Advancing Health Podcast

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.

00:00:01:02 - 00:00:23:19
Tom Haederle
Welcome to Advancing Health. Today's medical residents and fellows are tomorrow's doctors. In this podcast, we hear about Boston Medical Center's innovative program to provide mental and emotional support during the rigors of medical training, and to address the tendency of many medical trainees to deprioritize their own health.

00:00:23:21 - 00:00:53:21
Jordan Steiger
My name is Jordan Steiger, and I am the senior program manager for Clinical Affairs and Workforce at the AHA. I'm joined today by Simone Martell, who is the director of Boston Medical Center's Employee Resilience Program, and Dr. Jeff Schneider, the associate chief medical officer, designated institutional official and chair of the Graduate Medical Education Committee at Boston Medical Center, and the assistant dean for graduate medical education at BU Chobanian & Avedisian School of Medicine.

00:00:53:23 - 00:01:16:04
Jordan Steiger
So just to set the stage a little bit, in 2022 and 2023, the AHA received some funding from the CDC to identify the leading interventions for preventing suicide in the health care workforce. And we got to know the Boston Medical Center team through this learning collaborative that we hosted that focused on implementing these practices at hospitals and health systems across the country.

00:01:16:06 - 00:01:20:04
Jordan Steiger
So, Simone and Jeff, thank you so much for being here with us today.

00:01:20:06 - 00:01:21:18
Simone Martell
Thank you for having us.

00:01:21:20 - 00:01:22:22
Jeff Schneider, M.D.
Thank you.

00:01:22:24 - 00:01:35:03
Jordan Steiger
So to get us started, I'd love for the audience to just learn a little bit more about your roles at BMC, and how the two of you work together to support workforce well-being. So Jeff, let's start with you.

00:01:35:05 - 00:01:53:09
Jeff Schneider, M.D.
Sure. Thank you very much for having us. And, happy to share what we have done and also what we've made to do moving forward. By training, I am an emergency medicine physician, and I still work clinically in our emergency department. And then the other part of my job is I oversee all of our residency and fellowship training programs across the organization.

00:01:53:09 - 00:02:15:02
Jeff Schneider, M.D.
So it's more than 750 residents and fellows across roughly about 70 training programs. And I really oversee those residency and fellowship programs from a bunch of different perspectives, everything from operations, to finance to accreditation. Obviously, working very closely with our program directors and our program administrators, and the educators and teachers that we have here at BMC.

00:02:15:04 - 00:02:16:20
Jordan Steiger
Great, Simone?

00:02:16:23 - 00:02:44:06
Simone Martell
So I joined BMC in June of 2023. My background is I'm an LICSW, licensed independent clinical social worker in Massachusetts. And, the program here is to provide mental and emotional support and resources to all of our workforce, clinical and non-clinical, in the realm of mental health, emotional well-being, stressors around the workplace, occupational stress injuries.

00:02:44:08 - 00:03:04:10
Simone Martell
And we have a couple of initiatives that target residents and medical trainees in particular. One of the first I was also introduced to was this initiative that had started the year before I joined, which are these wellness chats for incoming trainees at the beginning of the academic year.

00:03:04:13 - 00:03:28:28
Jordan Steiger
That's great. So I know that health care workers overall can experience barriers to receiving mental health services, can experience challenges around well-being and taking care of themselves. I think everybody listening to this podcast probably knows that. But we also know there's a lot of research that shows that residents have some kind of special challenges and adjustments that they need to make as they're starting residency.

00:03:29:01 - 00:03:33:29
Jordan Steiger
But could you tell the audience about some of those maybe special challenges that face residents?

00:03:34:01 - 00:03:55:21
Jeff Schneider, M.D.
The genesis of our program really actually goes back probably 6 or 7 years now, when we realized that our residents and fellows really deprioritized their own health on many occasions, given the choice between learning something clinical, or learning how to do something or gaining experience and taking care of their own health. Residents across the country tend to deprioritize throughout health.

00:03:55:24 - 00:04:13:08
Jeff Schneider, M.D.
So one of the things that we did very early on was trying to understand what are the barriers for our residents taking care of themselves? If they're not taking care of themselves, how can we expect them to take care of patients, to learn and to grow? So we had an idea that we would introduce primary care appointments during intern orientation.

00:04:13:08 - 00:04:37:11
Jeff Schneider, M.D.
Again, this is probably 6 or 7 years ago now. And we set up a process, a mechanism really carved out an afternoon that was protected for residents and fellows, where those that wanted to get primary care appointments could have them here at Boston Medical Center. Our goal again really, just a little bit around reducing stigma, reducing barriers and normalizing the conversation around taking care of your own health is very, very important.

00:04:37:14 - 00:04:56:23
Jeff Schneider, M.D.
I will admit that when we started this I had no idea if anyone was going to show up. We put a lot of time and effort, operations and planning into organizing this, but not really knowing frankly how well it would land. And we were pleased to see that even after year one, the majority of our residents and fellows were very interested in participating in this.

