Advancing Health Podcast

00:00:01:00 - 00:00:28:18
Tom Haederle
Welcome to Advancing Health. Western Wisconsin Health recently put a lot of care, planning and resources into expanding its maternal care services for the rural population it serves. Was it successful? Well, the hospital CEO jokes that she took on a little bit of market research herself by having her own child at the hospital and checking out the experience from a patient's point of view.

00:00:28:20 - 00:00:54:01
Julia Resnick
Hi, I'm Julia Resnick, senior director of health outcomes and care transformation at the American Hospital Association. I'm so excited to be here today with Eilidh Pederson CEO of Western Wisconsin Health. Today we're going to discuss rural maternal health. As many rural hospitals are shutting their labor and delivery services, some are doubling down. Eilidh’s hospital is one of the ones that's expanding their maternity care for their community and for their patients.

00:00:54:03 - 00:01:06:15
Julia Resnick
And Eilidh has a special connection to share. So let's get right into it. Eilidh thank you so much for joining me for this conversation. To kick things off, can you tell me more about your hospital and the community that you serve?

00:01:06:17 - 00:01:35:06
Eilidh Pederson
Yes. Thank you, Julia, for having me. Thank you to the AHA. My name is Eilidh Pederson. I'm the CEO with Western Wisconsin Health, and we are Critical Access Hospital in Baldwin, Wisconsin. We serve a rural community and we serve as a safety net hospital to both our community and to our region. We employ about 500 people and offer a full breadth of service, focusing on a holistic approach to health care and meeting patients where they are.

00:01:35:08 - 00:01:39:15
Julia Resnick
Fantastic. And tell me more about your family and raising your family in Baldwin.

00:01:39:18 - 00:02:11:19
Eilidh Pederson
So now I have four kids. Very excited to share my pregnancy journey with you with my most recent baby. She was the latest addition to four kids. Two boys, two girls. And I absolutely love raising a family in Baldwin. I think there's nothing better than raising your children in a rural community. Having an opportunity to really get to deeply know people, both people with whom you're raising children at the same time, but also meeting and getting to know people who use and benefit from your hospital services.

00:02:11:21 - 00:02:37:27
Eilidh Pederson
I personally love that opportunity to meet patients in the grocery store, at the local football game, or my family at our hockey games, or big hockey players. And so that opportunity to get to know people outside of just when they're sick and when they're in the hospital, when they're feeling their best out in the community, I think is the absolute best thing about serving as a leader in a rural hospital and living in a rural community.

00:02:38:00 - 00:02:43:29
Julia Resnick
That's so special that you get to see your patients when they're healthy and out of the hospital and back to their day to day lives.

00:02:44:02 - 00:03:07:22
Eilidh Pederson
Yes, yes. I think it also is really what contributes to the quality of medicine and rural communities. There's nowhere to hide if something doesn't go well, if there is displeasure about a service, you're going to hear about it again at the grocery store, at the football game, at church, at the hockey game. And that high level of accountability translates into quality outcomes.

00:03:07:22 - 00:03:13:06
Eilidh Pederson
So it makes a difference to, to live and work in the same community.

00:03:13:08 - 00:03:20:20
Julia Resnick
Absolutely. So tell me about what maternity care is like in your community, all the way from prenatal care through postpartum care.

00:03:20:22 - 00:03:50:12
Eilidh Pederson
So all things encompassing, maternal and child health are really a staple in our hospital. We've made a conscious decision that these are foundational programs to us. So we offer prenatal care, through midwives, certified nurse midwives, obstetricians and family medicine physicians with obstetrical care as part of their training and their service. So the prenatal journey starts there. Patients have an option to see any of those providers.

00:03:50:12 - 00:04:12:28
Eilidh Pederson
It's their choice. Part of our very focused approach to medicine here. Patients are in control. They lead their own show. We're here to support and care for them. So the prenatal care journey starts there, and we see patients through anti-partum visits, and we see for them through their ultrasounds. All of their lab work is done within our hospital.

00:04:13:00 - 00:04:36:10
Eilidh Pederson
And then there's the birth experience that happens in our labor and delivery unit. We are now a seven bed obstetrical care unit where we deliver patients, either vaginally or through C-section. And then once those patients are born, we're there to be serve as their medical home. So on the pediatric side, we have two pediatricians. One specializes in developmental pediatrics.

00:04:36:10 - 00:05:00:23
Eilidh Pederson
So for our patients who have developmental needs, we have onsite pediatric care for patients in need of those services. We have a pediatric nurse practitioner. And then we have family medicine providers who also meet the needs of our pediatric patients. And we really want to be that wraparound service for a patient's life span. So through the birth through childhood and all the way throughout all stages of life, we want to be here for our patients.

00:05:00:28 - 00:05:11:18
Julia Resnick
And it's one thing to talk about pregnancy care in the abstract. It's another when you are the hospital CEO who's getting your pregnancy care at your own hospital. So can you talk about that experience?

00:05:11:21 - 00:05:35:27
Eilidh Pederson
It is just an absolute joy to have my own child at this hospital. One of the things that we do here for all patients is we sign kind of a quasi birth certificate. It's not an official birth certificate, but it's a welcome to the world. We put the baby's footprint on it. It's one of my favorite parts of the job is I get to personally sign all of those welcome to the world, through our hospital.

00:05:35:28 - 00:05:58:01
Eilidh Pederson
And so it was really special and fun too. I had my own baby, and I got my own certificate that I signed welcoming my baby into the world. Being able to experience prenatal care here, I went the midwifery route and had an absolute wonderful experience through prenatal care, sharing and the joys of practice with that personalized approach of a nurse midwife.

00:05:58:04 - 00:06:22:09
Eilidh Pederson
Then, through the labor experience to a nurse midwife by my side, we expanded our hospital a year and a half ago, and to be able to be in a room that we worked hard to bring on site for patients in need. Was great to see every aspect of that design come to life as a patient, to see firsthand why we built it that way.

00:06:22:12 - 00:06:38:11
Eilidh Pederson
All of the funds that we raised to bring that to life. Again, just to experience that firsthand was great. And nothing beats the joy of welcoming a child into the world. And to get to do it in my hospital is beyond words, how special that was.

