The Real Time HealthCare Podcast

(01:05) Growing strategically to keep quality care close to home
(03:22) Creating a hub and spoke model to provide care in rural areas
(06:00) Offering specialized services in smaller hospitals
(08:15) Building culture to deliver quality of care across the network
(10:08) The functions and roles in the DCARE Command Center
(11:34) Staffing a physician in the access center program
(13:40) Making the decision to invest in a command center
(16:55) A focus on transfers delivers direct income
(18:48) Justifying the decision to move forward with a command center
(21:56) Finding the right people to set up the command center
(23:23) Redefining MDRs to use the real-time insights
(25:40) Prioritizing and sequencing ancillary services
(26:10) Building a swing bed model
(27:35) Quickly finding the right patients to discharge
(28:40) The future of DCARE – moving from capacity to quality
(29:46) Using innovation to improve key processes

As a rapidly growing health system serving a wide geographical and largely rural area, Deaconess needed a way to address capacity and access to care issues. After an extensive internal and external search, they recognized that the GE Healthcare Command Center platform was exactly what they needed.

“When we found GE, we said, ‘This is really everything we have been asking for forever,’” said Dr. Phillip Adams, MD, MPH, Medical Director for DCARE.

In this episode, Dr. Adams and Amy Kruger, BSN, RN, CCRN, Clinical Manager for DCARE, share how they made the business case for investing in their DCARE (Deaconess Coordinating and Advancing Resources for Excellence) command center. They also walk through some key initiatives that DCARE supports, including increasing the number of transfer patients served, launching a swing bed model, and offering specialty services in smaller hospitals.

Discover how DCARE has helped Deaconess increase the number of transfer patients by 5.6 per day, allowing them to serve over 2000 additional patients annually. And, learn how the team is now expanding their focus beyond throughput and capacity to improve care quality.

Jeff Terry:

Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Amy Kruger and Dr. Phillip Adams from Deaconess Health System. Welcome to the podcast. Hi.

Amy Kruger:

Hello. Good morning.

Dr. Phillip Adams:

Hello.

Jeff Terry:

So to start, Deaconess's Journey the last decade, I guess, has been pretty exciting growing from, I think, something like five to now 13 and, within a couple of months, 14 hospitals. Obviously with the goal, which we all broadly understand and read about, which is growing as a hospital network to connect resources and get patients the care they need across a wide geography, but you guys have been at the forefront of really doing that. So if you wouldn't mind, bring our audience into that, Amy, maybe starting with you. What are the factors of that? How have you approached that, realizing the potential of that network expansion?

Amy Kruger:

Absolutely. So I think the strategic goal of Deaconess obviously is to provide some stability with the growth as we see some of our smaller hospitals and the state and the region that are unfortunately failing somewhat economically with healthcare and everything that's going on. And so Deaconess really wanted to approach with a strategy of really stabilizing our community hospitals, keeping patients closer to home, and then also giving that quality care to patients closer to home so they don't have to travel for those services.

So that's the strategy that's been implemented. It's been wildly successful, as you've said. We've grown tremendously, and it's so exciting to bring these new facilities on board, provide some of that stabilization and watch them grow, shine, and again, knowing that we're giving back to that community by keeping those jobs and that quality care close to home.

Jeff Terry:

And I should have mentioned at the open, Deaconess is centered in Evansville, Indiana, so southern Indiana, but now spans, I think, four states in the catchment areas.

Amy Kruger:

That is correct. So we serve Indiana, Kentucky, Illinois, and then somewhat into a portion of Missouri and then even looking to expand down to Tennessee. With that being said, a lot of those areas are very rural in nature, and especially in Kentucky and southern Illinois. And so they don't have a lot of resources or big systems close by, so we're geographically just right in that great spot where we can help provide those services, that quality of care and keep those patients in their community.

Jeff Terry:

Absolutely. It's tough to staff an ICU at a 50-bed hospital. It's hard and harder to do. So expand on that a little bit. Or maybe Dr. Adams, what does that look like? So we want to get patients the care they need close to home. Unpack that a bit for us.

Dr. Phillip Adams:

Sure. So as Amy mentioned, southern Illinois and western Kentucky is pretty rural. Most other health systems are shedding services. They're getting rid of health systems, smaller hospitals. This area is really covered primarily by critical access hospitals. Illinois is sometimes a difficult state to practice in in terms of some of the physician friendliness, litigation, and lots of other factors play a role in Illinois, in general, but southern Illinois, with the vast majority of the population being in or around Chicago, you have a lot of really rural areas, and that can be very difficult to get patients care.

And so as they start to shed services, the challenge is how do we get care to them? So they would either go to St. Louis, which is about equal distance for a lot of the patients. Sometimes it's a little closer. Or they're going to go further north, or they're going to have to go more east towards us in Evansville. And as the growth has gone over the last really decade or so, those patients really preferred going to Evansville. It's a little smaller. It's a little bit easier to get their healthcare, easier access. And so we capitalized on that by saying, "Why don't we create a hub-and-spoke model where we have a larger facility in different areas that can accommodate the needs of those patients?"

And in doing that, what we were able to do is really center our focus and look at the types of resources we have and take a little bit larger facility to handle the normal volume of the critical access hospitals that would be transferred to a larger facility. And so as we've grown, we used to be able to take all the transfers we wanted, and then, of course, COVID changed all of that for everyone. We were still taking lots and lots of transfers, but at that point we realized we just couldn't take transfers from everyone. And in the way we built our process, we were the easy button. And so the rest of the health systems in the region realized that, and so we became their preferred partner. And so we capitalized on that growth by creating these hubs, these little bit larger facilities that can accommodate care.

Jeff Terry:

Absolutely. And Amy, I want to double click on something you mentioned. I love that word stabilize. And I obviously don't want to be controversial or anything at all, but I think it's well-known that there's stress around rural hospitals closing. And so the strategy here has been, how do we ... Say more about that.

Amy Kruger:

There has been quite a bit of stress, and we've seen health systems within our own state of Indiana, even one of our larger health systems, are closing hospitals. And that ultimately is stressful to those communities. So again, I think it's important to help these smaller communities receive that quality of care. As Dr. Adams mentioned, our hub in Evansville, our mothership, are the most advanced services and where patients can come for those more complicated needs, but really capitalizing on the services that we can offer in those smaller hospitals. For example, one of our hospitals in Illinois has a strong cardiac program, so think of all those patients now that we can direct that way in that area and not have to take up beds at our mothership facilities. And so that's incredibly helpful to everyone to help with that balance loading.

Jeff Terry:

That's awesome. Amy, I love that example of the cardiac program. What are some of the other, I guess, pathways that you've worked on together to move certain types of cohorts of patients or certain clinical programs that you've stood up as the network has grown?

Amy Kruger:

Sure. So we've recently added a couple of neurologists to our facility in Kentucky. And with those two neurologists coming on board, they've had the capacity to really help us in telestroke and teleneurology. And so we took a hospital, Leapfrog scores weren't so great. In fact, we went from an F to an A in that facility in a few short years that Deaconess took on that facility. So we've really capitalized on that and saying, "This is a great place. If you are experiencing a stroke or you've had a stroke or you need neurological care, this is the expert facility to go to." So telestroke and teleneurology is an initiative that's really up and coming for Deaconess.

Jeff Terry:

And not necessarily all centered in Evansville.

Amy Kruger:

Correct.

Jeff Terry:

That's great. Absolutely. Dr. Adams, anything to add there?

Dr. Phillip Adams:

I was going to say just that we're really focused on the needs of those communities. So the hub-and-spoke model makes sense when you don't necessarily need a cardiologist in every one of those facilities, but you don't want your cardiologist to be three hours away, the closest one. So we're really paying very close attention to the needs of those communities. And a lot of times we've purchased facilities that may not have the best reputation, but have a lot of potential. And we're really trying to build our culture there so that you get the quality of care that you expect at our mothership hospitals, at our local, smaller communities, which helps to encourage those patients to stay local and makes it easier for the patient, for their families, and obviously for our system as well. So it just makes sense all the way around to try to create a win-win for everyone.

Amy Kruger:

I will add, just for an example, last year at this point in time, one of our newer facilities in Illinois had a census of 12 patients in the month of October. And we're up to 40, so that's pretty significant for that smaller hospital. We hope by December to get them up to 60. But they've taken pride in that, with that growth and that progress, and they're excited about really hitting that mark of 60. They're already in the talks of adding more beds, more units. We're getting some great physician recruitment in that area. So it just goes to show if you put the effort into it, it's quite fruitful.

Jeff Terry:

Absolutely. It's such a virtuous cycle for the staff, for the community and for the patient. Well, that's great. And if you wouldn't mind double clicking on, you guys lead teams that do a lot of things that are related to the management and the orchestration of the network. Would you mind explaining your roles a bit more in the teams that you lead?

Amy Kruger:

Sure. I can start. So I am the manager of our what was called the access center, but now we're calling Command Center. And I have two areas of that, a clinical side and a nonclinical side. The clinical side is quickly turning into what our Command Center program is. So within the Command Center, and I know we'll get to the structure of DCARE here soon, but of course, it's bed placement, transfer RNs, our clinical expediters. We now have EMS dispatch. We have environmental services dispatch. So bringing all those teams together into one combined space has been incredibly helpful.

My other area is practice transformation, which is taking a lot of the phone calls out of our clinic offices and centralizing them in one location, and then also providing that scheduling piece with that as well. And so they also provide scheduling for hospital follow-up, ED follow-up. And so we've been able to connect a lot of dots there by reducing admissions. For example, in our emergency department, if we can assure our physician that we can schedule an echocardiogram or a stress test the very next day for a patient, maybe he'll have comfort in sending that patient home, knowing that they'll have that follow-up care the next morning. So a lot of pieces intertwine within my areas, and then I'll let Dr. Adams explain what he does as well.

Jeff Terry:

Awesome.

Dr. Phillip Adams:

Sure. So I'm a hospitalist. I spend about half of my time working as a hospitalist still primarily at the midtown campus. That's the closest in proximity to the Command Center. It helps me to get to and from meetings and things as well. And then the other half of my time I spend, initially it was the medical director for the access center, so I helped to build our physician the access center program. So we have a hospitalist there from 11:00 to 7:00, taking transfer calls, the medical transfer calls, fielding some of the other calls as well, helping to get to the right specialist, make sure we get the right patient, right place, right time. So that's really important from that perspective.

We're actually working to grow that. That's been an integral part of our growth in terms of the regional growth. Having a physician that can access the transfer request within 15 minutes is our goal. A lot of times we're doing that in near realtime. They're calling, we get the information, we say, "Hold on just a second, let me get my doctor." And then the doctor talks and accepts that patient or whatever needs to happen. And so that process is very, very streamlined. It's been an incredible process for these smaller EDs that are trying to get their patients out of their facility when they can't handle that and get them into a facility that can help that.

So as we grow, that focus is really on making sure that we pick the right location. So that certainly is a little bit of a challenge with obviously the growth that we've had, but we really have to be on top of understanding where our services are at, what our capabilities are at each facility. And then of course, having DCARE with the GE software really helps us to understand where we have capacity and where we don't have capacity, because that really drives a lot of our decision-making to make sure that we get the right patient in the right place.

Jeff Terry:

That's brilliant. And I sometimes think this phrase is limiting, but I think it certainly applies to a part of what you do, which is together the access physicians, Dr. Adams and Amy, you and your teams, you are the air traffic control of that network that we spoke about. Not in theory, but in daily practice. Where should patients go? How do we get them there? And making the decisions throughout the day.

Amy Kruger:

Yep, that is correct.

Jeff Terry:

Awesome. And so Dr. Adams mentioned that you guys invested in something called DCARE, which we've obviously just been delighted to work with you on. And that is a Command Center to co-locate these functions that you mentioned and bring in some new information tools to make it easier to see who's where and waiting for what and all that sort of stuff. On the one hand, I think to the audience probably sounds great, but obviously Deaconess has a lot of things they could spend money and a lot of ideas, so evaluating something like that is serious business. So help us understand, how did you think about the decision to make this investment? What was important about it? How did you evaluate it?

