Advancing Health Podcast

00:00:00:02 - 00:00:18:19
Tom Haederle
Welcome to Advancing Health. Differences in health outcomes affect patients and communities, but also contribute to lost workforce productivity and hundreds of billions of dollars in avoidable health care spending. More health care leaders are recognizing these challenges and taking action.

00:00:18:21 - 00:00:48:25
Joy Rhoden
This is Joy Rhoden, senior vice president for the Division of Health Outcomes and Care Transformation at the American Hospital Association. And today, we're going to be talking about the economic impact of disparities in health outcomes. Health disparities have long been recognized for their impact on patient outcomes, but we know that they also carry significant macroeconomic and microeconomic impacts and consequences.

00:00:48:27 - 00:01:25:10
Joy Rhoden
At the macro level, I'd like to share just a few findings from our research as we developed this guide for the field. The data from 2022 show that national analyzes estimate that disparities in health outcomes are associated with approximately $320 billion dollars - with a B - in excess health care spending each year, with projections indicating that this figure could actually rise to $1 trillion dollars by 2040 if disparities remain unaddressed.

00:01:25:12 - 00:02:03:09
Joy Rhoden
I don't think this is a problem we can ignore. So our members often ask why, in a resource constrained environment, should they pay attention to and invest in strategies that will reduce health disparities? And today I am joined by Brian Peters, chief executive officer of the Michigan Health and Hospital Association. Brian and I will discuss how health disparities not only impact health outcomes at the individual level, they drive avoidable costs across health care systems.

00:02:03:09 - 00:02:29:08
Joy Rhoden
They reduce workforce productivity and lead to excess health care spending and expenditures for individuals, families and society writ large. Brian, thank you for joining me today. And I'd like to invite you to introduce yourself a little bit better than I did and share just a bit about the work you're leading in Michigan.

00:02:29:10 - 00:02:54:04
Brian Peters
Well, thank you, Joy, it's a pleasure to join you today and talk about this very important subject. The Michigan Health and Hospital Association has been around for a while. We just celebrated our 100 year anniversary a few years ago, and we've been a very strong advocate for literally every hospital and health system in the state of Michigan. They are all engaged members in good standing of our association.

00:02:54:04 - 00:03:22:20
Brian Peters
And we partner with the American Hospital Association, both on the advocacy up front, but also on a number of other issues outside of the public policy arena as well. And our mission is very straightforward. We advance the health of individuals and communities, and that's a mission that's very consistent, almost identical with the American Hospital Association. And I think that's given us a really excellent platform to collaborate on this work.

00:03:22:21 - 00:03:42:26
Brian Peters
I will tell you that it has been a great privilege for me to serve at the MHA for now 37 years, the last 11 as CEO, and to serve on the American Hospital Association board as well, with some really remarkable leaders. And I'm just so proud of the work that we're able to do together.

00:03:43:03 - 00:04:12:06
Joy Rhoden
Well, thank you so much for your strong leadership and certainly for the tight coordination that we enjoy with you and your other state hospital association peers, you know, really leading the charge to improve the conditions so that our hospitals can continue doing the good work that they do for the communities they serve. So to get us started, we often think about health disparities in terms of patient level outcomes.

00:04:12:06 - 00:04:38:14
Joy Rhoden
And we talk a lot about the moral imperative to act. I think an underexplored area, Brian, is the economic impact of those same disparities. And so I wonder if you could shed some light on why you think health care leaders should pay attention to the financial considerations that can sometimes be overlooked?

00:04:38:16 - 00:05:00:18
Brian Peters
Well, there's no question this should be a main focus. And, you know, I'm someone that always looks at the optimistic view anytime we're dealing with major challenges. And so as you know, Joy, both for the American Hospital Association, for the Michigan Health and Hospital Association, and frankly, for our colleagues all over the country. What is the hot topic, if you will,

00:05:00:19 - 00:05:27:06
Brian Peters
right now? It is an election year topic, and that is the topic of affordability. And I think we're all wringing our hands about this issue. And, you know, we've been called to task. Why are health care costs so high? I think we've been given a gift, quite honestly. This is my optimistic view because this new conversation on affordability, it's shining a very bright light on the underlying factors.

00:05:27:06 - 00:05:54:14
Brian Peters
And what I'm getting at here is when we talk about disparities and as you said, the economic impact of disparities. Now we have the full attention of everybody from, you know, our own membership to elected officials, the media and the business community to talk about the role that economic impact plays when it comes to these issues of disparities.

00:05:54:14 - 00:06:13:08
Brian Peters
We can make that very close connection. And so this is an opportunity that we don't want to squander. And I'm very pleased to see the American Hospital Association wading in in a very significant way. And with this new report, I think it's going to really help our efforts in a significant way.

00:06:13:15 - 00:06:43:22
Joy Rhoden
Thanks. Thanks for that, Ryan. I think to your point, we're bringing everyone in under the tent, now, when you start to talk about the finances as well. But let's remember that the backdrop for much of this conversation around affordability, as you just called out, is a resource constrained environment, right? So hospitals are facing increasing pressure to improve their outcomes and manage costs.

00:06:43:25 - 00:07:21:24
Joy Rhoden
And as I pointed out earlier, you know, it's growing exponentially at the macro level to it's at a pace that's just not sustainable. Healthcare is inching close to 20% of GDP. So something's got to give. What do you say - and you started to talk about some of the root causes - what's behind the affordability challenge. What are some of the benefits that accrue when hospitals and health system leaders start to really pay attention to variation in care and variation in health outcomes, and work to close those gaps?

00:07:22:01 - 00:07:48:27
Brian Peters
Right. You know, we've said for many years that high quality health care costs less in the long run. So that, for example, anytime you avoid a medication error or a wrong side surgery, or you avoid a readmission because you've done a really good job managing that post discharge process, you're going to ultimately create a better outcome for the patient, but you're going to save cost as well.

00:07:48:27 - 00:08:17:06
Brian Peters
And I think that the similar concept applies here. In other words, if we can do a better job of addressing health disparities and do that in a proactive way as opposed to just dealing with problems once they show up in the hospital emergency room, which is the model that unfortunately we have in many places today, I think we're going to clearly create better outcomes for patients, but we're also going to help to bend the cost curve as well.

00:08:17:06 - 00:08:46:14
Brian Peters
This is the ultimate win-win, and I think that's a message that we have to convey effectively and consistently to all of the audiences who are part of this conversation. That's really the challenge before us. I think the AHA and the state associations, because as we know that the states are often the laboratory for reform, not only in health care, but in terms of any public policy challenge.

00:08:46:16 - 00:08:56:14
Brian Peters
And, you know, we have the resources at our disposal to make our voices heard and to tell this story. That's really what this this will entail.

00:08:56:15 - 00:09:06:21
Joy Rhoden
And I presume when you talk about a proactive approach, you're really leaning into a data informed approach, right?

00:09:06:25 - 00:09:30:28
Brian Peters
Data has to play a role. It has to play a role. We found that, by the way, through our efforts at the MHA Keystone Center for Safety and Quality. It starts with data. You have to measure outcomes. You have to measure process so that you have a baseline, so that you understand where the challenges are. And then you can track your progress and you can identify where things are working and where things aren't working.

00:09:30:28 - 00:09:58:00
Brian Peters
And so that data is critically important. You're absolutely correct. And it helps to tell a story. And I've always been one who says when you're advocating. And that could mean advocacy at the state or federal level in the political environment. But frankly, it could mean advocacy with our constituencies at the local level. You have to have data and stories, right?

00:09:58:02 - 00:10:20:29
Brian Peters
You cannot you cannot have one without the other, because data on its own can be misleading. Stories without data to support them can be misleading. So you really do need to have both. And I think we have both. I think we have to do a better job collecting meaningful data and disseminating it. But clearly those two things are important.

00:10:21:00 - 00:10:43:22
Joy Rhoden
I think you're right, Brian. I actually don't think we have a shortage of data. The challenge becomes how do you make those data actionable, right, to drive the improvements that you're after. So we spend the first half of the year developing this guide that we've been referencing on this, in this conversation, a guide on the economic impact of disparities in health outcomes.

00:10:43:22 - 00:11:15:21
Joy Rhoden
And I have to say, it's a better deliverable because of the insights we received from you and your peers on the Divisions Advisory Council. In your opinion, what are some practical ways hospital leaders can use the insights from this new resource to make the case, right, for investing in strategies and interventions, and the right dosage of those interventions that will focus on the reduction of health disparities.

