Advancing Health Podcast

Advancing Health is the American Hospital Association’s podcast series. Podcasts will feature conversations with hospital and health system leaders on a variety of issues that impact patients and communities. Look for new episodes directly from your mobile device wherever you get your podcasts. You can also listen to the podcasts directly by clicking below.

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This special series explores the medical complications that can accompany pregnancy, successful prenatal and postpartum treatment programs, and how hospitals and health systems are addressing the social needs of new mothers. Pregnancy is a major stressor on a woman’s body, with cardiovascular conditions being one of the most prevalent complications and leading causes of maternal mortality.  In this episode, learn how Orlando Health is reaching outside its walls to support heart-healthy pregnancies and postpartum periods for new mothers.  


 

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00;00;00;20 - 00;00;25;29
Tom Haederle
While the impending arrival of a new baby is an occasion for joy, pregnancy is also a major stressor on a pregnant person's body. Cardiovascular conditions are one of the most prevalent complications of pregnancy and one of the leading causes of maternal mortality.

00;00;26;02 - 00;00;51;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, the AHA’s Julia Resnick, director of Strategic Initiatives, explores how Orlando Health is reaching outside its walls to create the conditions for a heart healthy pregnancy and postpartum for new parents.

00;00;51;23 - 00;01;15;18
Chinedu Nwabuobi, M.D.
My family and I moved from Nigeria when I was 16. And I always tell people this, which is, you know, growing up, unlike in the United States where I tend to see a lot of joy surrounding pregnancy, surrounding births. I grew up in a place where when a woman was pregnant, there was joy associated with it. But when it got closer to the time for delivery, there was a lot of fear.

00;01;15;20 - 00;01;40;10
Chinedu Nwabuobi, M.D.
There was a lot of uncertainty. There was a lot of prayer groups being brought together to pray that a woman makes it out alive. I lost my lovely aunt while she was having her seventh child from postpartum hemorrhage, which was very devastating. A lot of people in the U.S., when they think of pregnancy, they obviously, you know, most times think about how I'm going to go have the baby, come back home.

00;01;40;13 - 00;01;48;03
Chinedu Nwabuobi, M.D.
But the truth is that, unfortunately, anybody can lose their life in the pregnancy.

00;01;48;05 - 00;02;11;26
Julia Resnick
That was Dr. Chinedu Nwabuobi, grounding us in the medical risks inherently involved in pregnancy. He is a maternal fetal medicine physician at Orlando Health Women's Institute Center for Maternal Fetal Medicine. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association. And this is Beyond Birth in advancing Health Podcast. Today, we'll be focusing on matters of the heart.

00;02;11;29 - 00;02;40;24
Julia Resnick
Not only is February Valentine's Day, it is also Heart Health Month, a month dedicated to raising awareness of heart, health and cardiovascular conditions. Today, we will be exploring cardiovascular health during and after pregnancy and what hospitals can do to help create the conditions for a heart healthy pregnancy. So why heart health? Pregnancy is a major stressor on the body, and particularly on the heart  - complicating up to four in 100 pregnancies.

00;02;41;01 - 00;03;04;14
Julia Resnick
Cardiovascular issues continue to be one of the most common causes of maternal morbidity and mortality. One-in-three pregnancy related deaths in the U.S. are due to cardiovascular problems, and people who are black, American, Indian or Alaska Native are at higher risk of heart conditions during pregnancy and have a much higher risk of dying during pregnancy or soon after.

00;03;04;17 - 00;03;26;22
Julia Resnick
Hospitals know that creating the conditions for a heart, healthy pregnancy and postpartum period is key to improving outcomes. In this podcast, we'll be exploring how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues. You'll hear more from Dr. Nwabuobi, as well as Dr. Lori Boardman, chief quality officer at Orlando Health

00;03;26;22 - 00;03;46;09
Julia Resnick
Winnie Palmer Hospital for Women and Babies. Peggy Burgess, founder and CEO of the Center for Change and Crystal Wilson, a new mom who participated in Orlando Health's telehealth hypertension program after giving birth. We'll start with Dr. Boardman’s overview of Winnie Palmer Hospital and the population they serve.

00;03;46;11 - 00;04;11;14
Lori Boardman, M.D.
Winnie Palmer is really sort of almost iconic nationwide, and it has been that way because of generally the large volume of patients that we take care of here. So in the last fiscal year of full data that we have, we delivered 14,550 patients under one roof. We take care of 142 neonatal beds and their occupancy runs around 80 to 90%.

00;04;11;15 - 00;04;35;28
Lori Boardman, M.D.
So not only do we have a large patient population of persons who are delivering, but we have a lot of sick babies as well. So we have a lot of babies born early and a lot of babies with complex needs. So Winnie Palmer Hospital is a standalone women's hospital, it's an 11 story building. It houses a Labor floor of about 28 delivery rooms and houses, three floors for postpartum care.