Dr. Phillip Adams:

So honestly, when we first started the physician access center program, we started realizing we've got a lot of challenges. And historically we've been part of lots of committees. Amy and I have been on a lot of the same committees with throughput, working through some of the challenges that the system has. And what we've come to realize is that we really were having a hard time getting the patients to the right place, right time, and all of those pieces. And so we recognized that to be able to be successful, we really had to think about things differently. And especially in the height of COVID, when we were really struggling with beds, we had a waiting list, sometimes 20, 30 patients trying to get in. How are we going to really efficiently manage a system that's this complex?

And when I first started 10 years ago, we had two hospitals, and then over the last four or five years, we've added the other three. And then we were under the impression that we would have five hospitals when we started saying, "We can't manage all of this volume from all these around locations with the five hospitals we have." So we said, "We really need to think about this differently, and how do we do that?" So we started looking at the different options, and really our predecessor said, "I've got the permission to start looking into a Command Center concept." Well what's that? And she said, "Well, I'm not quite sure yet what that means, but I've got some ideas." And so I said, "Let's start looking."

And so we started looking, and we started realizing as we started looking at the different products, we first found GE, of course, and said, "Oh my gosh, this is really everything that we have been asking for forever. How do we tackle not only capacity in a broad sense, but how do we tackle capacity in an individual patient sense? How do we figure out what that one thing that's holding that patient up really is?"

So interestingly enough, during COVID, the CEO called me and said, "We've got 175 COVID patients in the hospital. Tell me who can go home." I said, "That's a really good question. Let me look." So I spent about three hours, I got through about 20, 25 patients, and I said, "I have no idea. I don't know how to take a chart and chart review all these different patients and figure out what does this patient really need to be able to progress on their care line, their care progression?" And so that really struck a nerve with us in terms of we didn't understand what we were really waiting on and what needed to happen to make this care progression happen.

And so that's where all of this started. And so of course, just like with any health system, you've got to figure out a way to pay for it. So we went with the simplistic way. We didn't want to find any quote, soft dollars or anything like that. We wanted direct income. And the easiest way to do that is looking at your transfers, and that had always been a growth area for us. We've always focused on transfers. And so we wanted to look at that and say, "If we're going to do that, what can we realistically add day by day to help impact those patients?"

And so we came up with a budget of two patients per day as our benchmark, and that way we could look over a course of a couple years, two-and-a-half years would essentially pay for the cost of the program. Well, we ended the first fiscal year at 5.6 transfers more than what we had from the previous year, so almost three times what we said we would do. So that made it a much easier process in terms of explaining and linking that to our administrative team. They could buy into bringing in more patients equals increased revenue, and so that was an easy sell for us from that perspective. Everything else is just bonus is the way they looked at that decreasing length of stay. Exactly. Quality metrics, all of those things that we think we can really improve on as we move forward, that's how we're bringing in other people, recruiting physician and more physician engagement, more nursing engagement. It's the successes that we accomplish after that, but we just had to come up with one way to be able to pay for the program to start with,

Jeff Terry:

And one that's tangible, it's not hard to track, which is important.

Dr. Phillip Adams:

Exactly.

Amy Kruger:

Right.

Jeff Terry:

So that all makes perfect sense, and you guys are both very close to it, so it's very clear. I'm curious, if you recall, as you're going through the committees and different people are getting involved, many of whom are not as close to this problem, was there any reaction or challenge or question of theirs that comes to mind that you had to address or explain?

Amy Kruger:

Oh, yeah, absolutely. We're a very frugal organization, and so there's a lot of red tape to get through if you want something. So I won't say that the process wasn't challenging to move this forward, but there truly was administrative support. They recognized the need, especially post-COVID when we were triaging and trying to figure out how to get patients to the right level of care. But I will say one question that we were challenged with over and over is, well, how do we use what we already have? What tools do we have that we can use? And we really pushed. We really tried. We explored every single option, because that's just what we have to do in order to push something. We have to explore every avenue, and there was just no comparison to what we found in our GE product.

Dr. Phillip Adams:

We also had to set a realistic target. We expected to increase four or five transfers, realistically, between the two of us per year over our baseline. But we couldn't go out and say, "Hey, we're going to bring in 10 more transfers or five more transfers a day for the entire year," because they would look at us and go, "Well, how are you going to do that?" And so that's been the backdrop of actually having fewer beds. So that's what makes it even more interesting. I think we could have actually grown quite a bit more. So having said all of that, we really spent a lot of time working with our senior admin, explaining the concepts and catching them in the hallways as we're walking to and from meetings, just presenting those little pieces. Setting the groundwork is so important to be able to help get that change management to occur. It's little baby steps, and it felt like it took us forever to do that, but we were constantly laying the groundwork for the next thing.

If we do this, then we can do that. If we only had this piece, if we only had that piece. And to Amy's point, we looked at everything, and we realized that there was no other product or service that could provide the information that we wanted the way GE could. And so that was an easy decision. That was probably our easiest decision, honestly, was to make that one. The hard work is really creating those metrics that you have to show that you're being successful by. You've got to create that return on investment. You've got to look at what your real ask is. How many people are you really asking for? This was a completely new project for the both of us. We're asking for new FTEs. We're trying to grow a program, all while doing our normal work too. So that's one of, I think, our biggest challenges in starting a program like that is just, how do you get all the resources and all the knowledge in place to be able to be successful at that? It's very challenging

Jeff Terry:

Actually making it happen. Amen. And congratulations to you both, by the way. It opened in August. It's beautiful. The place, but also the teamwork and the practices that are within it. And Amy, you used the word founder. It's a great word. Dr. Adams, I think you guys as the co-founders. But it's one thing to say, "We're going to do this." All the pieces you've got to do to make it go is remarkable, so congratulations.

Dr. Phillip Adams:

The other thing that I would really highlight too is it's really important to have somebody that's got similar strengths, but also some strengths that you don't have. So to partner with Amy, she's fantastic at being able to do all the things that I don't have time to do. She manages all of the people and the logistics of so much of that. And then I spend so much of my time working with the physicians and working with some of the ideas. So together we make a great team, because we compliment what each other does so well. And I think that's what you really have to look for when you're setting up your program as well is really finding the right people. And we've got a great one in Kate as well, and having somebody that really compliments us and that by extension, anytime you have a meeting or you have something you need to work on, you can trust your team to be able to take it whenever you're not available and have other responsibilities. And we rely heavily on each other to be able to do that.

Jeff Terry:

Amen. Complimenting and function and in style as a team. Go ahead.

Amy Kruger:

Yep, for sure.

Jeff Terry:

Awesome. I wonder if we could double click on one other thing, just almost like double clicking into DCARE. Could you highlight a practice or two, an example of what that group is doing that might be interesting to the audience, what a clinical expediter is doing, or how the transfer team is working differently and a practice or two to bring it to life?

Amy Kruger:

I think probably one of the biggest pushes that we're working through right now is really redefining our MDRs, having those meaningful conversations, make sure that we're tasking in our Tiles for DCARE so our clinical expediter can see those tasks and start working those. So that's been a huge educational piece at this point in time for our staff. And I feel like we're finally getting to a point of understanding and hardwiring. Even so, we're having great conversations on our leadership huddle in the morning with the entire health system where we're bringing up the Tiles, we're talking through our summary review, seeing how many outlying tasks that we have and where are they.

So that's been a culture shift for us in the past maybe week or so that we're feeling. We're finally getting there. We've been at this, well, we've been in implementation for over a year, and I will say that it's been a little bit of a struggle culturally as many healthcare systems know that when there's a huge change or shift. So that's one of the pieces that we felt recently is just overall engagement is finally rising and really getting into the Tiles and digging into that meaningful, realtime data, realtime view. So again, talking through those things on the leadership huddle, working on that MDR process that, like I said, that's completely being overhauled. And then having the ability for not only our expediter, but other areas, ancillary areas, whatnot, to start prioritizing correctly. So I feel like it's finally all coming together. There's finally a breadth of understanding.

Jeff Terry:

Totally. Dr. Adams, any practices you would highlight that I guess that have changed in the last year?

Dr. Phillip Adams:

It seems like everything's changed in the last year.

Amy Kruger:

There's a lot.

Dr. Phillip Adams:

There's a lot. But I think Amy hit on that as well. The ancillary services, just prioritizing echos and tests that sometimes have to be delayed until the next day for the right patient. That's such a different concept to really think about what's the right patient, what's the right order, how do you sequence them correctly? I think the other thing that I'm really excited about in the partnership with you guys is building a swing bed module. So as we've talked about these critical access hospitals, the thing that's so important for their survival is to be able to have patients in beds.

And so they get some of their patients from acute care from their ED, but a lot of their patients are what they call swing beds or beds that are used more for an inpatient rehab versus a SNF situation where they have those excess beds, and that drives the revenue that keeps these hospitals open. And so it's such an important part of keeping access in some of these rural areas is to have patients. And so to be able to create a process that we're able to really highlight the best patients, that small group of best patients to be able to get to the swing beds is so important. It's so much different than looking through 300 charts and trying to figure out which are the best patients to move to swing bed. It's just we're very excited for that.

Jeff Terry:

And do I have that right? When you say swing bed, you mean a bed that can swing in level of care between a SNF and an inpatient med surg type bed?

Amy Kruger:

Yes.

Dr. Phillip Adams:

Correct, correct.

Jeff Terry:

And then you said something which I think is so right, and it really resonates with me, is it's trying to find the small cohort of the right patients that match up with that is vital, and it's also harder than it sometimes sounds. And I love your example earlier, I was going to ask that, of, hey, it took you three hours to get through 25 patients, much less 185. Is that different now with DCARE? Is that an easier question to answer, who's ready to discharge?

Dr. Phillip Adams:

Absolutely. Hugely different. And that's one of the things that, in the stories that I tell people, if we had that to do again, we could change the filters on that, and I can tell you in a few minutes, I can give you 20 patients to look at. And we've got the top 20 patients that we might be able to impact. We can just forget looking at anybody else. And maybe it's not even 20, maybe it's really 10 that we have the most impact. And I don't have to dig through the charts. I don't have to spend hours trying to review everything. We can pull all that information into DCARE and really be able to see at a quick glance. Within a few seconds to a minute, I can probably review 20 patients and give you the best options for being able to discharge. And so that's completely different than the situation we were in a couple of years ago.

Jeff Terry:

That's great. I'm glad to hear it. Wonderful. I guess then last question, which is the future. So we've come a long way. You've already described a couple of things that are ongoing. Maybe Amy, starting with you and then to Dr. Adams, how do you see both Deaconess and DCARE evolving over the next couple of years?

Amy Kruger:

So right now we're really focused on throughput, balance loading capacity. That's been our phase one for DCARE. Phase two, we really want to get into the quality realm, really start adding ... potentially an EICU structure for some of our critical access hospitals that we've talked about, telehealth. So the possibilities are endless, but where we really want to focus on next once we have a good handle on capacity and throughput is more of the quality piece that we can impact. So I think that's exciting as well. So like I said, the possibilities are endless, but that's where we plan on going next.

Dr. Phillip Adams:

I agree completely with Amy. The quality part's so important, and we're really excited to move into that. But I think the other part of that is that we're constantly reevaluating or looking at current processes and seeing if we can do something different to make the system work better. And I think we continue to grow in those areas. We continue to look at innovation. What are new concepts or new ideas that other ecosystem members have? What are they doing? Well, one of the things we learned from Tampa was how to do a departure lounge. And so we stood one up, and we're still refining that process, but that was something we learned by visiting Tampa to see the GE product. And so as we learn from our colleagues in other places, the Dukes, the Tampas, the other fantastic organizations, we really are excited about the different things that we can do that we're learning from our partners.