00:11:15:24 - 00:11:41:24
Brian Peters
Well, in my mind, there's a two part challenge here. I think the first challenge is you have to win the home field advantage first, meaning you have to rally your own organization, the key leaders and the frontline caregivers in your own organization to let them know this is a priority for us. From this moment forward, this is now a priority with all that that entails.

00:11:41:24 - 00:12:06:21
Brian Peters
Meaning it's going to be a standing agenda item at our governing board meetings. We're going to have, to your point, actionable data that we're tracking. And we're holding supervisors and managers accountable for our progress so that you have everyone on the team pulling in the same direction. I think the resource guide that the AHA has pulled together and enjoy you in the team have done a great job in that regard.

00:12:06:22 - 00:12:30:20
Brian Peters
What I like is you spotlight some of the AHA members across the country who are doing some, some really neat things, and there will be many other similar examples where we can learn from each other. So you can you can share some of those learned experiences, but winning that home field advantage first and then from there, I think it's bringing in your key partners in the community.

00:12:30:20 - 00:12:53:03
Brian Peters
Because one thing we have learned without question in doing this work is you cannot move the needle by working in a silo. It will not happen. You know, when you're addressing disparities and all of the issues related to housing and transportation and language barriers and food insecurity and all the rest, we have to work with key partners in the community.

00:12:53:03 - 00:13:17:25
Brian Peters
And I really think about the business community as we're making this case, because you think about this fact - and you know this, Joy - so many of the people that we're talking about here that we want to serve in a better way, in a more proactive way, they could be better, more engaged and consistent participants in the workforce if they're healthy.

00:13:17:27 - 00:13:30:22
Joy Rhoden
As we wrap up, I guess I'd ask you for one key takeaway you hope our listeners will remember about the connection between health disparities and economic impact.

00:13:30:25 - 00:13:55:02
Brian Peters
Well, there's an absolutely significant and direct correlation between the two. We have to understand that and embrace it and tell that story and tell it very, very consistently. I really believe that in our very complex world of health care, we cannot move the needle on any of our challenges if we don't make it clear that this is a priority.

00:13:55:02 - 00:14:20:06
Brian Peters
And so I think what the AHA is doing in this work is stating that case for this as a priority. I think our leadership around the country has to follow suit. We have to speak with a united voice, and we have to bring in key partners who understand the only way we're going to create economic viability in our communities throughout the country,

00:14:20:06 - 00:14:42:16
Brian Peters
the only way we're going to start to bend the healthcare cost curve is to embrace this work, the work of health outcomes, particularly when it comes to underserved communities, and embracing all of these social drivers of health status. We can do better. We know we can. And I'm excited about this work that lies ahead.

00:14:42:19 - 00:15:15:01
Joy Rhoden
Super excited about the possibilities that lie ahead. To your point, Brian, for hospitals to do this work in partnership with others, I mean, at the end of the day, I can think of very many examples where the hospital actually ought not be in the driver's seat, but maybe serving more of that role as a as a convener, if you will, to bring together all of the assets that the community possesses, all of the other key stakeholders to design for the health of that community, right?

00:15:15:02 - 00:15:39:08
Joy Rhoden
And so if we multiply that across the various many communities that our members serve, we will be making a really good deposit towards a more a healthier environment for all, which is the goal, right? At the end of the day, the AHA's vision is of a just society of healthy communities where all individuals reach their highest potential for health.

00:15:39:08 - 00:16:01:22
Joy Rhoden
And so that really is our tall order. So I want to thank you for joining us and for sitting down with me today and providing your insights on this, on this topic. And I want to let the folks who are listening know that the new resource guide is available on the AHA's website, and we will also link to the guide in the podcast description.

00:16:01:22 - 00:16:05:24
Joy Rhoden
So thanks again and thanks for being with me, Brian.

00:16:05:26 - 00:16:10:08
Brian Peters
Joy, what a great pleasure. Thank you. I look forward to continuing our work together.

00:16:10:10 - 00:16:12:00
Joy Rhoden
Take care.

00:16:12:02 - 00:16:20:26
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:00:07 - 00:00:19:08
Tom Haederle
Welcome to Advancing Health. Florida's high proportion of older health care patients are being cared for by an aging health care workforce as well. Hear what one farsighted caregiver is doing to train younger workers and keep the people needed to meet future health care needs.

00:00:19:10 - 00:00:41:07
Elisa Arespacochaga
Hello, I'm Elisa Arespacochaga, AHA’s group vice president for clinical affairs and workforce. I'm delighted to be joined today by Nikki Daily, chief team resources officer at BayCare Health System in Florida. Today, we're going to be talking about how BayCare has developed partnerships, both inside their organization and with their community, to strengthen and grow their workforce for now and well into the future.

00:00:41:07 - 00:00:46:03
Elisa Arespacochaga
So, Nikki, thanks for joining me. And can you tell me a little bit about your role in BayCare?

00:00:46:10 - 00:01:09:16
Nikki Daily
Sure. Well, I'm very happy to be here. Again, I'm Nikki Daily, I'm our chief team resources officer. We are a large academic health system in west central Florida. I have been with the system 28 years, so this topic is very near and dear to my heart, being that I spent my career and have experienced and benefited from workforce development programs.

00:01:09:21 - 00:01:34:00
Elisa Arespacochaga
That's wonderful. It's always nice to have someone who's been through the programs, but also then helping to give back and develop them. Now we know that the demographic challenges that are coming at us as healthcare, as everyone trying to support the workforce with an aging workforce, increasing number of community members seeking care. How did you were you looking at this for BayCare and for your community?

00:01:34:02 - 00:02:00:27
Nikki Daily
Being in Florida, we're feeling this pinch quite acutely. We have over 1,000 people moving into Florida every single day, and 20% of those people are over the age of 65. At the same time, our workforce is aging. 13% of our team members are over age 60. And we do know that fewer people are coming into the workforce. So really coming up with programs that will allow us to fill those gaps.

00:02:00:27 - 00:02:16:03
Nikki Daily
At the same time, having those team members who are working towards retirement have a plan and a program to hand off that knowledge that they've gained was really important to BayCare as we were formulating our workforce strategy.

00:02:16:05 - 00:02:34:08
Elisa Arespacochaga
I know you looked at building programs both inside BayCare with the team you have, as you mentioned, but then also looking for ways to support your community and keep folks local, but also support those folks who are local to your community in advancing their careers. How did you manage to address both at the same time?

00:02:34:10 - 00:02:59:06
Nikki Daily
It is a partnership and a collaboration from all angles. So building workforce programs that one, meet the business needs and also focus on supporting the communities that we serve was really essential. The first thing that we look at is meeting those team members where they are. So we need to make sure these workforce development programs start at a level where they feel it's attainable and can grow.

00:02:59:08 - 00:03:28:16
Nikki Daily
Understanding the capabilities we have within the organization and having really good relationships with community partners, be it other workforce development programs, colleges, technical programs is essential to making this happen. A really great example is a surgical tech apprenticeship that we are just getting ready to launch. It's been in development for quite some time, but it is closing a gap for surgical texts, which there are a shortage of.

00:03:28:19 - 00:03:50:09
Nikki Daily
Also, it requires partnership with a local technical college, building programs and having preceptors within our organization. And it allows team members to continue to grow and become surgical techs without having to leave the workforce. They can do this on their job. We're really focusing on those programs that meet all the needs together.

00:03:50:12 - 00:04:07:22
Elisa Arespacochaga
I love that, and especially I mean, you can have the greatest surgeons in the world, but if you don't have the O.R. ready, if you don't have those support team members available and ready to join the workforce and continue in growing their own careers, those surgeons aren't going to be able to do what they need to do.

00:04:07:24 - 00:04:34:10
Elisa Arespacochaga
Absolutely. So I know you have built a series of approaches because of course, there's no one workforce approach. One is your surgical tech program. But can you tell me a little bit about the work you've done to work with your current team members and say, those in maybe entry level positions that might want to grow into something else, and how you've adapted all of the resources you offer to those needs.

00:04:34:18 - 00:04:58:24
Nikki Daily
Absolutely. So we've worked really hard to develop career pathways, and those are really roadmaps that show our team members each step that they need to take to get to what their dream job may be. And we've done this in both clinical and non-clinical fields. Something like food and environmental services, which are a very common entry level job in our organization,

00:04:58:24 - 00:05:21:25
Nikki Daily
we provided career pathways that show what knowledge and skills they need to grow to other roles. We even noticed through that work that we had a gap with helping people get a high school diploma. They can get that first level job without a diploma, but if they wanted to grow, they needed a high school diploma. So we just introduced a high school diploma program where we've graduated 31 team members.