00:04:56:23 - 00:05:22:18
Jeff Schneider, M.D.
And we continued to grow the program a little bit, to learn, to iterate. And a few years later we said, well, if we're introducing primary care, maybe we should do the same thing with behavioral health or mental health to really, really try to accomplish three things. The first was we really wanted to normalize the conversation. It is totally normal for residents and fellows who need any behavioral health support, any behavioral health or mental health contexts.

00:05:22:20 - 00:05:42:28
Jeff Schneider, M.D.
How can we help them do that? To really normalize the conversation? It's as normal as in anything else that we do. And then really trying to reduce the stigma around it. Talking about it in the wide open, not behind closed doors or at hush voices. It was something we talked about very early on, when these new residents and fellows were coming and really tried to make the conversation part of what we do.

00:05:42:29 - 00:06:01:14
Jeff Schneider, M.D.
It's an expected part of what we do. And then really trying to figure out how we decrease the barriers, how do we make it as easy as possible for residents and fellows to take advantage of the wonderful resources we've had here? And Simone and her team have really taken an idea and grown it so that it's flourished. I'll let Simone talk a little bit more about some of the details of how she's actually executed.

00:06:01:15 - 00:06:32:27
Simone Martell
Yeah, yeah. Thank you. So I do also want to give credit to the team that preceded me as well, because I inherited this. And so the first year that the behavioral health component was launched was in 2022. So now we're going into our fourth year doing it. I think the whole framework, at least as how I view it in our approach, is like this philosophy of preventative care, which I think, you know, as trainees who are going to be, fully practicing doctors would preach to their patients.

00:06:32:27 - 00:07:06:14
Simone Martell
We want them to be able to and have it, or embody that themselves as well. The way that it's been structured right now through a couple of key learning points over the past couple of years is that we use different tools for signups. So in the welcome letter that gets sent out by, Dr. Schneider's office in April, welcoming folks, there is a portion of the letter that talks about the PCP visits and a portion of the letter that talks about signing up for these wellness resource chats. And they're 15 minute chat sessions.

00:07:06:20 - 00:07:32:06
Simone Martell
They're not therapy, but they are really focused on an opportunity to talk about any concerns somebody might have, letting them know about the resources that are available to them, helping them kind of highlight what are some anticipated stressors or things that they can do ahead of time again, from a preventative standpoint. So oftentimes we'll talk about what are some coping skills that got me through medical school.

00:07:32:08 - 00:07:56:09
Simone Martell
What are some things and ways we can augment that knowing that you're going to be in a new situation, a new territory now, maybe away from the support community that you'd established and been a part of and need to kind of configure here. So sometimes, you know, it might come up where somebody and I think, generationally there's a stigma which has been really lovely to see and kind of capitalizing on that.

00:07:56:09 - 00:08:22:05
Simone Martell
So some folks might come in and they've had, experiences with mental health supports before, but they might not realize, oh, that person doesn't have a license to practice in Massachusetts. So I need to be able to keep that going and find the resources locally and work within my insurance, because now my insurance plan is moving from what I had previously to BMC is now their employer and putting on the network that that's here.

00:08:22:07 - 00:08:47:15
Simone Martell
And so we want to set it up so that it can be something where again, coming from how do we anticipate what some of those barriers might be? What are those challenges going to potentially be? And a big piece is about access point because it might be early on, there's a lot of excitement. They're still riding the wave of having just graduated, you know, and starting out their new program. Which is a stressor in itself.

00:08:47:15 - 00:09:06:06
Simone Martell
You know, sometimes there are positive stressors and this is a positive stressor. But at the time when, you know, mental health challenges potentially do arise or distress does arise, we don't want it to be, oh, now I'm having to start from scratch at the time where I'm already struggling. We want the groundwork to already be laid for them.

00:09:06:06 - 00:09:10:24
Simone Martell
So that's really sort of the framework, by which we're trying to approach this.

00:09:10:26 - 00:09:35:24
Jordan Steiger
You both hit on so many important things that I feel like we could dig into forever on this podcast, but I think, you know, addressing that stigma piece, I think is so important. Bringing that to the front of the table, the front of the room, the second a resident starts at BMC and saying, this is okay, we expect that you're going to be stressed because residency is hard and you're learning and there's a lot of things going on for you.

00:09:35:26 - 00:09:56:19
Jordan Steiger
I think just getting out in front of it is so important. I think one thing you mentioned, Simone as well, is that, it's not therapy. You know and I wonder sometimes if people kind of shy away from these programs or thinking about mental health because it's they don't want to be providing those therapy services, but it really sounds like it's just more connecting people to those services.

00:09:56:21 - 00:10:22:00
Simone Martell
Yeah, it has a lot to do with the awareness and the access piece. So what we've done with the chats is that, in addition to myself, some of my colleagues who are, you know, doctors level will be able to join in and hold the discussions. Also, they won't have to have the pressure of going into to anything that's outside of their territory.

00:10:22:00 - 00:10:58:12
Simone Martell
We also don't want to give a false impression to the residents for this session, either. I'll say residents or fellows, because we do this for fellows as well. But it's more about here are the different resources that you are eligible for and have access to, and here's the route with which to do it. And here's at least, you know, through our internet source, our fliers, our point of contact, so that you have an easy way of - you don't have to remember all of this - but there's just, a streamlined way to think about how do I set up what I might need.