And at the same time, we're also excited to share what we're doing with our partners as well. And to see the growth and the change in this realm, because it's so new for everyone, and yet it's so important. Everyone's looking at this as the wave of the future or the key to success, so to speak, over the next few years. And so we fully agree with that. Without having this knowledge, looking at capacity and what your strategies are and all of these things, this innovation, hospitals are going to get left behind. And the only way right now to get to success is you can't keep building buildings, you can't find staffing. Your only option really is to find ways to be more efficient. And that's what Command Centers do for you, and that's what GE has done for us.

Jeff Terry:

Amazing. Thank you for the kind words, Dr. Adams and Amy, that's wonderful. We love working with you and for you, and thank you so much for all the insights today.

Amy Kruger:

We appreciate you having us.

Dr. Phillip Adams:

Thank you for having us.

Amy Kruger:

Thank you so much.

Jeff Terry:

Thank you again. And with that, we'll close the podcast.

(01:14) Telehealth and remote monitoring at Deaconess
(03:56) How patients and providers benefit from telehealth programs
(05:26) The technology used to support telehealth
(08:43) How D-Care helps identify patients for remote monitoring
(11:24) The continued evolution of telehealth
(12:10) Evaluating new programs and investments
(13:17) New AI technologies and the pursuit of health equity impact the expansion of telehealth
(14:42) Using telehealth to serve a large geographical area
(17:40) Partnering with local libraries to increase access

Serving a large geographical area across four states, Deaconess Health System is evolving their telehealth programs to help them deliver care to all who need it. Alli Flowers, Telehealth Clinical Manager at Deaconess shares, “I think ultimately everyone appreciates the flexibility [of telehealth] and being able to treat patients where they're at and when they need it.”

In this episode, she talks about the technology that supports their telehealth programs, including their D-Care Command Center. “I was introduced to D-Care and within five minutes, they were able to create a profile for us to identify potential candidates for remote monitoring as well as where those patients are at with their care,” said Alli.

Deaconess is committed to extending services across the broad area they serve so that people do not go without care. Alli shares more details, including how one innovative program leverages a partnership with an area university and local libraries to offer accessible telehealth services in rural communities.

Jeff: Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Alli Flowers, who is the Telehealth clinical manager for Deaconess Health System, which is a six or eight or ten hospital integrated delivery network out of Evansville, Indiana, serving the Tri-State and I think becoming a four-state area around southern Indiana.  Alli, thanks so much for joining.

Alli:  Yes, thanks for having me.

Jeff: Awesome. So we're going to talk a little bit about the telehealth modalities that you guys provide for patients through Deaconess, the technology you use. Talk a little bit about how your D-Care Command Center supports that and then get your take on the future of telehealth. But maybe to start a bit with that, I mean telehealth, virtual care, digital health, e-health, like it's sort of all the talk, clearly a hot area so much it evolved quickly through COVID and so forth. But maybe just to start, like when I say telehealth, telehealth is in your title. What is telehealth to you, to Deaconess? What does it mean?

Alli: So to me, telehealth is just another way to connect with patients where we're not necessarily physically touching them, but we're still connecting with them and providing care. So more of just an extension of any care that we offer.

Jeff: And that can take a lot of forms, as you've schooled me on. So maybe for the audience, what are the telehealth services or modalities that you guys provide today?

Alli: Yep. So I think the highest level that everyone is very common, commonly known is just an audio video connection where you can see and hear each other just like we are today. And you can see your provider, talk to them and receive treatment. Below that there are just telephone visits. So sometimes we just have audio only visits depending on what it is, and then e-visits where you just fill out a form and receive treatment. So there's lots of lots of different ways to connect with patients.

Jeff: So an e-visit you think of as the form, the telehealth is the face to face through something like Zoom that we're doing. And then what are the sort of the clinical services I think you mentioned? Tele-neuro, tele-stroke. Like what? How has your program evolved clinically?

Alli: So yes, So just in the past 4 to 6 months, we did launch a tele-stroke  and Tele-Neurology program where we're able to connect with patients at some of our rural hospitals and treat them before they're out of time actually to receive treatment. So we did start that and then just our normal primary care and specialty care providers, they intermingle video visits within their normal schedule.

Alli: So they might have a patient come in person and then the next visit could be a video visit. So we do different things like that. We also do our emergent site consults. We do a lot of those over video as well, so we can serve a lot of facilities that do not have access to that type of treatment.

Jeff: And you mentioned particularly after hours that service is of even higher value.

Alli: Yes, less staff. And so they're able to cover more facilities by using video technology.

Jeff: And you also mention, I think remote patient monitoring is a service you provide.

Alli: Yes. So we do remote monitoring and we are really focused on patients with heart failure and COPD that are high risk for readmission to help them just stay at home where they're comfortable and manage their condition.

Jeff: May I ask I mean, I think clearly we all have a sense that this is good, you know, but you know, it's better for the patient, better If you can stretch the provider's expertise to many more patients, it's lower cost if we do it right. But I mean, you hear it on the front lines. What do you hear from providers and patients directly about these programs? How do they respond?

Alli: So I think it depends, but most patients appreciate. I'm going to start with the patient side instead of the provider. So I think the patients appreciate the flexibility with telemedicine. So less time away from work, child care, drive time, all of those things are help them overcome those obstacles because of telehealth. Providers I think are the same. You know, there are certain conditions because obviously not everything can be treated over telemedicine, but for those things that can, I think the providers appreciate that too.

Alli: So if they were typically driving an hour and a half to a remote clinic to see patients, now they can stay back at their office and still provide service for that community and not have that drive time. But I think ultimately everyone appreciates the flexibility and being able to treat patients where they're at and when they need it.

Jeff: Absolutely. And so there's different. And so next thing to ask about is the technology that you use and I mean the technology to enable that patient provider interaction. And I think it varies a little bit by modality. So could you describe that?

Alli: So we actually use it for like our primary care and specialty care visits we use. We have an epic shop, so we use epic video client and that is the experience I feel like for the patient and the provider is really good with that because they can launch their visit directly from their schedule. So that's how it's easy for them to go from an in-person to a video visit.

Alli: And then on the patient side, they're launching their visit directly through their MyChart app. So it's easy for them as well. Their instructions are right there, tells them exactly what to do. For our other services, like Zoom, we use Zoom. So for our mental health consults and we actually use it for some different things. But it's just really an iPad to iPad connection.

Alli: So it's not expensive to be able to support those programs. And you just basically have an iPad on a cart and wheel it in and they're able to connect in.

Jeff: Is that in what setting is that patient and is that patient in a residential home? 

Alli: So typically for this Zoom connection, it would be the patient would be at another hospital, maybe in an emergency room if they're getting an emergent site consult. So at another facility. So there is staff there.

Jeff: And so you can so you have the cart prepared to. Yes.

Alli: Yes.

Jeff: And you can you give us a sense of the scale of the program? I mean, how many visits in some of these modalities per year? What's the scale of that?

Alli: So we do track that in off the top of my head. I don't know that I can provide that, but overall, I do know our telehealth visits. So let's just talk about maybe our primary and specialty care visits. Overall, we're just right at about 2%. So our overall visit volume, just about 2% is video. So our site consults, we do track telemedicine versus in-person visits. And it's typically it depends on if the patient is in one of our rural facilities, 100% of those are going to be done over video. So it just depends on where our staff is located and where the patient is on if we can do those in person. So our bigger hospital in Evansville, a lot of those are done in person because we have staff there pretty much all the time now.

Jeff: So the programs are up and running, different technologies, enabling the interactions, you know, many of them out of Epic, Zoom, a key platform. And then you also have that a care command center which supports a lot of activity for Deaconess, but it also supports not the patient provider interaction, but it supports the management of the programs. Can you describe how DCARE supports?

Alli: Yes. So for remote monitoring, we were relying on referrals while the patient was in the hospital. So typically our case managers or we have nursing staff that can give referrals for the program as well. And as we started to sort of see a decline in those referrals, I was introduced to DCARE and within less than 5 minutes they were able to create a profile for us where we could identify any patient that is currently admitted, which we filtered on DRG and CPT codes with heart failure or COPD.

Alli: So that was huge for us because now we can see who's in the hospital with this particular diagnosis. So it's appropriate. We might get referrals for a patient that's in with maybe abdominal pain, with a history of CHF that they're not really struggling on managing that condition. So not necessarily somebody we would monitor. With this profile, we're able to see the exact patients that are admitted with those diagnoses.

Jeff: And so you're able and so that helps you drive identification of candidates that might be enrolled. And it sounds like in particular identify patients that are sort of high because of high readmission risk. They may be sort of extra appropriate for the program.

Alli: Yes, that is correct. And, you know, another really nice thing about DCARE, the particular nursing units that are using it, they make notes. So it's so easy to see exactly what's happening with the patient and where they're at in their care. You know, are they going to be here for several more days or will they be discharged within the next day or two? And that helps us decide when is when is it an appropriate time to contact them and discuss the program with them to see if they even want to participate in.

Jeff: Do you message back and forth? Does your team message back and forth to the care teams through the DCARE applications.

Alli: So not through DCARE. We we do that through EPIC. So if we do need to reach out to the case manager or the nurse, then we would just actually use Epic to do that. But for us, if they're entering notes though, we can quickly see exactly what's happening. So it's just nice. It gives us a quick overview.

Jeff: It keeps you joined up and allows you to see it, keeps you joined up and allows you to see the flow of the patients and the candidates. Yeah, that's great. And so, I mean, it kind of zooming out, which is thank you for all that and zooming out a bit. And I'm interested in your view of how this space will continue to evolve.

Jeff: And what I mean by that as we've got sort of, you know, telehealth, which is, you know, face to face through video, we've got e-visits, which is sort of the recording, the forms. We've got, you know, virtual care, which increasingly is a term people use, people use the term digital health. So you bring it down to the program level where you have emergency psych through telehealth.

Jeff: You have tele-neuro, tele-stroke, remote patient spaces and concepts and clinical services and technology and is sort of a lot it's exciting and it's sort of all for the good, but it's sort of a lot to get your head around. So I guess I'm curious how, how you think about the future of that space abroad really. And yeah, I guess broadly and also how you evaluate the next program or the next investment.

Alli: So I'll start with that. When we are looking at starting a new program, it is what is the need for the program? So we go through a whole process to evaluate is there reimbursement involved, is it sustainable? You know, can we see is there grant funding because a lot of times for telehealth there, there could be grant funding. But ultimately, when that grant ends, are you able to maintain what you've started? So that's a big thing. We don't ever just put a program out there just to have it. It is to fill a need. So why, why are we doing it? 

Alli: But ultimately, I think as we've seen nationally, there's a big disparity for people as far as broadband access and it's an issue. So having that health equity, this is that that's a concern I think, for a lot of people. So I do think telehealth is only going to grow. I think it's just a normal part of care now. And ultimately that all the new technology, the new softwares that are being created every day, it's extremely interesting to watch the amount of AI that is coming out.

Alli: And even with remote monitoring over the last couple of years, it has drastically changed with the current. What we had initially when we started, which is basically you're asking the patient questions and you are collecting biometrics and you're just tracking and trending their data and trying to see if anything is going to happen. You're kind of predicting yourself where with this new AI technology with RPM, they can pretty much tell you based on this last week's information, they're more than likely going to readmit to the hospital.

Alli: So it's very different and I think we're just going to continue to see that expand as we move along and technology just continues to grow.

Jeff: Well, that really underscores sort of your point you've made a couple of times, which is, you know, you said telehealth is a normal part of health. You say telehealth is just health care, right? It's not yes, it's not a separate category. It's just part of health care. And in that regard, it makes complete sense that, you know, the AI that's being applied to spot patterns and save time and all over the place is equally applicable here.