00:05:21:27 - 00:05:50:01
Nikki Daily
We also have within nursing, for example, different pathways because every person's journey is different. Some may start as a patient care tech and go right into nursing school. And they can. We have earn as you learn programs which help support training. Also understanding not everybody can leave the workplace to get their education. So it supports that. We also have pathways where some people might want to be a practical nurse first.

00:05:50:01 - 00:06:00:14
Nikki Daily
So we have partnerships with technical colleges and we have that journey as well. And then it takes them into internships and ultimately becoming a registered nurse.

00:06:00:20 - 00:06:27:13
Elisa Arespacochaga
I love that you've got these pathways, and then you're supporting your team members in helping them work through what's the right path for me, what are the options and how can I continue to do the job that I'm doing but also move forward? Can you tell me a little bit about  - it doesn't sound like there is a typical trajectory - but what would a trajectory look like for one of your trainees, and how they can then start to look at that portfolio of options available to them?

00:06:27:16 - 00:06:45:16
Nikki Daily
There isn't any one path, but typically we look at what that entry level role might be. Sometimes we get phone calls from people through our recruiters who are looking to get into healthcare, and we would pry. So if they ultimately want to be a nurse, they haven't had any experience or exposure, we might make them a nurse helper.

00:06:45:16 - 00:07:10:14
Nikki Daily
So that puts them on a patient care unit. They get to watch and observe what the team, the care team is doing and how they do their work. So from that nurse helper job, some might decide to go into a patient care tech. Others through that may have gotten exposure to other positions like imaging, radiology techs, respiratory therapists and decide to take those journeys as well.

00:07:10:14 - 00:07:36:13
Nikki Daily
So from there, that's where those career pathways are really important, because it would show them if that person decided they wanted to be a radiology tech. We have technologist assistants that they could take that nurse help or the skills that they learned there, and then move over and become a technologist assistant while they prepare for imaging or radiology school or what their next step might be.

00:07:36:20 - 00:07:56:14
Elisa Arespacochaga
I love that that you really are looking for ways to stack those credentials and just add to their knowledge base, and not have to go back and start at the beginning for the next level of schooling. Can you add a little bit of color on the non-clinical pathways? Because I think we have a lot of folks are looking for what are those clinical pathways

00:07:56:14 - 00:08:06:13
Elisa Arespacochaga
and certainly we need every clinician we can get. But what are some of the roles where I don't think most people think are in hospitals that you've been working on?

00:08:06:15 - 00:08:34:25
Nikki Daily
Yes. It takes every type of role to contribute to making our health care system successful. A lot of people want to work in healthcare but not be a clinician. So we do have pathways in areas like registration. So it really is important, I think, as people are looking at a career in healthcare or a hospital system, they have transferable skills like customer service, computer skills, organization skills.

00:08:34:25 - 00:09:12:21
Nikki Daily
So we see a lot of people come in to registration positions or billing positions, and from there they start to gain that knowledge and that experience. We can have pathways that show them how they can, if they really love that work, how they can grow those skills, expand them and move into leadership, or if they are looking to grow those skills and move into another area, things like registration and the skills that you learn there can transfer into medical offices, in a medical office rep position and other forward facing roles that we have.

00:09:12:23 - 00:09:34:06
Elisa Arespacochaga
Let's talk a little bit about how you involved your team and those departments that you worked with in building these programs, and especially attacking the culture that that may not be so open sometimes, but really creating a welcoming community to new roles, new team members, to training people. How did you accomplish that?

00:09:34:08 - 00:09:58:10
Nikki Daily
So first and foremost, our culture is so important to us. We are recognized as a top workplace. We are very passionate about having the right people who want to work here. We want to first ensure we get the right people. We really do work together. We have engaged our leaders. We have educators within our department and educators in the community, as well as program graduates.

00:09:58:10 - 00:10:23:13
Nikki Daily
We want to hear back from people who have been through the program to understand what works, what doesn't work, what we may need to do to evolve and change as we're putting together the programs that we need. Sometimes you have to publicize the work we're doing. A great example that Maria is our amazing manager of workforce development, who is really the person behind a lot of these programs. She said

00:10:23:14 - 00:10:55:24
Nikki Daily
digging into the data, we saw dosimetrists, which is a job where we don't have that many of them, but over half of them are preparing for retirement. Well, we weren't aware of that. You know, she and the leader have connected. They're having conversations about what we can do to now put a focus on ensuring we have a pipeline to either grow people into that or partner with colleges and universities where we can do internships and bring people, introduce them to our organization so we can ensure that we fill those gaps.

00:10:55:24 - 00:11:00:15
Nikki Daily
So really, it's that constant partnership and collaboration.

00:11:00:18 - 00:11:16:14
Elisa Arespacochaga
That's awesome. So what advice do you have to those who are listening about how to both build internally, but then reach to your communities to encourage people to apply into the system and show them that these pathways exist?

00:11:16:16 - 00:11:40:18
Nikki Daily
Absolutely. My advice is to start looking at the job board, to go to career fairs. So BayCare has career fairs where we invite people from the community to come in. There are recruiters present. There are leaders present over different areas so they can have conversations and learn about those roles. And don't make assumptions that you have to come in already knowing what to do.

00:11:40:19 - 00:12:00:03
Nikki Daily
That's what these programs are for. We want people to not come to BayCare for a job, but to understand they really can grow into their full career. So understand what your skills are and what you're good at, and some transferable skills you may have. Start to apply for roles that you qualify for, but then understand once you get in the system,

00:12:00:03 - 00:12:06:03
Nikki Daily
we have so many programs to help you grow and support you to move into your dream job.

00:12:06:10 - 00:12:12:27
Elisa Arespacochaga
I love that. Anything I didn't ask about your programs that you want to make sure to share for our listeners.

00:12:13:04 - 00:12:35:20
Nikki Daily
It's something we're very, very proud of. It is a continuous effort and journey. We look at the data every single quarter. We're always looking at developing and evolving our workforce strategy. And it really is a partnership and a desire from all levels. It can't be run just by team resources. We need that buy-in a partnership from the departments.

00:12:35:20 - 00:12:46:25
Nikki Daily
We need to have great relationships with our community partners to ensure that we're having these people trained and have the opportunities to grow into these really important, critical health care careers.

00:12:46:26 - 00:13:04:24
Elisa Arespacochaga
Well, Nikki, thank you so much for sharing the work that you are clearly very passionate about and all of the amazing work at BayCare that you've done to grow and keep and really encourage your team members to live up to their fullest potential in healthcare. I really love that we have such a strong community at your organization.

00:13:05:00 - 00:13:07:18
Nikki Daily
Thank you so much. I appreciate you having me.

00:13:07:20 - 00:13:16:14
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.

00:00:02:28 - 00:00:25:19
Blake McLaughlin, D.O.
With an oasis, typically its water that comes from an aquifer, that is from mountain regions or other regions far, far away. We know that the challenges that our rural hospitals face and providing perinatal services, they're not isolated and they can't be cut off from their water source.

00:00:25:21 - 00:00:59:02
Julia Resnick
That was Dr. Blake McLaughlin, senior medical director of women's health services at Banner Health. His words capture something fundamental about rural maternal care. No hospital exists in isolation. Welcome Back to Frontiers, a podcast series from the American Hospital Association. I'm your host, Julia Resnick. Today, we're exploring the role larger health systems in tertiary medical centers can play in helping rural hospitals continue to provide maternal care and what it takes to make those partnerships work.

00:00:59:04 - 00:01:23:00
Julia Resnick
Emily Brayton is a perinatal outreach nurse at Dartmouth Health in New Hampshire. She also serves as director of operations for the Northern New England Perinatal Quality Improvement Network. Dartmouth Health's connected care partners with health care providers and facilities throughout northern New England, giving them access to the expertise of an academic medical center, regardless of whether they are part of the same health system.

00:01:23:02 - 00:02:02:00
Emily Brayton, R.N.
I think it's really important for systems to have an understanding of the integral role that inpatient obstetric services really serves for their whole entire hospital and their communities is one of those things that we're seeing across the country. New Hampshire experienced closures. It just really changes the communities and maybe who's coming into those communities. I can understand the concerns about settling in a rural place that maybe you have to go far for OB services.