00:10:58:15 - 00:11:19:17
Simone Martell
And then again, for, you know, folks that maybe have had experiences before or are just saying, like, you know, coming into this, I know that this is something that was difficult for me in med school or something that I've found challenges with. So I want to kind of be thinking ahead. We can roughly just touch upon what are some coping strategies that have been helpful for you.

00:11:19:17 - 00:11:39:24
Simone Martell
Again, this being a new territory, a new framework, what do you think that you might need in anticipation and have you think through ahead of that without it being anything that would delve into the territory of therapy per se? That said, trainees are able to schedule confidential appointments with a licensed clinician in the resilience program at any point through their tenure.

00:11:39:27 - 00:11:47:18
Simone Martell
And we also help them navigate how to get connected to a therapist through their behavioral health benefits, if that's something they'd like to pursue.

00:11:47:21 - 00:12:10:09
Jeff Schneider, M.D.
I think another really important piece of this is getting the residents and fellows to normalize a conversation amongst themselves. So for every resident or fellow that Simone or her team meets with who goes through or has their eyes open to some of the resources that we have here, my hope, my deep hope is that even if you know, maybe it's not applicable to them today or tomorrow or the next day...

00:12:10:12 - 00:12:26:24
Jeff Schneider, M.D.
but if they see a colleague, if they see a friend, if they see someone, a resident or fellow who maybe they don't even know all that well and they just look at them and say, I'm worried about you. Are you okay? Like, that's always the right currence. It's always the right question to ask. It's never the wrong question to ask.

00:12:26:26 - 00:12:41:21
Jeff Schneider, M.D.
And then also so they can start arming themselves and say you know what, at the very beginning I went to this talk and I had this resilience chat, I learned a little bit about some of the resources we have at Boston Medical Center. I don't remember all the details, but I know that there's help out there. And I remember here's how you can help access it.

00:12:41:21 - 00:12:53:16
Jeff Schneider, M.D.
So again, the more we can start normalizing these conversations, I think for every resident fellow that Simone touches, the hope is that that spreads almost virally so that they can help themselves but also help their colleagues.

00:12:53:19 - 00:13:19:24
Jordan Steiger
Absolutely. I think the program and the work that you are doing at Boston Medical Center is setting such an incredible example for our membership, and we're so happy that we get to share your story with everybody today. Simone and Jeff, thank you so much for being here with us today. I think the work that you have shared and the work that you're doing and continue to do to support your teams is really setting such a strong, incredible example for our membership.

00:13:19:24 - 00:13:30:03
Jordan Steiger
And I'm just so happy that we get to share your story and hopefully others will get to learn from it and start to maybe, implement some of the things that you shared today.

00:13:30:06 - 00:13:31:00
Jeff Schneider, M.D.
Thank you.

00:13:31:02 - 00:13:33:03
Simone Martell
Thank you so much.

00:13:33:06 - 00:13:41:17
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:03 - 00:00:25:03
Tom Haederle
Welcome to Advancing Health. Sepsis - essentially an extreme and life threatening reaction of the body's immune system to an infection - is a problem in many hospitals, and at one point accounted for more than half of the mortality rate for Ochsner Health. In today's podcast, we hear how Ochsner tackled the problem with great success.

00:00:25:06 - 00:00:48:14
Chris DeRienzo, M.D.
I'm Dr. Chris DeRienzo. Thank you all again for listening in to this episode of our podcast. This is another one of our on-location podcasts and we couldn't be more excited to be down in Louisiana today visiting with the spectacular team at Ochsner Health. They're a 48 hospital systems covering everything in size, from large academic medical centers to small critical access hospitals.

00:00:48:21 - 00:01:09:14
Chris DeRienzo, M.D.
And the reason that we're here is because their work on sepsis is leading the way nationwide. Our visit today has actually been funded by a CDC grant around the sepsis core elements, and I'm super excited to get to spend some time on our podcast speaking with Stephen Saenz, who's a PA, and is a sepsis program manager for Ochsner,

00:01:09:21 - 00:01:20:15
Chris DeRienzo, M.D.
in addition to Teresa Arrington, who is the director of Quality and Performance Improvement. Thank you both so much for being willing to do this on site today. It is a real privilege that you get to record this with you.

00:01:20:16 - 00:01:21:08
Stephen M. Saenz
Happy to be here.

00:01:21:11 - 00:01:22:15
Teresa Arrington
Thank you for having us.

00:01:22:17 - 00:01:39:17
Chris DeRienzo, M.D.
Well, let's jump right in. So again, you all have managed to make such substantial strides in sepsis outcomes like risk adjusted mortality across your health system. Let's just start where you start. So how did this journey begin and where did it start?

00:01:39:18 - 00:01:59:14
Teresa Arrington
This journey, we've been on it for a number of years and in the prior iterations I was a stakeholder, but not really involved in any kind of leadership capacity. And we would often review sepsis cases, sit around a table. It would be conducted a lot like an M&M review with physicians where we would discuss what did we do right here, what our opportunities were.