00:06:38:13 - 00:06:42:26
Julia Resnick
Being a patient in your hospital, how did it make you think about care differently?

00:06:42:28 - 00:07:14:10
Eilidh Pederson
You know you have more vision as an administrator on what you think that care journey should look like. Of course you do that in partnership with physicians, providers, nurses, all of the, caretakers who are closest to the work. And that vision you hope you plan, you prepare that that aligns with reality. And so I joke that this was one way to do market research to determine, okay, did all of that planning go according to plan and a real life experience?

00:07:14:10 - 00:07:33:16
Eilidh Pederson
And I will say, for the most part, it did. It went exactly as we planned and prepared that it should, with few exceptions, and I'm happy to share those exceptions. But it was great to see that vision that we had, that plan of care come to life and to experience that as a patient. I'm thinking, you know, okay, this is what should happen next.

00:07:33:17 - 00:07:41:25
Eilidh Pederson
This is what we plan for. This is what it should look like. And really in every aspect, it it basically did, which was wonderful to experience firsthand as a patient.

00:07:41:28 - 00:07:47:13
Julia Resnick
Yeah. What were those exceptions and how are you thinking about changing things based on those?

00:07:47:15 - 00:08:05:22
Eilidh Pederson
You know, you can't predict some of these things, but I was glad to see how it played out. So this was a unique birth experience and that there was a storm coming when I went into labor. And, my midwife who is as great of a midwife as she is, storm tracker said, “okay, Allie, I need you to be prepared.

00:08:05:24 - 00:08:21:27
Eilidh Pederson
There's a storm coming. I think it's going to hit about 10 p.m..”And that's right around the time when your baby is going to be born. And I said, Sarah, how do you know this? I know you're a great midwife, but how do you also track storms? And she said, “in my spare time, I track the weather and I know there's a storm coming.

00:08:21:27 - 00:08:41:23
Eilidh Pederson
And so we need to prepare you.” Sure enough, I was ready to push at 10 p.m., right? At that time, all of the power went out in the hospital. We had a huge storm. Indeed. Power went out. We were on backup generator power. And so it was this dual thought, I need to have this baby right now.

00:08:41:23 - 00:09:03:00
Eilidh Pederson
And I'm also very curious to see how our emergency preparedness planning is going to work in this moment. Minutes before the power went out, the team moved everything to the red outlets, which are the outlets that make sure that when generator power comes on, all of the monitors and equipment still works the way that it should. They did this quietly, discreetly.

00:09:03:00 - 00:09:32:17
Eilidh Pederson
I, of course, knew what they were doing. My husband had no idea, which is what you want. It happened seamlessly. It was clear that our emergency preparedness planning went the way that it should. Everything functioned. Indeed, when the power went out a few minutes later and was able to safely and healthily deliver my baby girl in the midst of a storm with no power, only operating on generator power, the team knew the emergency preparedness policies training was effective.

00:09:32:20 - 00:10:03:21
Eilidh Pederson
The power was out until the next morning at 7 a.m., so we had a full evening of without, regular power. The hospital was still able to deliver many babies that night. The other unique thing about the experience that I thought about differently as a patient is when our OB rooms are full, which they often are because of the need in the community, we have to move patients to either a triage room or, to, a postpartum care room.

00:10:03:23 - 00:10:30:20
Eilidh Pederson
And we do this routinely. And as we plan for this, you know, I thought, okay, well, this won't be a big deal to families. They'll understand. We've got a patient coming in who needs a labor and delivery room. But as I experience that as a patient, I saw firsthand the challenges of moving everything. You know, the new baby, the partner, all of the mountains of things you have, and doing that at 3 a.m., was not an ideal time.

00:10:30:22 - 00:10:41:00
Eilidh Pederson
And so I saw firsthand that we can probably do that in a better way. So the market research continued with how do we interact with our patients better when those needs arise?

00:10:41:03 - 00:10:57:03
Julia Resnick
That is such a helpful learning that I think you can only realize by being in it. So I want to talk about rural maternal health generally. So many rural hospitals are being forced to close their labor and delivery services. While you all seem to be expanding, how do you do that?

00:10:57:05 - 00:11:27:07
Eilidh Pederson
We've made an investment and a commitment to sustaining rural obstetrical care. Despite all odds. We've really taken it as our personal mission that when others close, we have to be there for those communities in need. How do we do that? Number one, quality of care. That's the foundational aspect of this training, making sure that we know our patients needs because of that relationship, to be there to deliver the best care possible.

00:11:27:10 - 00:11:55:03
Eilidh Pederson
We have a 4% C-section rate. So clearly that foundational level of quality care rings true. Number two is workforce making sure that we have a diverse, sustainable workforce to meet the varied needs of our patients. And that's why we employ certified nurse midwives, obstetricians, family medicine physicians with OB, so we can have a variety and enough caregivers to meet the needs of our patients.

00:11:55:06 - 00:12:19:02
Eilidh Pederson
And then number three is advocacy work that needs to continue so that our government partners, our community partners, know the challenges that we endure and know how they best can support rural hospitals to stay open. And our minds, those are the keys to success. And that's our daily mantra. And how do we do this? How do we keep our doors open and do it well?

00:12:19:05 - 00:12:28:07
Julia Resnick
And as labor and delivery departments around you are closing their services, how are you adapting to meet not just the needs of patients in Baldwin, but in the communities that are around you?

00:12:28:09 - 00:12:48:24
Eilidh Pederson
The thoughts that we have as we work to adapt to the changing landscape and the ever growing needs, goes back to what I shared earlier. Number one workforce. We need more caregivers and providers to do this work. And the number two is increasing our space. Just a year and a half ago, we doubled the size of our labor and delivery unit.

00:12:48:24 - 00:13:10:06
Eilidh Pederson
And we're already pushing up against those limits. I personally had to move as a patient because we had more patients coming in to deliver. We need more space. And that's why as part of our five year strategic plan in this hospital, we intend to add yet again, more space, more clinical space to meet the needs of our growing region.

