Advancing Health Podcast

00;00;01;03 - 00;00;40;16
Tom Haederle
Sometimes you hear a fact so startling that you ask yourself, can that really be true? Here is such a fact. And yes, it's true. A health care worker has a higher chance of being exposed to violence than a prison guard or a police officer. Stunning, but accurate. And the question is, what can be done about it? Welcome to Advancing Health, a podcast from the American Hospital Association.

00;00;40;19 - 00;01;08;06
Tom Haederle
I'm Tom Haederle with AHA Communications. A survey of 1000 caregivers in April of 2022 found that 92% had directly experienced or witnessed workplace violence. The problem has been growing exponentially for years and prompted the AHA to create #HAVhope Day, a National Day of Awareness to highlight how America's hospitals and health systems combat violence in their workplaces and communities.

00;01;08;09 - 00;01;26;09
Tom Haederle
In today's podcast, Laura Castellanos, associate director of Hospitals Against Violence with AHA explores some of the ways health care leaders are tackling the problem of workplace aggression. Her guest is Dr. Ronald Paulus, president and CEO of Mirabel Health. Let's join them.

00;01;26;11 - 00;01;58;01
Laura Castellanos
Since the pandemic, the prevalence of workplace violence in health care has grown. Begging the question what can we do to mitigate it? I am Laura Castellanos associate director of Hospitals Against Violence for the AHA. It is very timely that I'm joined by Dr. Ronald Paulus, Ron is a strategic advisor for Commure StrongLine and former president and CEO of Mission Health, as well as former chief administrative officer and CIO for Geisinger Health System.

00;01;58;03 - 00;02;21;27
Laura Castellanos
Today, we will discuss the unfortunate growth of workplace violence in health care, including its financial, organizational and clinical consequences. Mitigating violence and investing in workplace safety initiatives and have an exponential impact on caregivers, patients and health care organizations. Ron, I'm glad to be back with you.

00;02;21;29 - 00;02;23;29
Ronald Paulus
My pleasure. Thanks for having me.

00;02;24;02 - 00;02;35;05
Laura Castellanos
So let's get started with today's discussion about learning about your health care background, your organization, and how you support AHA member hospitals and health systems.

00;02;35;07 - 00;03;10;00
Ronald Paulus
Well, again, it's a pleasure to be here. And you gave a good chunk of my background. Thanks for doing that. Today I'm here because I have a relentless passion to help keep health care team members safe, and I continue that work as an advisor to Commure Strongline. Strongline is a solution that enables each individual staff member to have a personal panic button that connects through low energy Bluetooth to a Wi-Fi network and can send alerts to PROXIMO, colleagues, security subscribers and so forth.

00;03;10;01 - 00;03;12;07
Ronald Paulus
So that's what the solution does.

00;03;12;10 - 00;03;27;20
Laura Castellanos
But definitely passionate about this topic. For years I've talked about it. And you know to set the stage for today's topic, let's talk about how workplace violence is impacting hospitals and health systems. Give me your take on that.

00;03;27;23 - 00;03;58;05
Ronald Paulus
Yeah. So I wish I had a better take. You know, last year was a year that spotlighted the insidious undercurrent and dire consequences of workplace violence in health care. And it honestly, it pains me to share that the numbers are truly staggering. A thousand caregivers were surveyed about their experience with workplace violence during April in 2022, and 92% of those surveyed caregivers shared that they had either directly experienced or witnessed workplace violence.

00;03;58;07 - 00;04;22;29
Ronald Paulus
Laura That's stunning. And the sad reality is that health care workers are nearly five times more likely to be the victim of workplace violence than those working in other industries. Tragedy in Atlanta is just one of a myriad of examples. Think about this, Laura. A health care worker has a higher chance of being exposed to violence than a prison guard or a police officer.

00;04;23;02 - 00;04;51;13
Ronald Paulus
And I know a lot of people don't think this is a really big issue, or maybe they think it only happens within behavioral health units or emergency departments. But real world data from Strongline customers tell us from tens of thousands of caregivers that more than 60% of all incidents happen outside of those areas. And those include hallways, cafeterias, ambulatory centers, billing offices and more ... essentially everywhere and anywhere.

00;04;51;15 - 00;05;14;14
Ronald Paulus
So not surprising given that reality, the health and well-being of our workforce, the exact people who we depend upon to take care of us when we're at our most vulnerable point of being ill is declining. And the surgeon general recently issued an advisory on health care workforce burnout citing unsafe conditions is one factor. That's the reality of where we are.

00;05;14;17 - 00;05;36;24
Laura Castellanos
It is a dire reality. And thank you for for setting that stage. So let's start breaking it down. And I think an important topic to cover is the cost, right? The cost of this violence on our hospitals and health system. Our caregivers, our patients pretty much overall the health system. So what can you share with us about the cost of this violence?

00;05;36;26 - 00;05;57;13
Ronald Paulus
I'm so glad you asked that question, Laura, because it's exactly the right one to ask. So often we focus on what is the cost of our investments to mitigate workplace violence. And we know it's our first priority in a professional and ethical obligation as leaders to keep our patients and team members safe. And without a doubt, that is singularly important.

00;05;57;15 - 00;06;20;29
Ronald Paulus
But the reality is that the hidden but very real costs of workplace violence are hiding in plain sight. And my experience is that most hospitals have no idea what their true costs of workplace violence are. And that's because they don't have the data to track incidents or severity. They're often unaware of the downstream costs. They just don't realize how pervasive the issue is.

00;06;21;01 - 00;06;49;16
Ronald Paulus
I say that without judgment because the person I'm describing was me. I was clueless about this issue when I first became the CEO of Mission Health in North Carolina, although I'd experience workplace violence personally as a clinician. It just wasn't top of mind. And that was until my world changed. When I was the CEO at Mission, I would routinely do focus groups with nurses and other caregivers, and at the end of the session I would always ask, Hey, what else is on your mind that we haven't spoken about?

00;06;49;19 - 00;07;09;04
Ronald Paulus
And then back to back focus groups, a nurse said, We don't feel safe at work. And I was shocked. And frankly, I was ashamed. And I used those feelings to push me to develop a deep understanding of this issue, to make all the evidence based interventions that I could. And that's what ultimately led me to where I am today.

00;07;09;06 - 00;07;32;21
Ronald Paulus
But getting to the core of your question. Workplace violence costs are multifactorial, starting with staff. A recent McKinsey survey found that a safe work environment was literally the number one most cited factor influencing nurses decisions about whether to stay or leave their job. And that same study found that one out of every three nurses actually intends to leave their role within the next three years.

00;07;32;24 - 00;07;58;05
Ronald Paulus
That alone tells us that the safeness of our work environment is paramount. Nationally, average workplace turnover is about 20%, with vacancy rates stuck in the 15% range. Another recent study by Epic Research found that there's been a 56% increase in shifts filled by nurses with less than one year of experience. These are nurses who are new to our industry and new to their jobs and who need extra support.

00;07;58;08 - 00;08;23;20
Ronald Paulus
So given all the investments that we make in recruiting and hiring and training and supporting, we need to have confidence that these team members will ultimately choose to stay in that role. And if they don't, the cost to replace just one nurse averages more than $50,000. Traveler nurses cost an extra $150,000 on average per year. And something else that people don't really appreciate:

00;08;23;22 - 00;08;53;13
Ronald Paulus
Days lost from work due to workplace violence are huge. Up to 13% of all non vacation days relate directly to workplace violence. And it doesn't stop there. Typical workplace violence OSHA fines exceed $100,000. And jury awards - when an organization is found guilty of not taking appropriate steps to keep team members safe average more than $3 million. So when people are thinking about making an investment to create a safer workplace.

00;08;53;15 - 00;09;07;24
Ronald Paulus
Framing it as simply, you know, yet another new expense when my budget is already tied is both inaccurate and counterproductive. The reality is it's a strategic investment with a highly positive ROI.

00;09;07;27 - 00;09;32;27
Laura Castellanos
Well, you definitely shared some staggering statistics, and thank you for sharing your story, your perspective, and obviously what drives this passion. You know, you even expand it to talk about the impact it has on the workforce. So let's talk about what are some ways that hospitals and health systems are currently investing in their workforce safety initiatives, keeping their workforce safe?

00;09;32;29 - 00;09;36;14
Laura Castellanos
And what evidence supports these strategies?

00;09;36;16 - 00;10;01;17
Ronald Paulus
Yeah, I've spent more than a decade trying to understand the answer to that question, and I hope I've contributed to some of what's out there. As you know, the AHA, you all have several tools available to support hospitals, including your toolkit for mitigating workplace violence and your guide for developing a workplace violence program. And so I want to applaud that work and encourage everyone to review those materials.

00;10;01;19 - 00;10;28;02
Ronald Paulus
And in January of this last year, The Joint Commission announced new standards across three domains that should help guide interventions. One, The Joint Commission says around environment of care that you have to initially assess your physical environment, looking for difficult areas to visualize staff and unlock entries and that kind of thing. Importantly, use data to guide where the highest risks are and where exposures occur and to whom.

00;10;28;05 - 00;11;00;05
Ronald Paulus
Now, this is exactly what we did in patient safety. So every health system needs to track incidents and rates of workplace violence occurrence. IHHSS has put forward a detailed framework for doing this. But just as a practical example, at mission, we use a workplace violence scale that began with unwanted verbal contact, progressed to verbal abuse and to unwanted physical touching on to physical assault, then to physical assault with injury, and finally to physical assault with injury and time lost from work.

00;11;00;08 - 00;11;25;25
Ronald Paulus
But whatever scale you choose, you need to strongly and repetitively encourage and reward reporting, because despite the statistics that I shared, 70% of all incidents go unreported. From a human resource perspective, The Joint Commission says that you should regularly survey your staff about their perceptions of safety, both as a baseline measure and across time and violence prevention, training and de-escalation is essential.

00;11;25;27 - 00;11;47;25
Ronald Paulus
At the time of hire and annually at least thereafter, per The Joint Commission standards. And let me be clear about something this training isn't like watch a PowerPoint and check the box kind of exercise. It needs to include de-escalation roleplaying and trauma informed care education, at least for the most vulnerable workers. So that's where the data map and should guide your interventions.

00;11;47;28 - 00;12;13;16
Ronald Paulus
And because staff need to practice and experience what de-escalation feels like to be comfortable doing it when it counts, they have to do that role play. Another intervention is behavioral emergency response teams. These are dedicated professionals that parallel our rapid response teams for medical escalations. We created one of the first in the nation at Michigan when I was there, and we did an AJ webinar on that very topic.

00;12;13;18 - 00;12;51;09
Ronald Paulus
These are now a best practice for behavioral escalations. From a leadership perspective, you need to develop an interdisciplinary committee specifically focused on workplace violence. That should include a broad swath of stakeholders from your clinical security admin, ambulatory, offsite operations, and this leadership focus and accountability is the secret sauce. It's exactly what it took for the patient safety movement to finally pick up steam and with the right leadership, we bring together the tools, techniques, technologies that will reduce this epidemic to a more manageable level.

