Advancing Health Podcast

00:00:01:06 - 00:00:23:22
Tom Haederle
Welcome to Advancing Health. The 4Ms are the core components of Age-Friendly health systems that aim to improve the quality of care for older adults. Today, we hear from California-based El Camino Health about how its adoption of the forums has produced measurable improvements for the older people it serves.

00:00:23:24 - 00:00:40:20
Raahat Ansari
Hi everyone. We're here in Chicago at AHA’s Advancing Age-Friendly Care Convening. I'm Raahat Ansari, senior program manager at the American Hospital Association. Today I'm here and joined by Carolyn Bogard from El Camino Hospital. Thank you so much for being here with us today.

00:00:40:23 - 00:00:43:19
Carolyn Bogard, R.N.
Thank you for having me. I'm so excited to be here.

00:00:43:22 - 00:01:06:18
Raahat Ansari
Great. So we wanted to take some time to understand your Age-Friendly journey and how you implemented the 4M's framework at your organization. And I'll just take a quick moment for those listeners who might be new to this work to explain that the 4Ms is: what matters, medication, mentation and mobility, and applying that care to older adults. So can you tell us how it got started?

00:01:06:20 - 00:01:29:09
Carolyn Bogard, R.N.
Absolutely. And again, thank you so much for having me and for this opportunity. I'm so proud to talk about the work being done at El Camino Health, and where we're at on our journey. We are still in the beginning phases of our journey and the 4M implementation at El Camino Health - it actually started with the leadership of one nurse.

00:01:29:15 - 00:02:02:08
Carolyn Bogard, R.N.
This nurse was making advances in her unit to implement an evidence based project, and her passion was really around delivering Age-Friendly care to older adults. And through her work and collaboration with pharmacy and our Epic analysts and other interdisciplinary team members, she was able to advance and roll out the 4M's on this medical unit within El Camino Health.

00:02:02:11 - 00:02:14:15
Raahat Ansari
It's amazing to hear. I just want to share that we do hear that a lot of organizations get started with this by one single individual championing this work, so I'm super excited to hear that that's the story at your organization.

00:02:14:18 - 00:02:37:21
Carolyn Bogard, R.N.
Oh, thank you so much. Yeah, we're super proud of her. And she continues to be a steadfast advocate for this work and continues to be so passionate about it and deeply involved with rolling out the 4Ms further throughout our health system. We certainly saw the impact in the benefits of rolling out the 4Ms and of this Age-Friendly health initiative.

00:02:37:24 - 00:02:47:22
Raahat Ansari
Did you see some outcomes and did you have data and what did you do with that data? And I wonder, were you able to share that with your leadership if you needed some help with leadership buy in?

00:02:47:29 - 00:03:26:18
Carolyn Bogard, R.N.
Yes. One of the things that we helped to do to advance this work, one of the first things is really to pull some of the data. And some of the data already on this unit was around high patient engagement scores and also the volume of older adults within this specific unit. We knew through the Age-Friendly initiative and the work with the IHI and American Hospital Association that rolling out the 4Ms within a health system impacts length of stay, readmissions, falls and other patient health outcomes and health system outcomes, too.

00:03:26:21 - 00:03:52:29
Carolyn Bogard, R.N.
And we were able to bring this information in this data to our chief nursing officer. And we began conversations around how can we expand this initiative throughout our health care organization? So, she was extremely supportive and excited and passionate around this work as well. And then it was a matter of identifying next steps.

00:03:53:03 - 00:03:58:09
Raahat Ansari
So it was the data that got your chief nursing officer on board. Did I hear that correctly?

00:03:58:09 - 00:04:32:15
Carolyn Bogard, R.N.
I think it was the data and also her passion around it. And I think what I've seen is there is a lot of health care providers passionate about caring for older adults. And I think the 4M framework really helps to create a platform for where to focus that passion and energy to help produce really tangible outcomes and help to really streamline health care delivery for the older adults in our health systems.

