, so that every dollar that came in, really provided $5.25 back to CommonSpirit. But that's only as good as where it goes. So I think the strategy of making sure it goes for the most critical programs and equipment and facility is really one of the most important things we're focused on right now.

00:02:56:05 - 00:03:22:17
Daniel Morissette, MBA
I'll just add to what Nancy said. You know, $360 million does make a really big difference for us at CommonSpirit Health. But it is important that we think about the fact that, you know, our alternative sources of revenue. You know, like such as patient care revenue, we would need to generate much, much more than the $360 million to actually have the same impact on our margins.

00:03:22:19 - 00:03:49:03
Daniel Morissette, MBA
So, you know, reverting to my CFO background, when you look at patient care revenue, we would need to generate about, oh, $100 or so in patient revenue just to net about $4 after you're done with all the expenses. But as Nancy said, when we look at it from a philanthropy standpoint, for every hundred dollars that we're able to receive, we do net about $81.

00:03:49:06 - 00:04:18:21
Daniel Morissette, MBA
You know, it really does have a big impact, particularly on the, you know, community based programs and initiatives that we have in our various markets. Therefore, I just want to mention that philanthropy is just a huge piece of what we need to do to be more and more effective from an operational and financial standpoint. And so it's been just a thrill for me to be part of our growing enterprise here, because it is so critical to what our mission is.

00:04:18:23 - 00:04:47:12
Daniel Morissette, MBA
You know, it is important to add that, you know, philanthropic funds have become a pretty significant data point when we meet with our outside investors, with bond rating agencies and the like. Because it is one way to help assess the strength that the health system's creditworthiness and its bond rating. But also it does help to know that the donors have confidence in us and the value we're bringing to our community.

00:04:47:19 - 00:05:20:08
Daniel Morissette, MBA
So the dollar amount really does make a difference from the, you know, just a pure financial and operational standpoint, because it is an alternative revenue stream that is, of course, less sensitive to the volatile environments we deal with, like payer mix and reimbursement pressure and fluctuating volumes. So, you know, philanthropy oftentimes does offset some of our debt funded capital project. Therefore it does reduce our leverage as well as strengthen our balance sheet.

00:05:20:11 - 00:05:43:21
Sue Ellen Wagner
Very important points about the value of philanthropy. Just to expand a little bit on what you both talked about. Philanthropy can be a strategic investment, and it has the value beyond the dollars raised. You both mentioned that a little bit. Can you expand a little bit and talk about why health care leaders should view philanthropy as a strategic investment, in addition to what you've already said?

00:05:43:24 - 00:06:13:29
Daniel Morissette, MBA
Well, first of all, we have so many projects in the large health system like we have even being a community based health system. And so we have both immediate needs. And I've always asked Nancy whatever she can do to get us unrestricted gifts that we could apply. It is important that we align our operational and our strategic leaders, partner closely with our philanthropy team so we can make sure the donations we receive do have the greatest impact possible.

00:06:14:02 - 00:06:46:23
Nancy Bussani
I think you can tell Sue Ellen how lucky I am to have a CFO that understands the nuances of philanthropy that, you know, donors at the end of the day are going to give where they're most passionate. But I do believe donors want to make the biggest impact for their entire community. And so when philanthropy teams have a seat at the table with their strategy leaders, with their hospital presidents, with their executive leadership, they can listen and understand where that strategy is driving the most critical investments.

00:06:46:25 - 00:07:19:17
Nancy Bussani
And it's those conversations with our donors that help to make for the best match. So when they do give, they understand how they're making the biggest impact. So we really do work hard to make sure that our leaders - we have 80 foundations throughout all CommonSpirit. They each have a seat at the table with their leadership team so that they can listen, they can learn, and they can understand how to have those important conversations with donors to make sure those dollars make the biggest difference they can.

00:07:19:17 - 00:07:46:24
Nancy Bussani
So it's not just about the volume, it's about the purpose. And to me, that only happens if your philanthropy leaders are sitting at the table listening to those conversations. Dan and I have had a lot of conversations about the timing of that, too. How do you have those conversations at the right time? And he's been - well, I'll let you talk about that, Dan, because you've been really helpful in helping us to determine when philanthropy needs to be brought in.

00:07:46:26 - 00:08:07:20
Daniel Morissette, MBA
You know, Nancy, that's a great point. Certainly I agree with that, right? We know that the timing is really important because, you know, if you engage the donors too early in the process and then somehow we decide for various reasons that the project doesn't go forward, you know, it can create some negative feelings in the, you know, in our donor community.

00:08:07:23 - 00:08:32:14
Daniel Morissette, MBA
And then, of course, on the flip side, if you wait too long and the major project is already up and going, you know, most donors feel like their support might really be needed. So, you know, we are continually encouraging our strategy and finance teams to include philanthropy, you know, so that we can all get, you know, better at finding that balance of the, you know, the desires of the donors.