00:13:10:08 - 00:13:29:01
Eilidh Pederson
I think we do this and can do this well because we're local, we're independent, we're very accountable to our community. And it highlights why it's so important for rural, independent hospitals to stay open, because they keep these things at the heart of their work, keeping labor and delivery open.

00:13:29:03 - 00:13:54:25
Julia Resnick
Absolutely. And it's just such a powerful story for how you can have rural medicine really serving the needs of the community and providing high quality care that even the CEO or be willing to have her baby at. And listeners, I've met that baby and she is adorable. So congratulations on your new little one. Thank you so much for the work that you do every day for your community, and I just really appreciate you sharing your story with our listeners.

00:13:54:27 - 00:13:57:12
Eilidh Pederson
My pleasure. Thank you for having me.

00:13:57:15 - 00:14:05:26
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:01 - 00:00:27:01
Tom Haederle
Welcome to Advancing Health. Behavioral health resources are in especially short supply in many rural areas of the country. Sutter Health in Northern California is committed to dramatically expanding access to behavioral health services for rural residents. And as we hear in this discussion, it's game plan goes beyond just constructing new facilities.

00:00:27:03 - 00:00:54:14
Rebecca Chickey
I'm Rebecca Chickey, the senior director of behavioral health at the American Hospital Association. And it is my honor, truly, today to have two speakers for this podcast. Dan Peterson, who is the CEO of Behavioral Health Services, as well as the CEO for Sutter Center for Psychiatry at Sutter Health; and his colleague, Dr. Matthew White, who is the chair of the behavioral health service line at Sutter Health.

00:00:54:17 - 00:01:26:11
Rebecca Chickey
Welcome to both of you, and thank you for being willing to share your time and expertise on how Sutter is expanding access to behavioral health in rural communities. Before I launch my first question to you, though, I just want to set the stage for the listeners who may not know the severity of accessing services in rural communities. 65% of rural counties do not have a psychiatrist, and 70% of rural counties have no child and adolescent psychiatrist.

00:01:26:13 - 00:01:50:29
Rebecca Chickey
And for nearly two decades now, suicide rates have been consistently higher in rural America compared to urban America. So just to level set, how important it is that Sutter is doing this work. As we start, could you give the listeners a sense of what is Sutter Health, you know, what's its clinical footprint? And, Dan, I'll pitch it to you.

00:01:50:29 - 00:01:53:26
Rebecca Chickey
And, then Dr. White, please weigh in.

00:01:53:29 - 00:02:21:14
Dan Peterson
Yeah. So Sutter Health is a large, integrated health care system. We're really geographically focused in Northern California, but we cover the breadth of services across our footprint in Northern California. We have 23 hospitals. We have 57,000 employees, 6,000 physicians, clinicians, and our medical groups, almost 6,000. And so we're really quite a large health system, but we are also quite geographically diverse, right?

00:02:21:15 - 00:02:41:00
Dan Peterson
We have hospitals and clinics everywhere from downtown San Francisco, right in the middle of the city, all the way up to Crescent City, a small town up on the Oregon border, eight hours north. We have a number of rural hospitals, critical access hospitals and rural health clinics that we're very proud to support.

00:02:41:03 - 00:02:48:02
Rebecca Chickey
And for the listeners who may not be health care experts, per se, can you describe a little bit of your critical access hospital?

00:02:48:09 - 00:03:16:19
Dan Peterson
Yeah. Thank you. A critical access hospital is just a designation for a hospital that is essentially a sole provider in a community. You have to meet certain geographic distance requirements from other hospitals. And really, by definition be in a rural area. I was actually the CEO at Sutter Lakeside Hospital in rural Lake County several years ago, about 8 or 9 years ago, serving in a community living in a town of Lake Park, with just a couple thousand people there.

00:03:16:25 - 00:03:45:24
Dan Peterson
And it's really meaningful care provided in those communities, because you really are the provider that those residents have to depend on. Many of them simply cannot travel. Either can't afford to travel, don't have the means to travel or logistically because of the needs of their care, cannot travel long distances in order to reach another provider. So the communities really depend on these providers in the rural communities to do - not just to be there - but to do a great job for them.

00:03:45:27 - 00:04:03:00
Rebecca Chickey
Well, and I can tell there's a piece of your heart that is clearly committed to rural communities. Sutter has recently made investments to expand behavioral health services in two rural areas in California. Can you tell me about that? Let the listeners know what you're doing and why?

00:04:03:02 - 00:04:27:08
Dan Peterson
Yeah, I'll start with some of our capital investments and then maybe Matt can talk about some of the programs. We have recently announced we're building more infrastructure in these rural communities. That's an important piece of what we have to do. So, we are going to be building some additional office buildings, about 18,000ft² of additional office buildings for primary care and urgent care up in Crescent City on the Oregon border.

00:04:27:10 - 00:04:57:24
Dan Peterson
We're also really excited to announce something called an empath unit, which is a crisis care unit, for individuals in a behavioral health crisis immediately adjacent to our emergency department there in Crescent City. It'll be a 3,000 square foot facility really designated for behavioral health crises. We're also building an additional medical office building on Lake County at our lakeside hospital, another 7,000ft² or so, about a $5.5 million investment in that community.

00:04:57:27 - 00:05:19:03
Dan Peterson
And this coming summer, we'll be opening another rural health clinic in Los Banos actually, just outside of Modesto. We have a rural hospital there, and we're excited to open a new rural health clinic there, which does tie into our behavioral health strategy as well as we're really looking programmatically to embed these services in our primary care offerings at all these communities.

00:05:19:03 - 00:05:26:03
Dan Peterson
And Matt, as a psychiatrist, can probably talk a little bit better about that. The strategy behind that and why that really works well.

00:05:26:05 - 00:05:27:26
Rebecca Chickey
Dr. White, you're up.

00:05:27:28 - 00:05:51:12
Matthew White, M.D.
First to expand, on the Empath unit a little bit and then talk about some other ways in which Sutter is supporting behavioral health in these rural communities. As Dan articulated, Crescent City is up in the far, far north coast of California, and it's really pretty much an island in a very rural community. So if you're in a behavioral crisis, you end up in our emergency room there more often than not.