00:02:02:01 - 00:02:23:02
Emily Brayton, R.N.
The strain that that puts on the local emergency departments and the local EMS crews are very, very hard. So I think really focusing on how to sustain inpatient OB services should be the job of every single health care system.

00:02:23:04 - 00:02:51:07
Julia Resnick
When a rural hospital loses inpatient obstetric services, the impact ripples into communities and nearby hospitals. So, if sustaining maternal care is a shared responsibility, what does that responsibility look like for large health systems? At Banner Health, Dr. Blake McLaughlin describes it as starting with a commitment to the communities the system serves and then using the resources of the health system to strengthen care across the entire network.

00:02:51:09 - 00:03:10:13
Blake McLaughlin, D.O.
One of the things that we do is we start from a heart posture, an attitude of care, of love. That is really what drives the work that we do, not fear. And so when we approach things with a scarcity mentality, with a fear mentality, really we're kind of starting on our heels and not from the best perspective.

00:03:10:14 - 00:03:37:08
Blake McLaughlin, D.O.
So our attitude moving into this work is we have a commitment. What we think about too is how do we leverage the benefits of the massive health care system that has a singular priority on safe moms, healthy babies to serve and resource these communities? There is this virtuous cycle that it creates, and it serves and it resources and elevates, really the quality of care,

00:03:37:09 - 00:03:42:19
Blake McLaughlin, D.O.
the standard of care, the entire culture within the whole health care system.

00:03:42:21 - 00:04:14:01
Julia Resnick
As we talked about in the previous episodes, distance can make access to specialty care a challenge for rural residents. But patients don't always have to travel to access specialized expertise. Sometimes the care can be brought to them. South Dakota based Avera Health has been doing this across the Upper Midwest for more than a decade. The system serves communities across a vast rural footprint where long travel distances, harsh winters, and limited access to specialty care are part of the reality for caring for mothers and babies.

00:04:14:03 - 00:04:24:13
Julia Resnick
Dr. Kimberly McKay, an OBGYN and medical research director for Avera Research Institute, says those geographic challenges are compounded by the needs of the communities themselves.

00:04:24:15 - 00:05:00:06
Kimberlee McKay M.D.
The challenge is really about geography, yes. Winter, yes. But also the further you get away from your urban center, you have your increased risk of chronic disease. Of social determinants of health like transportation, housing, food insecurities. You know, when you've got people who live in rural areas, who tend to have more chronic health needs within, especially in the setting of pregnancy, we're always trying to think of ways of how do we push out specialty services so we can keep folks local.

00:05:00:07 - 00:05:27:25
Julia Resnick
For Avera, the answer has been to push specialty expertise out into communities and keep patients local whenever it's safe and appropriate to do so. And it's technology that makes that possible. The work began more than a decade ago, with ultrasound. Using telemedicine to connect scans performed in rural communities with maternal fetal medicine specialists who could interpret that remotely. Today, Avera uses telehealth to bring specialists into rural communities virtually,

00:05:27:26 - 00:05:45:04
Julia Resnick
remote monitoring to stay connected with patients at home, and virtual consultations to give local clinicians another set of eyes when they need them. And there's a really important distinction here that technology isn't replacing local care, it's extending it.

00:05:45:07 - 00:05:52:27
Julia Resnick
In the Mountain West, Banner Health is also using technology to support local providers around the clock. Here's Dr. McLaughlin again.

00:05:53:00 - 00:06:17:14
Blake McLaughlin, D.O.
We have on call 24 over seven 365 OBGYN hospitalists. So those family medicine OB physicians in those rural hospitals, they can get any time a telehealth consult from those OBGYN hospital labor and delivery specialists. Sometimes that will just be a review of the medical record. Sometimes it will be a review of the fetal heart rate tracing. But we can actually provide the service where via tele cart

00:06:17:14 - 00:06:27:26
Blake McLaughlin, D.O.
so it really dissolves those geographic barriers and allows us to continue to keep folks in their community when it's safe and appropriate to do so.

00:06:27:28 - 00:06:50:19
Julia Resnick
Technology brings that second set of eyes into the room, without taking the local clinician or the local hospital out of the equation. The technology can only extend care if there's someone on the ground to deliver it. And in rural communities, that clinician may not always be an obstetrician. That's why Emily Brayton from Dartmouth Health describes rural obstetrics as a team sport.

00:06:50:21 - 00:07:15:15
Emily Brayton, R.N.
I fully believe that obstetrics is a team based sport, and kind of nobody really wants to be making choices fully on their own. But when you're the one obstetrician or midwife who's on, when you're one of two nurses and your other nurse is busy in another room, how nice would it be to pick up the iPad and initialize tele-OB?

00:07:15:18 - 00:07:28:20
Julia Resnick
Banner health has found another way to strengthen that connection, giving clinicians a shared framework for making decisions. And one morning in Wyoming, Dr. McLaughlin saw what that could mean in practice.

00:07:28:22 - 00:07:46:04
Blake McLaughlin, D.O.
They actually have a patient with a category two tracing. And they want to convene a virtual fetal safety team. Would you be willing to help? And I said absolutely. So went out to the desk and sat there with our nurses in Casper, Wyoming Medical Center. And virtually we connected with our team at Worland, and we reviewed the patient's tracing.

00:07:46:04 - 00:08:05:09
Blake McLaughlin, D.O.
We reviewed the algorithm, and according to the algorithm, the recommendation was to counsel the patient and proceed with a caesarian delivery. So we were able to support the team in doing that. They counseled the patient. They had an uncomplicated C-section. We had a healthy Banner baby girl after hours of eight and nine, and mom was so thankful and grateful that we intervened.

00:08:05:09 - 00:08:22:08
Blake McLaughlin, D.O.
The team felt so grateful that we were able to provide that support. So that's the real life stuff that's making a difference, that are keeping folks connected and really raising the bar in terms of quality, safety and the outcomes that we're looking for.

00:08:22:10 - 00:08:35:01
Julia Resnick
But there's another piece to this equation: the people who are there when the technology isn't enough. Dr. McKay from Avera sees that as an essential part of extending maternal care in rural communities.

00:08:35:03 - 00:09:01:28
Kimberlee McKay M.D.
So the technology to the patient, yes, is very important. But just as important is enabling the care teams in the small, the tiny towns. So we've been working with these small sites on not just simulation, but saying, what do you have in your house to be able to take care of pregnancies. So how do you sort of like figure out when you actually need the patient to come in for care or be seen in person?

00:09:02:01 - 00:09:22:27
Julia Resnick
The goal isn't for every hospital to provide every level of maternal care. It's for every team to know what they can safely manage, when they need more support, and how to reach it quickly. Years ago, Dr. Mackay got one of those calls. She was at her son's school conference when an OBGYN colleague from a small Minnesota hospital reached out for help.

00:09:23:03 - 00:09:34:06
Julia Resnick
A young patient had experienced a severe postpartum hemorrhage after delivery and the hospital had run out of blood. The physician caring for her needed help immediately.

00:09:34:08 - 00:09:54:09
Kimberlee McKay M.D.
You know, we face timed into the O.R., she's like, I don't know what to do. So I'm at my son's conference in the hallway of the elementary school, like, okay, like, yep, I'm going to find somebody to connect the dots with. And we got her evacuated. And, you know, just after a few phone calls because, again, the culture is just say yes.

00:09:54:12 - 00:10:16:09
Julia Resnick
For Dr. McKay, that experience helped shape Avera's work to strengthen transfer processes and build more formal support systems around maternal care. And when those types of connections extend beyond individual hospitals and providers, they can become something even more powerful - a regional system of care.

00:10:16:12 - 00:10:31:02
Julia Resnick
At Dartmouth Health, perinatal outreach teams work with hospitals throughout northern New England, including hospitals outside the health system. And that collaboration doesn't end when a patient is transferred. The transfer itself becomes an opportunity to learn.

00:10:31:04 - 00:10:55:00
Emily Brayton, R.N.
We provide debriefs to teams that send neonatal patients to us to kind of talk through and walk through the patient's care while they were at their home hospital, but then also give that follow up of what happened here. We also work really hard on what we call transport conferences, which is where we sit down with our referring hospital teams.

00:10:55:01 - 00:11:07:19
Emily Brayton, R.N.
It's a collaborative approach with both our OB clinicians and our neonatology friends, and really talking about the whole care of the patient.

00:11:07:21 - 00:11:32:08
Julia Resnick
A transfer can be the end of one patient's episode of care, but for the clinicians involved, it can also be the beginning of a conversation. And when hospitals across the region are doing that together, those lessons become shared knowledge. Banner Health has built that kind of peer to peer learning into its rural network through the Rural Whisk Consortium, where nurse and physician leaders come together regularly to share what they're seeing on the ground.