00:04:32:17 - 00:04:43:17
Raahat Ansari
So I'm hearing a little bit of outcomes across the board. So there were definitely some positive patient outcomes. And from what you just shared right now, there were some positive provider outcomes.

00:04:43:19 - 00:05:21:09
Carolyn Bogard, R.N.
Well, I think certainly our providers are interested in continuing to advance this work. I think from the pilot phases and initial rollout of the 4Ms and this unit, the nurses in particular in this area found the work to be important and meaningful. And recognized the value that this work can have for their patients. And, you know, one thing that we did within our health system, when we're talking a little bit about scope and spread and how to really expand this work is, where do you begin?

00:05:21:15 - 00:05:52:05
Carolyn Bogard, R.N.
We had some success on this medical unit within our health system. What nursing leaders, what key stakeholders within the health system do we need to further expand? And we are so thankful to have the executive support that we do. Because our CNO knows exactly who to pull into the conversation. And one of the stakeholders that was really helpful with advancing these conversations is our process improvement adviser.

00:05:52:07 - 00:06:19:20
Carolyn Bogard, R.N.
And we really started by identifying what problem are we trying to solve, and then really doing a value stream about current processes within our health care organization. And what do we need to do to further expand some of this work? And some of the things that we identified right off the bat is identifying some programmatic leadership.

00:06:19:23 - 00:06:48:24
Carolyn Bogard, R.N.
Who's in charge of further expanding this, this, health care initiative? And also, where can we get consistent data from? Data can help tell your story and we know that this is an important story to tell, both to our patients and our health system. And we were lucky enough to work with a fantastic data analyst within our health care organization and he helped to develop an Age-Friendly dashboard.

00:06:48:27 - 00:07:29:12
Carolyn Bogard, R.N.
It's still in the beginning stages because sometimes there's so much data you can get paralyzed. And so we have to really think about what data do we need and how do we act upon the data that we have. Part of the initial data collection was around our patient population. You know, better understanding who are we caring for in our health system, identifying certainly ages and demographics and what service lines are these patients on based on that data that's helping to inform us around which units will we spread to next?

00:07:29:14 - 00:07:45:24
Raahat Ansari
I think that makes perfect sense. And one question that I want to ask you that I imagine some of our listeners might have of you is do you have any tips that you could share that you used to get that leadership buy in? We all know how important that is to leverage.

00:07:45:27 - 00:08:30:04
Carolyn Bogard, R.N.
Well, I'm so thankful to have regular and consistent communication with my executive and that alone gives me a pathway to communicate where we need help and what type of support that we need. And through that support and engagement and ongoing communication, we were able to develop a plan. Now, the plan did not develop overnight. It took probably three months from that initial conversation to even get a quorum of nursing directors across the organization in one room, with the process improvement advisory to talk a little bit about Age-Friendly care within our health care organization.

00:08:30:04 - 00:08:35:16
Raahat Ansari
And that's a success in and of itself, right? And get have all the stakeholders in one room to talk about that.

00:08:35:16 - 00:09:13:09
Carolyn Bogard, R.N.
Definitely. And when we had these initial conversations, everyone had different thoughts and ideas and opinions and observations about what was going well within the organization and what could be improved. And following that, we completed an A3, which is really a, you know, a systematic way to tackle a problem. And through input in discussion and these observations from all the nurse leaders, we were really able to see what areas are we doing well in and what areas can we improve in.

00:09:13:12 - 00:09:39:05
Carolyn Bogard, R.N.
And because we did have the 4M framework already rolled out on one unit, we weren't starting from scratch. We already had a pilot unit that implemented the 4Ms and was successful with that. So it was really more about building upon that success. Now we're at a spot as we think a little bit more about spread and scale across the organization.

00:09:39:08 - 00:09:51:03
Carolyn Bogard, R.N.
How do we dive a little bit deeper into each M, and how do we gain further engagement from members of the interdisciplinary team?