00;12;51;11 - 00;13;20;02
Laura Castellanos
Let me do a quick follow up on your last comment about the patient safety movement. And I know you and I have talked about how workplace and workforce safety should truly be part of this larger framework of quality and safety because we've learned so much. Can you just share your insights as to how we can begin to leverage systems to learn from other systems to create safety?

00;13;20;04 - 00;13;47;14
Ronald Paulus
Yeah, you know, just harkening back to that patient safety moment, we can't repeat how long it took us to get our act together. It was more than a decade from the publication of "To Err is Human," which you'll recall flagged that as a health care profession, we killed at least 100,000 people per year. But it took a long time and it wasn't a total value-based purchasing took a foothold that things really began to accelerate.

00;13;47;16 - 00;14;11;29
Ronald Paulus
And the good news here, relative to the intersection between safety for patients and for staff is that they're correlated. So I feel like with so many of these statistics that I've been giving, I might be depressing everyone. So let me give you some good information. What we know is when the workplace is safe for team members, both patients and staff do better.

00;14;12;02 - 00;14;40;28
Ronald Paulus
Data from Press Ganey show that when staff do feel safe, patient outcomes improve and they're more engaged. So specifically, feeling safe is correlated with a 22% higher CMS hospital quality star rating, a 52% lower rate of nurse perceived mis-care. That's a key marker for patient safety and a 27% higher job enjoyment. So these are tied together and it starts with collecting the data.

00;14;41;01 - 00;14;49;00
Ronald Paulus
It starts with encouraging reporting, just like I did with patient safety. And we can make a difference if we focus on those things.

00;14;49;02 - 00;15;13;22
Laura Castellanos
Well, thank you so much for sharing. So let's give a message to how hospital leaders and executives -  as you mentioned, it's the secret sauce, right? So how can they collaborate to mitigate this violence and most importantly, support their workforce? We know that through the pandemic and through everything that has been escalating our workforce needs more support.

00;15;13;27 - 00;15;14;07
Ronald Paulus
Yes.

00;15;14;09 - 00;15;17;26
Laura Castellanos
What message do you have for leaders and executives?

00;15;17;28 - 00;15;46;25
Ronald Paulus
Yeah, I'm going to repeat that. I think that leadership focus and accountability around this topic is the secret sauce. This is not something that can't be managed and controlled and mitigated. You know, we used to think that surgical wound infections and retained sponges and all this stuff was just part of the process. It doesn't have to be. Leadership needs to bring together the tools, techniques and technologies to reduce and seek to eliminate this totally unacceptable epidemic.

00;15;46;28 - 00;16;12;10
Ronald Paulus
That's a repeat of what I was saying. In this fight to stop workplace violence, every one of us has a role to play. And measurable progress can be achieved if we get collaborative buy in from across the organization. Leaders have to set the tone around its importance, the need for reporting, the investments that are made in and tools and technologies to keep people safe.

00;16;12;17 - 00;16;38;01
Ronald Paulus
And they need to view and articulate those as what they are. Investments with a return on investment that manifest in both better patient outcomes and staff outcomes in addition to a measurable financial return. So as leaders, keeping our patients and team members safe must be our number one priority. And I know that we can collectively make a difference and turn this tide as an industry together.

00;16;38;01 - 00;16;57;06
Ronald Paulus
We've done it before. We did it with patient safety, no matter how long it took. We did it with COVID. And I'm 100% confident that we can do this again. So this is the time to stand up, acknowledge the problem, and apply what we know how to do to make an impact for our team members and our patients.

00;16;57;08 - 00;17;01;00
Ronald Paulus
It's not just the right thing to do. It's the right investment to make.

00;17;01;02 - 00;17;23;28
Laura Castellanos
Well, I applaud your efforts and your passion for this work. And please do know you're making an impact. I appreciate you sharing your insights. Definitely learned a lot. And what a packed podcast. There's so much information and what you share, and I'm sure we'll be able to share more with our listeners. So Ron, thank you so much for joining the podcast and sharing your takeaways with other AHA listeners.

00;17;24;03 - 00;17;34;06
Laura Castellanos
So for our listeners, if you'd like to learn more, please visit AHA.org/HAV. Thanks for listening.

00;00;00;29 - 00;00;49;18
Tom Haederle
America's health care workers are the backbone of hospitals and health systems and our most precious resource. Without a strong and resilient workforce, our system of patient care collapses. It's as simple as that. Welcome to Advancing Health, a podcast brought to you by the American Hospital Association. I'm Tom Haederle with AHA Communications. The numbers aren't pretty. More than 100,000 nurses left the profession in 2021, and the nation faces a projected shortage of up to 124,000 physicians by 2034.

00;00;50;05 - 00;01;15;08
Tom Haederle
Bold and innovative approaches are needed to support current staff, attract the workers to meet the health care demands of today, and design the care delivery models of tomorrow. Join us to hear valuable insights on the practical recommendations outlined in the AHA's 2023 Health Care Workforce Scan, designed to help organizations think and act innovatively to support, retain and recruit staff.

00;01;16;14 - 00;01;35;21
Elisa Arespacochaga
Hello, I'm Elisa Arespacochaga, vice president of Clinical Affairs and workforce for the American Hospital Association. With me today are Ron Werft, president and CEO with Cottage Health and chair of AHA’s board level Task Force on Workforce. And Felicia Sadler, vice president of Quality with Relias. Welcome to both of you. And thank you so much for joining me.

00;01;36;08 - 00;01;37;16
Ron Werft
Thank you. Happy to be here.

00;01;37;23 - 00;01;38;08
Felicia Sadler
Yes.

00;01;38;17 - 00;02;02;09
Elisa Arespacochaga
All right. We're here to talk about the health care workforce scan, which really focuses on three critical workforce challenges we are seeing confronting our members. And I know you're experiencing in the field and really how we can think about some of the strategies to address these challenges. Now, I know you are both working very deeply on these, both through the aging task force and in your own organizations.

00;02;02;19 - 00;02;24;05
Elisa Arespacochaga
But let me just quickly recap the three areas that we're focused on. The first is reconnecting clinicians to purpose. We know very much the value that that brings and the fact that in most cases, those who are in health care are there because they really believe in the work. The second is to think about how we can provide support, training and the technology that we all need

00;02;24;05 - 00;02;47;18
Elisa Arespacochaga
to thrive in the different care delivery environments and some of the changes and challenges we've all been seeing. And the last is really how to recruit innovatively and really invest in retention and building that pipeline for the future. So let me start out with you, Ron, to tell me a little bit about what you're seeing and how you're seeing these challenges really affect the field.

00;02;47;19 - 00;02;50;15
Elisa Arespacochaga
As you know, you're on the front lines of providing care.

00;02;50;29 - 00;03;17;21
Ron Werft
Thanks, Elisa. You know, we're talking about reconnecting to purpose here. And I would just make the observation that our staff, our health care clinicians and support staff, they are still connected to purpose. It's just become very, very hard. You know, our staff has been through ... more has been asked of them by society and by our organizations than really should be expected for anyone.

00;03;17;21 - 00;03;49;24
Ron Werft
We all know the story. They've gone from PPE to isolation units to visitor restrictions. And I think all of that has had the effect of a loss of human connection. And so as we think about how to reconnect, it's not so much finding their passion because they all share this core value of compassion and all they want to do is to have the resources and the environment in which to provide the very best possible care that they can.

00;03;50;16 - 00;04;14;06
Ron Werft
So we need to support that and find ways to support and strengthen that connection back to purpose. So what you know, what we're seeing around the country and in our own organization are a number of approaches that I think the first and foremost, it will vary by generation and by institution. And so the most important thing is to ask our staff what is important to them.

00;04;14;24 - 00;04;45;27
Ron Werft
And for us, we hear that recognition and celebration and hearing the stories is very, very important. And so we ask how how can we best do that? And we follow their lead on that. Secondly, there's the sense of finding ways to do meaningful work. And as the National Academy of Medicine says, get rid of stupid stuff. So how do you how how can we maximize their time doing what they do best and what they love the most?

00;04;46;13 - 00;05;08;17
Ron Werft
And then lastly, really addressing issues of burnout, providing mental health support beyond EAP for our staff and making sure we provide a safe environment with the rise that we've seen in workplace violence. So those are just some of the things that I know our organizations are all focused on and working on. And again, it's really about culture and listening to our people.

00;05;09;02 - 00;05;27;28
Elisa Arespacochaga
Couldn't agree more. I think you're right. They certainly were the ones who ran into the fire from the beginning of the pandemic and continue to do so in ways that we can support them in being able to do that work. Felicia, I know you trained as a nurse and this is something you feel passionate about. How are you seeing this affect the field?

00;05;28;24 - 00;05;53;09
Felicia Sadler
Absolutely. And thank you, Elisa. This is it's really interesting because we're in unprecedented times coming through. We're coming out of the pandemic and we're seeing some of the fallout and the consequences of that during the pandemic and during times of crisis. It was really, you know, as Ron alluded to, you know, there is connecting that passion. It's really reconnecting.

00;05;53;09 - 00;06;14;04
Felicia Sadler
Absolutely, that passion to purpose. Sometimes that gets lost in amidst the crisis and amidst the fires that, you know, that that folks were dealing with, if you will. So rediscovering and helping them to rediscover and getting back to that one on one, the reason they chose the profession. I know I was committed very early on at a very early age.

00;06;14;04 - 00;06;32;00
Felicia Sadler
I wanted to help people and that I didn't know really how to do that. I just knew I wanted to go into health care, to be able to accomplish that. And it was through the training and education that I was able to see that that path very clearly. So I think it's just reconnecting them back to the foundational principles that we all started from.

00;06;32;13 - 00;06;54;07
Felicia Sadler
And then also reconnecting them to their their the patient experience. You know, we have technology. We have other components that come into play. But certainly making sure that there is that, you know, as Ron alluded to, the human connection, which we know can impact patient safety and quality. Recognition as a huge driver, but also providing the meaningful recognition.

00;06;54;07 - 00;07;16;21
Felicia Sadler
I know I as as a frontline nurse, always appreciated when they were specific in that recognition and acknowledgment and expression of that gratitude. And that the difference I made that day on that shift with that patient in that same place, I think as specific as we can get with the recognition certainly helps not only for individuals but for teens, and it can be very empowering.

00;07;17;04 - 00;07;44;28
Ron Werft
Now, I had a an opportunity just last night to participate in the awarding of a Daisy Award to one of our emergency department nurses at one of our hospitals. And what is clear in these honoring ceremonies is there's a there's a important story, an inspiring story that's told. There is somebody who is honored for really for their their passion and sometimes often going above and beyond.

00;07;45;09 - 00;08;08;03
Ron Werft
But what was clear is that when we honor, in this case a nurse, when we honor a nurse, we honor all nurses. And I think there was as much joy and all of the other staff members who were there for that event as there was for the recipient. And so those are really important events to to formalize and and do on a frequent basis.