00:11:32:15 - 00:11:35:19
Julia Resnick
Here's Dr. McLaughlin.

00:11:35:21 - 00:11:57:22
Blake McLaughlin, D.O.
We meet together virtually. We talk about best practices. We share and have potluck style about, hey, these are challenges we're facing, these are opportunities. Here's how we're solving for this problem. What do you guys think about that? And it is a tremendously valuable opportunity to really share that one team experience virtually. And so we're proud of that as well to keep folks connected.

00:11:57:24 - 00:12:22:16
Blake McLaughlin, D.O.
It's central to our DNA. It's the core of who we are. And so we want to make sure that that doesn't just end when, you know, we've transitioned from urban metro academic centers and folks out in the rural hospitals are just sort of fringe and out there. Even though we're geographically maybe located across large volumes of space and many miles, we want to make sure that there's one heart and one mind.

00:12:22:19 - 00:12:42:19
Julia Resnick
The value of the network isn't just what any one hospital can provide. It's what becomes possible when they learn together. At Dartmouth Health, regional coalitions bring hospitals and community partners together around the needs of the families they serve. Emily Brayton describes how those coalitions reach far beyond the walls of individual birthing hospitals.

00:12:42:21 - 00:13:11:04
Emily Brayton, R.N.
It really does take a village to raise a child or children or to have a family. And we know that. And so one of the ways that we're broadening the reach from outside of the hospital and leveraging our rural communities and making sure that everyone has what they need is through our regional coalitions. There are 11 of them that are centered around birthing hospitals.

00:13:11:04 - 00:13:42:02
Emily Brayton, R.N.
So if you're doing the math, we have 15 birthing hospitals, but only 11 regional coalitions. And that's because we have a couple hospitals that are close together in drive time. So we're really centering the coalitions around those hospitals, but extending the reach far beyond those hospitals and really getting the support of the community to understand what do families need in order to survive and thrive.

00:13:42:03 - 00:13:46:16
Emily Brayton, R.N.
Right? We don't want people just surviving. We want people thriving.

00:13:46:19 - 00:14:01:14
Julia Resnick
The goal goes beyond connecting rural hospitals to a tertiary medical center. It's about building a regional network around the needs of families, one that can draw on the strengths of hospitals, clinicians and communities.

00:14:01:16 - 00:14:15:01
Julia Resnick
The infrastructure may be technology protocols and transfer pathways, but what makes those systems work is the relationships between the people on both ends. Here's Dr. McKay from Avera Health and Emily Brayton from Dartmouth Health.

00:14:15:03 - 00:14:26:00
Kimberlee McKay M.D.
Technology doesn't foster the relationship. The culture fosters the relationship, which is, if you call me, I'm going to answer and I'm going to try to answer your question to the best of my ability.

00:14:26:02 - 00:15:02:03
Emily Brayton, R.N.
Relationships drive your ability to be productive. And so it's really about getting to know each other, getting to know the hospitals. We find that people are more willing to reach out to us and say, like, hey, we're kind of struggling with this thing. What do you guys think? Having lots of relationships outside of our referral teams really allows us to draw on that vast knowledge and expertise that's in our region, allows us to just be stronger by working collaboratively.

00:15:02:06 - 00:15:32:28
Julia Resnick
Providing maternal care in rural communities isn't easy. It takes grit. It takes commitment, and it takes a deep love for your patients in your community. But it can be isolating, and it doesn't have to be. And perhaps that's what makes Dr. McLaughlin's oasis metaphor so powerful. An oasis may appear to stand alone, but beneath the surface it's connected to something much larger a source of water far beyond what you can see.

00:15:33:01 - 00:16:04:03
Julia Resnick
And that has been the undercurrent for this entire series. Rural hospitals can thrive when they are connected, and so can families in rural America. Thank you for joining us for the special podcast series Frontiers. I've been your host, Julia Resnick. Visit the American Hospital Association's website to explore more stories from rural hospitals and health systems across the country, and discover how they are finding new ways to strengthen maternal care and keep it close to home.

00:16:04:06 - 00:16:22:15
Julia Resnick
This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers or staff.

00:00:00:04 - 00:00:20:02
Tom Haederle
Welcome to Advancing Health. Many people may think of primary care and a visit to the hospital as distinctly different paths for their care needs. But as we hear in this month's Leadership Dialog podcast, more hospitals and health systems are investing in preventive primary care to keep patients healthy.

00:00:20:04 - 00:00:39:26
Marc Boom, M.D.
Greetings, everybody, and thank you for joining me today. I'm Mark Boom. I'm the president and CEO of Houston Methodist, and I'm the board chair of the American Hospital Association. As we continue with these discussions, we're going to focus today's conversation on something really near and dear to me as a primary care physician myself, which is the rise of primary care as a key strategy for so many hospitals.

00:00:39:27 - 00:01:00:13
Marc Boom, M.D.
Some may obviously not immediately think of very acute care hospital or health system when thinking of primary care, but increasingly our hospital field is getting much more involved and for very, very good reasons. Because our core mission is to keep people healthy. And certainly that means providing very high quality care when a patient is sick and inside our organizations in the hospitals,

00:01:00:13 - 00:01:21:17
Marc Boom, M.D.
but even more so, it means helping patients access preventive services that keep them healthy and out of the hospital in the first place. There's tremendous value for everyone in ensuring that patients and communities have access to primary care clinicians and clinics for screenings, wellness care, as well as a trusted care team to help with chronic disease management and other drivers of health.

00:01:21:18 - 00:01:43:24
Marc Boom, M.D.
So investing in primary care prioritizes a patient's overall health and helps avoid costly or unnecessary emergency department visits. I'm joined today by a guest whose health system really understands these reasons of why investing in primary care is good for patients. David Banks is here today. He is the CEO of AdventHealth, an integrated health system that serves communities across nine states.

00:01:43:25 - 00:01:47:12
Marc Boom, M.D.
David, thank you so much for joining us. And let's get started.

00:01:47:15 - 00:01:50:09
David Banks
Yeah, thank you for having us. It's really an honor to be here.

00:01:50:10 - 00:02:05:20
Marc Boom, M.D.
Well, I'll start very broadly. I'd love to just...tell us very briefly about AdventHealth as a whole, and then talk to us about how AdventHealth thinks about primary care as a strategic priority and how you thereby support primary care and all of those communities that you serve.

00:02:05:22 - 00:02:43:08
David Banks
Yeah. So, AdventHealth, our roots go back to the late 1870s, the sanatorium movement, and actually John Harvey Kellogg. And so this notion of staying healthy has been at the core of our organization's founding. And so fast forward to today, AdventHealth serves over 10 million people in nine states, as you mentioned. Initially were a hospital centric company, but we decided in 2023 that we needed to fundamentally reset our primary care strategy. In order to have exactly what you open with the most pervasive community impact,

00:02:43:09 - 00:03:01:21
David Banks
we knew we needed to get outside the walls of the hospital and really create care relationships at a community level that could be longitudinal and help people really live at the top of their health care potential. And we think primary care is an essential component to get that done.

00:03:01:22 - 00:03:18:16
Marc Boom, M.D.
Well that's fantastic. So talk about a further role in terms of how primary care plays expansion to access. Talk about how you make decisions, about how you invest, because there's different ways and explain some of those different ways and where you invest in primary care.

00:03:18:19 - 00:04:07:09
David Banks
Yeah. So the key decision we made in 2023 was to really take apart what was our physician network, move it into its own operating division, not a hospital division, but an operating division that had as its focus primary care. And so for us that spans created better definition for four ways we seek to connect with our communities. And that ranges from virtual 24 hour access, primary care all the way up through really complex senior care models for older individuals that may have a variety of clinical conditions, that with the right level of primary care and turn in primary care, really allows them to manage the complexity of their chronic conditions in a way that

00:04:07:12 - 00:04:25:24
David Banks
keeps them out of the hospital, keeps them from bouncing between doctors and really having a coordinated experience. So we realize primary care is not one thing. For some folks it's same day access, don't need a longitudinal relationship. Just trying to solve a problem to more middle range, which is the primary care I like. I want to know my provider.

00:04:25:24 - 00:04:41:24
David Banks
I want a longitudinal relationship - up to that more chronic care, complicated levels of primary care that really require care coordination across multiple specialties to ensure peak health for folks that are dealing with a number of issues.