00:09:51:06 - 00:10:05:06
Raahat Ansari
And I do hear another challenge from some organizations about breaking down those silos and having that those interdisciplinary conversations. Any advice that you could share and how you successfully made that happen at your organization?

00:10:05:09 - 00:10:29:19
Carolyn Bogard, R.N.
Oh, yeah. Thank you so much for that question. And I would just add, being here at this forum, it's just so fantastic because even just today, I learned different ideas from different folks within the community. So one of the areas that we talked about was how do we get that buy-in and collaboration from members of the interdisciplinary team?

00:10:29:21 - 00:11:04:27
Carolyn Bogard, R.N.
Being that it's, you know, pharmacy or rehab services, case management, social worker, even our physicians, and certainly one of the best practices that was identified is really trying to find a champion in each area. And in my experience and observations, I have seen some passion out there about delivering high quality care to our older adult patient population. So at least within my health system, I don't have to look too far for individuals that are interested in advancing this work.

00:11:05:00 - 00:11:32:02
Raahat Ansari
When we started this work, that provider re-engagement and that spark, that passion that really was reignited when providers were working towards implementing the 4Ms framework into a patient care plan - that was something we were not expecting to see. So I really appreciate that you're saying that it's not hard to find, because we have seen that in real life when we have new teams come and join the action

00:11:32:02 - 00:11:50:00
Raahat Ansari
communities a little unsure of what to expect, what they're going to get out of it. And come two, three months into this, we've got a whole host of providers from all different disciplines who are really excited and passionate about being able to implement this work with their patients. So just wanted to highlight that point. Thank you for bringing that up.

00:11:50:06 - 00:12:08:15
Carolyn Bogard, R.N.
Oh you're welcome. And actually to your exact point, I have been part of the action community intermittently, throughout a number of years based on various jobs that I've had. And I get it. Caring for older adults, it is a passion of mine and it's such a privilege to be able to continue to be part of this work.

00:12:08:18 - 00:12:46:11
Carolyn Bogard, R.N.
But I would even think 5 to 7 years ago, people were just better understanding the importance of delivering high quality, reliable care to older adults. And even in that short period of time, I feel as if I have seen some reinvigoration in interest into this real specialty area of medicine. It's fantastic because it really does take a village, and an interdisciplinary team to provide holistic care to our patients, certainly within the hospital setting, but also across the care continuum.

00:12:46:14 - 00:13:03:09
Raahat Ansari
And so what I'm hearing is you have nailed it at this at this one site, you are done and done. Just kidding. Because that work is never done, right? But you've made some really good strides at one care site and you're moving to expand to other care sites within your organization. And that is fantastic news and something to celebrate.

00:13:03:11 - 00:13:05:06
Raahat Ansari
Thank you again for being here with us today.

00:13:05:09 - 00:13:08:05
Carolyn Bogard, R.N.
Thank you. It's been an honor and a pleasure.

00:13:08:07 - 00:13:16:18
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.

00:00:01:06 - 00:00:23:23
Tom Haederle
Welcome to Advancing Health. Cyberattacks directed against hospitals continue to increase, and many cyber threats quickly escalate into a governance and patient safety issue. In today's podcast, we learn about how board members can educate themselves and prepare to help their organizations face these threats.

00:00:23:25 - 00:00:48:15
Sue Ellen Wagner
I am Sue Ellen Wagner, vice president of Trustee Engagement and Strategy at the American Hospital Association. I'm delighted to be with Ajay Gupta today. He is the board chair of Trinity Health Mid-Atlantic and Holy Cross Health, and he's also the co-founder and CEO of hsr.health. It's nice to have you with us, Ajay, today to talk about cybersecurity and what trustees need to know.

00:00:48:18 - 00:01:08:16
Sue Ellen Wagner
I am hoping this podcast will be a nice 101 for board members to educate them about [what] their role is in cybersecurity, and what they should know to prepare for a cyber incident should one occur at their hospital or health system. Ajay, you have both business experience in the cyber industry and you're also a board member.