00;04;36;00 - 00;04;53;18
Lori Boardman, M.D.
We have a floor dedicated to the NICU which again is large, and you get lost wandering around it because of the number of beds and pods involved. We have a triage area for taking care of those patients coming in with emergency needs and all the volumes in these sites are quite high.

00;04;53;21 - 00;05;04;20
Julia Resnick
Dr. Nwabuobi who you heard from at the beginning, specializes in perinatal cardiovascular health. I spoke with him about the prevalence of heart conditions during and after pregnancy.

00;05;04;23 - 00;05;41;02
Chinedu Nwabuobi, M.D.
About several hundred women die each year in the United States because of pregnancy related complications, right. Like no death is too little. So several hundred, that's that's too many already. And that's I can imagine with some of the numbers I'm seeing nowadays, probably higher now. The most recent report we have in the United States, as far as pregnancy associated mortality rates, and this is covering from 2007 to 2016, is pointing out that data is actually about 16.7 deaths per 100,000 live births.

00;05;41;04 - 00;06;09;13
Chinedu Nwabuobi, M.D.
And the top cause of that turns out to be cardiovascular disease, about 26.5%. So on a national scale, that is already quite an alarming number. The volume continues to increase. But when you look, we are talking about chronic hypertension, which is a cardiovascular complication. You're looking at about 8.6% in our African-American patients. You look at about 4.7% Hispanic patients and is Hispanic of any race.

00;06;09;19 - 00;06;42;12
Chinedu Nwabuobi, M.D.
And you're looking at about 6.2% in all non-Hispanic white. And then when you bring in something like actual preexisting cardiac disease, about 5.1% in our African-American patients, let me just say black patients as a as a whole, non-Hispanic blacks by about 3.9% in our non-Hispanic white and about 3.1% in our Hispanic patients of any race. So, again, these are numbers that continue to rise over time, but it's both a local and a national problem that needs all hands on deck.

00;06;42;15 - 00;06;52;27
Julia Resnick, M.D.
And you kind of touched on this, but are there certain populations that are particularly at risk for both maternal mortality and maternal morbidity due to cardiovascular issues?

00;06;52;29 - 00;07;24;07
Chinedu Nwabuobi, M.D.
I'm glad some of these things are starting to get national attention as far as like the media is concerned. But this is something that continues to marvel a lot of us, which is the fact that even among the black race, when you correct for education, where you correct for socioeconomic status, that a patient who is of a black race continues to have up to fourfold the amount of risk of maternal mortality, including cardiovascular causes of death when compared to the other races.

00;07;24;13 - 00;07;48;29
Chinedu Nwabuobi, M.D.
So that's definitely a fact. Something else that we continue to see to be a population that is at risk for some of these complications are women who are aged 35 and above. You know, I tell a lot of my patients, I joke with them when I say, you know, well, age is just a number. But in this case, it's not just the number because, as you know, your age goes beyond just having knee pain or aches, getting out of the bed

00;07;48;29 - 00;08;10;20
Chinedu Nwabuobi, M.D.
now. It really actually counts your chances of making it out of your pregnancy healthy, and the baby, you know, healthy as well. So age is a factor that we need to pay close attention to. And then there's also the factor of patients who do not have prenatal care and I think the angle of looking at this is probably thinking about access to care.

00;08;10;22 - 00;08;35;01
Chinedu Nwabuobi, M.D.
Most people do not just ignore care completely. There are several factors that limit them deciding that they will get up, go see a physician, go see a midwife, go see whoever that provides their prenatal care to get care beyond the fact that they are noncompliant. Right. Some people have issues with transportation. Some people do not even have a place to live.

00;08;35;03 - 00;09;06;25
Chinedu Nwabuobi, M.D.
Some people are probably a juggling two or three jobs to make ends meet and not able to make that appointment. Sometimes we do not have the best clinic hours to actually accommodate all of these patients with some of the things going on in their lives. It's very multifactor, but again, it comes down to that lack of access. So these three populations with the black race, the age and limited access to care can definitely exacerbate the issue of cardiovascular complications and pregnancy.

00;09;06;27 - 00;09;20;09
Julia Resnick
It is clear that some people are more at risk of experiencing cardiovascular issues during pregnancy than others. To target their efforts and address those inequitable birth outcomes, Dr. Boardman and her team dug into the data.

00;09;20;11 - 00;09;51;28
Lori Boardman, M.D.
There's a lot of disparities and we can talk about a number of them that we see in our data. This just mimics nationwide data, and we know that black women in particular are disproportionately affected by severe maternal morbidity and mortality. And we know that they, no matter what their background is, no matter how much education they've gotten, no matter how much money they make or where they live, they all have a similar pattern of unfortunately, being more likely to have a severe maternal morbidity event in their lives.