00;08;08;23 - 00;08;34;03
Elisa Arespacochaga
And I think they really support that connection not only to the leadership, but then between and among coworkers. So I think that's a really good point, and let me use that as a good way to transition into my next question, which is really about some of the things that both the pandemic and we have put in the way of some of those human connections.  As an industry, not had a great relationship with technology.

00;08;34;20 - 00;09;02;09
Elisa Arespacochaga
There are studies that show we actually lost productivity when we brought in various technologies along the years. So understanding how to best use technology, not only just for technology's sake, but to help support our teams in the midst of the changes that are happening, the needs to move to different solutions to take care of our patients because we don't have the same numbers and complements of caregivers.

00;09;02;25 - 00;09;14;09
Elisa Arespacochaga
How are you seeing and Ron, again, I'll start with you seeing technology and other resources in your organization helping to support your care teams in doing what they need to do.

00;09;14;29 - 00;09;44;29
Ron Werft
Yeah, I would say we're really at the very beginning stages of using technology in the context of supporting our workforce. You know, there's been incredible technology in medicine and in our health care organizations. But the focus, the objective has been very different from supporting our staff. Obviously, the focus has been on medical advances. It's been on timely access to health information and data, interoperability.

00;09;45;13 - 00;10;16;06
Ron Werf
And then, you know, EHRs hours and ERPs. When you think about the purpose of all of the above, incredible medical advances in device technology, minimally invasive access safety has been a focus. You know, pop ups that prevent and help us avoid the medical errors. I would say that none of these are focused on helping people maximize what they would define as meaningful work.

00;10;16;21 - 00;10;43;21
Ron Werft
Dr. Tait Shanafelt at Stanford. This is really important work that he does on burnout and he has found that if you can just increase the percent of time that someone spends on what they would define as meaningful work from 20 to 30%, you make a dramatic reduction in burnout for that individual. So I think we just need to partner with technology with a different objective in mind.

00;10;43;21 - 00;11;04;21
Ron Werft
Now we need to part with technology to find ways to not move people away from the bedside or away from the patient. The health information is very, very important, but we have to have as a focus and work with our tech partners on ways to get back to the first conversation about meaningful work and connecting to purpose.

00;11;04;21 - 00;11;47;28
Ron Werft
And I don't think we've really scratched the surface on that yet. I'll just say that the pandemic has really been very important. It has been the acceleration of virtual care and the use of and the acceptance of virtual care. So when we think about our workforce who may have left the bedside, many of them, to the extent that we can partner with technology, which is moving rapidly in response to a consumer movement, to make sure that our staff have more flexibility and the opportunity, if not working at the bedside, to continue to fulfill their passion in doing patient care virtually or in other ways.

00;11;47;28 - 00;11;50;05
Ron Werft
So I think we have a real opportunity there.

00;11;50;13 - 00;12;15;10
Elisa Arespacochaga
Yeah, I think there's been a very big shift in where we all feel comfortable with technology and even, you know, comfort with video calls and all of these other things that felt like they should be on The Jetsons and nowhere else. But I think there's a lot of opportunity, but there's also a lot of need to focus. As you mentioned, on focus on what we're trying to do with this technology most effectively.

00;12;15;19 - 00;12;24;29
Elisa Arespacochaga
So, Felicia, let me ask you, what are you seeing in terms of the best uses and best ways to bring that technology into your organization and into your work?

00;12;25;16 - 00;13;03;21
Felicia Sadler
That is a great question, and I totally agree. We've brought you know, the pandemic has brought about the embracing and expansion of technology like never before in health care and in new ways, innovative ways of utilizing technology to improve access to care, improve care, quality, streamline processes, make it more efficient. And that's really where I see that organizations have have included this as part of their strategic growth and priority is looking at how can we standardize, how can we streamline workflows to make it easier to do business and easier to work all the way to the front lines for our our staff.

00;13;04;10 - 00;13;42;27
Felicia Sadler
We've seen benefits that were realized very early on with the expand quick expansion and the use of technology when we went to virtual ICU use or virtual preceptors. One key realization and one thing that I witnessed personally was really helping assisting organizations in transitioning across specialties in times of crisis. And we're still still seeing some of that where there's an opportunity, especially to address workforce shortages around cross-training, upskilling, ensuring that they have everything they need to be able to be competent and safe, and they're using technology to do that.

00;13;43;18 - 00;14;06;22
Felicia Sadler
And it's become is being hardwired in the organization to really meet the staffing demands. So I think that there's opportunities to continue to expand that. And as we think about these increased competencies around virtual, you know, telehealth, telemedicine, if you will, a hospital at home and so forth, increasing the ability to measure those competencies, ensuring they have the education and training that they need via technology.

00;14;07;03 - 00;14;37;29
Elisa Arespacochaga
Absolutely. We need to be able to deliver some of that education, as you know, in the moment. And I think technology has helped us to be able to do that effectively. So let me pivot just a little bit to some of the work that has been done. And I know it's been every organization has had to get creative in understanding how they best could support their teams from some of the things we discussed around well-being, supporting their mental health, addressing some of the increases in violence.

00;14;38;14 - 00;15;01;17
Elisa Arespacochaga
But we've also had to think differently about how we both recruit and retain both the next generation but also the current generation of those who current generations who are in our workforce. Understanding what are the benefits structures that make sense? What are the things that people actually would like back from their organization? What does that relationship look like?

00;15;01;17 - 00;15;26;29
Elisa Arespacochaga
And I know, Ron, you touched on a couple and Felicia, that focus on additional training, additional education, what else can you know, my organization helped me be able to do? I think there are a lot of opportunities now, and given some of the challenges that we've had with the workforce shortages, I think we all need to think about how can we bring people in and make sure that we are building that robust pipeline.

00;15;27;01 - 00;15;47;20
Elisa Arespacochaga
So Felicia, let me start with you. In terms of those opportunities to educate, to train. How are you seeing not only keeping the workforce we have, bringing in new folks, but then helping those who are maybe in high school or grade schools think about a career in health care that isn't just a doctor or a nurse.

00;15;48;13 - 00;16;12;28
Felicia Sadler
I love that question because that's actually a trend that we're seeing organizations go across the country and it really is in line with with really reaching out in their communities, diving deep into the the community where you're actually exposing them to health care in general at the high school level. I know in my own experience I had a vocational industrial, you know, Club of America.

00;16;12;28 - 00;16;33;07
Felicia Sadler
I was part of a health occupations education program within our high school. It was through that program I was first exposed to health care and what the opportunities were that that afforded. In addition, I had a recruiter come from a nursing school to visit us as part of that program where you have different folks from the community come forward.

00;16;33;21 - 00;17;04;01
Felicia Sadler
And I really it really engaged me. And there was a tremendous interest in how can I be part of this community. This is this seems like a great way that I can help people. And that's really what pulled me into the pipeline early on. And I think we do have that opportunity to really revisit. In addition, I think health systems are for forming academic partnerships with local communities alike across the world of academia to really help build a community or a workforce community.

00;17;04;01 - 00;17;12;04
Felicia Sadler
If you will. And because health care is one of the largest contributors to the economy locally as well as nationally. So I think there are opportunities there as well.

00;17;12;24 - 00;17;19;03
Elisa Arespacochaga
Ron, your thoughts on how we grow both keep the folks we have and then really make sure we have the folks we need in the future.

00;17;19;26 - 00;17;54;03
Ron Werft
Yeah, I think that's really the kind of the near, now, and far of our challenge here is focusing right now on making sure that we retain our staff and give them the support that they need to continue to thrive in this health care environment. And as Felicia said, that we think really strategically about the the academic pipeline and start early and make sure that we're messaging to youth really the benefits of committing your your your professional lives to a health care career.

00;17;54;12 - 00;18;14;14
Ron Werft
And there are many just, you know, locally. And what I've heard from other task force members and elsewhere around the country: clearly start with compensation and benefits. It's a tough market. We know that labor costs are increasing at a very challenging financial time for hospitals and health systems and yet we have to get that part right.

00;18;14;14 - 00;18;37;02
Ron Werft
It's sort of the bottom rung on an Maslow's need. And so we just have to get that part right and we have to think a little bit differently about that because as you said, Elisa, we have four or five different generational cohorts within our organizations and where one population is going to feel that child care access is critically important.

00;18;37;21 - 00;19;03;17
Ron Werft
Let's say the baby boomer generation who are still actively contributing, they need more flexibility, maybe need to go part time, maybe need to move to a virtual option. So we need to be much more flexible in terms of our benefit and support structures. I think that one of the advantages that we have in health care is that there are tremendous growth opportunities within health care.

00;19;03;17 - 00;19;29;01
Ron Werft
And so I know that right now we're mapping career paths that start with community health workers and go all the way to RN. We're mapping 20 different career paths this year. And we're starting with our local health health academy at one of the local high schools here, which is becoming, as Felicia said, much more common practice around the country. As we look at the different generations, again, we need to understand the different needs that they have.

00;19;29;08 - 00;19;55;16
Ron Werft
I know that for some in our organizations, just the focus on diversity and equity and inclusion as is very, very important to some. So the advent of employee resource groups that can help people thrive and feel included as part of the health care team is very, very important.

00;19;55;16 - 00;20;19;17
Ron Werft
For us, shared governance is a critical foundation for our work here, and we have systems to make sure that every voice has an opportunity to contribute. And frankly, the ideas that come from our frontline staff are far better when it comes to workflow and workforce, I'll say, than the ones made in my office, certainly. And so, so important to listen to that.

00;20;20;17 - 00;20;50;06
Ron Werft
Lastly on that, I'll just say that workplace violence has escalated dramatically for a number of reasons. And so our staff have dealt with push back on mask mandates and visitor restrictions and all that they've had to deal with. And we've seen a significant increase in workplace violence. So providing a safe, secure facility ... that's on the agenda of many of our networking meetings, our state association meetings, our national meetings.

00;20;50;16 - 00;21;17;22
Ron Werft
And there are some important solutions there that can be as simple as safe escorts to parking lots and better lighting. So, again, it really important to hear: what do your staff say is important for them to feel that they're in a safe environment? And our ability to respond quickly to that and make those changes sends a very powerful message that they are supported and safe in our environment.

00;21;18;15 - 00;21;40;23
Ron Werft
So that's a long answer, Elisa, to your question about how we retain people, and I think we just have to do all of those things and we shall cover the the academic pipeline very, very, very well. I know for us, these are going to be local and regional solutions by and large, and there's tremendous variability across the country and supply and demand coming out of our professional schools.

00;21;41;12 - 00;22;02;23
Ron Werft
And so just our local experience has been that we are partnering with ten local colleges and ten local health systems. And just through that work, we found out that there was a 3 to 1 ratio on the number of new grads we all hire each year. These are nursing grads, and the number that are graduating from these local schools.