00:01:59:21 - 00:02:19:04
Teresa Arrington
And I think that the teams would come away with some knowledge, but we had trouble systematizing the things that we were learning and the trends we were seeing. Around 2020, Dr. Richard Guthrie, who is our chief quality officer for our system, you know, he really started to do a deep dive into mortality as a whole and what the drivers of mortality might be.

00:02:19:10 - 00:02:45:00
Teresa Arrington
And we knew that sepsis was absolutely one of those arms. In fact, it is associated with more than half of the mortalities in our system. So it felt like a really great place to start. And we put together as an initial step a system drive team, which was comprised of Dr. Guthrie as our champion and sponsor, myself as a change management professional who reports that through the quality structure.

00:02:45:02 - 00:03:11:21
Teresa Arrington
And then we had initially an anesthesiologist who was just fantastic in terms of structure and getting people started on that journey. What we did is we tried to craft just some structure that we felt would be foundational in moving anything we wanted to do with sepsis forward. When I say structure, I mean things like identifying what kind of roles you might need to be successful if you were to stand up a sepsis committee or council at a local campus.

00:03:11:28 - 00:03:35:09
Teresa Arrington
And then from there it grew into to tools and whatnot. But we've come up some ways. And the anesthesiologist, he was the thought leader stepped back and in came Dr. Lisa Foret, who is an ED physician, as well as an associate chief medical information officer; as well as Dr. Jason Hill, who represented the hospital medicine side as a clinician and as a chief medical information officer.

00:03:35:16 - 00:03:40:04
Teresa Arrington
And I think between that group, we started to put things together.

00:03:40:06 - 00:04:15:23
Chris DeRienzo, M.D.
Let's pause on that for a moment, because your sepsis implementation team here, and it looks a little bit different in an important way than some things I've seen elsewhere in that we know that it's important to have multi-stakeholder buy-in. Obviously that's one of the CDC's hospital sepsis core elements, but how you've approach that on the physician and APP side with not just Ed and hospitalists as part of the team, but also an ED provider and a hospitalist provider who understand informatics and can help translate how you're trying to solve for sepsis outcomes into workflows that that's really quite novel.

00:04:15:26 - 00:04:23:24
Chris DeRienzo, M.D.
I'd love to hear you share a little bit, you know, with our audience around the unique nature of those sepsis workflows.

00:04:23:26 - 00:04:46:03
Teresa Arrington
Yeah, it has been fantastic. And it's certainly it's something I'm very aware of as a gift that we've had in the organization. You know, it's been important, of course you need clinicians at the table. But when you can combine that clinical acumen as well as some of the tech in IS and IT supported workflows, you really start to get somewhere that feels like it's manageable and making a difference.

00:04:46:04 - 00:05:17:26
Teresa Arrington
I'll give you an example that comes to mind. Interruptive - some people call them BPAs, OPAs, that's now what we refer to them as within our system. You know, clinicians, while they recognize that they can be valuable, there's also a tremendous amount of alert fatigue. So in having clinicians who have led the program and understand what that feels like on a day to day basis, we've moved, say, from an OPA that would fire only to say be aware of X, Y, and Z to we're not going to ever shoot over an OPA to say, be aware.

00:05:17:26 - 00:05:33:18
Teresa Arrington
We want to prompt an action. So if there is not an action associated with it or something we want you to do, we're not going to push that to you. And thereby it reduces some of that alert fatigue and helps to harness the attention where it needs to be. So that's just an example that comes to mind of one of the benefits.

00:05:33:20 - 00:05:37:09
Chris DeRienzo, M.D.
It's a wonderful example. And Steven, I'm wondering if you have something to add there as well.

00:05:37:12 - 00:05:59:12
Stephen M. Saenz
Yeah. As you can imagine, physician who knows informatics is in high demand for other projects. So we got sepsis off of the ground and there's still work to be done. And my role as a clinician as well, and understanding the ins and outs of a big hospital system, is really being in those tools every single day. I am in those dashboards.

00:05:59:12 - 00:06:24:14
Stephen M. Saenz
I am looking at sepsis care, identifying problems quickly, understanding how to triage, who needs to know, who can help me fix it. You know, there's going to be leadership at an executive level who's pushing these big projects forward, but you really need somebody in the day to day, nitty gritty, understanding how to best utilize the tools, send up suggestions of how to make things better, and then watching those process metrics change from there.

00:06:24:17 - 00:06:45:27
Chris DeRienzo, M.D.
And the leadership engagement again, one of the CDC sepsis core elements. Let's talk about action a little bit though, because again, how do you have scaled this work across a multi-state endeavor, really I think is worthy of some deep conversation. When we look at sort of the red to green conversions, for example, of your ED president on mission sepsis workflow.

00:06:45:27 - 00:06:58:29
Chris DeRienzo, M.D.
Talk to us about how not only that works here -and we're recording this podcast today at, you know, a large a flagship academic medical center site. But perhaps out in, you know, Oschner Rush or some of your other critical access locations.