00;09;52;00 - 00;10;15;29
Lori Boardman, M.D.
And you see it on television. Serena Williams can't get it done. Nobody can. So what we did and what I've done for the last decade is, is create some dashboards that really allow us to look at different things. So we have a whole set of dashboards around severe maternal morbidity. One is just outlining and knowing what those severe maternal morbidity events are.

00;10;16;02 - 00;10;41;24
Lori Boardman, M.D.
So our most common forms of severe maternal morbidity tend to be sepsis, which is a severe infection, tend to be renal failure, and then also tend to be more of those hemorrhage events. So we do follow those. And the biggest one probably is now hypertension or hypertension related causes. So we look for those rates and we are able to calculate that.

00;10;41;24 - 00;10;59;26
Lori Boardman, M.D.
But we also want to have a way to identify those patients who are at greater risk for having a severe maternal morbidity event. And one of those is to use something called the comorbidity index. So we've been able to collect that information at the time of delivery so we have a good idea what our patients are struggling with.

00;10;59;29 - 00;11;21;07
Lori Boardman, M.D.
For example, if we look at the black population, that population comes in with a preexisting history of anemia and almost half of those patients. We know there's opportunity there to follow them more closely. We know that when we looked at our patients coming back after they've been here for delivery to be readmitted to the hospital, the most common cause was hypertensive disorders.

00;11;21;10 - 00;11;46;20
Lori Boardman, M.D.
So using that as a way to move forward, we also knew we were in the middle of a pandemic and a lot of people weren't coming into the hospitals or going to practices. So we use the telehealth platform to have a program that we established while those patients were in the hospital, they delivered. If they had any kind of hypertension problem or they had even had a history of chronic hypertension before they came in, we wanted to follow them

00;11;46;20 - 00;12;07;12
Lori Boardman, M.D.
when they went home. It did really well. And then a lot of providers were, well, skeptical of the program. But then when they saw the results, everybody jumped on board. So at this point, we have everybody involved with our postpartum hypertension program. That means that when those patients go home, we want them to be teed up as much as we can to go home in a healthy way.

00;12;07;12 - 00;12;28;12
Lori Boardman, M.D.
So the institution started doing something called "meds to beds" so that you would go home with your prescription in hand. If you had to be on something for your blood pressure, you were given it so that you didn't have to go to a pharmacy and try to get it delivered to you or have to go through anything. So most patients were able to go home with a prescription.

00;12;28;14 - 00;12;48;24
Lori Boardman, M.D.
We recruited them before they left the hospital. Our retention rate from recruitment was over 90%. So every month we had about 300 patients and we would have close to almost all of them would be in the program. Initially, we wanted to do day two after you got home and then a day five visit, because most of our readmissions were in that first week.

00;12;48;26 - 00;13;10;11
Lori Boardman, M.D.
But we found out very quickly that we needed to do one the day after you went home. So we caught more people doing that. We were able to engage with them in the platform like we're using. So I'm looking at you and we're having a conversation. We use the platform to not only ask them about their blood pressure, but also to ask some other related questions.

00;13;10;13 - 00;13;40;27
Lori Boardman, M.D.
We screened all the women for depression and anxiety. We screened everybody for social determinants of health and social drivers of health and we also talked a lot about breastfeeding because we know that black women are much less likely to breastfeed, so to provide them the support to do that before the patient went home. Everybody went home with a cough and a monitor and then they were given education about how to know when there's a sign or symptom that you're having that needs to be addressed.

00;13;41;05 - 00;14;00;16
Lori Boardman, M.D.
Who to call. If the blood pressure was sort of in the middle range, you would call the provider. If it wasn't, they would come to the hospital. And for most patients, and particularly for those patients that struggle probably with social support and transportation, they couldn't believe that they could do all of this in their kitchen or their bedroom or wherever they wanted to be.

00;14;00;18 - 00;14;23;02
Lori Boardman, M.D.
And it just took off that load of having to worry about who's going to drive you. We could even do some of those social determinants, social drivers of health like hunger and food, getting them delivered directly from one of our community partners and they can drive that stuff to their home so they can have fresh vegetables and other perishable and nonperishable items.

00;14;23;04 - 00;14;32;13
Lori Boardman, M.D.
So when I would even be recruiting them, people would cry. They just couldn't believe that this kind of program would exist.

00;14;32;16 - 00;14;35;03
SFX
Baby cooing

00;14;35;05 - 00;14;54;16
Julia Resnick
Crystal Wilson delivered her third child at Winnie Palmer last year. During the course of her pregnancy, she learned that she had previously undiagnosed cardiovascular issues. After giving birth, her provider knew her heart was at risk for future complications. Enter the perinatal hypertension telehealth program.