00:08:32:16 - 00:08:55:27
Daniel Morissette, MBA
I'd like to point out that how critical philanthropy can be to innovation for a major health system like ours, as well as for the future of health care. Philanthropy can really help support to make a difference in from an innovation standpoint. Certainly we as a mission based health system, are fully devoted to serving everyone in our communities. Certainly

00:08:55:27 - 00:09:19:04
Daniel Morissette, MBA
we have a unique, strong focus on those who are most vulnerable. But with the health care dollars so tight right now, we often do wish to rely on our donors, whether they be individual corporations, foundations, government agencies, you name it. You know, to invest in our vision for what innovative programs or research is going to make a difference in the future.

00:09:19:06 - 00:09:29:15
Daniel Morissette, MBA
You know, you can be our most dedicated, long term connected donors that will walk with us to launch high risk but hopefully super high reward projects.

00:09:29:17 - 00:09:53:07
Sue Ellen Wagner
Thank you so much. Nancy, you talked a little bit about the importance of having a seat at the table. Successful philanthropic initiatives really need the support of the board and executive leaders, and I believe that equates to having a seat at the table. Can you talk about, both of you, what are the ways you see boards and leaders fitting into your philanthropic investments?

00:09:53:10 - 00:10:24:11
Nancy Bussani
Yeah, absolutely. Well, I want to start by saying that our CEO Wright Lassiter, has been very supportive of the importance of philanthropy, and he plays a really strong role in it. He serves not only as the CEO for CommonSpirit, but he's also the CEO for our national foundation. And that sends a really strong message to our boards that we have the attention and the investment of the leadership. We have throughout all of our 80 foundations about 1500 local board directors.

00:10:24:13 - 00:10:58:26
Nancy Bussani
And so it really is that connection between our philanthropy leaders understanding the strategy, being able to articulate it, and then taking that back to those board directors and helping them be our advocates. They can only help us as much as we give them the information to help us. So being able to have kind of those succinct messages about what really is going to move the hospital forward in their community, what's going to make us be able to provide the best clinical, excellent care to everyone?

00:10:58:28 - 00:11:22:27
Nancy Bussani
Because, as you heard Dan say, we have a lot of hospitals in very vulnerable communities. But our goal isn't just to open the doors and have access. It's to make sure that everyone has the best care. And that's where our donors come in. They can make the difference between, you know, covering our costs and creating great investments in the innovative programs that really make us excellent.

00:11:23:00 - 00:11:48:02
Nancy Bussani
We can't do that without the boards. Their voices really help to expand. So you take in a community, two or three executives in the philanthropy leaders, and then you maximize that by 20 or 30 people on the board who typically are very influential people in their communities. That's where we start seeing true visibility and awareness and believe in the work we're trying to do.

00:11:48:02 - 00:11:56:06
Nancy Bussani
So I can't overestimate the value that our board directors have in making these investments a reality and the right investments.

00:11:56:09 - 00:11:59:20
Sue Ellen Wagner
And, Dan, do you want to elaborate any more on that point?

00:11:59:22 - 00:12:39:05
Daniel Morissette, MBA
Just really briefly, thank you. You know, over the years, I've gotten more and more involved in partnering with our philanthropy teams and making sure that all of our local chief financial officers, for example, at our hospitals and within our regions - they do know the importance of putting every dollar raised, you know, into action. So I consistently discussed philanthropy and in our regular meetings, but also through issue a quarterly memo to all the CFOs to share how critical it is for them to work with their philanthropic leaders to get the funds transferred so that we can put it to good use.

00:12:39:08 - 00:12:47:02
Daniel Morissette, MBA
And this certainly helps our philanthropy leaders by having an equal partner on the financial and operational side of the hospitals.

00:12:47:04 - 00:13:18:18
Nancy Bussani
And that's information that - when that doesn't happen, Sue Ellen, if you don't have a CFO that partners with you that way, sometimes our dollars don't get put into action as quickly as we need. We cannot go back to donors and to boards and show the impact of their investments if that doesn't happen. And so it's such a critical bridge for us to be able to say, not just raise the money, but to demonstrate back to those who were generous to us how we used it and the impact that made.

00:13:18:18 - 00:13:40:20
Nancy Bussani
And so sometimes it's this financial partnership that allows that to happen. You know, with everything going on that's not always the top priority for a CFO to make sure those dollars get transferred to cover all of those costs that   those dollars will help to support. And it really doesn't allow us to feedback to the board what's happening in their communities if we don't have that partnership.

00:13:40:20 - 00:13:45:29
Nancy Bussani
So it really has changed how we work with our CFOs throughout all of the hospitals.

00:13:46:00 - 00:14:24:21
Sue Ellen Wagner
I love those final words. Thank you. Well, Dan and Nancy, thank you so much for being with me today. You've talked a lot about the importance of not only your CEO partnership, but your CFO partnership. So I think our listeners have a lot to learn about that. And really, given the complex environment that we're in, still being able to get that return on investment for your philanthropic dollars is really important so that you can continue to fund your innovations and your initiatives. And getting that board to, you know, be supportive and participating in the philanthropic initiatives, I think is really important.

00:14:24:21 - 00:14:29:01
Sue Ellen Wagner
So thank you both. Really appreciate all of your great information.

00:14:29:03 - 00:14:37:15
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.