00:06:59:02 - 00:07:22:28
Stephen M. Saenz
I really do think that, you know, the system as a whole really made this the standard of care. You know, Oschner was going to be taking care of patients with sepsis in a standardized way across the whole system. You have to listen to how different hospitals work and understand that there may be some different variation in how they work, but you really have to support that team in making their workflow work for everybody.

00:07:22:28 - 00:07:44:28
Stephen M. Saenz
Because if the main hospital needed a change, we can't have a different iteration at a different hospital. Really, everyone had to be on the same page. And that's been from the beginning with even just going live with EPIC in general, having everybody on the same system, having everybody with the same workflows, helps in standardizing a message across all the hospitals.

00:07:45:00 - 00:08:13:09
Chris DeRienzo, M.D.
Theresa, I'm curious in your travels across all of the different hospitals in the system, do you see that any differences in approach to implementation, for example, in a critical access emergency department that doesn't have in-house pharmacy 24/7 and as compared to a larger community hospital or an academic center where you have to tweak how the protocols are implemented in order to be able to get, you know, a patient who would present in both settings to the same excellent outcome.

00:08:13:11 - 00:08:33:01
Teresa Arrington
We've actually purposely tried to not be overly prescriptive. We have the certain tenets that we have to follow and things that we're held to. For example, CMS is total perfect care, sepsis bundle which is built into the checklist that you reference with the red and green. And we know that that's going to be critical for a patient's chances of survival no matter what ED they present to.

00:08:33:03 - 00:08:56:05
Teresa Arrington
They're expecting that level of care. But in terms of how to operationalize that, we have left that largely to the leadership at the individual facilities, because they know their resources and their constraints and their culture better than we ever could at a system level. You know, using the example of you might have an academic site with 24/7 pharmacy support in the Ed, but then what about, you know, a smaller hospital?

00:08:56:12 - 00:09:14:23
Teresa Arrington
In a case like that, it might be more important that we're very forward thinking about keeping our pixis stocked with exactly what we need in that moment to be available to our patients. So it's taking the broad goal of what we have and then saying, no matter how you get there like that, it's okay how you get there if it looks different, but get there.

00:09:14:25 - 00:09:47:05
Chris DeRienzo, M.D.
Excellent. And so important, I mean, the patchwork tapestry of America's hospital landscape. There is never going to be one perfect solution, one perfect implementation. But what you've created, there's a standard protocol with a flexible approach to implementing it. Now, I know in that that approach to implementation technology obviously plays a big role. We touched a little bit on the nature of the workflow, which really leverages human factors and in some ways almost gamified the approach to hitting every element.

00:09:47:07 - 00:10:07:12
Chris DeRienzo, M.D.
Because as humans, we just love making red things green. And of course, within that, you know, you have appropriate clinical knowledge and understanding. But what other kinds of technology are you leveraging within your broader sepsis program as you seek to scale, you know, again, across a large multi-state, a 48 hospital enterprise?

00:10:07:15 - 00:10:29:12
Stephen M. Saenz
Some of the other things we've done are around predictive algorithms. So using all the vast information that's input into EPIC, whether it's coming from a flow sheet, whether it's coming from a past medical history, surgical history, kind of all the intangibles that we know as clinicians but have a hard time getting the computer to kind of understand.

00:10:29:12 - 00:11:06:05
Stephen M. Saenz
And so what we've done is offload some of that thinking onto EPIC to help us provide risk levels for different patients, to alert us earlier to a potential sepsis diagnosis. And then, you know, really supporting the workflow on the nursing side to get a screening done for those particular patients. So really, I feel like here at Ochsner and leading on the AI front, using those tools that are available to us in a way that can help protect patients,  as well as developing all the workflows to help them support that decision when it's made.

00:11:06:08 - 00:11:25:11
Chris DeRienzo, M.D.
I learned early in my career in health care that if you're going to embark down a technology pathway, you've got to involve those who are going to be using it from the very beginning, and that's baked into your model. Teresa, as you were sharing your wheel, you know, has those bedside clinicians as part of as part of that dialog, which again, clearly a leading practice.

00:11:25:11 - 00:11:38:11
Chris DeRienzo, M.D.
And again, one of the reasons that we're down visiting with you in Louisiana today. I think we've only got a couple more minutes. And so I would love to give you a chance just to share some of the incredible outcomes with our listeners that you shared with us.

00:11:38:13 - 00:12:02:25
Teresa Arrington
Absolutely. We are excited to share that we have, over the past two years, dropped our primary sepsis risk adjusted mortality by 20%, which is incredible, especially we're talking about at this large system level, not at a singular campus. And to be able to move the needle at scale like this, it's challenging. And we are we are so very proud of the work that has been done.

00:12:03:00 - 00:12:17:00
Teresa Arrington
We've had tremendous success, as Steven mentioned earlier, with some of our AI and just the direction we're headed with virtual nursing support being on that cutting edge, it is so exciting to see the care that we're providing for our patients.

00:12:17:02 - 00:12:34:13
Chris DeRienzo, M.D.
Those numbers translate into hundreds of people who are now going home, where you know in the past, given the severity of their illness, they would have succumbed and so I cannot congratulate you enough. I get to spend a lot of time in hospitals. And the outcomes that you are driving here really are leading across the country.