00;14;54;18 - 00;15;05;01
Crystal Wilson
At the hospital in the recovery room, I met with this woman. I can't remember her name and she gave me like a monitor for my blood pressure and a

00;15;05;01 - 00;15;05;18
Crystal Wilson
scale and

00;15;05;18 - 00;15;32;01
Crystal Wilson
she asked me if I wanted to be involved with some of the programs. And I'm like, You know what? It's not going to hurt. You know, it can do nothing but help me. There were a bunch of programs available for me. I call it counseling. That for me was a really good coping mechanism. So I heard from different moms, you know, building relationships.

00;15;32;03 - 00;15;37;11
Crystal Wilson
So I think it was a really, really good program. The support group was

00;15;37;14 - 00;15;38;19
Crystal Wilson
a huge thing.

00;15;38;21 - 00;15;48;16
Crystal Wilson
The counseling, the meeting of the moms and all of that. Try to reduce stress anxiety, which also affects your blood pressure.

00;15;48;18 - 00;16;00;15
Julia Resnick
The health care workers at Winnie Palmer couldn't accomplish this alone. They partnered with a local organization run by our guest, Peggy Burgess. Peggy shared the origin story of her organization.

00;16;00;18 - 00;16;30;01
Peggy Burgess
It is a interesting story. I started Center for Change in 2003. I started it because my sister, who was only 48 years old at the time, died of colon cancer. And what amazed me about her reaction to having stage four cancer that early is she had no resources. So I wrote a program and it was called the Renee's Dream Program.

00;16;30;03 - 00;16;51;26
Peggy Burgess
And what it was about was educating people who had less resources than she had to find out where they can go for treatment, who they could talk to, what they can do to improve their health, and trying to give her just a sense of security or control.

00;16;51;28 - 00;17;05;10
Julia Resnick
Out of this original program grew The Center for Change, an organization that leverages community health workers and offers health coaching and self-management courses and chronic disease, amongst other opportunities to improve health.

00;17;05;13 - 00;17;34;21
Peggy Burgess
What we were actually doing was - and I'm so glad Orlando Health had the program designed where they had the bus available. They had the clinicians available and they were part of the program was requiring them to make sure that they go it. And for our end, it was no more than providing that extra push, that extra check in with them to see, are you doing okay?

00;17;34;24 - 00;18;07;26
Peggy Burgess
Are you following through? Why haven't you gone to check on this or that really doesn't sound normal to me. I would suggest that you check on this. You'll be surprised at the number of young mothers who are unaware of signs and symptoms and would say, Well, I have an appointment in three weeks. No. If you have swelling to this extent and is moving up your legs, something is wrong

00;18;07;27 - 00;18;36;01
Peggy Burgess
now. You need to have that checked. Sometimes just that motherly push is enough to say, okay, okay, I'll go. And they know that we're going to call back because we are their accountability partner in a way, because it is our responsibility to make sure that not only are we educating, but we're there for support and we're also there to listen.

00;18;36;04 - 00;19;20;11
Peggy Burgess
One of the biggest things that the community health workers  - and we train them to do - is please listen to what your client or your patient is saying to you. Listen, because they will give you all the clues that you need to help them. I love the program that we're working with with Orlando Health now, But if it was my goal, my goal would be for it to continue to grow so that not just a few of the mothers that are high risk, but all mothers that are high risk would have access to this.

00;19;20;14 - 00;19;31;20
Julia Resnick
The Center for Change wasn't the only community partner involved in this program. Dr. Boardman spoke to the other groups that have been instrumental in providing holistic wraparound services for new moms.

00;19;31;22 - 00;19;54;02
Lori Boardman, M.D.
I'm going to call out a couple that really have done a fabulous job, and one of those is Second Harvest Food Bank. So Second Harvest has been a partner with us through two of the grants that we've gotten from the Florida Department of Health. They've been able to identify those patients. They have a very streamlined process and they were able in the one grant, we enrolled about 1200 women about six months.

00;19;54;02 - 00;20;25;09
Lori Boardman, M.D.
They had touched 500 patients and their families with food boxes. They were 90 days of food boxes being delivered every other week. For families that really needed it continued. And then another group that we worked with, we've worked with a number of folks was Christine Certain who a perinatal licensed mental health counselor. She's been doing group counseling for patients who screened positive for the depression or anxiety, which is a very common side effect of pregnancy.

00;20;25;09 - 00;20;30;13
Lori Boardman, M.D.
And in the postpartum period, it manifests itself. But you can see it throughout pregnancy.