00:04:41:26 - 00:04:49:26
Marc Boom, M.D.
I'm curious, do you have people move from one of those different type of channels to another? Does that happen frequently?

00:04:50:01 - 00:05:15:04
David Banks
We do. In our traditional primary care offering, if you will, as they start to age into Medicare, we encourage them based on their clinical conditions, the support they need - they can either stay put or maybe they the senior care model really is a better model for them. There's just a lot of consumer choice that's built in in all of the models that that we have, and we realize that was essential.

00:05:15:04 - 00:05:45:26
David Banks
What was so interesting to us when we started is how few people really had a longitudinal relationship with their primary care doctor. And when we investigated that as to why it really came down to a question of value, we realized we needed to change our offering, support our clinicians better, and create more comprehensive clinical models that really allowed them to engage more fully with their patients and create more solutions for their patients in a way that the patients could find more value.

00:05:46:01 - 00:06:08:09
Marc Boom, M.D.
And I assume that the clinicians in those different kind of channels, I mean, they embrace the fact that there's differences. It's interesting you talking about so few having that longitudinal model. I still practice a tiny bit. And that's like the most valued thing for me, not to mention I think patients that I see is just known him for a quarter of a century or more many times, and it really helps with caring for them.

00:06:08:09 - 00:06:33:22
Marc Boom, M.D.
And I will say sometimes as people get older and very complicated, those senior type clinics can be a really much more logical place for somebody. So how do you navigate that sometimes? Does a clinician actually sometime raise his or her hand and say, you know, I love you, I've been taking care of you for 20 years, and I think you're going to actually be better over here because you're so complicated.

00:06:33:25 - 00:06:35:21
Marc Boom, M.D.
Does that get pretty fluid there?

00:06:35:27 - 00:07:00:01
David Banks
Yeah, we've actually had that exact case happen. And it takes a lot for the clinician to want to maybe give up that 25 year longitudinal relationship. But when the patient has, as you know, five specialists involved in their care, maybe some home based care, the senior clinics with the wraparound services from social work and other in-home support, some of the remote monitoring, it just makes more sense.

00:07:00:01 - 00:07:21:18
David Banks
And usually the families are so appreciative because it takes a lot of the burden off of that adult child, if you will. And we've all been in that situation of really having to be a clinical quarterback between a primary care provider and five specialists and trying to keep med rec straight and all those sorts of things, they really need to be in a more intensive setting when that happens.

00:07:21:18 - 00:07:26:15
David Banks
And the benefits are so clear that usually that transition is not a difficult thing.

00:07:26:18 - 00:07:39:27
Marc Boom, M.D.
Fascinating discussion. Give us an idea of scale and scope across AdventHealth. How many primary care physicians? And I'm sure you have nurse practitioners and physician assistants and others in that realm as well. But how many are we talking about?

00:07:40:00 - 00:08:13:18
David Banks
Yeah. So if we look at the state of Florida, for example, probably 700 employed providers in our model, majority of those physicians, although we have been really adding to our APP complement. We know they're really a great augmentation to care. Right levels of care from the right provider really allow reach. What we've really been able to do in our model in Florida is we've opened up since we started this, almost a quarter of a million more appointments for patients to be seen because access was such a major problem.

00:08:13:18 - 00:08:38:10
David Banks
And so by increasing the number of employed physicians we have up in that seven, really about 700 range actually relocated and redesigned our clinics. We again, I don't think we're atypical in this, but in our health system, we ended up with 100 doctors in 100 sites. And so we really built primary care pavilions that allowed an aggregation of up to ten providers.

00:08:38:10 - 00:08:57:27
David Banks
That allows then the other support services to be aggregated there as well. And so that's really created about a quarter million visit gain in the last two years. Because if you can't get in to see your doctor, it doesn't really matter. You know, that's really the thing that matters most. We're taking this strategy now out into what we call our multi-state division.

00:08:57:27 - 00:09:24:28
David Banks
So Chicago, Dallas-Fort worth, Kansas City, Colorado, where we have, again, large, large employed. In Colorado, we probably have close to 500 employed primary care providers. And so we've made a big investment in this simply because I don't think, like I said, we can have the community impact if we just stay within the walls of the hospital. We have to be able to ideally get people under a care plan that allows them to optimize health.

00:09:25:00 - 00:09:40:10
David Banks
Our hospitals are there when you when you need that level of acute support. But most of our interactions happen away from the hospital, so those need to be clinically robust, consumer focused, you know high value opportunities for the patients we have.

00:09:40:12 - 00:10:01:20
Marc Boom, M.D.
So sometimes the economics can get in the way like how much of this is in a fee for service type of environment? How much of this is in more of a value based or global care or some version of financing? And then as you talk about the economic side of the benefits, and we're gonna come to the other more important clinical and others, you know, how does that mesh with all of that?

00:10:01:24 - 00:10:36:15
David Banks
Yeah. So two ways we think about it. I like the idea of value based care in that, giving additional resources to primary care physicians to provide more longitudinal support. So we're active participants. We have about 900,000 lives in some sort of government program. We've been very active participants in reach. We've done work with MA providers as well. We like those models because it puts more resources into the clinic, and it allows us to be able to help people stay at the right level of care to get what they need.

00:10:36:16 - 00:10:59:25
David Banks
Additionally, what we've done in our own employee base, because the real pressure point for this comes for the self-funded employers. We've created a very high value. It's actually a high actuarial value option for our employees that is really primary care centric. So we have traditional insurance, we have the high deductible plans. We created a mid-level plan that is really a primary care centric plan.

00:10:59:25 - 00:11:23:10
David Banks
First year we had 9000 enrollees of our employees. This year it grew to almost 18,000. And really trying to understand can we get better care and can we see better economics? Because the thesis is if you see your primary care doctor, you should have a less financial burden because your care is being managed. And so we're testing that inside of our own employee base.

00:11:23:10 - 00:11:39:26
David Banks
And we're seeing some very good results in terms of access to care and some of those early indicators, some of those, those health factors we want to see from early screenings, chronic care as well as inpatient hospital admission avoidance.

00:11:39:26 - 00:12:03:00
Marc Boom, M.D.
So, what do you see in terms of total cost of care at this point then? Are you seeing ER visits going down in that population? Are you seeing better and less frequent hospitalizations in a chronic disease management group? Are you managing, I imagine some of these senior clinics you're managing complex end of life issues. You're managing complex dimension and neurodegenerative disease issues.

00:12:03:00 - 00:12:04:20
Marc Boom, M.D.
What are you seeing in that realm?

00:12:04:25 - 00:12:28:00
David Banks
Yeah, probably the most compelling statistic to me - and this would be true in our Reach program with CMS, as well as what we see in our employees. For those of our patients that are stratified in that rising risk or high risk category, when they're under care management, they're avoiding about $6,200 of cost a year. So you think about the expense of those patients at the top of your pop health pyramid.

00:12:28:03 - 00:12:49:15
David Banks
You know, those often are 30 to $40,000 a year type expenditures. So getting $6,000 a year of expense off of that group is a material gain. On the front end, we saw a 90% utilization rate of primary care in our employee base that are in that high value plan, and so we think that's going to pay dividends long term.

00:12:49:15 - 00:13:11:10
David Banks
And as I mentioned with our care management program, we put into our ERs. This year we've already diverted 511 admissions. And the way we were able to do that is we knew their providers, we knew their plan of care, and it allowed us to say, look, clinically, this is a this is safe to send this person back to this level of care.

00:13:11:10 - 00:13:31:06
David Banks
They don't need to be admitted. As you know, hospital admissions carry their own benefit and risks. And so we've seen those benefits across the board and we've seen those CMS benchmarks we've been able to come underneath them at 2%, you know. So those benchmarks are at 13,000 per member per year. So we're starting to see some early numbers.

00:13:31:06 - 00:13:35:15
David Banks
But we have a lot more to go, I think, to really prove out the case.

00:13:35:18 - 00:13:57:04
Marc Boom, M.D.
Well, I want to end with one last question of, you know, you've got many others watching this saying, you know, we need to go there. We haven't gone there. We're a very legacy like hospital system and different types of economic models and environments and things. What are the lessons learned? What would what advice would you give to somebody like that who leads a system and says, I think we need to go embark on a journey similar to this?

00:13:57:08 - 00:14:25:27
David Banks
I think we've learned two things. One is maybe it was unique to us, but we were losing subsidizing about $225,000 per primary care doc pre this this model. We've been able to cut that in half. So just the financial burden or expense if you will. We've been able to become more efficient through again redesigning the model, putting primary care out front, optimizing the way our practices flow, supporting with different resources.