00:01:08:19 - 00:01:38:14
Sue Ellen Wagner
So your insight will be very valuable to our members and our listeners. Cybersecurity vulnerable cities and intrusions really do pose significant risks to hospitals and health systems, and the threats continue to increase each year. It's important for trustees to be ready should an incident happen at their hospital or health system. So, Ajay, can you tell us what trustees should know to be prepared should an incident occur?

00:01:38:16 - 00:02:04:04
Ajay Gupta
Thank you, Sue Ellen. It's great to be here with you today. And thank you for this question. It's a great overall question for a 101. I wish there could be a short answer, right? You only need to know a couple of things for cybersecurity. It's unfortunately not quite like that. I think the first place to start is to recognize that cybersecurity is a technical issue, and it's always really been thought of as something that IT would handle.

00:02:04:06 - 00:02:31:12
Ajay Gupta
But today we need to know that given how much of our care delivery relies on IT systems, should those systems become unavailable, whether due to a cyberattack or any cause - it very quickly becomes a patient safety and governance issue. As such, trustees need to ensure hospitals are prepared. And for cyber, preparation means can our clinical teams continue to provide care if systems go offline?

00:02:31:15 - 00:02:53:12
Ajay Gupta
The board's role is to provide oversight and confirm the organization is ready, not just to defend against the cyber attack, but also to operate through one safely. But this starts by understanding what the nature of our IT infrastructure is and how stable is it? How secure is it? Are we comparing ourselves against benchmarks? What measures are we taking to ensure its security,

00:02:53:12 - 00:03:15:09
Ajay Gupta
and are those measures tested? Are our IT and cybersecurity departments aware of the trends the security of the industry is facing overall from a cyber threat landscape? Because that will depend and it will influence what kind of measures we take in the defense and in the resilience during the middle of the year of an incident. I hope that's a good starting point for discussion.

00:03:15:12 - 00:03:34:25
Sue Ellen Wagner
It's a great starting point and cyber security is very complicated. You had mentioned, you know, patient safety and quality, which are very important. How do trustees know if their hospital or health system is secure to continue to operate and provide that clinical care that's safe should a breach really occur?

00:03:34:27 - 00:04:11:00
Ajay Gupta
Well, if a breach has occurred, Suellen, by definition, the system is not secure at that moment, unfortunately. But to more broadly respond to your question, trustees need to ask about the resilience of the IT systems in the face of a possible cyberattack. That's really the question that we need to say. Unfortunately, we are operating in an environment where some level of cyberattack, whether an overt attack from a bad actor or even just the system's combination of users across the spectrum and anything else causes an IT issue that brings systems down.

00:04:11:06 - 00:04:32:29
Ajay Gupta
We need to know how resilient we are in any and all of those systems. And the only way to know if operations can continue during a breach is to experience continuing during a breach. Of course, we don't want that. So we have to do the next best thing: testing, preparation and practice. All of that is more and more important.

00:04:33:06 - 00:04:59:24
Ajay Gupta
That means having an incident response plan in place, which is not terribly unlike plans we may have - we likely have - in place for a natural disaster, or if there is a an expected surge in trauma. We have plans in place for surge and we need to have a cyber plan in place as well. This is a plan that lets everyone know what to do exactly during a cyber event, without any confusion or momentary disarray, because we know that can cause patient harm.

00:04:59:27 - 00:05:27:15
Ajay Gupta
Our critical care workflows like medication administration, lab orders, and surgical schedules operational without digital systems. Do clinicians know how to access key information when digital systems go down? And do clinicians remember how to treat patients when they don't have access to all of the digital sources of information, like lab reports or film that they do typically use in the course of patient care.

00:05:27:18 - 00:05:29:20
Ajay Gupta
That's a big, big issue as well.