Jeff: Can I ask one other thing that comes to mind is clearly, it seems to me that these that these capabilities are even more important in a catchment area like you serve, which is a geographically broad catchment area. How do you think about that? You mentioned health equity and yes, a little more about this sort of served the kind of catchment area that you serve and the need to push care out into the into all the corners of that.

Alli: So we're in Indiana, Illinois and Kentucky, so we do have a broad area that we are serving. And when you think about it, I actually got to travel to one of our Illinois facilities a couple of weeks ago and it was a little over 2 hours drive to get there. And when you think about that, those patients are coming to that facility and ultimately they could stay there and receive their care if they had the specialty services that they needed.

Alli: So being able to extend our specialists to them is extremely important because they're the reason we continue to expand our health system and grow is to keep that care local. Don't make those patients have to drive to receive care. So that could be in many different forms, not just in that patient being hospitalized. We can open up clinics where they could have a visit with a specialist and stay right here at their facility.

Alli: So you hear it so much and just people unable to receive care because they couldn't drive to their appointments. So it's just trying to figure that out and how we can help you extend all of our services to all locations so people do not go without care.

Jeff: Definitely. And and you said it, but, you know, when you're extending specialist care to patients that are at another one of your hospitals, that takes the sort of broadband issue off the table. Right. You have the infrastructure and then that's a great pushing all the way to the patient's home can sometimes be more challenging because of things like broadband, but nonetheless is useful in many cases, and that all those services and capabilities are I think a part of it is no secret, Deaconess is doing really well, right. Expanding across the regions, growing in that those capabilities seem strategic and ability to serve such a broad and diverse geography and population.

Alli: Yes, in something that we've been able to do that's been interesting, we partnered with one of our universities. It's the University of Southern Indiana and our local libraries. And we put equipment in the libraries and patients can go and they put them in a quiet room and they can actually do a visit there. So we want to expand that to a lot of our rural communities because that would allow patients just to have someplace close because, you know, all small towns have a library and they have access to wifi. And they have broadband. Yeah, yeah, that's brilliant. So now everything.

Jeff: Every library becomes a specialty clinic, basically.

Alli: Yeah. Yes. Yeah, yeah. So they can go there. The librarians are trained to help them, at least to get logged on and know where to go to start their visit, and then they leave. And that patient has privacy and they can complete their visit. So we're trying to figure out those connections and how we can help with that.

Alli: So if somebody can't even get to their hospital, at least they could maybe get to their library because a lot of them are within walking distance if you're familiar with these small towns, that they're they wouldn't even have to drive.

Jeff: Well, that's brilliant. And what a great use of the library. I mean, I know libraries sometimes are struggling these days with, you know, people obviously check out less books. And so how do they still stay relevant and high value to their communities? What a what a wonderful synergy. That's really cool. Awesome. Well, Alli, we'll leave it there.

Jeff: I think. Thank you so much for joining the podcast and talking about this.

Alli: Yes, thank you for having me.

Jeff: Awesome. Thanks again. And with that, Will, we'll close the podcast.

(00:45) Vicky Martin's nursing background
(01:45) Experience with hospital amalgamation
(02:45) Became charge nurse on unit 8.2
(03:45) Evolution of nursing during Vicky's career
(04:45) Nurse development on Vicky's unit
(05:45) Professionalism in healthcare
(06:45) Motivations for nursing
(07:45) Diversity of nursing roles now
(08:45) Recommendations for new nurses
(09:45) Complexity of medicine patients
(10:45) Adopting Patient Manager system
(11:45) Replacing whiteboard with Patient Manager
(12:45) Wider staff involvement with Patient Manager
(13:45) Retiring the whiteboard
(14:45) Patient Manager's impact on workflows
(15:45) Improving discharge date predictions
(16:45) Challenges predicting medicine discharges
(17:45) Escalating barriers to discharge
(18:45) Full nursing team adoption
(19:45) Using Patient Manager in shift handover
(20:45) Vicky's perspective on Patient Manager
(21:45) System-wide coordination
(22:45) Advice for other hospitals adopting
(23:45) Spreading Patient Manager across Nova Scotia
(24:45) Ease of use and benefits of Patient Manager
(25:45) Transparency and breaking down silos
(26:45) Expediting care with Patient Manager
(27:45) Appreciation for Vicky's work and credibility

As an experienced charge nurse for a fast-paced Medicine unit with complex, high-acuity patients, Vicky Martin and her team have no time to waste. They’re driven by the desire to improve patients’ lives and leave their shift knowing they’ve made a difference. That compassion is core to Nova Scotia Health Authority’s mission to work together to achieve excellence in health, healing, and learning.

GE HealthCare Command Center technology is supporting clinicians as they deliver on that mission. In the latest episode of the Real Time HealthCare podcast, Vicky shares how their C3 Care Coordination Centre is helping streamline key processes, improve care coordination, and save time in her unit and across the enterprise.

Jeff Terry:  

Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Vicky Martin, who's the charge nurse on 8.2 at Halifax Infirmary. Hello Vicky. Thanks for joining us. Good morning.  

Vicky Martin:  

Hi Jeff. Good morning. 

Jeff Terry:  

Awesome. So happy that you're here. Maybe to start, describe your background, you know, why did you get into nursing and how did you end up on 8.2?  

Vicky Martin:  

Well, a long time ago, in 1979, I graduated from a little hospital in Cape Breton. I started there on a surgery floor, basically very busy. Worked there for a year and a half and decided to move to Halifax. When I got there, I switched over to medicine and medicine has been my love for the last 35, 40 years. I've been there at the HI, we were in a teaching hospital, something I had never done before and I loved working with the residents, those kind of, it was compared to what I worked in Cape Breton, it was very much a hierarchy whereas here in Halifax it was much more of an equal playing field. Everybody seemed to work together, it was much more of a team. So I worked there for about nine years and moved to Ontario. I did some more medicine there and then I came back to Halifax because I really missed Nova Scotia. So when I got back here, it was in the process of, they were amalgamating all the hospitals. They were amalgamating the old Camp Hill, which is a really, it's gone now, but the old Camp Hill, switching over to the HI and then they joined from the HI to the VG. So it was kind of like skipping stones. You just kept going from one place to the other. And finally I ended up on 8.2. And 8.2 at one point was orthopedics, but now it's switched over to medicine and I took the job of charge nurse and I've been here 22 years. 

Jeff Terry:  

That's amazing. And that amalgamation process, was that sort of the formation of Nova Scotia Health Authority? Is that what was driving that?  

Vicky Martin:  

It was the beginning of that. Yes. It was, basically, we just kept getting bigger and bigger and it all became one. Yeah. 

Jeff Terry:  

And then I'm curious, 8.2, does that mean that it's the eighth floor and it's one of two units on the eighth floor? Is that how that works or?  

Vicky Martin:  

One of four. It's one of four units on the eighth floor and there was surgery, orthopedics would've been on another wing and it was medicine and family medicine type patients. Yeah. Yeah. 

Jeff Terry:  

And I mean, that's amazing that you've been playing, but, in like, I think all of our audience, but have such massive respect and appreciation for charge nurses and for that leadership role and the caregiving role of that. You must have developed a lot of young nurses over the years and seen people, I mean, do you mind commenting on that, the sort of the leadership development aspect of it or the nursing development?  

Vicky Martin:  

Yes, I have to say, when I was a nursing graduated in 1979, this is a different nurse today. The nurse today is so much better in the sense that they are much more involved with the patient. Their assessment skills are so much better than when we first graduated. We were kind of the handmaidens of the lord kind of thing in the sense that, you know, the doctors were here and we were at a much lower level. We didn't seem to have the same amount of respect or teamwork. And now it seems that the nurses today are bright, they're goal oriented, they want to keep on gaining new skills. And so they come to this unit particularly because it is probably one of the fastest-paced, highest-acuity medicine units on the floor. And all of the internal medicine doctors come through here for the rotation. So they want the most interesting cases. They want, you know, the complexity of a medicine patient. So yeah, I've seen a lot of nurses come through here and they've gone on to so many other things, but I think it's a great starting point for a new nurse. 

Jeff Terry:  

And do you think that that shift in the teamwork that I hear described is sort of the elevation of the role of a nurse and with that, a different way of a care team working? Do you think that's common or that's representative of sort of an overall trend elsewhere?  

Vicky Martin:  

I think it has changed, yes. I think that now the nurse is recognized for what she brings to the table. Like, I mean, she contributes a lot. She's the person that spends the most time with the patient so she gets to know the patient really well. But you can only do this job with good teamwork. I mean, you have to have respect on all sides. It doesn't matter what level you are when you come into the program, you still need like excellent communication skills. You need mutual respect, you need lots of compassion and you need to be able to handle the stress load. 

Jeff Terry:  

Absolutely. You know, one thing that I've always enjoyed, by the way, about just the clinical context and the clinical environment on, you know, on nursing units and in different parts of the hospital is what I have found to be tremendous professionalism and respect among the different caregivers and disciplines of caregiving. You know, even in sort of the chaos of it all, the way that people engage with each other is so, I find, focused, professional. To be honest, I sometimes I wish more people would see it, 'cause sometimes healthcare is an easy thing to pick on. It's expensive, you know, and everybody dies in the end. So, you know, it can't be perfect and what does it all mean? But I think if more people saw inside those activities, I find it, just, to me, it's like watching Navy Seals teams on an operation 24 hours a day that are calmly delivering these really quite remarkable services to people 24 hours a day forever.  

Vicky Martin:  

Yes, and I do believe that, you know, when a nurse is in the right place for her, I mean, she does do an excellent job, but it's the reward factor as well. I mean, we do this job for the reward of actually doing it. And in a lot of cases, at the end of the day, it's, you know, you've gained skills. You're, you know, very important, but it's more important to have the sense of satisfaction at the end of the day that you've contributed something to somebody that somebody is better off because you were there. 

Jeff Terry:  

Hmm. And that's clearly why you got in into nursing and have stayed with it. And do you find that that remains the thing that draws most people into the profession?  

Vicky Martin:  

I think that it draws a lot of people into the profession. I also think that nursing now has become so diversified that there is so many avenues for people to go, that it doesn't necessarily mean that you have to be, you know, necessarily a people person. You could be someone that likes to be behind the scenes. There's just so much work that any nurse, that a lot of nurses can do that we didn't have open to us when I first started. So we branched out to a lot of different places. And I think that, you know, depending on your skillset, it depends on where you end up. 

Jeff Terry:  

Hmm. And out of curiosity, is that the typical new nurse to join your team, is she an like an early-career nurse, a mid-career nurse? Is it a mix? Is it people coming from other part? Yeah.  

Vicky Martin:  

I think it's early career. I think that I'd say it would be highly recommended that most people would say, if you can do medicine, you can do anything. So what that means is- 

Jeff Terry:  

Absolutely.  

Vicky Martin:  

That it's not just one thing over and over again. It's a wide variety of illnesses and so therefore, a new nurse needs to gather as much skill as she can in assessing that and treating. So she needs that background. I think that then they'll branch off sometimes to something more focused. But I mean, there's also the group out there that love the complexity of, you know, it's basically a balancing act between, you know, your kidneys and your heart and your this and your that. And it's kind of like that's what they like to do. It's a bit more of a puzzle. That's why I think I chose medicine. But I do believe that from a basic nurse starting the profession, I would absolutely recommend that she start in medicine. Yeah. 

Jeff Terry:  

You can do medicine, you can do anything. And you've got enough of a sense to probably know what you want and be useful everywhere.  

Vicky Martin:  

Yes, yes. 

Jeff Terry:  

That's great. Well, one thing I should mention for our audience is that Halifax Infirmary and some of the other hospitals in Nova Scotia have recently started using our Command Center software, particularly the Patient Manager. And we wanted to get your take on that, obviously, as a super knowledgeable voice on how, you know, what really works and what really doesn't. So would you mind commenting on how you use Patient Manager and how it's changed your daily workflow in unit bullet rounds and shift handover and things like that?  