00:14:25:27 - 00:14:49:27
David Banks
Our subsidy costs actually been cut in half, not to zero yet, but in half. Additionally, we've seen more access for that investment. And like I mentioned, we're starting to see some of those early pop health indicators coming. So it's the better organization just created a better expense management structure. And we're seeing patients use primary care at a rate they weren't using it before.

00:14:49:27 - 00:15:10:02
David Banks
I think the real lesson is give it its own leadership and focus. Tucking it up under a hospital. You and I both know a hospital just sucks all the air out of the room. And there's when you think about community based care, it's just hard for them to compete for the time, attention and resources. It's worth creating the special focus so they can thrive.

00:15:10:02 - 00:15:19:22
David Banks
And it's really one of the best decisions we've made, giving them their own focus. And I'm excited to see what this will produce for us in the coming 2 or 3 years.

00:15:19:25 - 00:15:41:12
Marc Boom, M.D.
Really fascinating discussion. Like I said, near and dear to my heart. Love seeing this impact that you've made. I mean, think about all the wins there, most importantly for your community in terms of access, in terms of coordination of care, all those different things. And things like lower subsidies, which of course enable the sustainability of health care and the affordability of health care for everybody.

00:15:41:12 - 00:15:48:27
Marc Boom, M.D.
And I would imagine you've got some pretty darn happy primary care physicians in that, in that model as well when you're building that structure around them.

00:15:49:02 - 00:16:16:04
David Banks
They definitely feel more seen and heard and valued. And they are. Listen, hospitals are great at rescue care. The longitudinal impacts, though are going to be outside the walls of the hospital. And to me, we believe it's built on a robust primary care. They're scientists, they're clinicians, they're compassionate. They care about their patients. That's just such a powerful model for community health that we just fully believe in.

00:16:16:07 - 00:16:34:20
Marc Boom, M.D.
David, thank you very, very much for your time today. This is fascinating conversation. I know a lot of valuable insights for our listeners. And you may be getting some calls for some, some help from some out there who want to go this way. So to all of our viewers, thank you for listening. And I'll be back next month for another one of our Leadership Dialog conversations.

00:16:34:20 - 00:16:36:26
Marc Boom, M.D.
Thanks, everybody for listening.

00:16:36:28 - 00:16:45:22
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:18 - 00:00:10:16
Ashley Blake, D.O.
You have to love it. You have to love your job. You have to love your community. And really, it helps if you just think your feet in and embrace it.

00:00:10:19 - 00:00:32:28
Julia Resnick
Welcome back to Frontiers, a rural maternal health podcast series from the American Hospital Association. I'm your host, Julia Resnick. Voice you just heard was Dr. Ashley Blake, an OBGYN in Cynthiana, Kentucky. In our first episode, we heard from rural hospital leaders who made the choice to invest in maternal care and keep it close to home. But leadership alone isn't enough.

00:00:33:01 - 00:00:49:15
Julia Resnick
Even the most committed leaders can't sustain maternal care without the people to provide it. Today, we'll hear how rural hospitals are rethinking the maternal care workforce so that they are prepared to care for the next generation of rural families.

00:00:49:18 - 00:01:18:00
Julia Resnick
In rural communities, maternal care is deeply personal. Providers care for neighbors, coworkers, and oftentimes generations of the same families. Those relationships create a sense of purpose and connection. Many of the rural clinicians we spoke with chose rural medicine because of those relationships. At the top of this episode, you briefly heard from Dr. Ashley Blake, an OBGYN at Harrison Memorial, her hometown hospital.

00:01:18:02 - 00:01:20:09
Julia Resnick
Here's Dr. Blake.

00:01:20:12 - 00:01:43:02
Ashley Blake, D.O.
One of our labor nurses - I now see her sister, I see her mother in law, I see her cousins. They send pictures of me delivering her babies. They're three year-olds now that I delivered. Or color me pictures and bring me in gifts. You know, it's just like that is a reward and a benefit that no one like prepares you for how much of an impact it has.

00:01:43:07 - 00:01:54:21
Julia Resnick
In our first episode, you also heard from Jill White, chief nursing officer at Hutchinson Regional Medical Center in Kansas. She returned to her hometown to continue caring for the community that helped shape her.

00:01:54:24 - 00:02:19:13
Jill White
So I grew up here in Hutchinson, moved here at a very young age and spent my growing up years here through high school. I did move away, but quickly found that I missed it and wanted to move home and be back close to family. And as I've spent my adult years here, there's so much value in the size of the community that we are in raising a family here.

00:02:19:14 - 00:02:29:26
Jill White
I'm friends with people I work with, and we see each other, you know, outside of work, and there's so much to be said for that. It really is a big family.

00:02:29:28 - 00:02:40:13
Julia Resnick
If big families and relationships are what make rural medicine so rewarding, how do you help clinicians and training see the value of practicing in rural communities? Here's Dr. Blake again.

00:02:40:18 - 00:03:04:23
Ashley Blake, D.O.
I think that that is probably our biggest struggle, because all of the training takes place in these large cities that have targets, and they have Starbucks and they have malls and all the things that you need. And then you get your med school occurred there, your residency occurs there. And then the thought of going to somewhere without those things, I think, is sometimes hard for some physicians.

00:03:04:24 - 00:03:10:27
Ashley Blake, D.O.
The thing that makes it work the best is if you just plant your roots and, you know, embrace it and enjoy it.

00:03:11:00 - 00:03:26:10
Julia Resnick
But for rural hospitals to build a sustainable maternal health workforce, they have to create opportunities for students and trainees to experience rural practice firsthand. At Western Wisconsin Health, CEO Eilidh Peterson has made building that pipeline a strategic priority.

00:03:26:13 - 00:03:28:15
Eilidh Pederson
That pipeline starts at

00:03:28:15 - 00:03:57:27
Eilidh Pederson
different levels of training, so we do host rural residents. That's a wonderful opportunity to expose new physicians to rural medicine. We partner with all of our local colleges and universities to host midwifery students, to host medical students. And then recently, we've actually expanded the way in which we've hosted students to create that passion for rural medicine, namely obstetrical care.

00:03:57:27 - 00:04:22:10
Eilidh Pederson
So we do host high school students through our local scrub pumps. And then we started mentoring middle school students. We call it Mentored in Medicine. They are exposed to various careers in healthcare. And of course, we're going to talk to them about obstetrical care and the joys of entering into that practice. So we're starting early, but really through many channels and pipelines.

00:04:22:13 - 00:04:44:21
Julia Resnick
The future of rural maternal care is multidisciplinary teams where patients receive the right care from the right provider at the right time. For many rural hospitals, building that kind of team may be one of the most important strategies for sustaining maternal care into the future. Eilidh Peterson believes that diversity within the workforce has been one of the keys to strengthening maternal care at Western Wisconsin Health.

00:04:44:28 - 00:05:12:06
Eilidh Pederson
A diverse workforce has really been the number one solution for us. Not putting all of our eggs in one basket, but making sure that we have a number of different professionals for patients to choose from. To extend and expand our pipeline from where we can get qualified obstetrical providers has really been key. And a diverse workforce is really critical. For us

00:05:12:06 - 00:05:23:13
Eilidh Pederson
that looks like certified nurse midwives, obstetricians, family medicine with OB, and we'd love to hire our family medicine with OB and C-section.

00:05:23:15 - 00:05:51:07
Julia Resnick
One important member of that multidisciplinary team is the family physician with obstetrical training, often called an FMOB. In many rural communities, these physicians provide prenatal care, deliver babies including C-sections, and care for entire families, making them an important part of a sustainable workforce. Benjamin Anderson, CEO of Hutchinson Regional Medical Center, has become a strong advocate for expanding high quality training opportunities for FMOBs.

00:05:51:09 - 00:06:19:22
Benjamin Anderson
This is a passion point for me and I've seen the very best of full scope family medicine. There are a handful of residencies, maybe a dozen or two dozen residences in the United States that are consistently graduating board certified family physicians that are ready to do surgical OB. it's important to know the difference, and a lot of them are in training in what are called unopposed family medicine programs, where they're not competing against any other specialty for their numbers.

00:06:19:22 - 00:06:42:27
Benjamin Anderson
They're graduating with 200 deliveries and 101 hundred plus primary C-sections, where they are the surgeon, the primary surgeon on that. And so those are programs where there's a strong relationship between the OBGYN department and the family medicine residency. So they're getting that kind of exposure and that kind of direct, hands on experience. And so those are the ones from which we recruit.