00:05:51:14 - 00:06:15:10
Matthew White, M.D.
So Sutter recently got some state funds to build a specialized kind of crisis care unit, a crisis stabilization unit. But an empath unit is really a particular type of crisis stabilization unit. It's designed differently in a more therapeutic way. It doesn't have the bright lights of an emergency room. It tends to have chairs rather than gurneys. It's really just a much more soothing environment.

00:06:15:10 - 00:06:31:26
Matthew White, M.D.
And it's shown to have significant reduction in hospitalization rates and reduced length of stay. So we're really fortunate to be able to leverage a state grant opportunity to kind of provide a place for folks in crisis in that area can go to get more therapeutic relief than the current state.

00:06:31:28 - 00:06:52:15
Rebecca Chickey
So it sounds much more patient centered for someone who is in a psychiatric crisis compared to an emergency department, which, as you articulated, can be loud, with lots of lights and lots of activity. You really are being able to deliver patient centered care in a different way. Is there an average length of stay? What is the time period?

00:06:52:15 - 00:07:16:25
Matthew White, M.D.
Usually it's significantly less than 23 hours, so that the average length of stay in an emergency room in these rural communities can be literally days sometimes, because if you need to be in a hospital, there's very few resources around. So people can spend several days sometimes waiting to get a hospital bed and then travel six hours to the nearest hospital. Because empath units are more therapeutic

00:07:16:25 - 00:07:26:15
Matthew White, M.D.
actually, if folks don't end up getting hospitalized quite as frequently and didn't get the care they need right then and there, instead of going a long, long distance after a long stay.

00:07:26:17 - 00:07:36:21
Rebecca Chickey
If that's not patient centered care, I don't know what it is. I know that Sutter has been the driving force behind some of these initiatives, but have you had engagement or worked with community partners?

00:07:36:24 - 00:08:00:03
Matthew White, M.D.
Yeah, the empath unit is a perfect example. It actually started a number of years ago where our community benefits liaison had been working with local behavioral health and local tribal entities, because it's been a long identified problem. And they actually got some early seed grant funding a number of years ago to sort of plan for something like this empath unit.

00:08:00:06 - 00:08:25:03
Matthew White, M.D.
So when this larger grant opportunity came along last year, which was prioritizing projects that were kind of, quote, "shovel ready, ready to go because of the existing kind of groundwork that Sutter had done, working already with the local communities and hoping and planning for one of these empath units. It was a project and a grant application that really rose right to the top and got funded because again, some of that community work that had already been happening.

00:08:25:06 - 00:08:28:21
Rebecca Chickey
Dan, anything you'd like to add about the community partnerships?

00:08:28:24 - 00:08:54:28
Dan Peterson
One of the things that I have loved about working in rural communities is you have an opportunity to truly rally everyone in the community around something, right? Because there just aren't that many people to rally. And so it is logistically possible to bring together all the stakeholders, you know, to bring together multiple interested parties, multiple interested organizations, and get them all physically at the same table and co-develop some of these ideas.

00:08:55:05 - 00:09:16:00
Dan Peterson
It's an ideal scenario in many ways. I think sometimes we think of the rural communities as having challenges and difficulties because that's true. But on the other hand, there are some of these advantages where you truly can bring the whole community together and come up with a dream and a vision as a community in a way that is far more difficult in a metropolitan area.

00:09:16:02 - 00:09:43:10
Rebecca Chickey
I so concur. I grew up in rural Alabama, in a community of about 30 homes, so everyone knew everybody. The local police officer, you know, of the tiny little town seven miles away, used to come on my mother's grass. I mean, her primary care physician was right down the street. And so the support system and the ability to identify needs and then come together and collaborate to meet those needs, it's truly unique in rural communities.

00:09:43:13 - 00:09:50:24
Rebecca Chickey
Beyond the empath unit, can you share how center is working to expand access to care in rural areas in California?

00:09:50:27 - 00:10:11:17
Matthew White, M.D.
There's a couple ways, actually a number of ways. As Dan mentioned earlier, finding a psychiatrist or even a therapist is so challenging in this environment. So one of the initiatives Sutter has been leveraging virtual opportunities and tele-psychiatry, and one such way is through embedding primary care into pay for help using a nationally recognized model called collaborative care.

00:10:11:20 - 00:10:37:13
Matthew White, M.D.
And so we've been able to stand up collaborative care using a virtual provider. So this is where a primary care physician can get support and access to a therapist for the patient and psychiatric support for help medication management through Content Health, our virtual partner. Additionally, in Los Banos, which Dan mentioned earlier, Sutter has recently hired some nurse practitioners to serve patients in their rural health clinic.

00:10:37:15 - 00:11:05:19
Dan Peterson
One of the reasons that this model is so successful - at Sutter Health we've embraced this collaborative care model - is because it really allows our clinicians to work at the top of their license, and it allows us to maximize our clinician workforce, right? There are only so many psychiatrists out there, and there are only so many psychiatric nurse practitioners and advanced practice clinicians, it's like clinical workforce especially in rural areas is difficult to come by.

00:11:05:21 - 00:11:34:15
Dan Peterson
Recruitment is difficult. There are many rural communities that you just can't find a dedicated psychiatrist to come move to that rural community, but by embracing other care models that sort of allow these clinicians to come in and consult on the care of the patient and allow the primary care doctor to continue to be the prescribing clinician but with the support of a psychiatrist, those models really lend themselves towards virtual support, which is very helpful in the rural communities.

00:11:34:17 - 00:12:06:22
Dan Peterson
And second of all, it helps you sort of maximize the impact of the workforce that you do have available. And so then, you know, we look at places like Los Banos where we haven't been able to bring in a psychiatrist for that model, but we have had success in recruiting a psychiatric nurse practitioner or some of the other areas where we're able to find some therapists and they just need some support, or we have a strong core of primary care doctors, but they just need some support from a psychiatrist. Embracing different types of models like that really just helps logistically embrace the challenge of recruitment in those areas.