00;20;30;16 - 00;20;49;19
Julia Resnick
Addressing the medical, social and emotional needs of new moms helps create an environment where they and their babies can thrive. And the perinatal hypertension telehealth program has been incredibly successful in moving the needle on pregnancy and postpartum outcomes. Dr. Boardman shared the impact that it has had on their patient population.

00;20;49;21 - 00;21;14;01
Lori Boardman, M.D.
So when you look at participation from patients that have known hypertensive disorders, we recommend coming in for a visit in about 7 to 10 days. White women and Hispanic women, about 80% of those patients will go to them. About 25% of black patients will go to those visits. With the virtual visit platform, everybody participated in excess of 70 to 75%.

00;21;14;03 - 00;21;35;27
Lori Boardman, M.D.
So we didn't see those disparities anymore. And if a patient completed at least one of those two visits, the readmission rate was about half of what it was for patients who didn't do that. It's now become embedded in Winnie Palmer. It's part of what we do. It's not a pilot, it's not a study. It's really how we treat our patients.

00;21;36;00 - 00;21;39;13
Lori Boardman, M.D.
That's gone exceedingly well.

00;21;39;16 - 00;21;56;23
Julia Resnick
Everyone's needs are different. To get the best outcomes and reduce risk, hospitals need to design care with and around patients and create systems that make it easier for new moms to care for themselves and their babies. We'll wrap up with some closing thoughts from doctors Nwabuobi and Boardman.

00;21;56;25 - 00;22;32;17
Chinedu Nwabuobi, M.D.
Like I said earlier, pregnancy being kind of a stressor can mask this. So just be on top of your care, be very involved, be an advocate for yourself, speak up, ask questions. Those symptoms that you've read online, you've seen on Tick-Tock that you consider are normal should not be normal until it has been completely addressed by your OB provider. To make sure we care for women more before they become pregnant so that when they become pregnant, there's already that understanding of what the risk is, hopefully we've mitigated it, and how we can make for the best pregnancy outcomes of it.

00;22;32;19 - 00;22;55;10
Lori Boardman, M.D.
I know from thinking about even creating programs and all this kind of stuff, having the end user be involved in the conversation, and I think listening to our patients learn from our patients and then when you start to implement your whatever you're deciding they're going to do, make sure that it aligns with what they want to do because otherwise we're never going to be successful.

00;22;55;12 - 00;23;02;04
Lori Boardman
And I think they know better than we know what's going to work, for them and often for their communities.

00;23;02;07 - 00;23;27;26
Julia Resnick
Heart Month can be a catalyst for health care organizations to reimagine what it takes to create the conditions for a heart healthy pregnancy. And that will require going beyond the hospital walls to engage patients and collaborate with stakeholders who all share the same goal, healthy moms and healthy babies. By designing pregnancy care around patient needs, recognizing who is at risk of complications and reducing barriers to support,

00;23;27;28 - 00;23;56;06
Julia Resnick
hospitals can make progress towards reducing maternal morbidity and mortality. A big thank you to all of our speakers: Lori Boardman, Chinedu, Nwabuobi, Peggy Burgess and Crystal Wilson. I appreciate everything you do to support the health of your patients and community members. For more resources on improving maternal health visit www.aha.org/betterhealthformothersandbabies

00;23;56;09 - 00;24;08;17
Julia Resnick
Thank you for tuning in to this episode of Beyond Birth and Advancing Health Podcast. If you missed any of our previous podcasts, you can find them wherever you listen to your podcasts and please subscribe to the Advancing Health Channel. We'll see you next time.

00;00;00;20 - 00;00;25;29
Tom Haederle
While the impending arrival of a new baby is an occasion for joy, pregnancy is also a major stressor on a pregnant person's body. Cardiovascular conditions are one of the most prevalent complications of pregnancy and one of the leading causes of maternal mortality.

00;00;26;02 - 00;00;51;21
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. In this podcast, the AHA’s Julia Resnick, director of Strategic Initiatives, explores how Orlando Health is reaching outside its walls to create the conditions for a heart healthy pregnancy and postpartum for new parents.

00;00;51;23 - 00;01;15;18
Chinedu Nwabuobi, M.D.
My family and I moved from Nigeria when I was 16. And I always tell people this, which is, you know, growing up, unlike in the United States where I tend to see a lot of joy surrounding pregnancy, surrounding births. I grew up in a place where when a woman was pregnant, there was joy associated with it. But when it got closer to the time for delivery, there was a lot of fear.

00;01;15;20 - 00;01;40;10
Chinedu Nwabuobi, M.D.
There was a lot of uncertainty. There was a lot of prayer groups being brought together to pray that a woman makes it out alive. I lost my lovely aunt while she was having her seventh child from postpartum hemorrhage, which was very devastating. A lot of people in the U.S., when they think of pregnancy, they obviously, you know, most times think about how I'm going to go have the baby, come back home.