Vicky Martin:  

Sure. So when that came on, I mean basically we were involved in the beginning setup of it. So basically we were the pilot project, which was good for us because we got in on the ground floor and we could see things as they were forming and we had input into the whole process. When I first looked at it, I thought, oh, this, I was mesmerized by it all and I mean, I'm the older one in the group, so technology isn't necessarily something that I gravitate towards. So to get rid of my whiteboard, which is what I used to do, and, it basically, we did bullet rounds on the floor, which is a daily meeting that we have with all of the team. And it's quite a large team. All of your clinicians, all of your interdisciplinary staff, your PT/OT, pharmacy, all of those people, and the nurses and the docs as well. So we would meet at 2:30 and we would basically go over, and using my whiteboard, all of the patients, it's a 30 minute for 38 patients and you have to be quick and you have to keep moving. And it's mostly about why the person is still here, what do they need to have happen, how quickly can we get them out and in a safe manner. So that was replaced by the Patient Manager Tile, which after using it, I am a big fan and it took a little bit, but I mean like in the sense of, initially I didn't necessarily know if we would have all of the information, but it became clear that actually we have more information because now we're not erasing as people leave in our discharge. We used to erase out the name of the person that started over, or we move them around due to infection control concerns. And now it's all kept up to date on the computer and we just basically have to go through our patient load, but it's much more accurate and it's also, it's got a good history. So you can look at that history and know what's happened to your patient. And each day is a very different day sometimes for some of these people. And they may have been stable one day, they're not stable the next day and this is all captured on the computer much easier than actually trying to follow it on a whiteboard. So it took, I'm the dinosaur in the group, I'm kind of like the one that hasn't, you know, I've moved forward, but basically they've taken me, you know, with me. So some of these people, especially the younger nurses are very, you know, they're used to computers. That's what they grew up with. But I really like the fact that it's a simple, easy-to-use, accurate, very accurate, piece of information that is constantly changing as the information is being inputted into it. So it's a lot less work for us than it used to be. 

Jeff Terry:  

Well, that's what I was going to ask. So was it you personally who maintained the whiteboard or others in the team? Or how did that work?  

Vicky Martin:  

It was my role to run the bullet rounds, which means that I'm the one that basically is sort of at the whiteboard, changing it up as they're going through and giving me the information. It's very much a team approach and like, you know, what's physio's findings are and what OTs findings are and all that stuff. And the barriers of discharge are being identified as we do the bullet rounds. But if now the interdisciplinary team are involved as well, they are probably inputting the data. They take turns so everybody gets to use the system and to basically get, you know, familiar with it. And it's also more buy-in. Like, I mean, I think that I'm the one that runs it, but at the same time, there's a lot more buy-in from the fact that everybody's using this system. It's not only the people at the bullet rounds, it's a unit clerk that's at the helm every day facing the public. I mean if I know that something's changed during night shift and now the patient is ready to go where they weren't ready the day before, then we tell the unit clerk, "Well, input that into your system." And then the information is, you know, as time happens, it's accurate. It's basically, we're not doing a lot of phone calls saying, "Well, I think this person's going to go, that person's going to go, or no, something else has changed." It's on the computer, everybody's seeing it. So the Command Center downstairs has the information that they need and we are using the information at the bullet rounds to update it so that each day they're kept up to date. 

Jeff Terry:  

And has the whiteboard officially been retired? Is that...  

Vicky Martin:  

We have basically thrown it out. 

Jeff Terry:  

Which is amazing and I have a sense of how big a deal that is and I say, I think, sometimes it's fashionable to say, "Well, you know, these clinicians are resistant to change." But I always say, "Well, there's probably a good reason for that." You know, you have to actually, you know, provide something that solves the need that is useful in the real clinical context and that can be very difficult to do. So that's tremendous that it's actually provided that value for you. And does it reduce the time of the bullet round, for example?  

Vicky Martin:  

Yes, it does. I think it does in the sense that I'm not trying to keep up with, you know, my lovely little marker. Basically, you know, somebody's inputting the data as we speak and we're being very clear about what our goal is, which is basically, "Okay, this is happening. Is our EDD, our estimated date of discharge, is it accurate? Does it need to change? How much time do you think you need?" So we're constantly updating the EDD, which means that we're hoping for more accuracy when it comes to predicting who's going and, you know, how fast can we get them out the door. 

Jeff Terry:  

And do you, I'm curious if you agree with that, I find like the magic, a well-groomed EDD is magic, right? Because the others can prioritize off it, but it yeah, the best groomed EDD is one where yeah, the people closest to the patient are making an informed consideration on an ongoing basis 'cause the situation does change. And, I believe, and I've found that if we can make that easy then people are more likely to engage and therefore it's a higher-value problem solving process, and therefore, a more accurate and a more current EDD which then can be used by others. And that's, I think, the same wavelength you're on.  

Vicky Martin:  

Yes. Yeah. I think that it's accuracy that we're looking for and I mean, we don't have it down pat yet. Like, I mean we are working on it, but I mean, and people are changing all the time. You can't say with a hundred percent certainty that someone's going to go out the door because something can happen overnight and it's changed. But I mean, as we get better and better at it, I think that we are going to get closer and closer to, you know, more accuracy as far as predictions go. 

Jeff Terry:  

So, and as you know, the medicine units obviously can have some of the toughest to predict because of the mix of the patients and the change, the nature of the, yeah, it's not a total needs right, which you can really dial in with a higher degree of accuracy in many cases.  

Vicky Martin:  

Yes, I mean it's not a surgical procedure where they're given four days after and then they're going to go home. This is complex medical patients, they're the hardest ones to predict and they also have some of the biggest social issues as well. So I mean there's big barriers in the system with this. The social problems that we have and identifying barriers that we can actually do something about is huge because then we will save, you know, like what's keeping the patient in, what can we do about it? And then, you know, the escalation Tile or the escalation piece of the Tile where they're basically looking at, how can we solve the problem so that we can actually, you know, get the person to where they need to go. 

Jeff Terry:  

So you guys in Patient Manager, you're escalating from time to time up to the Command Center that we have and they're responding and barrierbusting for you, is that?  

Vicky Martin:  

Yes, exactly. And that is so good to see because, you know, for years we've talked about all the problems and we know that there's lots of barriers, but you know, everybody actually having a spotlight on those barriers is helping. And to know that somebody out there is basically, not just us but everybody, you know, every floor is on this, so we all know that everybody's doing the same thing. So that those things are what's going to change things. Like, I mean, and to do things just for the sake of doing it, I mean, we're all tired of that. And the workload on every floor, I'm sure everywhere is so much more difficult. There's less personnel to work with, there's all kinds of stresses in the system, but when you see something change for the better and you actually think that the energy and time that you put into it is actually making a difference, that's a good thing. That's a really good. 

Jeff Terry:  

Hmm. That's wonderful. And would you mind commenting briefly on shift handover? Do you use it the same way in shift handover?  

Vicky Martin:  

So we're not completely there yet because we would like to bring the nurses on board. Like there's a few people that would replace me or my counterpart and they would do charge and so they'll be brought on board. But because of the lack of staff right now and the number of vacancies on the unit, we haven't had time yet to actually bring all of the nurses on board. And those are the gals that would be, or guys, that would be on at nighttime that might be able to access and basically change some of the data. I think we'll get there eventually, but until we get the staffing issues rectified, we're still working on that. But when I come on in the morning, I get shift handover and then basically the first thing that we do in the morning before we do anything else is check our Tile. So we check what the predictions are and then we also check, you know, what has changed so that maybe those predictions aren't actually right. And then we would have the unit clerk actually go in, change those numbers before our bed meeting, which is at 8:30 in the morning. 

Jeff Terry:  

And do all the charge, that's the campus bed meeting, is that right? And do all the charges join that? Is that how that works?  

Vicky Martin:  

Yeah, all the charges and I think a lot of the unit managers and directors, I'm sure there's a large group. Yeah. Yeah. 

Jeff Terry:  

Yeah, that's awesome. And you've been at on 8.2 for a long time and seen a lot, I'm sure, seen a lot of initiatives come and go on EDD and throughput and access and all these topics and they're going to, you know, these topics will go on forever, right? It's the nature of it. But there's also the tools that are used to make things easier. And I'm sure you've seen specific tools come and go. I guess what, I don't want to put words in your mouth, but from your comments, it seems like you're having a good experience with Patient Manager. So, I guess, what gives you confidence in Patient Manager or how do you think it's different than some other things that have come and gone perhaps?  

Vicky Martin:  

I think it is more central. I think that everybody's involved. I think before it was always, we were doing things separately. In other words, we'd try something, someone else would try something. It didn't seem to be like a very well-coordinated process. So basically at this point, the information that we're all seeing is basically to try and solve the problem. I think everybody understands the problem. I just think that now with the technology that we have, it's going to make it easier. I think it was much more difficult before and I think we had a lot of meetings that we had to attend to and there was, you know, it seemed like we lost our energy and this seems to be something that, you know, it is a good system. It's actually been tried elsewhere and we are just seeing the benefits start now. I'm sure that there's lots more that's going to come from it and all of the information that we have inputted into it, I'm sure that there will be things that they can actually, you know, pull from it that basically is going to change how we look at how patients come through our system. I don't know for sure all of the benefits, but I do know that it's not just B and it's not just 8.2, it's the entire system. So we're hoping. 

Jeff Terry:  

Heck yes. And can I ask, my sense, I guess I'm thinking of, you know, obviously 38-patient unit, you have a lot of nurses and there's, you know, turnover and new nurses and as you mentioned, and my hope and belief is that something like Patient Manager can be particularly useful for the novice nurse because it scaffolds some of the activity. It almost gives a playbook, you know, sort of work left to right to get through the round. And I think that's important 'cause the last thing we want to do to a novice nurse is make her life more difficult. So is it your sense that it's helpful even for the novice nurses, if you will?  

Vicky Martin:  

I think it will be. I think that number one, they also need to, by attending bullet rounds, by seeing how the team works and how important their information is. I mean, they're doing the basic assessments every day of the patients. They see them the most, the interdisciplinary team. Like it just shows how a well-run team would work. And the C3 is kind of a representative of that. It's just at a much bigger level. I mean we are the floor unit, but when you actually take the entire thing and put it together, it's basically everybody's energy is on the same thing. Better patient outcomes I'm sure will come out of it. 

Jeff Terry:  

Totally, and you mentioned that before, but it's one, yeah, you can't have a, well this is, we're working on throughput in this way on 8.2 in a different way in another unit. And the the set, you know, the bed control's got a different approach and... By working in a joined-up way, clearly we perform better. So another thought, so Halifax Infirmary, no surprise, is on the leading edge of the use of this tool in Nova Scotia. Some other hospitals are adopting it now and others will begin adopting it in a few months. What would your words of wisdom be to that charge nurse, you know, in the next hospital in line?  

Vicky Martin:  

I think I'd say, "Don't panic, don't panic." It's not something, I mean, for someone that's not used to working with this program, it looks like a lot when you first look at it, but it actually makes a lot of sense. And I think that very quickly when we were working with it, we incorporated it into a daily routine. I just think that anybody that's trying it for the first time, initially it looks like it's, you know, a little bit more complex, but it's actually quite user-friendly. And the other thing is the benefits that you gain from it, you don't realize, but they are there and we've seen quite a few positive results and that's in the short time that we've been using it. So I wouldn't be here to spread the news about C3 if I didn't believe that. I really believe that it's a good program, but it's also something that for all of us that are using it, that it's not complex. The information is accurate, we're transparent. We're not working separately. Like each unit is not in this, we're all in the same boat. And I think that most people don't understand, like, I'm not against, you know, like we're not against each other. We're working together. And I really believe that people sometimes used to think, "Well, you know, 8.2 is so busy they get..." you know, whatever. I think now it's like everybody's busy. Everybody has barriers. What can we do about it? 