00:12:06:25 - 00:12:32:15
Rebecca Chickey
So it sounds like from this approach, you are meeting the patients where they are, you're better supporting the staff, the clinicians that you do recruit practicing at the top of their license. I've seen some studies in integration that show that integrated care or collaborative care not only improves patient satisfaction, but workforce satisfaction. It can reduce stigma, which can be great in rural communities.

00:12:32:17 - 00:12:56:26
Rebecca Chickey
It has just an abundance of positive outcomes. So thank you for taking it there. Dan, Matthew, thank you so much for being here with us today. And for sharing your experiences and your innovative ideas on how you're improving access to behavioral health services in rural communities. And before I go, I'd like to remind everyone that November 20th is National Rural Health Day.

00:12:56:29 - 00:13:06:01
Rebecca Chickey
Be sure to check out the links in the show notes below for a wide variety of resources that'll allow you to participate in this important awareness day.

00:13:06:03 - 00:13:14:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:00 - 00:00:21:06
Tom Haederle
Welcome to Advancing Health. Homes built before 1978 did not have the prohibition against the use of lead based paint that's in place today. Let's hear what one proactive city is doing to protect its residents against this environmental danger.

00:00:21:09 - 00:00:50:03
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the American Hospital Association. Thank you so much for joining us today. We've all heard the phrase "get the lead out," meaning get moving, pick up the pace. But in Cleveland, Ohio, those words have a more literal meaning. Our two guests today will talk about the massive effort to reduce and eliminate lead poisoning in the city's population, especially among kids who are four times more likely to have elevated levels of lead in their blood than the national average.

00:00:50:05 - 00:01:03:04
Tom Haederle
So joining me to talk about this effort are two experts from Cleveland Clinic. Vickie Johnson, executive vice president and chief community officer and pediatrician Dr. Roopa Thakur. Thank you both for joining me on Advancing Health today. Appreciate you being here.

00:01:03:10 - 00:01:05:02
Vickie Johnson
We're glad to be here.

00:01:05:04 - 00:01:21:12
Tom Haederle
Well, Vicki, maybe we can start with you to bring this into focus. A lot of people may assume that the problem of lead poisoning is a thing of the past. Why is the problem of exposure to lead in the environment so acute in Cleveland, to the point where it's become Cleveland Clinic's top priority for community health?

00:01:21:14 - 00:01:59:12
Vickie Johnson
It is our number one public health priority, because 90% of Cleveland's homes were built before 1978, which means that lead is in the paint in the homes. And as the home deteriorates, it's likely to poison those children living in the homes. So we talk about this as a public health crisis with a housing solution. So often the solution isn't very clear on so many issues, but this is one where we know where the problem is, and we have an ability to partner with others to address it.

00:01:59:14 - 00:02:08:29
Tom Haederle
Is it a matter of the deterioration of the paint itself as time goes on that releases more and more lead into the environment or into the atmosphere? Is that what's going on?

00:02:09:01 - 00:02:34:13
Roopa Thakur, M.D.
Yes, exactly. So, paint deteriorates over time, especially in areas of high friction. So if you think about a door frames, window sills, areas where you're opening and closing a lot, areas that are tread on a lot. So porches and decks are a common source in Ohio. But as the paint chips or rubs off, it creates lead dust that then settles on the floor or settles on the carpet.

00:02:34:15 - 00:02:40:24
Roopa Thakur, M.D.
And then our little ones, who are playing on those floors pick up that lead dust and either inhale or ingest it.

00:02:40:26 - 00:02:49:05
Tom Haederle
So it's really everywhere. And Dr. Thakur, what is the effect of high levels of lead exposure on the human body and particularly in children?

00:02:49:07 - 00:03:09:18
Roopa Thakur, M.D.
Yeah. So we think about our little ones, especially at one and two years old, because that's when their brains are actively growing. We know from the CDC that even the lowest levels of lead exposure can damage the brain and nervous system, can slow growth and development, and can lead to learning and behavior problems. So it can definitely prevent children from getting to their full potential.

00:03:09:27 - 00:03:20:15
Roopa Thakur, M.D.
But we also can see - because lead affects every single organ system in the body - we might see bone problems, we might see kidney problems, liver problems, heart problems as an effect of lead poisoning.

00:03:20:17 - 00:03:31:22
Tom Haederle -
Are the effects less dramatic on full grown adults? If somebody moves into a house, you know, in midlife that happens to be a house built before 1978, are they at the same level of risk or not so much?

00:03:31:24 - 00:03:41:03
Roopa Thakur, M.D.
We definitely can see health effects in adults, but because the brain has kind of fully grown by then, the effects are different. We don't tend to see those same lifelong effects.

00:03:41:05 - 00:03:54:28
Tom Haederle
I know that Cleveland Clinic recently pledged $55 million to the Let's Save Cleveland Coalition and the United Way of Greater Cleveland. How will these funds be used to address the problem of lead exposure in people's homes? What's the plan for the money?

00:03:55:00 - 00:04:22:19
Vickie Johnson
So it's been about three years since we've made that commitment. And we worked with the Lead Safe Coalition to identify the greatest need. So the dollars primarily are allocated to remove the lead from the house. Primarily. But we also have other initiatives such as workforce development, marketing evaluation. We have a budget for that. And most excitingly, we have a budget for childcare centers.

00:04:22:26 - 00:04:39:08
Vickie Johnson
Once we got involved in the coalition, we thought, yes, kids live in homes, but also little ones who go to childcare spend as much time during the week there as they do at home. And that's when we launched the Let's Save Childcare Center initiative.

00:04:39:10 - 00:04:46:09
Tom Haederle
Are these grants that people have to apply for, or how would they go about getting some of that available money to do the clean up?

00:04:46:11 - 00:05:13:13
Vickie Johnson
Absolutely. Yes. There are grants and there's also incentives. As you can imagine, even when resources are available, it takes time to educate the public that the funds are available, that there's an issue that can be resolved. In many cases, we're talking about a landlord and not necessarily a homeowner. So it's different in terms of how you need to engage with those different populations, the homeowner versus the landlord.

00:05:13:20 - 00:05:39:16
Vickie Johnson
Resources are available as incentives. If you apply for Let's Save Cleveland dollars, which is a grant, then there's an incentive available for you just to get utilization increase so that we can address the issue. This is a sense of urgency, and we want every child in the city of Cleveland, you know, for us, as a beginning. We also collaborate with partners on a county level.