00;22;02;23 - 00;22;32;00
Ron Werft
And so it just elevates the argument for and the opportunities for local partnerships that expand classroom space and perhaps have partnerships with our staff and their faculty and importantly, increase clinical rotations so we can increase that enrollment. Lot of people still interested in health care. 92,000 qualified applicants to nursing school last year didn't get in, not because they weren't interested or weren't qualified.

00;22;32;00 - 00;22;42;27
Ron Werft
We didn't have space for them. So high level of interest. That's the good news. We got to figure out how to get them in these schools and and taking care of our communities.

00;22;43;25 - 00;23;10;03
Felicia Sadler
Elisa, I'd like to add to the retention component that you had mentioned you now in addressing the needs of the workforce regarding the training education, how can we better retain our workforce? I also wanted to add to this around taking a proactive approach. We think about acclimating to the culture, the environment. Having an effective onboarding process is absolutely critical because we know that leads to improved retention and decreased turnover.

00;23;10;14 - 00;23;47;17
Felicia Sadler
Part of that is really emphasized. We think about the importance of providing robust and personal, personalized experience, if you will, beginning with this effective onboarding process and then providing solutions and resources around that. We know that we can improve in our satisfaction, communication, increase critical thinking through content, personalized learning, as well as improved performance and knowledge. We were able to demonstrate that in the work we did with Virginia Mason Franciscan Health, which is part of CommonSpirit, for example, is a great example of using competency assessments as well as personalized solutions to demonstrate those outcomes.

00;23;47;24 - 00;24;14;00
Felicia Sadler
One other note I wanted to mention around effective onboarding was the work at Memorial Hermann around effectively transitioning to practice, which is so critical for new grads today and being able to personalize that experience through data driven, personalized coaching for new hires. Personalization, especially when we think about across generations, is absolutely critical because you're actually speaking to the unique needs of that learner and then being able to provide include well-being, patient safety, career growth opportunities as Ron alluded to.

00;24;14;00 - 00;24;24;03
Felicia Sadler
In addition, I've seen fellowships, mentorships, programs being developed to support them even beyond year one to support and grow the workforce.

00;24;24;18 - 00;24;41;01
Elisa Arespacochaga
I think that's key. We no longer can have just one way for everyone to learn. We have to have opportunities for them to learn that work for them. Well, as we wrap up, can I just see if there's anything else that we haven't covered that you want to touch on before we wrap up? Ron, let's start with you.

00;24;41;16 - 00;25;09;11
Ron Werft
I would just add to two comments, really. One is following on Felicia's last comments, and it is the need to provide scholarship support for our staff to give them those growth opportunities. And certainly what we've seen is a significant increase in the interest of philanthropists to support those activities. So I think there's a real opportunity to get our community involved.

00;25;10;02 - 00;25;39;11
Ron Werft
They have you know, we've gone from banging pots and pans in New York to posters at our hospitals and health care heroes. And now I think there are real ways we can engage our communities in supporting our staff. And they really want to do that. So that's an important linkage. And the other thing I would just mention that we haven't touched on yet is that the retention of our staff is often times heavily driven by their support for and appreciation of their manager.

00;25;39;29 - 00;26;05;00
Ron Werft
And so the importance of supporting our our management team, elevating the role of preceptors, maybe moving from preceptor to mentor. So there's an ongoing relationship there. I've seen good examples of that. I think those are really important - I'll say tools to use - but just smart things to do that will keep our staff really engaged and supported in our organizations.

00;26;05;18 - 00;26;33;22
Ron Werft
I would really encourage everybody to make sure that they take advantage to the resources that are available at AHA. I've been so impressed and being involved with this workforce task force with the contributions of the staff are enormous. And by accessing this information on the AHA website, you're you're provided access not only to work done by the AHA, but work that's done by many other organizations for which the AHA serves as a clearinghouse.

00;26;34;00 - 00;26;38;27
Ron Werft
It's really important and valuable information for all of us. I'd encourage you to take a look.

00;26;39;18 - 00;26;43;12
Elisa Arespacochaga
Wonderful. Felicia, anything else to add now?

00;26;43;12 - 00;27;16;07
Felicia Sadler
I completely agree. Just a few things. And we think about building a culture of retention. I think all these key components certainly play into that. The Workforce Scan provides several key strategies to really improve retention, proven impact retention. And I think health care is really a journey. We are headed in the right direction. Of course, we have arisen from an unprecedented pandemic better, more agile, taking those lessons learned forward and then the meaningful strategies really needed to address our workforce.

00;27;16;07 - 00;27;29;15
Felicia Sadler
I think the organizations can definitely find those in the workforce scan. We are improving patient safety. Certainly that's a key focus while developing stronger collaborative partnerships and expansions in our communities, in the communities we serve.

00;27;30;12 - 00;27;58;09
Elisa Arespacochaga
Well, thank you both so much for joining me today and sharing your insights. If you'd like to learn more about the latest health care workforce trends, be sure to check out the AHA’s 2023 Health Care Workforce Scan on aha.org/aha-workforce-scan. The 2023 AHA Health Care Workforce Scan is sponsored by Relias. To learn more about Relias, please visit www.relias.org

00;00;01;02 - 00;00;28;06
Tom Haederle
The shortage of health care workers in America is not news, but the shortage of behavioral health care professionals is especially acute. And that's even truer in rural areas. As one expert says, If you thought it was bad before the pandemic, we've got a new definition of dire over the past two and a half years. But the scarcity of qualified professionals hasn't stopped some rural care providers from recruiting, training and retaining behavioral health specialists with some success.

00;00;32;13 - 00;00;59;01
Tom Haederle
Welcome to Community Cornerstones: Conversations with Rural Hospitals in America. A new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. The state of Iowa didn't have a reputation as a magnet for psychiatrists or other mental health professionals just starting out on their careers. But in recent years, Iowa has chosen to fund the expansion of psychiatric residency programs, now numbering about 20 across the state.

00;00;59;11 - 00;01;11;17
Tom Haederle
Iowa is investing in the training and retention of future psychiatrists who want to be change agents and who are passionate about working with underserved populations. Hear how it's all working out in this podcast discussion.

00;01;12;12 - 00;01;34;21
Rebecca Chickey
Hi, this is Rebecca Chickey, senior director of behavioral health services for the American Hospital Association. And it's my honor today to be joined by Dr. Jodi Tate, who is the clinical professor, as well as vice chair for education and director of the Intellectual Disabilities and Mental Illness Program at the University of Iowa Health Care in Iowa City, Iowa.

00;01;35;10 - 00;02;06;11
Rebecca Chickey
Jodi, thank you for being here with us today. I had the honor, since I'm at the AHA Health Care Rural Leadership Conference, being on a work session where you spoke about improving behavioral health workforce and services in a rural state. I have to tell you, the room was packed because if we thought the shortage of behavioral health workers prior to COVID was dire, we got a new definition of dire in the last two and a half years.

00;02;06;27 - 00;02;24;05
Rebecca Chickey
So for the benefit of the listeners and those who aren't here at the Rural Leadership Conference, could you describe for me, can you tell me about how you have expanded the psychiatric residency programs, particularly in the rural parts of Iowa?

00;02;24;09 - 00;03;01;08
Jodi Tate
Well, thank you very much for having me. And we are very lucky in the state of Iowa that our government has been extremely supportive in expanding our residency program into rural parts of the state. And in 2019, our governor allocated funds to expand our residency program. And Dr. Shay Jorgensen, who was a resident when this was all going down, has taken on the lead and has developed a rural psychiatry track from our in our residency program.

00;03;01;08 - 00;03;32;24
Jodi Tate
And she graduated from the University of Iowa and moved to Mason City. She grew up in rural Iowa, and her dream was to return to rural Iowa. But she wanted to have a connection with academic medicine and expand psychiatry throughout the state. So she has been a trailblazer in making that happen. And this is the third year where she has two residents per year in the psychiatry residency program.

00;03;33;14 - 00;04;04;02
Jodi Tate
And so that's going amazingly well. She is also single handedly developing substance use treatments and treatments in rural Iowa with her connections. And so we she's gotten that off the ground. And then our state last year provided more funding to expand our residency training program even further, funding for up to 12 additional residents per year, which is huge.

00;04;04;03 - 00;04;31;17
Jodi Tate
Right now we have nine per year, phenomenal. And so I was in a different position when this funding came down and I was very excited about the possibilities of changing psychiatry across the state of Iowa and improving services to underserved populations wherever they are. And I went to medical school in a rural state and spent time in rural areas and had that experience as well.

00;04;31;18 - 00;05;02;19
Jodi Tate
So I'm trying to figure out how to expand our residency program even further, which is challenging because part of the state appropriation bill that funds this new addition mandates that the residents spend time in locations that are in rural Iowa. It's a mandate. And many of these specific locations where they mandate that we have to be ... there isn't the capacity, there aren't physicians or there's not the capacity of the current physicians to have residents.

00;05;02;22 - 00;05;23;23
Jodi Tate
So they have the capacity to teach the residents. So we wouldn't be able to receive ACGME accreditation to expand our residency training program. So we're having to be really creative about how we go about doing that. And the thing that I have learned through this process in meeting with folks at these institutions is everyone is passionate about this.

00;05;23;23 - 00;06;04;01
Jodi Tate
Everybody wants to improve psychiatric care, but there's just a limited resource. So what we've decided to do is to develop a public psychiatry fellowship program in Iowa, and there are about 20 public psychiatry fellowship programs across the state, and most of these are in urban areas. So not sure how it's going to go in a rural area, but I'm very hopeful that it will be successful. The way that the Public Psychiatry Fellowship works in with expanding the residency is that these fellows will have graduated residency program already so they can practice independently and they can supervise residents.

00;06;04;18 - 00;06;55;23
Jodi Tate
The fellowship gives them extra training and exposure to learning more about our health care system, learning more about being a change agent, about social determinants of health and our hope is that we recruit psychiatrists to do this fellowship that are really passionate about underserved populations and who will be future change agents in improving our health care system. And these fellows would spend time at these sites that are mandated for our residents to be, and then we'd slowly create a culture of education and excitement in these rural areas, which in turn would allow us to have residents there, which hopefully would in turn, the residents would stay there and they would be physicians there in rural

00;06;55;23 - 00;07;01;14
Jodi Tate
Iowa. So that was a very long answer to your question, but it is a long process.

00;07;02;20 - 00;07;14;01
Rebecca Chickey
No, that was excellent. But for perhaps some of our non-health care listeners, could you describe or articulate what ACT is as well as a ACGME.

00;07;14;09 - 00;07;41;27
Jodi Tate
ACT: Assertive Community Treatment. Dr. Williams talked about that at our talk earlier today. So it is a treatment for individuals with chronic severe mental illness that live in the community, that have multiple hospitalizations, interactions with the legal system, lots of complications. So essentially, it's a it's an inpatient team that goes out in the community and takes care of patients in the community.

00;07;41;27 - 00;07;47;18
Jodi Tate
Evidence based treatment that shows to improve outcomes for people with serious mental illness, including schizophrenia.