Jeff Terry:  

That's such a great, I love that we're all in the same boat. Helping people understand that and operationalize, which can mean for people who maybe haven't been around that environment can sound crazy. Well of course we're in the same boat. How hard can that be? But it's actually quite tremendously difficult to give the frontline a sense of the enterprise situation and the folks at the enterprise level, a sense of the frontline situation. And it's really, really hard.  

Vicky Martin:  

Yeah. 

Jeff Terry:  

That's tremendous. And if we can give a little bit of time back to you with all of the knowledge and skill that you have and obviously your peers, that's immensely valuable in the way that you can reinvest that, I think.  

Vicky Martin:  

Yeah, and I think that the patients, they don't want to be in hospital. They would like to get out as soon as they can. And sometimes, I mean, we're stuck waiting for a diagnostic test. I mean, if C3 can expedite that test so that person doesn't have to be in hospital away from their family, they're going to do better at home and they need to have this test done if it's one of the blocking, you know, like one of the barriers of getting this person out, thank God somebody's doing something about it. You know, let's get them out. 

Jeff Terry:  

Heck yes. And I should mention for our audience, by the way, C3 is the Care Coordination Center, which is a physical center at Halifax Infirmary that's supporting the, well, more and more of Nova Scotia Health Authority over time. And it's also the name of sort of this program that's using this software to work in a more joined up way for throughput and access and more and more down the road. Brilliant. Well, Vicky, with that, well, I'm so happy that you joined us. I could talk about it all day. I appreciate your insights very much and I guess I just had such a admiration and appreciation for the work that you do and have done for such a long time. So your feedback and perspective is super. Yeah, it's not just valuable, but it's so credible. So thank you very, very much.  

Vicky Martin:  

Well, thank you very much for having me. 

Jeff Terry:  

Awesome. We'll leave it there. Thank you for joining the podcast, everyone.

(00:16) Helping older adults age in place
(01:07) Understand care professionals perspective
(01:42) How Honor provides non-medical home care
(02:13) Partnering with hospital-at-home providers
(03:32) Technology to aggregate care pros and provide transparency
(05:28) Improving care pro performance
(07:59) Extensive data on care pros and clients in the home
(10:36) Integrating with health systems' EMRs
(12:48) Machine learning to reduce care pro call-offs
(15:09) Respect and schedule flexibility
(18:39) Improving predictive algorithms
(20:26) Lower turnover and higher satisfaction
(21:13) Care pro satisfaction is feeling respected
(22:01) Schedule flexibility 
(23:07) Honor's mission to honor care pros

Jeff:
Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Seth Sternberg, who's the CEO and co-founder of Honor Technology. Hi, Seth.

Seth Sternberg:
Hey, how are you doing, Jeff?

Jeff:
Wonderful. Great to be with you. I think a great place to open is where we were sort of just hit chatting offline, which is something that we have in common is between our firms and I think ourselves personally is a real appreciation and commitment to serving caregivers, which I think is what motivates you. So please talk about your mission as a company and caregivers in general.

Seth Sternberg:
Yeah, so we started a company to literally try to transform the way society cares for older adults. And as we unpacked that and kind of narrow that down, we said, "Well, let's really focus in on helping mom and dad stay in their homes as they age." It's too broad to transform everything up front. You have to pick a smaller slice to try to work on first.

And so then we looked at all the various ways to potentially do that. And we found this space called Home Care where what Bureau of Labor Statistic calls personal care aids, goes into homes of older adults and helps them with things like getting out of bed or getting food or getting dressed. And these are called Activities of Daily Living or ADLs. And so the way this service is delivered, it's a huge industry, it's an 85 billion dollar industry, is these personal cares get hired by local agencies. It's super fragmented, and they go into the homes of the adults and help them kind of individually one-to-one.

And so what we did is we went and interviewed about 50 of these folks at the Starbucks in Sacramento, California, and then at another Starbucks in Phoenix, Arizona. And a couple of things came out from those conversations, but the most poignant one was this person who said, "Look, I'm called unskilled to my face, treated like crap by the families, by the agencies, but I'm a professional, and I want to be treated like one. And that's how I act. That's how I see myself." And so that's actually where the term Care Pro or care professional came from. We said, "Okay, if these truly are professionals and let's call these caregivers what they see themselves as and what they really are, which is professionals. Call them care professionals." And then we coin the term really quickly thereafter, care for the Care Pros. And we've really built the company on that notion. And what it is if we do a good job caring for the Care Pros and put them in a better place into their own lives, then they can in turn do a better job caring for our customers, the older adults and then often their children.

Jeff:
This is great. Can I just, because I'm thinking of many in our audience who this will be super interesting, but we'll use some of these terms a little differently. So I want to make sure that we're all tracking. So the focus of your firm is on Care Pros who are home nursing and home care providers who go into homes and do that ADL work which is a great and important form of care giver. And so the focus of Honor, initially at least, is to serve those Care Pros, that type of caregiver. Is that right?

Seth Sternberg:
Well I think that our customers think that our mission is to care for older adults, and very specifically let's provide them better home care than they've been able to get elsewhere because we can actually go to scale. We have a whole bunch of technology that allows us to aggregate up a thousand Care Pros in a market. And so therefore we're much more likely to have the right Care Pro for your mom. And then your Care Pro's going to have much better, more modern tools so that they do a better job following a very clear care plan. You, the son or daughter who's helping take care of your mom, are going to get a lot of transparency in our app that's going to show you who's going to mom's home, what are the notes that they took, how the wellness check go, what did they did do while they were there? So I think our clients think of us as home care and they think of us as, hey, I'm hiring Honor or Home Instead, which we also own, in order to care for my mom or dad. But the background reality of how to deliver that service really, really well is actually the focus in your efforts. We as a firm focus in our efforts on caring for the Care Pros, our employees.

Jeff:
Which translates into better care for the end customer, for mom and dad at home. But that's really the focus of your approach that-

Seth Sternberg:
Exactly.

Jeff:
That makes great sense, thank you.

Seth Sternberg:
Yeah, and we build a lot of really cool technology, and I'd say about 70% of the budget goes to features that are about affecting Care Pro performance or behavior or job type. And usually it's like how do we give the Care Pro an even better job that's even more perfect for either their desires or their skills so that they will then perform better? Because we're not only giving them the right tools to perform well, but we're also putting them in the right environment for them. So often people miss it. Look, professionals do well when they're in the job that they're naturally good at.

Jeff:
Even Michael Jordan wasn't a great baseball player, right?

Seth Sternberg:
Exactly. Yeah. It's the same thing for the Care Pros. So if we recognize, look, you're going to be the best in this kind of job, that's the kind of job therefore we should offer up to you, that means that they'll perform better. And there are lots of other pieces to it I could take you through, but it's a huge focus of ours.

Jeff:
That's great. Another question maybe you might want to comment on is another growing area is Hospital at Home, but that's different than the kind of in-home care at least that we're talking about so far. Talk about that, please.

Seth Sternberg:
Yeah, so we provide what people refer to as non-medical home care or ADL supports home care. So we're basically doing everything up to piercing the skin. So we're doing help people get out of bed, help people with bathing, toileting, lifting and transferring, up to late-stage dementia, light wound care. So we're doing kind of right up to the bloody edge of things that become healthcare services that are reimbursed by either commercial insurance or the government. But we're usually private pay.

And then the other big difference is we're usually in an average home for, call it, 20 to 30 hours a week. So when we're serving someone, we're serving them in a really, really deep way as opposed to Home Health or Hospice, which will tend to pop in for 30 or 45 minutes and pop out. They did the thing. They changed the IV, or...

And then you asked about Hospital at Home. So we actually have partnered with Hospital at Home companies, and the way that we've done that is when we have a customer who may benefit from Hospital at Home, we will give them a call and bring them in. And the reason we're doing that is we want to help that person stay at home. That's a big part of what we do is help people stay at home. We do not provide Hospital at Home ourselves, but we have relationships with so many clients. We're the largest network in the United States by multiple. Largest network in the world by a multiple. So we have so many clients that we see people who have clear medical needs, and then we can get in touch with those providers and bring them into our network.

Jeff:
That makes total sense. So are you then, because clearly you're a partner too, in many cases you would be the discharge disposition of an inpatient, whether it's Hospital at Home or in a typical acute environment. And so you must partner with all the name brand hospital systems, or many of them, to make those transitions easy.

Seth Sternberg:
So that's a big part. When you look at where our customers come from, a big part that they do come from is some kind of acute setting. It might be a hospital discharge, it might actually be ER diversion. It can be something subacute, it can be I've been in a nursing home or a rehab for X amount of time and now I'm discharging to home. I need help. So that is one of the places that customers come from.

Jeff:
Sure. Many sources I'm sure, but just much of our audience is of hospital-oriented. So just to make that connection. And the work that you're describing, and thank you for clarifying it and helpful to me for sure to get my arms around it, is some of the most compassionate and important. Everybody needs and we're all going to need at some point. To your point about caring for the people doing that vital work certainly resonates with me.

Seth Sternberg:
And I think also when you're in the healthcare system, you know how important all the other stuff is. You know how important it is that the discharge home goes smoothly. Was the DME there? Was the food there? Were the meds there? Did this person get discharged into an environment that's extraordinarily likely to create a bounce back or not?

And so a big part of what we focus on is just ensuring that people are in a really good situation in their home when they get home from whatever acute setting that they're in. But then we're caring for people for years as well. And so when we're caring for those people for years, we also kind of send people the other way. It's like, "Hey, they're at home but they need some kind of healthcare service, and so let's make sure that we line them up appropriately." So we kind of flow in and out of the healthcare ecosystem and we partner with it closely, but we don't provide it directly ourselves. And that's actually intentional.

Jeff:
And may I ask, it sounds like you've got a pretty sophisticated app that serves your Care Pros and probably also your customers.

Seth Sternberg:
Yeah.

Jeff:
May I ask, do you do integrations with the health systems EMR ever, or how does that work?

Seth Sternberg:
Yeah, so we've done some light stuff in the past. They used this protocol called HL7. Some of your audience, maybe you know what HL7 is. So we've done some really light integrations in the past where we've passed a [inaudible 00:10:12] HL7 files, but we haven't done a deep integration into someone's EMR. It's something that we could do, but to be blunt, the volume would have to be really high. And so it would have to be, to get us to do that kind of technology work, it would just have to be a lot of volume.

Jeff:
And it may in the end be certain target integrations. I'm thinking of our software, we'll make it visual to the care team. Is the DME ordered in time, and is it there yet? And maybe some of those very targeted messages might be worth it that we could find a way to make it really easy to do.

Seth Sternberg:
So there's this alternate concept, and this is a platform that we actually have built, which is giving people a dashboard where they can see kind of status of what is the care that someone's getting or what's a care plan or whatnot. And that's available right now to two different kind of actors in our ecosystem or in our network if you will. Both kind of agencies that we partner with and then also the families. So there's already kind of a really robust set of tools that enable people to be able to track the care and situation of our end recipient of care-

Jeff:
Perfect.

Seth Sternberg:
-should they appropriately need that information.

Jeff:
So we talked about some of the things you're doing and might do. If you don't mind sharing, what are some of your development priorities? Where are you taking this? Where is this concept going?

Seth Sternberg:
So the thing that's really interesting is, we probably see more in the home and record all of it. Our roots are very technology and then we got into this, hey let's care for our parents and quickly learned the care and healthcare ecosystem. And so with those roots we recognized early on, look, when we're in the home for, call it 30 hours a week, we know almost everything. We know what the refrigerator looks like. We know the state of the bathroom. We know what meds are being taken. We know what food is being eaten. We ask people every day, every time we see them, "What's your state of mind? Are you happy or sad? How many bowel movements have you had in the last 24 hours? How many meals have you had in the last 24 hours? Let's talk about your sleep." We call this a wellness check.