00:06:42:27 - 00:07:02:21
Benjamin Anderson
And so there is a need to grow the number of unopposed family medicine slots in the United States. And there's some rural hospital transformation funds that are focusing on that to, to the program's credit. But those are the ones that it's really important to, to, to look at. We're looking for the Peyton Manning and Serena Williams of that. In Hutchinson

00:07:02:21 - 00:07:14:07
Benjamin Anderson
we're a larger community to accommodate full scope family medicine. But right on the right, right on the brink, we believe we have the capacity for and the volume to accommodate both.

00:07:14:09 - 00:07:38:25
Julia Resnick
Certified nurse midwives are another example of how rural hospitals are expanding the maternal care workforce. Working alongside physicians and nurses, certified nurse midwives provide prenatal, labor and delivery, post partum, and well woman care. Let's meet Samantha Crouch, a certified nurse midwife and director of the nurse midwifery program at University of Arkansas for Medical Sciences, also known as UAMS

00:07:38:27 - 00:07:40:16
Samantha Crouch, DNP
Midwifery care

00:07:40:19 - 00:07:42:01
Samantha Crouch, DNP
is, I mean, the

00:07:42:01 - 00:07:43:10
Samantha Crouch, DNP
reason that people are drawn

00:07:43:10 - 00:07:44:15
Samantha Crouch, DNP
To it,

00:07:44:15 - 00:08:14:26
Samantha Crouch, DNP
for a few different reasons. Really, the art of midwifery and the midwifery model of care, which places a really big emphasis on building trusting relationships within the health care provider and patient relationship. We spend a lot of time focusing on social determinants of health. And what's the holistic picture here for this patient? Not just checking in on mom and baby and what are the vital signs and what do the heart tones sound like.

00:08:14:27 - 00:08:51:26
Samantha Crouch, DNP
But really, how are you feeling about, you know, how is your partner feeling? What does your support system look like? What things are you nervous about? And really diving into some of the more emotional and psychological components of pregnancy. That really comes through for a lot of people and translates really well to rural health, because we do have a lot of specialized training in providing community based health care and providing continuity of care, which builds trust and builds partnerships and improves outcomes as well.

00:08:51:28 - 00:09:14:16
Julia Resnick
Recognizing the important role midwives can play, UAMS is investing in the next generation of the profession. This fall, they are launching the state's first publicly funded nurse midwifery education program to help address the growing need for maternal care providers and expand access to midwifery services across rural Arkansas, including many communities where midwifery services are not currently available.

00:09:14:19 - 00:09:57:27
Samantha Crouch, DNP
I have spent a lot of time looking into and kind of reflecting on as we've built is how to create better recruitment and better awareness about nurse midwifery as a career path in our areas across the state that don't currently have exposure to midwifery within the workforce. Trying to find ways where we can get certified nurse midwives practicing in some capacity, even just a day or two a week, so we can create exposure for the nurses and for the families of these rural communities, so that we can then recruit them into our program and send them back to their communities to practice.

00:09:58:00 - 00:10:11:22
Julia Resnick
The greatest impact comes when these professionals work together as a team. For Hutchinson Regional, building those connections across disciplines has transformed the way they deliver maternal care. Chief Nursing Officer Jill White shares more.

00:10:11:25 - 00:10:36:16
Jill White
OB itself can't sustain the health system. So how do we layer that to where you know someone who has that family med background, they can care for that entire life continuum, starting with OB and newborns, building that practice, building that relationship with their with their patients and families. And that really has had a huge impact in our delivery numbers as well.

00:10:36:19 - 00:10:41:02
(Dr. and Baby Background)
Okay. Next contraction. I think you're going to have a baby.

00:10:41:04 - 00:11:01:01
Jill White
We are on pace for over 100 more deliveries this year than we did even just last year, with onboarding of some new providers and working closely with the nurse midwives and getting them actual privileges to bring their patients on site. If they have that patient who, you know, can't deliver at the birth center, but they want their nurse midwife to follow them, great.

00:11:01:01 - 00:11:21:28
Jill White
We can do that here. The people that we serve are better the more that we serve. And so it's so important that we really maintain frequent touchpoints with patients like this, keeping those skills up, keeping our presence up. You know, it's so much about trust and relationship building in that patient population.

00:11:22:01 - 00:11:48:18
Julia Resnick
In low birth volume hospitals, providers may encounter obstetric emergencies less often than their colleagues in larger hospitals. That makes ongoing training, simulation, and peer learning especially important because every team needs opportunities to practice for the moments that matter most. Dartmouth Health partners with rural hospitals in northern New England to facilitate simulation drills. Emily Brayton, a perinatal outreach nurse, shares how that works.

00:11:48:20 - 00:11:52:15
Julia Resnick
You'll hear more about Dartmouth Health's work in the next episode.

00:11:52:18 - 00:12:28:27
Emily Brayton
Simulation and skills has been really beneficial to teams. We have one hospital in the North Country that has done a lot of work with a group at DHMC. We are teams that are kind of existing together, but we're not necessarily the same exact team. They are well supported, and so being able to go into that hospital and provide those teams with dedicated time with a neonatologist, and it really said it all with the people that showed up.

00:12:29:00 - 00:12:43:06
Emily Brayton
We didn't just have people who were there from their inpatient unit. We had all of the people who come and help when there's an emergency happening, regardless of whether it's happening on the OB side or with the baby.

00:12:43:08 - 00:13:09:21
Julia Resnick
Simulation is one way to maintain clinical skills. Another is creating opportunities for rural clinicians to spend time in higher volume settings, and then bring that experience back to their communities. At Banner Health that idea has become the rural OB pathways program. Here's Dr. Blake McLaughlin, an OBGYN and senior medical director of women's services at Banner Health. You'll also hear more from Dr. McLaughlin in the next episode.

00:13:09:24 - 00:13:36:27
Blake McLaughlin, D.O.
So something that we have done within Banner, we've created what's called the rural OB pathways program. And so what we do is we offer this program that folks can opt into where they will come from a rural facility like Paige, Arizona, or from Washakie, Wyoming, and they will come to one of our large volume facilities in Phoenix, and they'll spend seven, ten, 14 days embedded with that obstetrics team on labor and delivery.

00:13:36:27 - 00:14:06:06
Blake McLaughlin, D.O.
So they'll get high volume, high complexity of all of the things. But particularly they're focusing in on their optimization of their surgical skills and their obstetric skills. So we have had tremendous positive feedback from everyone involved in those experiences. Both for the physicians that are going and being embedded in that team, they're able to go back to their facilities and their communities that they came from, and they just have maintained that skill set and optimization.

00:14:06:08 - 00:14:17:14
Julia Resnick
Dr. McLaughlin believes that the same philosophy should begin during residency. Rather than asking clinicians to choose between urban and rural training, Banner is intentionally connecting the two.

00:14:17:16 - 00:14:38:12
Blake McLaughlin, D.O.
Those interns will spend their first year at the mothership there at the North Colorado Medical Center in Greeley, and they really get that foundational direction and education and training that they need. And then they'll go out to rural communities like our hospital in Sterling. So Sterling Regional Med Center, and they'll spend their last two years of their residency program embedded in that role community.

00:14:38:12 - 00:14:57:01
Blake McLaughlin, D.O.
And so they're really anchoring their heart, their mind, their attitude, their perspectives to rural medicine, but they're staying directly connected to that source program where they're getting that premier residency and fellowship equivalency training. Really ingrained them then, this connectedness.

00:14:57:03 - 00:15:27:08
Julia Resnick
Building a strong workforce is about creating a continuum of learning from early exposure and multidisciplinary teams to ongoing training and mentorship throughout a clinicians career. Together, these investments are helping ensure that role providers have the knowledge, skills and support they need to care for mothers and babies close to home. But no rural hospital can do it alone. Even the strongest workforce benefits from connection to colleagues to specialists, and to partners who can help expand what's possible.

00:15:27:10 - 00:15:52:03
Julia Resnick
That's where we'll go next. Join us for the final episode of Frontiers, as we explore how regional collaboration, digital tools, and new models of care are helping role communities strengthen maternal care for the future. This series is supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on healthcare issues and makes grants to improve healthcare practice and policy.

00:15:52:10 - 00:15:59:10
Julia Resnick
The views presented here are those of the author and not necessarily those of the Commonwealth Fund, its directors, officers or staff.