00;07;47;27 - 00;07;59;25
Rebecca Chickey
And I think it's also been proven to reduce the number of readmissions and the number of visits to emergency rooms and all of that, as well as be able to meet the patient where they are in their own home.

00;08;00;04 - 00;08;27;19
Jodi Tate
We do not need any more evidence that ACT works. It works. You know, the challenges in rural areas. And Dr. Williams talked eloquently about that. And Dr. Jorgensen actually has started an ACT program in rural Iowa. And she has you know, she's running the rural track that we talked about earlier, expanding the psych residency program. So she's exposing residents, psych residents to the ACT program.

00;08;27;20 - 00;08;48;00
Rebecca Chickey
Yeah. Gotcha. Yeah. Can you go back and and tell me a little bit about the psych residency sort of structure? There's four years to the program, is that correct? I'm hoping I'm going to get this right for ACGME: the American College of Graduate Medical Education, correct? Right. Yeah. So before you can even go on this journey, you have to go through a process where you get their blessing.

00;08;48;00 - 00;09;09;24
Rebecca Chickey
And it's not a one stop process, is it? So, you know, just at a high level, you don't have to give us each step. But what did you have to go through in order to be able to move this program forward? And then how is it structured? Because if you are in rural areas, you know, how are they connecting back to, you know, sort of the mega metro centers, you know?

00;09;10;05 - 00;09;11;28
Rebecca Chickey
So how is that structured? Two questions.

00;09;12;09 - 00;09;38;14
Jodi Tate
So Dr. Jorgensen did that already for the rural track. So we have two additional residents right now. And to get ASCGME accreditation, essentially you have to meet a whole bunch of requirements about space, about faculty, about time, about learning. And it's not easy. And Dr. Jorgensen accomplished that, got the accreditation for that. And it's a long process, so it can take up to a year to get all that done.

00;09;38;14 - 00;09;44;20
Rebecca Chickey
It's just good for the listeners to hear, you know, and know what's realistic. Yes. It's not going to be a fix in six weeks.

00;09;44;21 - 00;10;12;17
Jodi Tate
No, this is a very long process. Okay. Yeah. And the ACG acknowledges an understands that we as a state, as a country, need to do better in educating our physicians in rural America. And they've created a think tank for rural and medically underserved populations to try to determine how they can help states develop programs and reach ACGME accreditation and given all the strict requirements.

00;10;12;28 - 00;10;15;18
Jodi Tate
But that is just started. So they're just trying to figure that out now.

00;10;15;24 - 00;10;29;27
Rebecca Chickey
Gotcha. So what about the structure of the residency program? You said that is underway and I think you have had six residents go through so far or are in the process of going through? What's the first year, second or third year, fourth year look like for them?

00;10;30;03 - 00;11;03;17
Jodi Tate
Yes. So, again, this is Dr. Jorgensen's area and this is all her developing this. So there so I hope I'm going to get this right. But their first year they do a primary care rotation in rural Iowa. And then their second year, they have three months of electives that are all in rural areas. And then their third year they have a telesite clinic to a rural area. And then their fourth year they can do any of those electives that I just mentioned.

00;11;03;29 - 00;11;26;03
Jodi Tate
And she is currently working with other parts of the state to expand and rural locations for residents. So that's our current state. Our future state will be to develop our residency program even further and there will be a lot of collaboration between Dr. Jorgensen's program and what we decide to do in the future with expanding throughout the state.

00;11;26;15 - 00;11;48;25
Rebecca Chickey
Well, and also through the fellowships that you're just now establishing in terms of what does this look like and feel like in rural America? Right, Right. So thank you for being on what I often call the bleeding edge of innovation. So it's not always comfortable and but but often, you know, thank heavens for the Wright brothers who were the first people to go up in that plane.

00;11;48;25 - 00;12;08;26
Rebecca Chickey
Right. You're the first person to try to do this in rural America through the fellowships. So you've mentioned a couple of times that the government of Iowa has been incredibly supportive. And you even mentioned that the governor, I think, had put forward a we can do better than this for individuals with mental illness and substance use disorders in our state.

00;12;09;05 - 00;12;13;24
Rebecca Chickey
Its really it's been the state legislature to some degree that's been driving this?

00;12;13;24 - 00;12;32;05
Jodi Tate
It has. It's been the state legislature that's been driving it. So they advocated strongly for it. It was the number one priority for for folks, and they made it happen. So it came from them. So the academic world can't claim any pats on the back for that one.

00;12;32;08 - 00;12;49;22
Rebecca Chickey
Well, you had to be ready to catch the ball when they threw it to you, right? Yeah, right. You know, I think you get a little street cred there. The other thing I was wondering, I think in the breakout session I heard you say that for the new 12 slots that the state is actually funding $100,000 per residency slot.

00;12;49;22 - 00;13;15;09
Rebecca Chickey
Is that correct? Yep. So just to give the listeners that sense, that may not cover all of the cost of a residency, but it certainly covers a significant part of it. So just know that your state legislature should be in contact with the Iowa State Legislature to be inspired for helping us get more health care workers. In terms of the key success elements,

00;13;15;22 - 00;13;39;26
Rebecca Chickey
based on your experience with the psych residency program under Dr. Jorgensen's leadership and passion for this and now looking at the psychiatric fellowship programs which will once achieved, have dual role, they'll have that fellowship and also will be, you know, at the same time as they go through the fellowship, are able to oversee the residency slots. What do you think are some of the key success elements that got this off the ground?

00;13;40;09 - 00;13;45;07
Rebecca Chickey
Certainly Dr. Jorgensen deserves a bright star, but were there other elements in addition to that?

00;13;45;13 - 00;14;22;13
Jodi Tate
Well, I think willing is to collaborate and communicate across different organizations. It always comes down to communication and collaboration. So I have met a lot of new people during this adventure and finding out that we all share something in common and that's trying to improve health, mental health care to Iowans. And so I think willingness to collaborate, willingness to communicate, willingness to think big, but then also realize, okay, well, this is our big end dream, but what are the steps we have to get to do that?

00;14;22;25 - 00;14;40;24
Jodi Tate
And is it going to be perfect starting out? Probably not. But let's just go and let's try it. So I think collaboration and communication and willingness to to try and to think and then willingness to actually make it happen and put the hard work in to make it happen.

00;14;41;00 - 00;14;50;00
Rebecca Chickey
And I thought I heard in there the ability to pivot. Yes. In case it's not going to be exactly going in the direction that you dreamed of initially. Okay.

00;14;50;07 - 00;14;55;07
Jodi Tate
Right. Who knows where this will end up, But we've got to start trying to figure it out. Yeah.

00;14;55;18 - 00;15;17;24
Rebecca Chickey
So let me ask you this two last questions. One, if you had to pick the biggest barrier that you overcame or went around or underneath, what would that be? Something for people to learn from your lessons, your own experience, so they can see the barrier is there and perhaps prepare better for it?

00;15;18;06 - 00;15;46;07
Jodi Tate
Well, I wish Dr. Jorgensen was up here because she's actually gotten over all those hurdles and her program is off the ground. And I'm just in the early stages of doing this next phase. But but I would say that the biggest hurdle so far has been getting everybody together here to talk, to have a similar vision, even though that vision may be not exactly clear, but at least something that everyone can agree on.

00;15;46;07 - 00;15;57;24
Jodi Tate
And I think we're still working on that. But I think having something that the group can agree on is where we need to go. So I would say I'm in the middle stages of that.

00;15;58;12 - 00;16;01;09
Rebecca Chickey
But you're building the foundation for the collaboration.

00;16;01;12 - 00;16;01;26
Jodi Tate
Thank you.

00;16;01;26 - 00;16;07;01
Rebecca Chickey
Yes, that sounds like. Right. Yeah. And that's not easy work because it means relationships, right?

00;16;07;01 - 00;16;08;16
Jodi Tate
It's all about building relationships. Yeah.

00;16;08;16 - 00;16;35;01
Rebecca Chickey
And learning the things about the other organizations that you didn't know were struggles or challenges. And they for you. Yeah. All right. So we are going to wrap this up. Are there a couple of things that you want to leave the listeners with that might inspire them to say, Hey, I'm going to start talking to my state representative and see if we can get something off the ground or I'm going to talk to my local academic medical center, something to inspire them as we close this out.

00;16;35;13 - 00;16;58;22
Jodi Tate
Yeah, I think at least for some of us that have been in the mental health system for a long time, it's hard sometimes not to think there's so many problems that we can't overcome. But I think that we have to keep optimism and keep some idealism that, you know, I've lost some of that. But to keep it that, you know, that we can fix this or we could please try to fix this.

00;16;59;09 - 00;17;18;22
Jodi Tate
And there is hope. And if we work together and we get the right type of people together that are passionate about mental health care and are passionate about making changes, then it can happen. So never give up hope and always keep trying.

00;17;19;00 - 00;17;28;16
Rebecca Chickey
That's exceptional. And I do believe that the Generation Z and all of those the millennials, they are going to demand.

00;17;28;29 - 00;17;29;10
Jodi Tate
Good.

00;17;29;20 - 00;17;42;11
Rebecca Chickey
Treatment for their entire for their whole self, right? Just like the surgeon general said, you know, there is no complete good health without good mental health. So hopefully we have a lot of champions coming behind you and I.

00;17;42;11 - 00;17;44;11
Jodi Tate
Yes. So we need them. We need them.

00;17;44;12 - 00;17;50;12
Rebecca Chickey
Keep the optimism going. And thank you so much, Dr. Tate. This has been a joy and thank you for the work you're doing.

00;17;50;14 - 00;17;50;29
Jodi Tate
Thank you.

00;00;01;04 - 00;00;20;12
Tom Haederle
For health care workers finding the right words to support a colleague struggling with their mental health or with thoughts of suicide can be challenging. They want to help. But the stigma surrounding the discussion of mental health concerns, along with the fear of potentially saying the wrong thing to the struggling colleague, can deter health care workers from checking in with each other.

00;00;21;08 - 00;01;07;20
Tom Haederle
But according to Luci New, assistant professor of nurse anesthesia at Wake Forest University School of Medicine, the best thing you can say to a struggling colleague is simple. I care about you. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, Luci joins Jordan Steiger, senior program manager of clinical affairs and workforce at AHA, to share how her organization is using a peer support model and QPR...that's “Question, Persuade, Refer” suicide prevention training

00;01;07;25 - 00;01;30;29
Tom Haederle
to empower and educate the workforce to respond to colleagues who are experiencing mental health concerns or suicidal ideation. This work is part of an ongoing AHA initiative to support hospital and health system leaders in their efforts to enhance the mental well-being of the health care workforce and prevent health care worker suicides.

00;01;31;16 - 00;01;43;20
Tom Haederle
The work of the initiative has been captured in a newly released guide from AHA titled "Suicide Prevention Evidence Informed Interventions for the Health Care Workforce." And now let's join Jordan and Luci.

00;01;44;05 - 00;02;02;24
Jordan Steiger
Thanks, Tom. So, Luci, we're really excited to have you with us today. You are such an expert in this field and in this space, and I think you are going to be able to help our membership really understand the issue of suicide prevention a little bit better today. Could you just tell us a little bit about your connection to workforce well-being and suicide prevention?