So with all of this data collection, there's very interesting things you can do to link that person that we're caring for into both the broader kind of retail and consumer ecosystem, and also more appropriately into the healthcare system. And both are areas that we're pretty focused on. So in the broader retail ecosystem, I start thinking about if you're 80 years old, and you are in a chair, and it's hard for you to get up and move around, it's actually really hard to use Amazon. Not because you can't use Amazon's app, but because it's hard to get the box that arrives at the front door. It's hard to use the box cutter to open the box. It's hard to distribute the contents.

Jeff:
Yeah.

Seth Sternberg:
We can make that so easy, because we know the milk is low. We know that light bulb burned out, and so let's take care of that automatically and ensure that our Care Pro when they're in the home knows, hey the box just arrived from whoever, Amazon or Walmart, and let's go ahead and replace that light bulb.

And at the same time we can know a lot about what someone's kind of current condition is. And like I said, if it's appropriate for them to then start to seek or go talk to their medical provider. So that's another really interesting area for us.

Almost all of the features that we build are based on this data and watching this data, and it's almost always machine learning that's doing the heavy lifting. So an example would be, let's talk about the workforce for a second. Anyone who's a provider of care, they have a workforce that's providing the care, and their workforce has some kind of performance statistics that they look at over time. One performance statistic a lot of people look at is call offs. It's how often does do my care providers call me and say, "Hey I'm not coming."

Jeff:
Not work as scheduled.

Seth Sternberg:
Yeah, exactly. Not work as scheduled. Exactly. So we zeroed in on that problem. This is just one example and we said, "Hey, we want to get the call off rate down." And what we first did is we showed the machine all the data associated that we collect: GPS track logs, and care plan track logs, and scroll data on the app and the phone, and seconds viewing a page, and ratings customers are giving Care Pros, and ratings Care Pros are giving customers, like everything.

Jeff:
That's great.

Seth Sternberg:
We said, "Here's all the data around when there is a call off. Here's all the data when there is not a call off. Can you, the machine, figure out the pattern. Can you tell me what are the relevant-"

Jeff:
What did you find?

Seth Sternberg:
So the biggest one by far is actually distance from where the Care Pro lives to the client. That's a really big deal. The second one, which is super interesting, is the Care Pro will often say, "Yes, I'll take this job that's not perfect along a lot of dimensions," because they need a new job reasonably quickly, but in their heads they're taking it temporarily. And so it's kind of like I really need work right now. This is not great. Not just because of distance, but maybe so we've done another ML work that looks at the hours and type of work Care Pros want to work. And it turns out that you can kind of say, "Hey, you are a generalist. You are a nine to five. You are an overnight. You are a backfill." When you do the ML work on how [inaudible 00:16:04].

Jeff:
Clustering those behavior. I bet. I believe that.

Seth Sternberg:
It's behavioral life circumstance. Those are the four big buckets that people end up falling into. So someone who's an overnight might take a nine to five during the day because they lost a customer, the customer passed away, or moved to a facility.

Jeff:
So by understanding that you were then able to try to make matches differently to reduce those likelihoods. Is that...

Seth Sternberg:
Exactly. And so what we started doing is saying, "You know what? Since we now know that you're probably choosing this customer not because they're really great for you, but because you probably need to fill in, we're going to actually direct you to a different kind of job that is designed for fill in."

So what we ended up doing is we designed an area in the app that was literally the fill-in section. So it's like, if you just lost a customer because they moved into a facility or passed away or whatever, go to this tab over here. And in fact you might be able to fill in with lots of different shifts where there's a call-off that we have to back fill, or a new customer we're just spinning up or whatnot, or a condition changed and you're more appropriate for that condition change. But then keep watching this one over here and in fact we'll send you the machine, we'll send you automated notifications when a new customer pops up who's really like a direct hit.

Jeff:
That Meets your profile. Yeah.

Seth Sternberg:
Yes, exactly. So...

Jeff:
That makes a ton of sense, and I can see how it's good for the Care Pro, it's good for the customer, it's good for the cost of the system, it's good for everybody.

Seth Sternberg:
Yes, exactly. Everybody wins.

Jeff:
Can I come back to something that you touched on that I think is super interesting too is what you described, and the kind of information that your team's routinely capture would be roughly equivalent to a lot of what is considered nursing documentation in an inpatient environment. There are several deterioration scores that predict future clinical trajectories, like the Rothman Index, that call it 10 years ago, got a lot better when they started incorporating turning nursing notes into structured data and incorporating that into algorithms as opposed to just vitals and signs and labs and so forth. And it seems to me then you probably already thought about this. So I guess how are you thinking about turning those? It seems like you're sitting on something that could be really useful.

Seth Sternberg:
So we have that data, and actually importantly, you just said something that's really interesting. You said turning the unstructured data into structured data. You could actually take that a step further and you could say, "What if we went to observe data versus reported data?" So if your technology is embedded deeply enough in the use of the system, the technology can capture a lot of the data, kind of [inaudible 00:18:52].

Jeff:
Absolutely. Yeah. By one way or another, by turning things into sensors, by using natural language processing, by going to check boxes, lots of ways. But in the end, the net of that has been the ability to incorporate into an algorithm a signal that 10 years ago couldn't be incorporated.

Seth Sternberg:
Exactly. It's like a much more reliable signal that you have.

Jeff:
And it turned out, and the reason I always remember those, because it turned out that nursing documentation, which is exactly analogous to the kind of things, those were a game changer in the accuracy of those algorithms.

Seth Sternberg:
Yep, yep. Exactly. So [inaudible 00:19:24].

Jeff:
Are you guys thinking about it? I assume you're considering ways to use your data.

Seth Sternberg:
Definitely an interesting area for us. I have nothing to talk about there.

Jeff:
Okay, fair enough. We'll look forward to reading about that from you.

Seth Sternberg:
We have a lot of that data, and you would think that we could process it in interesting ways.

Jeff:
Let me ask you one last thing then, which you kind of started with, we've alluded to a few times, but I'd love to hear the sort of other end of the rainbow, which is you've put a lot of work and thought into how do we make it easier for Care Pros to do this work and so forth. What's been the reaction, the feedback of Care Pros from sort of experiencing how you serve them?

Seth Sternberg:
So we literally operated about half the turn rate of the industry. That's probably the headline stat. And then when you do our satisfaction scores with Care Pros at various market by market. We operate in lots of markets and states throughout the country and then Western Europe. But when you do the satisfaction scores about 80, mid eighties are usually satisfied or better, which is really awesome for this workforce. So we're really happy about that. We just looked at this one cohort, it was interesting, we analyzed them. 76 Care Pros came in from this one cohort back in 2019, pre-pandemic. And 40 of them are still with us today. Three years later, through a pandemic, in an industry that has average 80% annual turn, and over half are still here. And that's amazing. So the statistics kind of speak for themselves.

Now the question's why? And we've talked about, let's deliver to the Care Pros a professional experience, blah blah blah. But we actually have done the statistical analysis on what truly makes a happy Care Pro. And it turns out that the number one thing they care about is what they call respect. And this is the number one statistical correlate with I'm happy and I'm satisfied. And what they call respect when you break it down is things like, did you pay me what you said you would pay me? Did you pay me on time? Did you put me into an environment where my skills are appropriate? Do you guilt trip me? That's a big one. Do you guilt trip me into working with customers that I don't actually want to work with? Come on Janet, can't you take this shift? I know it's Christmas Eve, but I did that favor for you. They hate that. So that is the number one statistical correlate.

And then the number two statistical correlate is hours availability. So if I have two customers, 20 hours each, and one of them moves to a facility next week, did I just lose 50% of my income? Or is your system large enough in design such that no, no I can actually backfill the majority or even more than what I was working so that I don't lose that income. That's a big one.

But then the other one is not presupposing that we know exactly which customers and exactly which time slots that Care Pro wants to work in. And it turns out you don't even want to ask the Care Pro directly when they work. The data, they tell you, I don't want to work on Saturdays. Very frequently you will find they will actually violate what they said same day, and rather you go to inferred data where you watch their behavior and then you see, oh okay, you would work on Saturdays if it's within this geographic band or within these times or whatever. So if you deliver a system to Care Pros that lets them work on their schedule as they want, that's also really huge. So those are the two kind of clear correlates with a happy Care Pro who retains.

Jeff:
Super interesting and clear. And I'm curious, is that emphasis on respect, is that part of why the name of the firm is Honor?

Seth Sternberg:
Yeah, so when we started the company, this is 2014, we hired a naming firm. There were so many names that they went through, and I just kept not liking any of them. And we had gotten to the point where my co-founders were like, "Seth, you're screwing the company up, because we don't know what to [inaudible 00:23:26] base at this point. You're slowing down coding, because we don't have a name." And so one night I literally pulled out a thesaurus and just started going through lots of word associations, and I saw honor and I was like in isolation that's pretty bold, but the whole point of the company is honor the Care Pros, and honor the clients, the older adults. It is actually what we're about. And we're trying to do that better than anyone has ever done it before. Honor felt appropriate. So then I went to the team and I was like, "Hey, let's mock up Honor." So we mocked it up and looked at it, and it felt really good, and that's where it came from.

Jeff:
Makes a lot of sense. And yeah, honoring caregivers, certainly something we can get behind. Congratulations to you and maybe we'll leave it there. Thanks for joining and chatting, Seth.

Seth Sternberg:
Awesome. Thanks for having me, Jeff.

Jeff:
You bet, man. Really enjoyed it. Thanks very much to our audience. Well, that will close the podcast.

(00:26) The nursing shortage, made worse by pandemic
(01:42) Loss of 1.2 million nurses by 2030
(02:13) Mental health issues, early retirement
(03:15) Shortages cause unsafe ratios, liability issues
(05:09) Technology to minimize shortage impact
(07:58) StaffHealth provides fast staffing to facilities
(09:23) Flexible scheduling, fast pay, and communication
(11:04) StaffHealth vets credentials, reliability and culture fit
(12:31) When outside nurses join existing teams
(14:20) 62% of nurses became travelers
(15:35) Affording high traveler wages long-term
(16:37) Wage expectations
(18:32) Passion for nursing and bedside care
(18:47) Technology for staffing and maintaining ratios
(19:03) Solving shortages together

Matthew Mawby is a nurse and co-founder of StaffHealth, and he's working to take the hassle out of nurse staffing. Jeff and Matthew discuss the current state of the nurse staffing crisis. We may be getting close to turning the corner. But hospitals are still struggling to fill open shifts. Listen in as they share how hospitals are using innovative technology and processes to address staffing shortages.

Jeff Terry:
Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Matthew Mawby, who is the CEO and co-founder of StaffHealth, who joins us today from North Carolina. Hi, Matthew.

Matthew Mawby:
Hello, Jeff. How you doing?

Jeff Terry:
Perfect. Thanks for joining. Looking forward to this. Hey, I wanted to start, I know a common topic of interest to our audience is the nursing staffing challenge. You live in that world. If you don't mind, let's just unpack that a little bit. What are you seeing in the staffing world? Are we still in shortage? Is it getting a little better, getting a little worse? And for the audience, we're recording this August 29th, 2022.

Matthew Mawby:
Thanks, Jeff. I mean, it's a great question that a lot of people ask on a daily basis. The fact of the matter is, is that we were in a slight nursing shortage before the pandemic. The pandemic, unfortunately, just added to that stress level of really finding nurses, keeping facilities staffed at proper levels. On top of that, there's a lot of factors that actually came in play through the pandemic that added more stress to that shortage. We're projecting, I think, to about to lose 1.2 million nurses by the year 2030. Roughly of that number, actually we have a lot of baby boomers and a lot of people will be retiring, and then choosing early retirement.