00:05:39:16 - 00:05:46:28
Vickie Johnson
But we want every child to live in a lead safe environment for the reasons that Dr. Thakur explained just a moment ago.

00:05:47:01 - 00:05:56:03
Tom Haederle
In terms of what actually needs to be done, is it painting over that original layer of dangerous paint, or does it physically have to be stripped from the wall and replaced entirely?

00:05:56:05 - 00:06:30:10
Vickie Johnson
It's both. So in Cleveland, we have two different approaches. It's making a unit lead safe, which is encapsulating. Yes, you can paint over with the special paint and we can wrap an area that has paint with aluminum or vinyl, if you think about outside a home. And we can also replace and tear out, which is more lead free than let's say, can you put a brand new deck on the porch as opposed to scraping, painting, which you would then have to repeat every couple of years?

00:06:30:15 - 00:06:47:20
Vickie Johnson
So it's two different approaches. It really depends on the state, the current state of the unit as to which method is best. We believe that lead safe is best for the immediate. And then when we can make units lead free as well.

00:06:47:22 - 00:07:09:09
Tom Haederle
A question for both of you. The immediate goal, of course, is to improve the environment and make it healthier, and especially for young kids who are still developing. What are some of the other benefits that we realize from dealing with this problem in terms of health care, lost earnings, societal costs that that have spiraled, I guess, because of the prevalence of lead in the city's homes?

00:07:09:11 - 00:07:43:27
Roopa Thakur, M.D.
So there's actually been a study done by Case Western Reserve University a few years ago that looked at the downstream effects of lead poisoning in our community's children. And what they found was that when you look at the dollars spent on various therapies that those children require over time, if you look at the public benefit spending on some of the services that those patients require as they become adolescents or young adults, many of them deal with homelessness, unemployment, they have several mental health issues and ADHD that can affect their ability to be to remain employed.

00:07:43:29 - 00:08:03:24
Roopa Thakur, M.D.
And so when we think about the long term spending on those public benefits as well as then, you know, there is a subset that is at higher risk for incarceration or juvenile detention, and we look at the spending there. Their data showed that each dollar invested in lead poisoning prevention can have as much as $220 return on investment.

00:08:03:27 - 00:08:17:06
Tom Haederle
Wow. That's impressive. Dr. Thakur, I wonder, is there any reason to think that there will ever be an effective treatment for the damage caused by chronic lead exposure? Or will prevention always remain the best solution?

00:08:17:09 - 00:08:36:01
Roopa Thakur, M.D.
Prevention is our best option. As far as we know, there is no cure for lead poisoning. Once it's happened, we can try to mediate results as best as we can with the therapies that we can provide, such as occupational, physical or speech therapy. But there's no way to reverse the damage that's been done.

00:08:36:03 - 00:08:56:01
Tom Haederle
Sobering message. Final question for both of you. And I know this is not a box checked, this is not a done initiative. But what you've learned so far, and what Cleveland Clinic's experience has been in helping the city deal with this problem. What advice would you have for other health systems across the country that may be looking at the same problem?

00:08:56:01 - 00:08:58:24
Tom Haederle
And also considering, you know, how do we tackle this?

00:08:58:26 - 00:09:27:06
Vickie Johnson
This work takes a long time, and we need to be patient with the results that we hope for. For example, Cleveland has over $100 million available with all of the investors. It's not just Cleveland Clinic. They're other partners that are involved. And so we thought for once, money resources was not an issue. So we just thought that people would run in and take advantage of these resources.

00:09:27:06 - 00:09:50:20
Vickie Johnson
And in a couple of years and five years, we thought our problem would be fixed. And that is not the case. That's not the case. In fact, only a small percent of the resources overall for the Let's Save home piece of it - not testing, not screening, not marketing, not evaluation. A a small percent of the resources have been utilized.

00:09:50:24 - 00:10:19:00
Vickie Johnson
We're still trying to educate the population on the danger of lead poisoning and we're taking different approaches to deal with this. Knocking on doors, going to war club meetings, working with the faith community, childcare centers, state, county, city, public housing, you name it. Everyone is trying to address the issue. There are over 400 members in the coalition.

00:10:19:02 - 00:10:39:14
Vickie Johnson
And when I say members, these are representatives of organizations. So we have thousands of people who are working together on this policy, government. We're trying and we're not satisfied with where we are today, but we're all committed to stay until we accomplish our goal.

00:10:39:17 - 00:10:47:25
Tom Haederle
It sounds like the takeaway message here is there's also a big messaging dimension to this whole initiative that people have to pay attention to.

00:10:47:28 - 00:11:08:00
Roopa Thakur, M.D.
I'll add to that as well, that, you know, Vicky's talking about partnerships. When we think about what we knew about lead poisoning in Cleveland 15 years ago, compared to what we know now, a lot of that required breaking down barriers between all the different silos that we're working on this separately. So our public health departments had the data.

00:11:08:03 - 00:11:16:25
Roopa Thakur, M.D.
We knew clinically what was happening with our patients. But to bridge the gap, to understand well, where is the lead coming from? It takes a lot of people working together.

00:11:16:27 - 00:11:33:18
Tom Haederle
Well, thank you so much for helping shed some light on a very serious problem that is probably more widespread than most people are aware of in other cities as well. Thank you so much again for being on Advancing Health today, and best of luck in this important work you're doing as you work to improve the health of the people of Cleveland.

00:11:33:20 - 00:11:42:01
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:27 - 00:00:17:08
Tom Haederle
Welcome to Advancing Health. When it comes to treating children's diabetes, the old saying that two heads are better than one has been put into practice with impressive results, as we learn in this podcast.