00;02;03;06 - 00;02;31;23
Luci New
Yes. And first of all, thank you for having me, Jordan. It's an honor to have been selected as part of this collaborative. It's a passion I've had for many years and I just am grateful to be able to share a little piece of my contribution to this vital topic. So I when I was pursuing my doctoral degree, I became passionate about second optimization and peer support programing, and that is what I pursued for my doctoral work.

00;02;31;23 - 00;03;00;23
Luci New
And I implemented a pilot peer support program at the facility of which I was employed as a full time CRT. And again, the intention of the organizational leadership group time and 100% grassroots efforts because one's friends and more people want to buy into the program. Our facility leader and the hospital where I was employed said, Hey, there's a survey on suicide prevention from the American Hospital Association, maybe you can fill this out. 

00;03;01;13 - 00;03;21;24
Luci New
And so I filled it out, not thinking that I would be selected, but I was and very honored to have been selected for that. And then coming back this year as well to part to participate in the collaborative of everyone putting their money where their mouth is, you know, let's do something about it.

00;03;21;24 - 00;03;45;27
Luci New
But with second victimization encompasses so much more than just being involved in an adverse event. When you look at the down stream effects of being involved in adverse events or medical error, there are certain trajectories that we all go through. Anyone in health care, it's not just physicians or nurses. It can be anyone that's working inside the hospital at the time.

00;03;46;19 - 00;04;20;07
Luci New
And so my passion has grown and extended to other areas as well. Burnout, suicide prevention, I think. And unfortunately, all in health care probably know of someone that has attempted or died by suicide. And certainly we want to prevent that from occurring. And we have to is multi-layered. We have to look at mental health conditions, mental wellness and get started on getting these efforts implemented across the country.

00;04;20;24 - 00;04;33;08
Jordan Steiger
Absolutely. It's a vital topic and we're really excited that we have your expertise to help the collaborative along. Tell our listeners what the collaborative is like. What have we worked on so far? What have you learned from it?

00;04;33;16 - 00;05;04;12
Luci New
Well, I've been in each time it's it's exciting connecting with people from across the country. Of course, we're looking at based on a report that was released last fall, on looking at the drivers of suicide, stigma and job related stressors and access and those to find likelihood of a mental health condition or of suicide. And so we're looking at how to mitigate those barriers for health and the health care workforce can definitely make an impact down the road.

00;05;04;12 - 00;05;33;22
Luci New
And that's why I had implemented a peer support program. I selected the job related stressors because I actually had already and I got ahead of the game before I even knew this was going to be a collaborative group. Because as in my faculty, where I'm a faculty member, we actually do a suicide prevention training every year for all faculty, staff and our learners and the nurse anathesia program.

00;05;34;04 - 00;05;56;20
Luci New
So I took a suicide prevention course and became an instructor in that course. So as I was taking that course last fall, I thought, wow, we really need to incorporate this into our peer support programing. And so when we got a letter asking for us to return, I thought, I've already got something, yah! And so it was kind of easy and easy.

00;05;56;24 - 00;06;28;27
Luci New
So like for us and the current facility I'm working with, they started their implementation process last fall and the force behind them really aggressively starting to seek out peer support. And this was related to a suicide of one of their colleagues. And so they have chosen to honor this this teammate by having the name in this person's memories and so approach the CNO.

00;06;29;15 - 00;07;04;27
Luci New
So that facility and she says, oh, yes, come in because because, you know, suicide prevention was why we first were kind of really pushing towards going ahead and getting this peer support program developed. So it was not a tough decision on what to do. Of course, there are barriers and we recognize that and the networking that we do in that group, there's challenges, of course, with and including in my own organization, we have three people that do our peer support training, our EAP director and my long standing partner in crime who's a CRNA. Dr. Bernadette Johnson, is her name.

00;07;04;27 - 00;07;27;19
Luci New
I want to give her credit as well. We were implementing pilot peer support programs, so we joined forces in creating this peer support program. And so there begins to be an exponential increase in the desire of different facilities and departments that while we want the peer support program in and it's like you can't do it fast enough because these resources are certainly needed.

00;07;27;19 - 00;07;49;14
Luci New
So I've enjoyed the networking and got lots of great ideas. I mean, we're all very sharing with each other and share what we have. I mean, why reinvent the wheel for anything? And I've really loved Speaker, simply proud to share their passion and their expertise on the different subjects related to suicide.

00;07;50;03 - 00;08;07;08
Jordan Steiger
Great. Thank you for sharing that. And I know, yeah, you've had your peer support programs going for a while. I think you're ahead of the game, which we love to see. I know one of the things that you've incorporated is QPR training. Could you tell our listeners a little bit about what QPR is?

00;08;07;24 - 00;08;34;13
Luci New
Yes, QPR is a program. It's been around for a long time. I was surprised. I first took the what they call a game keeper training, which is kind of like if you equate it to CPR, QPR and the gamekeepers kind of like someone that just has the basic life support skills. But QPR, they have an instructor level, which is a course that you can play online.

00;08;35;02 - 00;09;11;25
Luci New
It goes through the history of QPR or history QPR, yes, but the history of suicide and shares different cultural beliefs and values around the history of suicide. And then it goes through specifics of conducting this training because of course it is a very heavy topic and it it really summarizes everything into a one hour course to just equip people to be able to have the courage to ask someone, are you thinking of hurting yourself?

00;09;11;25 - 00;09;39;17
Luci New
Because so many times we don't know what to say to someone. You know, we know someone's struggling and so we think we don't have the words to say or something to say might make them feel bad or feel worse or really go through with hurting themselves when actually by ignoring and just walking away, they're even wrestling with more intense emotions or more like nobody cares or nobody.

00;09;39;24 - 00;10;08;27
Luci New
You know, everybody thinks that because I made this medical error that I really should be in practice. And so by not being able to do it or at least find someone, you know, if you know someone's struggling to be able to go and say, hey, we have this peer support program here, or hey, we have these resources that might be helpful to you because I care about you and what you're going through and because a lot of people don't know the resources are there.

00;10;09;07 - 00;10;42;13
Luci New
A lot of organizations have an abundance of resources. People aren't aware of those resources, or they may think they're not a benefit for being an employee there or finding resources. Sometimes a lot of health care organization and trauma can be challenging to navigate sometimes, especially for someone like me who's not very tech savvy and you're trying to find information and it can be difficult to find and you're afraid or embarrassed by the stigma, right, of reaching out and asking someone or telling someone, I need help.

00;10;42;19 - 00;10;45;15
Luci New
I'm struggling and I need someone to help me.

00;10;46;03 - 00;10;57;29
Jordan Steiger
So what I'm hearing from you now is just thinking about empowerment, thinking about education, making sure people have the resources in their hands, and just encouraging them to speak up. Could you tell us what QPR stands for?

00;10;58;25 - 00;11;30;28
Luci New
Yes. Is question persuade and refer. It's been around since the eighties. I was surprised that it has the longevity that is, that it has had. And and again, I guess when you look at the statistics for suicide, they have gradually increased over the years, especially since 2000. I think they've steadily increased. They dipped a little bit, I think in 2021, but now they're they're increasing again.

00;11;31;00 - 00;11;47;10
Luci New
So it is certainly a great program. I mean, it's not just for health care, civic organizations and houses of worship or faith schools, first responders. It's not just tailored specifically for health care workers.

00;11;47;21 - 00;12;09;16
Jordan Steiger
I think that approach makes a lot of sense. And it sounds like there are community benefits to training on QPR as well as benefits to health care workers. We know that health care workers are at a point right now after the pandemic is slowing down, the public health emergency has ended, but those mental health effects from being a caregiver during these last few years are not going to just go away.

00;12;09;16 - 00;12;11;17
Jordan Steiger
So this sounds like a really great approach.

00;12;12;05 - 00;12;36;00
Luci New
Yeah, and there's actually research that I did for a paper looking at the workplace challenges and the risk of substance use in the health care workforce. And one of the things that I wrote about was COVID. And we we like I think we're all kind of a little bit happier because we're like, yes, it's done. It's behind us.

00;12;36;11 - 00;13;18;05
Luci New
But really, when you look at the lingering effects of especially for so many those on the frontline, our ICU nurses, they saw so many sick patients and and there was exposure to a lot of patients dying and ... that certainly contributes to seeing that day in and day out is certainly can weigh on your emotional state and a lot of those ICU nurses I think were exposed to very traumatic experiences.  Saw them very early in their career and more abundant than than what is seen over long periods of time for other people.

00;13;18;16 - 00;13;30;28
Jordan Steiger
Absolutely. I think the support that we're going to provide now in the next few years is going to be critical, especially for that younger workforce. What positive outcomes have you seen from this project so far at your organization?

00;13;31;18 - 00;14;01;17
Luci New
Well, the positive outcomes, we have almost hit our benchmark because we've done two peer support training sessions since we started our action plan, we have one tomorrow as well. And the feedback we've gotten from our surveys, we do have tracking metrics. One of our tracking metrics is on if you provide peer support, what is the reason for providing that peer support, whether it's a medical error or a near miss?

00;14;02;01 - 00;14;33;16
Luci New
And we do have one of our boxes that can be tracked is suicide, and that could even be from a patient as well. I mean, because certainly that's a traumatic event too. But as far as some of the comments we have received from doing the training, people said it was done well. They had never heard of this training and they hope they never need it, but they're glad they have that skill set in addition to their peer support skills, and that it was incredibly helpful.

00;14;33;28 - 00;14;59;21
Luci New
And then one person stated, which this really makes a lot of efforts that you in time that you commit outside even your normal work time and environment. One of the persons commented that I'm ready to help my peers. A good friend and mentor of mine at one point said, if you help one person, its successful, we have to help people.

00;15;00;03 - 00;15;03;26
Luci New
But you want to do more. Of course you want to get out there for everyone.

00;15;04;16 - 00;15;11;26
Jordan Steiger
Luci, as we wrap up, what is your big takeaway? What do you want our listeners to know about suicide prevention or the work that you're doing?

00;15;12;25 - 00;15;45;10
Luci New
Don't be afraid. Don't hesitate. You know, sometimes its as simple as saying, I care about you and I care what you're experiencing. Let's go see what options or resources there are to help you through this. A lot of times when people get to that point of despair, you do think that that nobody understands and you might not understand 100% what someone's going through, but you can just say, I care about you.

00;15;45;26 - 00;16;06;15
Jordan Steiger
I think that's something everybody listening to this today can commit to doing. It's four very simple words: I care about you. I think that's very powerful. Luci, thank you so much for joining us today and for sharing your insights. We're so happy to have you as part of our AHA collaborative, and we're looking forward to our continued work together.

00;16;07;02 - 00;16;24;01
Luci New
Yeah, thank you again for having me so much. And again, it is such an honor to be working side by side with so many people that have this same passion about promoting and developing plans to help reduce suicide in our health care workforce.