00:12:34:13 - 00:12:52:13
Chris DeRienzo, M.D.
And I think that's one of the notes I'd like to leave our listeners on, which is when you go through that, that list of hospital a sepsis core elements, one of the last ones, if not the last one, I think is education. And you obviously have been not only a spectacular job of educating your own teams, but also the entire health systems teams.

00:12:52:14 - 00:13:17:19
Chris DeRienzo, M.D.
And as I understand it, the workflows you've developed have been so impressive that they're actually being scaled to other health systems across the country through the EMR platform. Would you touch a little bit on that? Because, you know, I heard today about your mission to not only serve patients here, but if there's a way to help share that story and other health systems who want to learn from that and implement some of the tools that you have implemented, you're up for it.

00:13:17:21 - 00:13:41:12
Stephen M. Saenz
Yeah, we've developed a lot of tools in collaboration with EPIC. We've really pushed them to kind of help bring our idea to life, and we're happy to share that information at EPIC conferences, at other medical conferences, and then across, you know, anyone who's using the EPIC system, for their EHR. You know, I will add that this wasn't a perfect rollout.

00:13:41:12 - 00:14:06:12
Stephen M. Saenz
You know, we learned as we went to get that type of success requires you to have an idea, roll it out, and then take feedback and change it. Understanding how it's working in real time, with the people, with the clinicians, with the nurses. You know, this is still a learning process for us, and we're happy that other hospitals are kind of being inspired by some of the work that we're doing.

00:14:06:14 - 00:14:10:18
Stephen M. Saenz
But we're not done yet. You know, there's still a lot more to keep at.

00:14:10:21 - 00:14:23:10
Chris DeRienzo, M.D.
Improvement is, is a journey, right? It is not a destination. And your words, you are preoccupied with sepsis. And I'm confident that no matter how good you get, you will always be finding ways to get even better. Teresa, any closing thoughts?

00:14:23:12 - 00:14:44:15
Teresa Arrington
Just, you know, we believe we have found a recipe for success and how to bring attention and drive change in time sensitive, you know, disease states. And we are excited to be replicating the same structure that we have for sepsis with stroke and with Stemi now as we're moving forward as an organization. So I think that Ochsner Health has a lot to share on the horizon.

00:14:44:17 - 00:14:59:21
Chris DeRienzo, M.D.
That is a perfect place to leave it. It's again, y'all, it is such a privilege to spend the day with you today. If you want to learn more about sepsis, come to New Orleans. And because these folks here are really leading the way. And thank you so much for your time. We really appreciate it.

00:14:59:23 - 00:15:00:22
Stephen M. Saenz
Of course. Thank you.

00:15:00:25 - 00:15:02:15
Teresa Arrington
Thank you.

00:15:02:18 - 00:15:10:29
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 - 00:00:25:20
Tom Haederle
Welcome to Advancing Health. Food insecurity doesn't always mean not having enough to eat. It can also describe lack of access to healthy food. Coming up on this podcast, we learn more about Cleveland Clinic's broad strategy to provide opportunities for healthy eating to all of the communities it serves. As today's guest says, "we look at food as medicine."

00:00:25:23 - 00:00:52:14
Nancy Myers
Hi, I'm Nancy Myers from the American Hospital Association. Thank you for joining us today as we have a great conversation planned with Vickie Johnson, who's the executive vice president and chief community officer for the Cleveland Clinic, based out of Cleveland, Ohio but with operations worldwide. Today, we'll be talking a little bit about how they're understanding and meeting the needs of both their patients and their communities as they seek to drive better health for all.

00:00:52:15 - 00:00:56:23
Nancy Myers
So, Vickie, thanks so much for joining us today. Appreciate you being here.

00:00:56:25 - 00:01:01:03
Vickie Johnson
You are welcome. And thank you for the invitation. It's an honor to be here.

00:01:01:09 - 00:01:07:06
Nancy Myers
Tell me a little bit about the work that you and your team lead at the Cleveland Clinic, just to ground us.

00:01:07:08 - 00:01:33:21
Vickie Johnson
Sure. So in 2023, Cleveland Clinic established the community health office. And I'm blessed to be the leader. As you said in the introduction, we are an enterprise with a global footprint. So it's my job to lead an awesome team at developing a strategy to care for every community in which we're located. And our objective is to build healthy communities together.

00:01:33:24 - 00:02:01:04
Vickie Johnson
We have a strategy that we'll talk about a little later to make sure that we use the same approach to engage with every community, so that the outcomes and the strategies that we have are locally relevant. So we're happy to do this work. We are a service line to every institute and department at Cleveland Clinic so when we discover the needs of our local communities, we work as a partner, a non-physician partner

00:02:01:04 - 00:02:12:09
Vickie Johnson
so we have a dyad partnership to work together to leave the walls of the hospital and go into the community where patients and community members are to address those needs together.

00:02:12:14 - 00:02:33:01
Nancy Myers
So I know that one area that you've been focusing on through the work of your team and over the last few years has been what some people would refer to as food insecurity. But your lens is a lot broader than that, or broader than just simply access to food. Can you tell us about the work to address nutrition that the Cleveland Clinic has undertaken?