00:05:29:22 - 00:05:55:10
Sue Ellen Wagner
Well, relying on the digital world that we live in today is something that we're all used to. You had mentioned that, you know, most trustees won't have an idea of what a cyber security incident is until it actually happens to them. So preparing is really difficult. And I think that's something none of us want as board members. Can you explain to trustees the impact that that breach will have and what their role specifically should be?

00:05:55:10 - 00:06:01:21
Sue Ellen Wagner
Because management leadership has one role, the board has another. So can you just kind of describe that?

00:06:01:24 - 00:06:26:06
Ajay Gupta
It's important to remember that a breach is more than a tech failure. It is a system failure. It's a failure of our system and ability to deliver care. As such, trustees will have a specific role. A breach can paralyze care delivery, right? Shutting down systems, delaying surgeries, leaving clinicians without access to medical records. This means patients may not receive the care they need, the care they trust us to provide.

00:06:26:09 - 00:06:53:14
Ajay Gupta
It's important for trustees to know and understand that while the fault is not ours, the fault resides entirely with cyber criminals who perform the attack. But patients don't see the hackers. They see us. And so they see us as unable to provide the care they need when they need it. And this is a stain on our reputation. That is a critical thing for the boards and trustees to recognize.

00:06:53:16 - 00:07:15:12
Ajay Gupta
Breaches trigger reputational damage as well as regulatory damage and a financial fallout. For instance, health systems may face fines, according to the breach. The average cost of a cyber breach was reported at just under 10,000,000 in 2024, as reported by IBM, which was less than 2023 when it was reported at 11 million. However, I don't think that we can plan for that trend to continue.

00:07:15:16 - 00:07:43:03
Ajay Gupta
Trustees have to lead from the front by ensuring the organization is prepared with strong cyber governance, risk management practices and a culture of preparedness in place. Our role is to ask strategic questions and ensure readiness, and that we are able to continue serving patients and to recover swiftly, regardless of the situation. We need to make sure that we have the experts ready to act on our behalf in a cyber attack.

00:07:43:10 - 00:07:57:12
Ajay Gupta
Technical experts who can respond to the technical details and dimensions of the attack, as well as legal and communication experts that can help us communicate and handle some of the regulatory and legal fallout that may follow a cyber attack.

00:07:57:14 - 00:08:17:22
Sue Ellen Wagner
So I hope our listeners never have to deal with a cyber incident. We obviously can't control whether that will happen or not. So I'm hoping that this is really helpful for folks. I think if they listen to it, they can actually start asking their leadership if they don't have a plan to develop a plan, or the board should know what the plan is and what their role is.

00:08:17:22 - 00:08:28:24
Sue Ellen Wagner
So Ajay, the last question, can you highlight some of the key takeaways for our listeners, some nuggets of information that they should just, you know, take away from this podcast to prepare themselves?

00:08:28:26 - 00:08:53:25
Ajay Gupta
Absolutely. One thing I want to mention, what you just said is that we can't control. That's true, we can't. We can't control the weather. Yet hospitals and health systems in a hurricane prone region certainly know to prepare for a hurricane, right? In that same sense, hospitals have to be prepared for this. Cybersecurity is a patient safety issue because, as I said, we use technology in everything we do in a hospital today almost,

00:08:53:28 - 00:09:14:19
Ajay Gupta
or it seems. If it's a patient safety issue, it's a governance issue and the trustees have to be involved. The impact is very real. Any event that can halt care and erode trust and cost millions of dollars has to be of great concern. Continuity demands preparation. Again, just like we practice our surge plans, we practice our hurricane plans.

00:09:14:25 - 00:09:35:06
Ajay Gupta
We have to develop and practice technical continuity plans from a cyber breach perspective. And trustees must lead. Our role is oversight, which means we have to ensure management has thought through all aspects from defense against attack, resilience in the face of attack and addressing the potential fallout after the attack.