00:00:17:11 - 00:00:39:08
Tom Haederle
Hi everyone. I'm Tom Haederle senior communications specialist with the American Hospital Association, and really glad that you're along with us today. I'm going to start this podcast with a quote: "Prevention is always the way to go. If we can equip families with knowledge, support and community, we change health trajectories for life." So, those words are referring to childhood type two diabetes,

00:00:39:08 - 00:00:59:29
Tom Haederle
and they come from one of our guests today, Matthew Edwards, a certified diabetes care and education specialist at Children's Wisconsin Diabetes Prevention Clinic. And we're really pleased to also have Matt's colleague, Dr. Elizabeth Dabrowski, who is a pediatric endocrinologist at Children's Wisconsin, with us as well. So thank you again for coming on Advancing Health today. Really appreciate your being here.

00:01:00:01 - 00:01:13:09
Tom Haederle
A couple of years ago, when Children's Wisconsin opened its new diabetes prevention clinic, it seems like it decided to come at the problem a little bit differently than it has in the past. What can you tell us about that? Maybe Matt, if you take the first crack at that?

00:01:13:12 - 00:01:39:14
Matthew Edwards
Yeah. I think what we saw was a gap in our care. We had patients who had these comorbidities that were finding their ways to maybe our diabetes clinic or to our new kids clinic, but we were getting referrals from patients who maybe just had elevated BMI and not comorbidities to go along with it. And we just wanted to find a home for these patients before they ended up in those other clinics with the comorbidities.

00:01:39:17 - 00:01:45:02
Tom Haederle
So what was the treatment approach from the outset that was it was doing things a little more innovatively, shall we say?

00:01:45:09 - 00:02:06:00
Matthew Edwards
Yeah, we wanted closer contact points. There's several programs that have existed that showed more close contact with these patients leads to greater outcomes. And we knew we wanted to pair with our endocrinologist because their insight is just so helpful. We've got these other modalities of care that we can use now that are at our fingertips, that we can provide these patients with.

00:02:06:02 - 00:02:25:24
Matthew Edwards
And then we knew we also wanted to add some movement component with our physical therapist. That's really the piece that has been a little lacking in our program. And more recently, within the last two years, we've been able to refer a number of our diabetes patients and our prevention patients to physical therapy. And the relationship has been really great working with them.

00:02:25:26 - 00:02:38:29
Tom Haederle
Doctor Dombrowski, combining treatment for children's type two diabetes from endocrinologists and dieticians at the same time seems like a logical thing to do. Why wasn't it standard practice in the first place all along?

00:02:39:01 - 00:03:01:12
Elizabeth Dabrowski, MD
I think in part because usually by the time kids we get to the diabetes clinic, they already had type two diabetes, the horse was out of the barn. And we've been seeing, especially with the advent of GLP medications and new medications that were previously only FDA approved in adults are now FDA approved in children, some for weight and some for type two diabetes management.

00:03:01:19 - 00:03:33:09
Elizabeth Dabrowski, MD
We were seeing more referrals of kids for pre-diabetes or their labs were a little abnormal, but they didn't have diabetes yet. And we did not in standard practice have dietitians in our clinic. I think if we're looking at changing lifestyle they are the most important people to have with us. And then if we're looking at deconditioning and physical activity, that's why our physical therapists are wonderful, coming up with exercise regimens for kids that work for them, meeting them where they're at, teaching them a safe way to start.

00:03:33:11 - 00:03:40:06
Elizabeth Dabrowski, MD
And I think all of that's more important than what I can do. And so that's really why we tried to bring all these groups together.

00:03:40:08 - 00:03:53:28
Tom Haederle
So from a young patient's point of view, what is the hospital experience like when they when they come to Children's? If you could maybe walk us through a typical day, the kind of care they get, who they're seeing, what kind of advice they're getting, what would that look like?

00:03:54:00 - 00:04:19:02
Elizabeth Dabrowski, MD
So the way our clinic is set up, they'll be seen by endocrinologist first. That hospital is actually very kid friendly. My kids actually really enjoy their visits here. And so we'll see them. We'll get a general idea of history, medical problems, family history, all of the general stuff you talk with your physician about. And then we'll talk a little bit about diet and exercise, what the patient's goals are, what their concerns are and why they're there.

00:04:19:03 - 00:04:34:07
Elizabeth Dabrowski, MD
I don't like to focus on weight. I don't like to focus on a number I like to see. What are your goals as your goal? To be able to play like one of my little kids, he wants to be on the football team, and they told him he cannot be on the football team where he's at right now.

00:04:34:07 - 00:04:39:20
Elizabeth Dabrowski, MD
And so, okay, how do we get to that goal? And we'll meet my goal in the background at the same time.

00:04:39:22 - 00:04:46:16
Tom Haederle
It sounds like you're really making a point to stay away from any negative messaging about their condition or like you say, weight or anything else like that.

00:04:46:18 - 00:04:47:27
Elizabeth Dabrowski, MD
Correct? Yes.

00:04:48:00 - 00:04:55:24
Tom Haederle
What kind of diet advice are kids hearing and are they hearing it for the first time? Maybe you know something that they should have been hearing all along.

00:04:55:26 - 00:05:13:21
Matthew Edwards
Yeah, I think absolutely. A lot of times our patients are hearing our message for the first time because I think it goes beyond that. Typical eat healthy, more fruits, more, more vegetables kind of messaging. We really individualize our approach for our patients. When the dietitian hops into the visit, they'll do what's called the 24 hour recall

00:05:13:21 - 00:05:34:04
Matthew Edwards
where we get a sense of what this patient's day looks like. Are they eating breakfast, lunch, dinner? Where are those meals happening and what are the portions or typical foods look like? And we also do talk a great deal about physical activity. We'll talk about sleep. We'll talk about hydration. We'll talk about stressors or other things that might impact their food choices or food decisions, their health environment.

00:05:34:06 - 00:05:54:07
Matthew Edwards
We often cover social determinants of health, access to healthy foods and healthy fruits, vegetables, those kind of things. And so it's much greater than just kind of healthy eating. It's how do you take some knowledge and apply it to a glucose environment or a blood sugar environment to help your body stay in regulation?

00:05:54:09 - 00:06:09:25
Tom Haederle
Does it ever feel like you're fighting an uphill battle? And I only ask that because, you know, there is so much - I think we all admit this - there's so much sugar and garbage and junk in the typical American diet that it's very difficult, I would think, to wall off, you know, especially a young person from those influences.