00;16;24;28 - 00;16;36;08
Jordan Steiger
If you're interested in learning more about our suicide prevention work for the health care workforce, please visit aha.org/suicideprevention/healthcareworkforce.

00;16;36;19 - 00;16;58;12
Tom Haederle
Development of this product was supported by Cooperative Agreement ck202003 funded by the U.S. Centers for Disease Control and Prevention, CDC, the National Institute for Occupational Safety and Health. The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC or the Department of Health and Human Services.

00;00;00;28 - 00;00;39;05
Tom Haederle
Hospitals and health systems are playing an increasingly important role in providing behavioral health care, whether in their own facilities or by helping patients connect with community resources. It's a positive trend, but the need for behavioral health resources is great, and the gap between needs and resources remains wide. Welcome to Advancing Health, brought to you by the American Hospital Association.

00;00;39;15 - 00;01;09;14
Tom Haederle
I'm Tom Haederle with AHA Communications. In this leadership dialog series podcast, John Haupert, president and CEO of Atlanta-based Grady Health System and the 2023 chair of AHA’s board, is joined by Jesse Tamplen, vice president of Behavioral Health Services at John Muir Health. That's near San Francisco. Tamplen notes that in all of California, our most populous state, there are fewer than 100 acute psychiatric beds for children under the age of 12.

00;01;09;26 - 00;01;32;06
Tom Haederle
John Muir Health has 10% of those beds. It's a nationwide situation. The two leaders discuss how hospitals are working with local and state organizations to create new pathways to appropriate care and treatment, as well as preventive services. And they review the role of adequate reimbursement to cover the cost of behavioral health services. With that, let's join John and Jesse.

00;01;33;11 - 00;02;03;28
John Haupert
Good afternoon and thank you, everyone for joining me today for another leadership dialog session. I'm John Haupert, president and CEO of Grady Health System in Atlanta, Georgia, and also chair of the board of trustees of the American Hospital Association. I'm very much looking forward to our conversation today as we talk about the critical issue of behavioral health, an issue that has only worsened during the past few years since the pandemic, but has long been  stigmatized as well as underfunded.

00;02;04;28 - 00;02;32;21
John Haupert
With the mental health crisis in our country worsening, the hospital field is finding itself more active in developing an advocate for solutions to help patients and families, as well as also our own caregivers who have seen increased rates of anxiety and burnout. At Grady, like other organizations, we are working to build a stronger infrastructure to meet all behavioral health needs of those we serve.

00;02;33;06 - 00;02;54;15
John Haupert
And as a matter of fact, Grady Health System is the largest provider of mental health services in the state of Georgia outside of the prison system. I am very pleased to introduce my guest today, Jesse Tamplen, an expert in this area, who will offer his insights on some of the most pressing challenges currently facing our behavioral health system.

00;02;55;29 - 00;03;27;07
John Haupert
Jesse is the vice president of Behavioral Health Services at John Muir Health, a not for profit health system organization east of San Francisco. John Muir Health offers both inpatient and outpatient treatment programs across the entire spectrum of care for children, adolescents and adults who have psychiatric or behavioral problems. And Jesse also serves on AHA's Committee Behavioral Health. Welcome, Jesse.

00;03;27;07 - 00;03;30;03
John Haupert
It's an honor to have you join us today.

00;03;30;23 - 00;03;34;09
Jesse Tamplen
Good morning, John. It's a pleasure to be here and have this conversation with you.

00;03;34;27 - 00;04;03;12
John Haupert
So, Jesse, let's go ahead and dive into a few questions so that you can share your views on several different issues surrounding mental health, behavioral health, and how health systems are bridging the gap. We know that the pandemic only worsened the longstanding challenges our nation faces around access to adequate behavioral health services. What trends have you seen over the past few years, particularly in the period post-pandemic?

00;04;04;08 - 00;04;37;19
Jesse Tamplen
Thank you. As you mentioned, we know that there is a behavioral health challenge with people, children, adolescents and adults receiving care in the United States pre-pandemic. Post the pandemic, we've seen the incidence rates of self-harm, suicide, substance abuse, anxiety, depression, eating disorders increase dramatically. Where we're seeing that impact many times within the system the most is in our primary care settings. 

00;04;37;19 - 00;05;03;12
Jesse Tamplen
When it becomes very acute, it comes into our emergency rooms and then our med surge acute care hospitals. If a hospital emergency room is fortunate enough to be associated with an acute psychiatric hospital, they're able to get patients the care that they need. But many times that I think people have seen throughout the country that we have a lack of acute care, behavioral health beds in the United States.

00;05;03;20 - 00;05;30;28
Jesse Tamplen
And unfortunately, when people become acute, they often stay in our emergency rooms waiting to get care. We do everything we can to make sure that people can go back to either their primary care provider or find specialty mental health providers. But we know that we're in short supply within that workforce. So those have been some of the clinical challenges that have been impacting the the community and the patients that we serve.

00;05;31;22 - 00;05;47;00
John Haupert
I was really pleased to see that you all offer psychiatric behavioral health services to children and adolescents as well. What are your views on the availability of mental health services for children and adolescents?

00;05;47;19 - 00;06;21;14
Jesse Tamplen
There's opacity for children and adolescents. The Children's Hospital Association for America mentioned that we are just at a, you know, a crisis in youth mental health. In California, one of the largest states, there's less than 100 acute psychiatric beds for kids under 12 years old. John Muir Health has ten of those. So we represent 10% of all of the states, the ICU level of care for youth.
 
00;06;21;14 - 00;06;46;22
Jesse Tamplen
We have 24 adolescent beds and John Muir, 20 years ago made the commitment to youth and adolescent mental health to make sure that kids would not be sent out of their communities to receive treatment. So we're very fortunate in our local community that when kids need to access that critical lifesaving care, they can remain in their community. Across the country and through the state of California,

00;06;47;04 - 00;07;18;09
Jesse Tamplen
many times you don't have those services within your community or your health system. So those kids who need care, who need to be as part of their family are many times sent four or five hours away from home. John Muir is a local nonprofit where we serve our community. But when it comes to our acute psychiatric hospital, we are an anchor institution for all of Northern California and many times the state for our youth and adolescent specialized psychiatric inpatient treatment.

00;07;18;25 - 00;07;45;16
John Haupert
Wow. Know, that's a stunning number to hear that in a state the size of California, there's 100 beds available for those services. But at the same time, as you and I know, we shouldn't be stunned because nationwide, the amount of inpatient care available for pediatric and adolescent patients is woefully underfunded and available. So let's move on to another question.

00;07;45;27 - 00;08;09;20
John Haupert
Hospitals and health systems are playing an increasingly more important role in providing behavioral health care, whether in their own facilities or by helping patients connect with the resources available in their community. Can you share with us any short term collaborations you've seen that are successful in meeting the behavioral health needs of a community or even longer term solutions we should be talking about?

00;08;10;10 - 00;08;37;27
Jesse Tamplen
Yeah, this is an exciting area. After the pandemic, some of the stigma and discrimination of mental health decreased in talking about it and allowing people to really share their behavioral health. And I think and the pandemic really allowed more innovation to come forward where we've had some very exciting partnerships with our state in California and locally, our local health jurisdiction, is we've created...

00;08;38;10 - 00;09;01;27
Jesse Tamplen
it started off as a substance abuse, a navigator in our emergency room just supporting the opioid crisis. And then that really evolved into a behavioral health navigator. We know that there's not enough preventative services in the community. And so no matter where people are getting services, many times when they become acute, you hear everybody say, if you become acute, go to your local emergency room.

00;09;02;04 - 00;09;28;10
Jesse Tamplen
And our emergency rooms are already strapped with the care that they're providing and COVID 19. So we've created a behavioral health navigator that supports those patients, both substance abuse and psychiatry. Many times they're people with lived experience or they have professional education, working with the emergency room team, the family and the community to get the person that care that they need to be able to access care.

00;09;29;03 - 00;09;54;08
Jesse Tamplen
Not only do we keep them in the emergency room, but they're able to float up into our medical hospital. And many times, if they are following up with our own primary care, they will go support that individual into primary care. It's been incredible to have that that behavioral health navigator for our patients because we're meeting them anywhere they are in our health care system and helping them navigate the complexity of getting services.

00;09;54;22 - 00;10;26;24
Jesse Tamplen
One of the challenges in behavioral health, you may know the service that somebody needs, but they're are significant waitlists. It doesn't exist in your community. So you really need an expert navigator to support the patients. And so that's one area that we have been using are behavioral health navigators. And then we partner with our fire departments. Right now we're doing an innovative project with one of our local fire departments where they're looking to not have a police first response, but a fire response to behavioral health care.

00;10;26;24 - 00;10;35;06
Jesse Tamplen
So we're working with them to create a new clinical pathway. So those are two innovative programs that we're currently working on.

00;10;35;26 - 00;10;58;10
John Haupert
I thank you, Jessie, and I'm so pleased to hear you bring up the topic of navigators and behavioral health, particularly navigators that have a lived experience with behavioral health issues, have been there, done that. So not only are they navigating for the patient and getting the care that the patient needs, but they're also also serving as a peer support individual for that person.

00;10;58;10 - 00;11;13;22
John Haupert
And that's really great. So I know top of the list for many is better integrating and coordinating behavioral health services with physical health services. Any thoughts, advice or maybe wishes that you can share on this type of integration?

00;11;14;19 - 00;11;44;23
Jesse Tamplen
This is where I'm passionate about. I think for us to really move the needle on the health inequities in behavioral health, we need to treat physical medicine and psychiatric medicine the same. We need to treat it clinically, which many people want to do, but we also need to treat it economically. The reimbursement in those areas. One area that I would love to share with you is that in hospitals, John Muir has two acute care medical hospitals and one acute care psychiatric hospital.

00;11;44;23 - 00;12;10;14
Jesse Tamplen
And we have a transfer center. And as you know, the transfer centers, when you need a bed, when you need specialized care, referring provider calls up the transfer center to find the best care for them within the hospital. Over the last year and a half, we wanted to make sure that we integrated both physical and psychiatric medicine. So we integrated the transfer center with our acute care psychiatric hospital.

00;12;10;20 - 00;12;39;12
Jesse Tamplen
So now there's one number for anybody to call to get inpatient treatment. And not only does it create easier access and decreases the stigma and discrimination for people seeking care and providers seeking care, but it's an upstream area where we're working with our workforce also to say we're not treating physical medicine and psychiatric medicine different because we know that we don't have enough beds in California for psychiatric patients.

00;12;39;21 - 00;13;02;10
Jesse Tamplen
We are so we know they end up in our emergency rooms, which is not the best care or in our medical hospitals, which is not the best care, but we're still going to treat that. So if we start with a transfer center, develop those clinical pathways, it's part of the education model that we're increasing care clinical protocols no matter what setting you are within that, within the hospital needing care.

00;13;02;19 - 00;13;13;24
Jesse Tamplen
So that is an area that I'm very excited about and we've had unbelievable success over the last year with integrating our transfer centers, both physical and psychiatric.