00:09:35:09 - 00:09:55:29
Sue Ellen Wagner
So thank you, Ajay. In addition to this podcast, AHA Trustee Services does have a few resources to help boards prepare should a cyber incident occur. So trustees should visit trustees.aha.org to access the resources. Ajay, I want to thank you so much for sharing your expertise with us.

00:09:56:02 - 00:09:59:11
Ajay Gupta
Thank you, Sue Ellen. It's great to be here.

00:09:59:13 - 00:10:07:24
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.

00:00:01:04 - 00:00:25:09
Tom Haederle
Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid.

00:00:25:12 - 00:00:51:27
Rebecca Chickey
Hello, I'm Rebecca Chickey. I'm the senior director of behavioral health at the American Hospital Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states.

00:00:51:29 - 00:01:20:25
Rebecca Chickey
So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I'd love to have you share a little bit about Sanford Health, what it's like to really - I say rural - but you're in frontier states for the most part.

00:01:20:28 - 00:01:35:05
Rebecca Chickey
So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you've had to come up with but help the listeners understand the barriers.

00:01:35:07 - 00:02:01:07
Jon Ulven, Ph.D.
Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but  I'm just going to mention a few more states that we cover, Rebecca, because we're also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area.

00:02:01:09 - 00:02:26:05
Jon Ulven, Ph.D.
We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% - 80 to 85% - of our counties are known as a behavioral health shortage areas.

00:02:26:07 - 00:02:49:24
Jon Ulven, Ph.D.
So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages.

00:02:50:01 - 00:03:14:10
Jon Ulven, Ph.D.
It's hard to recruit to this part of the country. We're in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of...I've seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state.

00:03:14:15 - 00:03:31:21
Jon Ulven, Ph.D.
So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is - when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm.

00:03:31:24 - 00:03:50:22
Jon Ulven, Ph.D.
There's some nice opportunities for connectivity in a rural setting, but there's also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody's business. So it makes it really hard to reach out and seek care.

00:03:50:24 - 00:04:10:09
Rebecca Chickey
I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else's business.

00:04:10:09 - 00:04:21:00
Rebecca Chickey
And with that comes the stigma of seeking care. It's incredible. That's one of the things we've been working on. So glad you're working on it, too. What about broadband? Can you speak to that for just a minute?

00:04:21:02 - 00:04:45:23
Jon Ulven, Ph.D.
Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time.

00:04:45:26 - 00:05:08:16
Jon Ulven, Ph.D.
So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it's something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care.

00:05:08:21 - 00:05:17:06
Jon Ulven, Ph.D.
I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that's virtual.

00:05:17:08 - 00:05:20:23
Rebecca Chickey
And so you complement that with in-person visits, I assume.

00:05:21:00 - 00:05:46:17
Jon Ulven, Ph.D.
We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we've had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community.

00:05:46:19 - 00:06:08:06
Jon Ulven, Ph.D.
And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we've done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there.

00:06:08:08 - 00:06:31:16
Jon Ulven, Ph.D.
And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we're trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology

00:06:31:16 - 00:06:56:19
Jon Ulven, Ph.D.
and so they can't do the virtual care themselves, that we offer that up to people. And in this building that I'm in right here in Moorhead, we have 17 psychologists and master's level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women's health, pediatrics. We have a lab here.

00:06:56:19 - 00:07:20:28
Jon Ulven, Ph.D.
We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we're all here for, it's talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care.

00:07:21:00 - 00:07:37:26
Jon Ulven, Ph.D.
A lot of it has to do with in our country the ways that we pay for health care. And that's where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid.

00:07:37:28 - 00:08:04:18
Rebecca Chickey
I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been - so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community.

00:08:04:20 - 00:08:09:18
Rebecca Chickey
What are some of the personal stories you've seen that have impacted the lives and how?

00:08:09:20 - 00:08:30:08
Jon Ulven, Ph.D.
Many stories that that I could share around this. I've been here with, Sanford for 21 years. I'm a licensed psychologist, and as you were saying, I'm the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time.