00:06:09:25 - 00:06:11:28
Tom Haederle
So how do you handle that part of it?

00:06:12:00 - 00:06:31:02
Matthew Edwards
It's extremely difficult. I think it's important to meet the families where they're at. Maybe not every meal is ideal, but could we have an optimized snack or an optimized meal at certain times of the day? Can we focus more on satiety or filling foods? Maybe not changing the foods that are on their plate, but what is that composition look like?

00:06:31:02 - 00:06:44:06
Matthew Edwards
Can we decrease the amount of less filling foods like grains and increase the filling foods like proteins, fruits and vegetables or fibrous foods? And it's just really meeting the patients where they're at and individualizing their approach.

00:06:44:09 - 00:07:03:02
Elizabeth Dabrowski, MD
I think a big part also is the family approach. And so I'm not asking my patients to do anything that I don't already do in my house. And I'm also, you know, if Mom and dad aren't doing it, the child is not going to do it. And so one of our big things is juice. My personal take, no one needs juice.

00:07:03:04 - 00:07:19:06
Elizabeth Dabrowski, MD
It is not a healthy option. And so if  - the kid you're buying juice and the kid's drinking the whole bottle in two days - let's just not buy it anymore. I had one little kid. I must have seen him last October because I told the mom my approach to Halloween candy and all of that. And the next visit, I saw him.

00:07:19:06 - 00:07:34:17
Elizabeth Dabrowski, MD
I was like, oh my gosh, you're doing so well. Why did you change it? She's like, well, you mentioned how you just limit the snacks in your house to a few days a week, like the really sugary things, you still get them, but it's limited. And she's like, that's all we did. It's not that simple all the time, by any means.

00:07:34:17 - 00:08:05:28
Elizabeth Dabrowski, MD
But that one just stuck out because I was like, oh, I didn't even realize I was helping there. But, I think meeting them where they're at, trying not to make anything off limits because then you're going to limit, limit, limit and then overdo it. And so just like Matt said, talking about portions, talking about how much carbohydrates versus protein and all of that, or when you're talking about snacks, kids who are having chips three times a day, oh, like maybe replace one with a fruit and one with salted popcorn or something a little better, but maybe not what we all see

00:08:05:28 - 00:08:09:13
Elizabeth Dabrowski, MD
as great. It still makes a big difference overall.

00:08:09:16 - 00:08:29:19
Tom Haederle
And I imagine in some cases you're really working not just to change an individual's behavior, but that of their family or their peer group or whoever or whoever they're spending time with. In the first two years the program served approximately 200 children, and not one of the program's participants went on to develop a type two diabetes diagnosis, which is remarkable.

00:08:29:22 - 00:08:32:21
Tom Haederle
Did you anticipate such a record of success?

00:08:32:23 - 00:09:06:19
Matthew Edwards
I don't think so. It's been really hopeful to see that kind of results. Now, the one caveat I can put on that result is that there may be patients that have been lost to follow up, that we don't know if they've now experience a diagnosis of diabetes. So I want to just put that out there. But I would say that, you know, we see so much success in this program for those patients that really invest in the long term follow up plan with this kind of clinic. Because again, the more contact points we have with the patient and with the family, the better the results that we're seeing.

00:09:06:21 - 00:09:30:23
Elizabeth Dabrowski, MD
We really created the clinic to fill a need. And we just I went in with zero expectations. I really wanted to see what would work for families. We have these kids getting referred to a lot of subspecialists, a lot of different places. And when we're looking at causes of excess weight and all of that, there's a lot of social determinants of health that go into that that may limit their ability to come to appointments or to miss that much work to go to appointments.

00:09:30:26 - 00:09:44:25
Elizabeth Dabrowski, MD
So seeing how much we could bundle things in one appointment or add some virtual touchpoints or things like that where kids weren't missing as much school, parents weren't missing work, we were hoping to get more of those touchpoints in. So it looks like it's helping.

00:09:45:02 - 00:10:03:25
Tom Haederle
Yeah. You must be encouraged by the success you've seen so far. It's wonderful. Any final thoughts about maybe what your peers, another health system or hospital could take away from your experience so far in terms of your patient population, what you've seen work? What would you say to somebody, another hospital, say, that's considering doing something similar?

00:10:03:27 - 00:10:27:06
Elizabeth Dabrowski, MD
I'd say don't take no for an answer. If you see a need that's there for patients, you just keep asking and asking and asking until you get what you think is best for them and until you get the care from external sources and dieticians, physical therapists. We're talking about getting some other people into our clinic to serve some of those other needs our patients may have.

00:10:27:09 - 00:10:30:13
Elizabeth Dabrowski, MD
I'd say just keep chipping away until you get the "yes."

00:10:30:16 - 00:10:35:10
Tom Haederle
Great advice. Matt, any final thoughts? Anything we haven't discussed so far that you want to touch on?

00:10:35:12 - 00:10:59:14
Matthew Edwards
Yeah, I just have one analogy that I do want to really sneak in here. And just to highlight the benefit of a prevention clinic. It's something that I remember from being an intern, during my internship. And one of the mentors that I had at the time said, prevention is like a bridge over a river. And that bridge is broken and people are crossing the bridge and they're falling into the river and they're heading downstream.

00:10:59:16 - 00:11:24:28
Matthew Edwards
Now, our diabetes clinic is the river. We're pouring in tons of resources and tons of effort to relieve this metabolic syndrome. But I just think about the benefit of preventing people from going into that river and having to struggle and having to pour all those resources in. To me, that's what our prevention clinic is, is where we're preventing them from going into the river and turning that life trajectory around.

00:11:25:00 - 00:11:39:14
Tom Haederle
Well, that's a wonderful image to end our discussion on. Thank you so much. I appreciate your time this afternoon and your excellent work on behalf of your patients. It's really inspiring. So thanks again for appearing on Advancing Health and good luck continuing with your great work.

00:11:39:17 - 00:11:40:08
Matthew Edwards
Thank you.

00:11:40:10 - 00:11:41:13
Elizabeth Dabrowski, MD
Thank you.

00:11:41:15 - 00:11:49:26
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.