00:02:33:03 - 00:03:02:24
Vickie Johnson
Yes, I'm happy to do that. So you're correct. So we look at food as medicine and we look at food as something that we can engage communities around. It's easy to understand that at the foundational level, everyone needs access to food, but it needs to be good food. So in the urban communities in which we're located sometimes it's not access to food, it's access to good food.

00:03:02:27 - 00:03:41:24
Vickie Johnson
We have patients and neighbors who shop at gas stations and convenience stores, and so they have something to eat, but it's not necessarily nutritious. So we've worked in partnership with the communities in which we're located, with local health departments, with the business community, our stakeholders, to figure out how we can leverage the economic impact that we have in each community to address nutrition, which then includes how do we leverage who we are to attract retailers who will provide nutritious food so access to better food options.

00:03:41:27 - 00:04:06:04
Vickie Johnson
And then also how do we educate and work in collaboration with our community to understand how nutrition is a really big part of health. And children in particular, how they perform at school, and everything really is based on that foundational need that we all have. But we do not all have access to the same quality of food.

00:04:06:07 - 00:04:27:01
Nancy Myers
So it sounds like you're really taking a multi-pronged approach in terms of the strategies as you go from community to community that you serve. And I heard you mention retail partnerships and education. Can you maybe talk a little bit more about what some of your foundational strategies are in different communities that you're most proud of?

00:04:27:03 - 00:04:54:22
Vickie Johnson
Absolutely. So let me start even broader, first, to say that when we think about food, we looked at food from an enterprise perspective and as a health care provider. So food at the bedside. Food that we sell on our campuses. So the types of retailers and restaurants that we allow to have a presence on our campus that we sell to patients' families and caregivers.

00:04:54:29 - 00:05:22:15
Vickie Johnson
And then food in the community, which is the space that I lead. So we've leveraged relationships that we have with food vendors, those that we do business with at the bedside and on campus to see how can we partner together. The whole thing, the whole approach that we use is how do we leave the hospital? We want to go where people are so that we have the greater opportunity to have an impact on the health outcomes.

00:05:22:15 - 00:05:46:00
Vickie Johnson
So how do we leverage partnerships? So we have great partnerships with Morrison Health, for example. The relationship started inside the hospital, but we both care for the same community. So how do we go together to provide education. So how do we leverage the chef that is preparing great meals for our patients in the community as well? And how do we bring that to communities where people are?

00:05:46:00 - 00:06:21:18
Vickie Johnson
So how do we use cooking demonstrations and education and recipes in libraries and community centers, combined with other partners like the American Heart Association. So we leverage those relationships we have. Also, we've been so fortunate on our main campus area, which is in the city of Cleveland in the Fairfax neighborhood where we've been over 100 years, and we've been in a community where the people who are our neighbors had not had a quality grocery store for over 30 years.

00:06:21:20 - 00:06:52:13
Vickie Johnson
And in 2018, they told us the best thing that we could do for them as a partner, as an anchor institution, is to leverage our employee base and the amount of dollars that we spend to attract a retailer to a community, quite frankly, that they could not do this on their own. So the population was declining, the number of households, the educational attainment, all the things that retailers look for to make a good business decision.

00:06:52:15 - 00:07:18:12
Vickie Johnson
This community did not have it. But what they did have is a committed partner in Cleveland Clinic. So we leverage the number of caregivers on main campus, the number of patients that visit every day, the number of construction workers that parked cars. We use all of this data to have conversations, and were successful in attracting a high quality retailer.

00:07:18:15 - 00:07:45:08
Vickie Johnson
And now we're working together. It's Meyer, and they're using the urban format to work with us in the community. So 40,000ft² of fresh groceries that did not exist before for our community. And so we're really pleased and so happy about that because when we went back to the community in 2023 to have the same kind of conversation, to ask on a regular basis, how do you define health?

00:07:45:10 - 00:08:12:13
Vickie Johnson
How can we be a good partner? And we collect data. And once that was looked at, we found no one described a food desert anymore. No one said, can you help us with access to food anymore? And we also had an economic impact with the 50 jobs that were created as well as a result of that. So that's what we've been doing, is talking with the community on a regular basis.

00:08:12:13 - 00:08:39:17
Vickie Johnson
How can we be helpful and really be really transparent about what we can and what we cannot do, and then work together to make that happen? So in other communities, we do not have 20,000 caregivers. You know, we do not have that type of impact. But how can we leverage, again, our vendors to make those opportunities and to increase the healthiness of every community that we serve?

00:08:39:19 - 00:09:03:25
Nancy Myers
And I love how you talked about bringing your workforce in, your caregivers, because they are one of our first communities, right? And so being able to put in this market, as you have in Cleveland, serves the people who live in the neighborhood. And it also is a nice benefit and service to your team members, who I assume use it every day or on a regular basis as well.