00;13;14;11 - 00;13;39;13
John Haupert
Well, that that's a fantastic approach. And it's interesting in the evolution of health care in our country that we have separated those two mental and physical health aspects of an individual, when I always refer to it as whole person care. If I'm a primary care physician, I need to be able to evaluate not only the physical, but are there mental health issues at present as well.

00;13;39;13 - 00;14;11;21
John Haupert
And let's treat all of that together. And I so appreciate the work you're doing around that. There have been long been issues around inadequate reimbursement, as you just mentioned, for behavioral health services, as well as significant shortages of behavioral health workers. Those challenges have likely only worsened over the past few years. Can you explain for our audience how poor reimbursement drives shortages of behavioral health workers, and how does that have an impact on inequities within our health system?

00;14;12;10 - 00;14;36;02
Jesse Tamplen
Thank you. And when you get into behavioral health economics, it's almost like you have to have a Ph.D. in economics because it's not a simple: two plus two equals four. I wish it was. And so what we know is many times behavioral health is either capitated or their stringent authorizations, or in physical medicine, you can show up to any emergency room and be treated.

00;14;36;10 - 00;15;08;00
Jesse Tamplen
But many times, if you're on government insurance, especially at a local health jurisdiction, you have to go to your county of origin to receive care. So your zip code is determining your access and ability to receive care. We also know if your zip codes determining that it's increasing health inequities. And so one of the challenges that we have is the mental health reimbursement does not cover the cost of care, especially in a hospital system that wants to provide whole person care as you mentioned.

00;15;08;00 - 00;15;32;04
Jesse Tamplen
I'm a big proponent that to integrate physical and psychiatric medicine, you need to be part of a hospital system that runs emergency rooms, that runs surgery, that runs primary care, specialty cardiology, because that's where you're going to be taking care of the patients and you're going to have a system and a leadership group and clinicians who know how to take care of the whole person.

00;15;32;22 - 00;16;00;16
Jesse Tamplen
When you carve that out, then you start having standalone behavioral health programs, which there's nothing wrong with that. But when you look at the health inequities that you are talking about  - when you're diagnosed in the United States with serious mental illness, you're dying 25 years younger than the average population. And it's not due to your mental illness, it's due to preventable health conditions, obesity, diabetes, cardiovascular care.

00;16;00;27 - 00;16;24;04
Jesse Tamplen
How we carve out our reimbursement and we say we want to treat all person care. When you carve out that reimbursement and your providers and your workforce are just focusing solely on behavioral health, but then they're excluded from providing that primary care, that whole person care. Making sure you're managing somebody's diabetes or obesity or you're not part of a system that has that knowledge.

00;16;24;12 - 00;16;55;14
Jesse Tamplen
You see the impact of that stigma and discrimination. And it's one of the reasons why people are dying 25 years younger in the United States with a serious diagnosis. When we look at reimbursement behavioral health providers, you look at our BSN, our Bachelor of Science in nursing, large education, financial investment of time investment becoming a psychiatrist, significant financial time investment, becoming a social worker, a psychologist, a marriage, a family counselor.

00;16;55;22 - 00;17;17;01
Jesse Tamplen
So people want to follow their passion, provide whole person care. They've taken out the student loans. They made the time investment. And then when they're looking at where do they want to practice? They look at the level of reimbursement and they're like, I may not be able to pay off my student loans because of the reimbursement. So many of them will go into private practice.

00;17;17;10 - 00;17;39;19
Jesse Tamplen
So in behavioral health, you really see kind of a two tier system where you have private practice, where people are taking cash because they don't want to deal with the carve out reimbursement in private practice, which we want to support. But being part of a hospital, we're looking to recruit our professionals. Our professionals are on call 24 hours a day, seven days a week, providing critical care.

00;17;39;23 - 00;18;02;22
Jesse Tamplen
And the challenge of reimbursement puts a huge impact on our ability to recruit. We know recruiting for health care workers across the country is a challenge now. In behavioral health it's even more exacerbated not only because of the low reimbursement, but additionally, after the COVID 19 pandemic, there was a huge investment in digital health specifically and behavioral health.

00;18;03;01 - 00;18;35;00
Jesse Tamplen
Behavioral health, many times it's not a procedure medicine. It's cognitive medicine. Cognitive medicine goes nicely, virtually. So there's a huge drain on the behavioral health workforce. If you're a psychiatrist or if you're a nurse, if you're a counselor, to be able to provide online therapy counseling, which is incredible for a work life balance. But when you're providing ... when you're an anchor psychiatric institution, not only in your community, but across the state for children and adolescents, that exacerbates the workforce.

00;18;35;08 - 00;18;55;15
Jesse Tamplen
And a lot of that drop is driven by the reimbursement that we're getting for behavioral health, which is vastly underfunded. I think in March of last year, 2022, the General Accountability Office just highlighted how mental health reimbursement is underfunded in the United States.

00;18;56;17 - 00;19;39;27
John Haupert
Well, Jesse, thank you for that answer. You touched on so many important points. And I'll be honest, I had not heard before that significant lifespan difference for patients with chronic mental health conditions, that really is tragic. And it really points to the issue of having separated the two and underfunding mental health across the board. So one last question, Jesse, a challenge I'm hearing more and more about is the growing administrative burden, a huge piece of this, as in prior authorizations. Some state Medicaid programs are trying to reduce the burden behavioral health workforce teams face, and there's talk of other efforts.

00;19;40;13 - 00;19;50;14
John Haupert
But how are you managing that? Are there solutions you all have been able to work through with your state Medicaid program or commercial insurers to to reduce that burden?

00;19;51;15 - 00;20;36;29
Jesse Tamplen
That is a great question. And many times to patients, it is an offstage challenge that they don't know until they face it. Prior authorization for behavioral health is significantly overburdened. Then you are is significantly overburdened because of the carve out. And I'm going to highlight some of the challenges that people may not be aware of, and I'll tell you what we're working on with the American Hospital Association, California Hospitals Association with our local municipalities ... is one of the areas that I try to bring education to is when somebody comes to our emergency room, we know our emergency rooms, they're our to support the most vulnerable and their most critical time of need.

00;20;37;08 - 00;21;04;05
Jesse Tamplen
And when any other outpatient service can't take care of somebody, they send them to our emergency room to see that receive that care because we're there 24 hours a day, seven days a week to care for the members of our community. Well, if you have a cardiac condition and you go into the emergency room and it's a life threatening condition, regardless of your payor, socioeconomic status, race, ethnicity.

00;21;04;28 - 00;21;33;16
Jesse Tamplen
If you have urgent and emergent care, you get admitted into the psychiatric hospital and then you work on all of the authorizations. If they have insurance, not insurance afterwards. We have a federal law, Empala, that really supports that level of care and that level of access. The challenge with reauthorization and behavioral health is many times when it comes to Empala people don't feel that Empala oversees behavioral health.

00;21;34;09 - 00;22;02;27
Jesse Tamplen
We know that it does from the Centers for Medicaid and Medicare Services. But when an individual comes into an emergency room and they need care, many times it's requiring pre-authorization, but it's an emergency care. And that reauthorization could take five, six, eight, nine hours. And so people are talking about the lack of beds in the community for psychiatric beds, behavioral health, which is true.

00;22;03;07 - 00;22;29;21
Jesse Tamplen
But they also what what they're not talking about is the burdensome of pre-authorization where we're delaying care, because if it is a Medicaid program, a local health jurisdiction or a commercial insurance program, they're requiring authorization or they're going to deny that care. Many times we will the hospital or admit that person. But then on the back end, we get denials.

00;22;29;21 - 00;22;54;01
Jesse Tamplen
We have to fight with authorization because we said that's the right thing to do because we need to get the person to the specialized care that they need. And so for me, when I really look at what are things that we can do to really help provide whole person care, integrate physical and psychiatric medicine, many of it is following the guardrails that the regulations are already in there and making sure that they are enforced.

00;22;54;08 - 00;23;24;02
Jesse Tamplen
That's also what the General Accountability Office mentioned last March in their report is that there's regulations on the books. But when it comes to behavioral health, not everybody always follows those rules. So I've been working with the California Hospital Association, our local health jurisdiction and the state, to really make sure that we know that when somebody comes into our emergency room, we do not look at their financial status and we get them to the specialized care that they need in-patient.

00;23;24;15 - 00;23;50;18
Jesse Tamplen
And for people who are not familiar with this, they may say, wait a minute, this is what's always supposed to happen. But there's been a long precedent, a community standard where people require pre-authorization, which backs up our emergency room. But most importantly, it delays critical lifesaving treatment to people with acute psychiatric or addiction medicine challenges. And the worst situations of this is what is called the ping-pong effect.

00;23;51;00 - 00;24;09;26
Jesse Tamplen
I don't know if you've heard of the ping-pong effect before in behavioral health, but somebody comes into your emergency room. They're like, oh, we're not quite sure if this person needs inpatient treatment. Our attending ED physician says, yes, they do. Then somebody says, send them to our psychiatric emergency services. And so we're like, but we have an open bed available.

00;24;10;09 - 00;24;30;21
Jesse Tamplen
But they say, send them to ours. We send them to theirs. They're like, oh, we agree with you. And then they send them back to your acute psychiatric hospital. Not only is it a burden on that patient and delaying care, but you're using ambulances, you're using people's times. The cost is coming up. But because behavioral health is carved out, the costs are in different domains.

00;24;30;27 - 00;25;04;09
Jesse Tamplen
So people are not seeing that total cost or focusing on that total care. So I'm kind of a zealot when it comes to making sure that we have access in our emergency rooms to lifesaving care for acute psychiatric hospitals. And I've been in the field for over 25 years. I've made some progress, but it's still a fight. And I think right now, with behavioral health being in the spotlight after the COVID 19 pandemic, we can really start driving some of those quality measures which we have in the physical health side many times.

00;25;04;15 - 00;25;18;07
Jesse Tamplen
But I feel all parties are mainly government health insurance, are coming together to really drive for, you know, drive that forward. So I'm hopeful, but we're not quite there yet on the issue.

00;25;19;06 - 00;25;49;05
John Haupert
Well, Jessie, you really have done a fantastic job today in getting the points across that we need to be focused on. There's a very real reason that HHS has has targeted specific issues within society and health to assure funding for and behavioral health is one of those. I want to thank you for joining us today. I appreciate you sharing your insights on how we can best support behavioral health services and integrate treatment and the whole person care.

00;25;49;29 - 00;26;16;07
John Haupert
I know this is a topic that can benefit everyone listening, and I encourage anyone who may be struggling with feelings of anxiety or depression to please reach out to someone who can help. You can visit AHA.org and AHA's Physician Alliance website for additional resource is focused on stress coping and mental health for health care workers. Until next time.

00;26;16;07 - 00;26;23;09
John Haupert
Thank you, everyone, for joining us today. I hope you'll be back next month for our next leadership dialog. Thank you.