00;01;40;13 - 00;01;48;03
Chinedu Nwabuobi, M.D.
But the truth is that, unfortunately, anybody can lose their life in the pregnancy.

00;01;48;05 - 00;02;11;26
Julia Resnick
That was Dr. Chinedu Nwabuobi, grounding us in the medical risks inherently involved in pregnancy. He is a maternal fetal medicine physician at Orlando Health Women's Institute Center for Maternal Fetal Medicine. I'm Julia Resnick, director of Strategic Initiatives at the American Hospital Association. And this is Beyond Birth in advancing Health Podcast. Today, we'll be focusing on matters of the heart.

00;02;11;29 - 00;02;40;24
Julia Resnick
Not only is February Valentine's Day, it is also Heart Health Month, a month dedicated to raising awareness of heart, health and cardiovascular conditions. Today, we will be exploring cardiovascular health during and after pregnancy and what hospitals can do to help create the conditions for a heart healthy pregnancy. So why heart health? Pregnancy is a major stressor on the body, and particularly on the heart  - complicating up to four in 100 pregnancies.

00;02;41;01 - 00;03;04;14
Julia Resnick
Cardiovascular issues continue to be one of the most common causes of maternal morbidity and mortality. One-in-three pregnancy related deaths in the U.S. are due to cardiovascular problems, and people who are black, American, Indian or Alaska Native are at higher risk of heart conditions during pregnancy and have a much higher risk of dying during pregnancy or soon after.

00;03;04;17 - 00;03;26;22
Julia Resnick
Hospitals know that creating the conditions for a heart, healthy pregnancy and postpartum period is key to improving outcomes. In this podcast, we'll be exploring how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues. You'll hear more from Dr. Nwabuobi, as well as Dr. Lori Boardman, chief quality officer at Orlando Health

00;03;26;22 - 00;03;46;09
Julia Resnick
Winnie Palmer Hospital for Women and Babies. Peggy Burgess, founder and CEO of the Center for Change and Crystal Wilson, a new mom who participated in Orlando Health's telehealth hypertension program after giving birth. We'll start with Dr. Boardman’s overview of Winnie Palmer Hospital and the population they serve.

00;03;46;11 - 00;04;11;14
Lori Boardman, M.D.
Winnie Palmer is really sort of almost iconic nationwide, and it has been that way because of generally the large volume of patients that we take care of here. So in the last fiscal year of full data that we have, we delivered 14,550 patients under one roof. We take care of 142 neonatal beds and their occupancy runs around 80 to 90%.

00;04;11;15 - 00;04;35;28
Lori Boardman, M.D.
So not only do we have a large patient population of persons who are delivering, but we have a lot of sick babies as well. So we have a lot of babies born early and a lot of babies with complex needs. So Winnie Palmer Hospital is a standalone women's hospital, it's an 11 story building. It houses a Labor floor of about 28 delivery rooms and houses, three floors for postpartum care.

00;04;36;00 - 00;04;53;18
Lori Boardman, M.D.
We have a floor dedicated to the NICU which again is large, and you get lost wandering around it because of the number of beds and pods involved. We have a triage area for taking care of those patients coming in with emergency needs and all the volumes in these sites are quite high.

00;04;53;21 - 00;05;04;20
Julia Resnick
Dr. Nwabuobi who you heard from at the beginning, specializes in perinatal cardiovascular health. I spoke with him about the prevalence of heart conditions during and after pregnancy.

00;05;04;23 - 00;05;41;02
Chinedu Nwabuobi, M.D.
About several hundred women die each year in the United States because of pregnancy related complications, right. Like no death is too little. So several hundred, that's that's too many already. And that's I can imagine with some of the numbers I'm seeing nowadays, probably higher now. The most recent report we have in the United States, as far as pregnancy associated mortality rates, and this is covering from 2007 to 2016, is pointing out that data is actually about 16.7 deaths per 100,000 live births.

00;05;41;04 - 00;06;09;13
Chinedu Nwabuobi, M.D.
And the top cause of that turns out to be cardiovascular disease, about 26.5%. So on a national scale, that is already quite an alarming number. The volume continues to increase. But when you look, we are talking about chronic hypertension, which is a cardiovascular complication. You're looking at about 8.6% in our African-American patients. You look at about 4.7% Hispanic patients and is Hispanic of any race.

00;06;09;19 - 00;06;42;12
Chinedu Nwabuobi, M.D.
And you're looking at about 6.2% in all non-Hispanic white. And then when you bring in something like actual preexisting cardiac disease, about 5.1% in our African-American patients, let me just say black patients as a as a whole, non-Hispanic blacks by about 3.9% in our non-Hispanic white and about 3.1% in our Hispanic patients of any race. So, again, these are numbers that continue to rise over time, but it's both a local and a national problem that needs all hands on deck.