About 4.7 million of healthcare workers will retire by 2030 as well. We're talking some pretty staggering numbers here. Just to highlight a little bit on the pandemic, and I know the pandemic has accelerated and exacerbated this whole kind of field or industry, but it's changed a lot of things, Jeff. What I mean by that is people were stressed out. There's a lot of mental health issues. There was a lot of people who chose early retirement. There was wage problems. There was people who didn't want to deal with COVID during that time, and they couldn't even get a break during their shifts because the facilities were just so short staffed.

When a facility gets short staffed, just a little background, it affects every level. You have CNAs that are a support system to the nurses, and then it just goes up and up and up. When the ratios are very unsafe and you have so many patients, for one nurse, that workload is tremendous and it causes issues. It causes safety concerns. It causes liability problems. It's definitely something that we need to take head on and find innovative solutions from what we found, including technology, just to help out and to minimize these numbers, get new nurses onboarded, get new nurses interested in nursing again.

That's another thing. It goes on and on. I know we can talk about this all day long, but it's definitely an issue. Here at StaffHealth, we're obviously trying to tackle it head on as well along with everybody else. We're all in the same boat here together. That's where that's at with it.

Jeff Terry:
One thing that struck me, because we serve health systems West Coast to US, East Coast, to the US, Canada, the Netherlands, the UK, and almost all of our health systems are struggling with those shortages. I find the fact that it's so international is remarkable. I guess on my mind, you probably see a lot of data in your role, different metrics that you guys watch and things. I ask this because we all see the world through our little straw. I can tell you 10 anecdotes from the clients I serve. Do you have any sense if we've turned the corner, where we are sort of in working through this?

Matthew Mawby:
It's so tough to tell, Jeff, at this point. The reason I say that is because it's innovation and it's using a lot of technology. But when it comes to the nursing shortage, it's something that's not going to happen overnight. We need to understand that. We can put band aids on it all day long. We can find short-term solutions, but what about that long-term impact? A big part of that is getting people to be interested in nursing again, graduating from nursing school, going to nursing school actually in the first place. There's a funding out there, a lot of tuition reimbursement programs that are being offered. There are ways that schools are enticing people to join the nursing profession again.

I do think we're making headway. One of my personal opinions about it is throughout the past two years, I think that we went five, 10 years ahead almost in the healthcare space just because we were forced to find solutions and forced to put our funding and our resources in the right places. Technology is a huge part of that, especially when it comes to doing speedy staffing. Have we turned a corner? Yes, we have. Is it noticeable yet? That's very tough to tell this early on from our point of view. But with some simple solutions and listening to the nurses and what they need, that's a big factor.

Jeff Terry:
I want to get to that. But maybe as we get into that, you went to nursing school. By the way, I love nursing. What motivates me to do the work that I do is serving nurses and helping them in the work that they do. What do you love about nursing? What inspired you to go to nursing school?

Matthew Mawby:
It's a passion of mine. I mean, growing up, I was five years old when my little brother was born with major handicap issues, premature. We had to learn sign language when I was like seven or eight. He's had 80 operations. The consistent, I guess, factor that you can say throughout my life was the nursing piece of that, because the nurses are there for you when nobody else is. You are at your worst of the worst, right? I mean, you need somebody to believe in you. You need somebody to get you over that hump. That's what got myself, my family and my brother through a lot of those issues throughout life on the long-term scale.

And that's why it's so important for nursing right now at the bedside. We want to carry that passion for nursing along everybody that we staff, all the nurses that we have and we see and touch, or whatever it may be. It's a make or break when these patients are just at their worst or their worst and it's just encouraging and it's needed.

Jeff Terry:
I love that statement, nurses are there when nobody else is. That's the nature of the beast. Certainly if you're an inpatient, there's always nurses and that's looking after you and what tremendous work they do. Thank you for that. Clearly this is a big problem. Lots of people are working on it. There's policy issues and incentive issues, all sorts of things that are playing out, but StaffHealth is trying to help as well. Would you mind describing StaffHealth, the work that you guys do and what it is that you bring that's distinctive?

Matthew Mawby:
Here at StaffHealth.com, we help facilities who are in need of staffing solutions, especially short-term staff. We do offer long-term and travel as well, but we're here to help... We're about speed here. Let me start with that. If you're short staffed at your facility, we want to send people in as fast as possible. Let's say if you have a nurse that showed up, got tested for COVID, for example, and was asymptomatic and got sent home, well, that's one nurse down that you are for that whole shift. Your ratios are crushed. We developed an app called NurseShifts. We listened to the nurses. What did the nurses want during all this?

They wanted work-life balance. They wanted wage increases. They wanted to be paid faster. They wanted flexible scheduling. A lot of these nurses have children, childcare issues the pandemic sprouted, right? Everyone was short staffed. Early retirement as well, that led to a lot. But overall, we're here to find and be part of that solution to offer very fast services for when these facilities need it the most. That's why our app offers that nurses can pick up shifts that they want, when they want. They can work when and where they want. We offer same day pay so they can work a shift, get paid hours later.

Communication is a big one. We offer communication between us, the nurses, the client, which is the healthcare facilities. We're trying to use technology to our advantage and really be a solution rather than a burden to these healthcare facilities that really need help.

Jeff Terry:
You guys provide the app, and then the nurses are able to register in there. Do you also then work with the providers so that your app is the broker between them?

Matthew Mawby:
Absolutely, Jeff. We take it out of the administrator's hands, right? Because all this takes time and cost money. When you're talking about recruiting, then onboarding, vetting, collecting credentials, you're talking about sometimes it takes three months just to onboard one person for a permanent role. Here at StaffHealth, we have people that do this. We have a team that does this every single day. We're doing all that for you. We're vetting these nurses. We're trying to find the best cultural fit for your facility, your healthcare facility, reliable people. Like I said, it's speed before is that let's just say, Jeff, you need a nurse right now or maybe you need one for tonight.

We can post that on the app, and we have a database of 98,000 nurses who we could reach out to, and then we will fill that position fast. We'll get the credentials over so you have them immediately through the app, and then you guys are there. You don't have to sit there on the phone, call. You don't have to have your director of nursing sit there and make calls all day. It's taking that gap out, and that gap is time. Time is money. It's really minimizing that. It works tremendously for all healthcare facilities that we work with.

Jeff Terry:
I can see the value of that, making it easier, more frictionless, particularly in that scenario, I need a nurse for tonight who's credentialed, who's available. You mentioned something very interesting. I don't know that I've come across before, which is you're vetting them for credentials and reliability and flexibility of scheduling, but also for culture. That's really interesting. Do you mind sharing how you do that?

Matthew Mawby:
We all have challenges and some of the challenges that we've seen in this, I guess, industry, when you have people from the outside going inside to an internal facility who may have a group of people they've worked with for 20 years, right? Anytime you have someone new come in, the dynamic changes a little bit. Our goal is to send the right people in so that dynamic changes very minimally or not at all. If we can learn a facility's culture, what they need, what they believe in, what their values are, what kind of people they want to hire, we can use that to our advantage and actually vet people for those skillsets or values or whatever it may be.

Therefore, it causes more of a seamless entry of a new candidate, a new nurse going into a facility, and it gives them the chance to hit the ground running, right? I mean, I'll be honest, there's been bullying. There's been jealousy issues. There's been, "Hey, who's this new person, all of a sudden for this one shift? How much are they getting paid? What do they do? Where do they come from? Are we being fired? What is it?" There's a million things that could go on that really could disrupt the floor of a facility. We've seen it in the past with us. We've seen it with other facilities, other companies.

We've seen it across the board. We're really trying to minimize that to make it effortlessly as possible so people just have a good vibe in the facility, because that means a lot to these people. It really does.

Jeff Terry:
Well, let me ask one last question there that you brought to mind is... I hear that question asked a lot. I'm curious your experience with it. We've always had travelers, but we've had more traveling the last couple years, which means, yeah, you do get that scenario where you could potentially have a big disparity between what two people do in the same job shoulder to shoulder are making on a given day. Not a new phenomenon, but more frequent of late. What have you seen as maybe good approaches to handle that?

Matthew Mawby:
The first and foremost approach is you got to know what you're stepping into as a nurse going into that environment. You might not want to talk about pay rate. You might not want to talk about those details that are personal to you, but these are facts that we all are facing in this industry. I mean, from 2020, 62% of nurses became travel nurses. That's a lot. It's a lot. I mean, I've seen it firsthand, people leaving healthcare systems that they've been with for years and years and years because they need the money. It comes down to money. It comes down to what's good for their family. It comes back to that flexible scheduling that, hey, I can go when I want and come back.

I have childcare. All those things determine whether an individual, a nurse, is going to go, "Hey, I'm going to go travel, or I'm going to go work for an agency, or I'm leaving my current spot." With that being said, I mean, there's a flip side to that too is, how sustainable is that in reality? Can these healthcare systems keep giving away $20,000 sign on bonuses to just be a body to fill in the spot? It's definitely a challenging spectrum that we're in when it comes to the travel nurses. And on top of that, they're needed. They're needed and that decision is in the nurse's hands now.

They have the ability to control and say, "Hey, I'm going to take XYZ amount of money because I can and I need it," and then that causes a really big bottleneck effect in our industry because... One transparent fact and honest fact is that there's very large healthcare systems that can afford that affordability, but a huge percentage of the population of healthcare facilities are nursing homes and caring for the elderly, postacute, facilities that don't have the budgets for that. Who's winning in that balance act? Is it saying, "Hey, if you have the money, you can get the better nurses, or you're getting more nurses?"

But back to the main point of your question, it's very difficult. Unfortunately, people judge. If you and I are working at the same facility and I'm making 30 bucks an hour and you come in and you got a $5,000 sign on bonus and making $60 an hour to do the same job I'm doing for the next 12 weeks, that's challenging. It's challenging. That's what brings up friction in the workforce and cultural issues.

Jeff Terry:
One technique that I saw from a health system we serve is where they do an internal traveler program where they sort of pay people the traveler rates, but they have to take the dirt and the tough shifts that people don't want to take, but they keep them in their system. I think in the end, the things you mentioned, we've got to create the right incentives.

We've got to invest in the pipelines and we've got to have systems like yours so we're getting the workforce to where they are optimally so maybe we're less dependent on travelers, because I don't think any of the health systems can afford it in the long run. I mean, the numbers you hear are staggering. You understand why they pay them, but I don't think it's sustainable in the long run.

Matthew Mawby:
I completely agree with you on that one. I mean, I see it on a daily basis. I mean, how far can we go? And then one outcome of that that we're starting to see that is even a bigger challenge for us on our side, and I'm not meaning to take any side here at all, but nurses are expecting to get paid more now. If you're working travel for a year and a half and you're making $100,000 more than you did the year before, let's say, they're expecting to get that now. How are they going to go back to where they were? We're seeing a lot of that. It's unsettled conversations per se, but it's concerning. It really is concerning. Where is that fine line of payment, of income, because wages are an issue.

Jeff Terry:
Absolutely. Well, there's no easy answers to that, but I certainly understand the phenomenon. I'm glad that people like you and a lot of other people and us to some lesser degree, but all of us are working on helping with that problem. Because there's one thing obviously for sure is we need our great nurses to be well taken care of and available. Awesome.

Matthew Mawby:
Understood. We all got to work together and bring the passion back in nursing and really get the bedside back to normal, back to where it was, if not better. I know you guys are working on a lot of technology as well. I think technology is going to be the future of our industry. It really is. I mean, I know it already is, but now in terms of staffing and keeping staffing levels and patient ratios and getting shifts covered fast, I mean, it all starts with that. We're here for that too. We're here to do part of the solution.

Jeff Terry:
Brilliant. Well, I appreciate your coming on, Matthew, and sharing your thoughts. It's great meeting you and congratulations on the work and the progress with StaffHealth.com.

Matthew Mawby:
All right. Thank you, Jeff. You have a great day. I appreciate you having me.

Jeff Terry:
You too, man. Cheers.

Matthew Mawby:
All right.

Jeff Terry:
Thank you, everyone. With that, we'll close the podcast.