00:08:30:08 - 00:08:56:24
Jon Ulven, Ph.D.
And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they're there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit.

00:08:56:26 - 00:09:23:18
Jon Ulven, Ph.D.
Patient is admitted there. While they're there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they're having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications.

00:09:23:18 - 00:09:42:21
Jon Ulven, Ph.D.
And then let's say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don't have the benefits to have, that standard type of health care that a lot of us are able to have.

00:09:42:23 - 00:10:07:29
Jon Ulven, Ph.D.
And so we get this person on Medicaid, and what we're able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we're able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care.

00:10:08:02 - 00:10:27:16
Jon Ulven, Ph.D.
What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we're bending the trajectory for their health throughout the course of that person's life. And it is such an important time.

00:10:27:18 - 00:10:50:10
Rebecca Chickey
That's phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you're going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I'm wrong here, keep me honest. But then by the time you're 21 to 24, we're up to 75%.

00:10:50:12 - 00:11:13:05
Rebecca Chickey
So that early identification and intervention and treatment, there's so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It's just critically important. And you're being there, is equally so.

00:11:13:07 - 00:11:33:12
Jon Ulven, Ph.D.
Thank you for that. You know, as we're having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that's nice. And it's important to hear about that. But we, it's a bit abstracted from us. If we don't have the ability to treat that type of individual, we see, as we see, diminishing services across the board.

00:11:33:14 - 00:12:02:13
Rebecca Chickey
Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community.

00:12:02:15 - 00:12:22:02
Jon Ulven, Ph.D.
Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that's the that's the example of that, something that I think a lot of people don't think about. And that's health care coverage for foster kids, for foster children. So, if you think about that for a moment, you're a family who's taking on a foster child.

00:12:22:05 - 00:12:46:25
Jon Ulven, Ph.D.
We  don't allow that those folks to go under the foster parents' insurance. There's a gap. There's a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they're obviously coming from a situation that is a distressing and challenging situation.

00:12:46:27 - 00:13:13:13
Jon Ulven, Ph.D.
Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what's the impact of that?

00:13:13:13 - 00:13:39:27
Jon Ulven, Ph.D.
And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved.

00:13:40:04 - 00:14:08:14
Jon Ulven, Ph.D.
I'll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits.

00:14:08:16 - 00:14:45:00
Jon Ulven, Ph.D.
So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we're actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I'm covering on our inpatient unit and I can see that I'm working with someone who has gone without care for a significant amount of time.

00:14:45:02 - 00:15:09:13
Rebecca Chickey
Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners?

00:15:09:13 - 00:15:19:23
Rebecca Chickey
If there's something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast.

00:15:19:25 - 00:15:48:29
Jon Ulven, Ph.D.
My heart often goes to children. I only work with adults in my practice, but I but I mean, I'm a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it's important that one study found that there children who have Medicaid coverage, they're four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met.

00:15:49:01 - 00:16:08:28
Jon Ulven, Ph.D.
And that that includes behavioral health and that they're 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they're five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective

00:16:08:28 - 00:16:34:28
Jon Ulven, Ph.D.
I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it's going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we're going to see some pretty significant reduction in services

00:16:34:28 - 00:16:51:12
Jon Ulven, Ph.D.
would be I think a reasonable guess. The thing that like call to action? I think one of the things I'm so I feel so privileged about in, in that, in North Dakota. I'm a citizen of North Dakota, I practice in Minnesota, I'm right on the border. Because we're in a small state of North Dakota,

00:16:51:15 - 00:17:30:05
Jon Ulven, Ph.D.
I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That's been a great opportunity through connections of - here's me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it's a win for everybody.

00:17:30:08 - 00:17:49:16
Rebecca Chickey
That's phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field.

00:17:49:18 - 00:17:51:13
Jon Ulven, Ph.D.
Well, thank you very much.

00:17:51:16 - 00:17:59:27
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.