00;06;42;15 - 00;06;52;27
Julia Resnick, M.D.
And you kind of touched on this, but are there certain populations that are particularly at risk for both maternal mortality and maternal morbidity due to cardiovascular issues?

00;06;52;29 - 00;07;24;07
Chinedu Nwabuobi, M.D.
I'm glad some of these things are starting to get national attention as far as like the media is concerned. But this is something that continues to marvel a lot of us, which is the fact that even among the black race, when you correct for education, where you correct for socioeconomic status, that a patient who is of a black race continues to have up to fourfold the amount of risk of maternal mortality, including cardiovascular causes of death when compared to the other races.

00;07;24;13 - 00;07;48;29
Chinedu Nwabuobi, M.D.
So that's definitely a fact. Something else that we continue to see to be a population that is at risk for some of these complications are women who are aged 35 and above. You know, I tell a lot of my patients, I joke with them when I say, you know, well, age is just a number. But in this case, it's not just the number because, as you know, your age goes beyond just having knee pain or aches, getting out of the bed

00;07;48;29 - 00;08;10;20
Chinedu Nwabuobi, M.D.
now. It really actually counts your chances of making it out of your pregnancy healthy, and the baby, you know, healthy as well. So age is a factor that we need to pay close attention to. And then there's also the factor of patients who do not have prenatal care and I think the angle of looking at this is probably thinking about access to care.

00;08;10;22 - 00;08;35;01
Chinedu Nwabuobi, M.D.
Most people do not just ignore care completely. There are several factors that limit them deciding that they will get up, go see a physician, go see a midwife, go see whoever that provides their prenatal care to get care beyond the fact that they are noncompliant. Right. Some people have issues with transportation. Some people do not even have a place to live.

00;08;35;03 - 00;09;06;25
Chinedu Nwabuobi, M.D.
Some people are probably a juggling two or three jobs to make ends meet and not able to make that appointment. Sometimes we do not have the best clinic hours to actually accommodate all of these patients with some of the things going on in their lives. It's very multifactor, but again, it comes down to that lack of access. So these three populations with the black race, the age and limited access to care can definitely exacerbate the issue of cardiovascular complications and pregnancy.

00;09;06;27 - 00;09;20;09
Julia Resnick
It is clear that some people are more at risk of experiencing cardiovascular issues during pregnancy than others. To target their efforts and address those inequitable birth outcomes, Dr. Boardman and her team dug into the data.

00;09;20;11 - 00;09;51;28
Lori Boardman, M.D.
There's a lot of disparities and we can talk about a number of them that we see in our data. This just mimics nationwide data, and we know that black women in particular are disproportionately affected by severe maternal morbidity and mortality. And we know that they, no matter what their background is, no matter how much education they've gotten, no matter how much money they make or where they live, they all have a similar pattern of unfortunately, being more likely to have a severe maternal morbidity event in their lives.

00;09;52;00 - 00;10;15;29
Lori Boardman, M.D.
And you see it on television. Serena Williams can't get it done. Nobody can. So what we did and what I've done for the last decade is, is create some dashboards that really allow us to look at different things. So we have a whole set of dashboards around severe maternal morbidity. One is just outlining and knowing what those severe maternal morbidity events are.

00;10;16;02 - 00;10;41;24
Lori Boardman, M.D.
So our most common forms of severe maternal morbidity tend to be sepsis, which is a severe infection, tend to be renal failure, and then also tend to be more of those hemorrhage events. So we do follow those. And the biggest one probably is now hypertension or hypertension related causes. So we look for those rates and we are able to calculate that.

00;10;41;24 - 00;10;59;26
Lori Boardman, M.D.
But we also want to have a way to identify those patients who are at greater risk for having a severe maternal morbidity event. And one of those is to use something called the comorbidity index. So we've been able to collect that information at the time of delivery so we have a good idea what our patients are struggling with.

00;10;59;29 - 00;11;21;07
Lori Boardman, M.D.
For example, if we look at the black population, that population comes in with a preexisting history of anemia and almost half of those patients. We know there's opportunity there to follow them more closely. We know that when we looked at our patients coming back after they've been here for delivery to be readmitted to the hospital, the most common cause was hypertensive disorders.

00;11;21;10 - 00;11;46;20
Lori Boardman, M.D.
So using that as a way to move forward, we also knew we were in the middle of a pandemic and a lot of people weren't coming into the hospitals or going to practices. So we use the telehealth platform to have a program that we established while those patients were in the hospital, they delivered. If they had any kind of hypertension problem or they had even had a history of chronic hypertension before they came in, we wanted to follow them

00;11;46;20 - 00;12;07;12
Lori Boardman, M.D.
when they went home. It did really well. And then a lot of providers were, well, skeptical of the program. But then when they saw the results, everybody jumped on board. So at this point, we have everybody involved with our postpartum hypertension program. That means that when those patients go home, we want them to be teed up as much as we can to go home in a healthy way.