00:09:03:27 - 00:09:24:25
Vickie Johnson
That is so true, and I would be remiss if I didn't say where we do not have those same opportunities because we don't have the same level of economic impact, we're working with local communities around food pantries and nourish pantries, where it's not just food, it's also the education and talking with a health care provider  - and almost issuing

00:09:24:25 - 00:09:49:28
Vickie Johnson
and we have - food prescriptions to make sure that we're making the connection. And again, food is health. And we have wonderful initiatives where we focus primarily on populations that need us the most, It's a place-based strategies. We've decided to focus on pregnant women and children around food and nutrition, infant and maternal health. All women in the community.

00:09:49:28 - 00:10:02:04
Vickie Johnson
So we've been able to really connect everything together: food insecurity, access to care, exercise, all of that to get to the outcomes that we hope to see in years to come.

00:10:02:06 - 00:10:17:24
Nancy Myers
Let's talk about what the outcomes are that you're measuring now, as well as those that you're looking to measure over time to see how you're making an impact through these programs and other community programs that you have in place.

00:10:17:26 - 00:10:40:15
Vickie Johnson
Well, time is the first thing we want to focus on. It will take time. And I think in health care, we're sometimes, you know, looking for instant results because that's what you see with health care in terms of surgery or medicine. And so in this case, we all know this will take time. So we look for indicators that evidence has shown us will have a difference.

00:10:40:15 - 00:11:20:06
Vickie Johnson
So for example we are looking for pre-and-post test. And so at the end of a 12 week or 16 week or 90 day initiative, whatever the time frame is, have we been able to increase one's awareness and knowledge and a change in behavior? For example, we have an initiative called Healthy Moms and Healthy Babies where we've eliminated barriers like transportation. Where a pregnant mom, she's pregnant and she has children, and so she's able to shop with $200 a month and shop for healthy food using her cell phone,

00:11:20:09 - 00:11:49:29
Vickie Johnson
using the computer. And having food either picked up or delivered at the door side. So through that experience, we're able to stay with that mom throughout the first year of the baby's birth. And then we can measure. And it's self-reported. And because we have community health workers that are really closely building relationships with these mothers, we know the change in behavior.

00:11:49:29 - 00:12:21:15
Vickie Johnson
We can believe it because we see it. We're closely aligned with them. So when we change our behavior and when we recognize, okay, we know better. I accept that and I'm actually going to change how I eat and what I purchase, how I prepare it. Then we can expect, based on evidence, that we will see an increase for example, in the birth weight of the newborn, we can see a change in the need for certain medications because we're eating better.

00:12:21:16 - 00:12:41:23
Vickie Johnson
So we're hoping and we expect to see a healthier community at the end of this work. And when it's not perfect, we do it again. You know, we continually form and keep these relationships with folks. And when you don't exercise as much as you used to, we'll start all over again because we're going to be in the community

00:12:41:23 - 00:13:15:04
Vickie Johnson
forever and we're there as a partner to institute these behaviors that we know will produce the outcome that we're looking for. The access to food piece, again, when we've removed the necessity of a person to buy their dinner at the gas station because they now can purchase it at a market, we know people will become healthier and the outcome and their future is brighter, because we've been a part of bringing that to the community.

00:13:15:07 - 00:13:44:15
Nancy Myers
Thanks so much. And one last question, kind of as a wrap up. We'll play Monday Morning quarterback. You've had several years of experience in this world. And you've had some successes and likely you've had some things that didn't go as planned. What are key pieces of advice, maybe 1 or 2 things that you would give to another organization that was either just starting out addressing some of these same things, or was interested in expanding the work that maybe they've already started.

00:13:44:18 - 00:14:22:06
Vickie Johnson
I think we have to give ourselves grace at the very beginning and celebrate every success. Sometimes we get caught up in huge numbers, but every success is huge to that individual, is huge for every child that we are a partner with to really care for people for life. And if we start well, then we can end well. You know, celebrate ten people completing an initiative, celebrate 30 and then those ten or 20 or 30 are going to share that experience with their neighbors.

00:14:22:06 - 00:14:55:23
Vickie Johnson
And then you'll get to the place where you're seeing 3 or 4 or 500 as we are today. We have a fitness center also on main campus with world class equipment, and now we're up to thousands of people that come in every day. Unique individuals that are using our fitness facilities with physicians on staff. You know, present, with dieticians present in the same building where you can have yoga and you can soon teach each other, teach your neighbors how to eat better.

00:14:55:23 - 00:15:21:09
Vickie Johnson
So be in this for the long term is what I would say. And community is also hard to measure impact. Again health care is different. We have 400 surgeries, you know, scheduled for today and we know the outcome within minutes. This is very different, but it has a greater impact in one's sustaining their health in the community in which they're living.

00:15:21:09 - 00:15:34:17
Vickie Johnson
So partner with the physicians and know that we are just as important and in some cases more important in partnering with patients when they go home and community members to live a healthy life.

00:15:34:19 - 00:15:52:23
Nancy Myers
Well, on behalf of AHA, I'd like to say thank you, Vicki, to you and your team and the Cleveland Clinic for the work that you are doing to make a difference one person at a time, one community at a time. It sounds like you've had amazing success and have many more successes to come.

00:15:52:25 - 00:15:54:26
Vickie Johnson
Thank you.

00:15:54:28 - 00:16:03:08
Tom Haederle
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