00;12;07;12 - 00;12;28;12
Lori Boardman, M.D.
So the institution started doing something called "meds to beds" so that you would go home with your prescription in hand. If you had to be on something for your blood pressure, you were given it so that you didn't have to go to a pharmacy and try to get it delivered to you or have to go through anything. So most patients were able to go home with a prescription.

00;12;28;14 - 00;12;48;24
Lori Boardman, M.D.
We recruited them before they left the hospital. Our retention rate from recruitment was over 90%. So every month we had about 300 patients and we would have close to almost all of them would be in the program. Initially, we wanted to do day two after you got home and then a day five visit, because most of our readmissions were in that first week.

00;12;48;26 - 00;13;10;11
Lori Boardman, M.D.
But we found out very quickly that we needed to do one the day after you went home. So we caught more people doing that. We were able to engage with them in the platform like we're using. So I'm looking at you and we're having a conversation. We use the platform to not only ask them about their blood pressure, but also to ask some other related questions.

00;13;10;13 - 00;13;40;27
Lori Boardman, M.D.
We screened all the women for depression and anxiety. We screened everybody for social determinants of health and social drivers of health and we also talked a lot about breastfeeding because we know that black women are much less likely to breastfeed, so to provide them the support to do that before the patient went home. Everybody went home with a cough and a monitor and then they were given education about how to know when there's a sign or symptom that you're having that needs to be addressed.

00;13;41;05 - 00;14;00;16
Lori Boardman, M.D.
Who to call. If the blood pressure was sort of in the middle range, you would call the provider. If it wasn't, they would come to the hospital. And for most patients, and particularly for those patients that struggle probably with social support and transportation, they couldn't believe that they could do all of this in their kitchen or their bedroom or wherever they wanted to be.

00;14;00;18 - 00;14;23;02
Lori Boardman, M.D.
And it just took off that load of having to worry about who's going to drive you. We could even do some of those social determinants, social drivers of health like hunger and food, getting them delivered directly from one of our community partners and they can drive that stuff to their home so they can have fresh vegetables and other perishable and nonperishable items.

00;14;23;04 - 00;14;32;13
Lori Boardman, M.D.
So when I would even be recruiting them, people would cry. They just couldn't believe that this kind of program would exist.

00;14;32;16 - 00;14;35;03
SFX
Baby cooing

00;14;35;05 - 00;14;54;16
Julia Resnick
Crystal Wilson delivered her third child at Winnie Palmer last year. During the course of her pregnancy, she learned that she had previously undiagnosed cardiovascular issues. After giving birth, her provider knew her heart was at risk for future complications. Enter the perinatal hypertension telehealth program.

00;14;54;18 - 00;15;05;01
Crystal Wilson
At the hospital in the recovery room, I met with this woman. I can't remember her name and she gave me like a monitor for my blood pressure and a

00;15;05;01 - 00;15;05;18
Crystal Wilson
scale and

00;15;05;18 - 00;15;32;01
Crystal Wilson
she asked me if I wanted to be involved with some of the programs. And I'm like, You know what? It's not going to hurt. You know, it can do nothing but help me. There were a bunch of programs available for me. I call it counseling. That for me was a really good coping mechanism. So I heard from different moms, you know, building relationships.

00;15;32;03 - 00;15;37;11
Crystal Wilson
So I think it was a really, really good program. The support group was

00;15;37;14 - 00;15;38;19
Crystal Wilson
a huge thing.

00;15;38;21 - 00;15;48;16
Crystal Wilson
The counseling, the meeting of the moms and all of that. Try to reduce stress anxiety, which also affects your blood pressure.

00;15;48;18 - 00;16;00;15
Julia Resnick
The health care workers at Winnie Palmer couldn't accomplish this alone. They partnered with a local organization run by our guest, Peggy Burgess. Peggy shared the origin story of her organization.

00;16;00;18 - 00;16;30;01
Peggy Burgess
It is a interesting story. I started Center for Change in 2003. I started it because my sister, who was only 48 years old at the time, died of colon cancer. And what amazed me about her reaction to having stage four cancer that early is she had no resources. So I wrote a program and it was called the Renee's Dream Program.

00;16;30;03 - 00;16;51;26
Peggy Burgess
And what it was about was educating people who had less resources than she had to find out where they can go for treatment, who they could talk to, what they can do to improve their health, and trying to give her just a sense of security or control.

00;16;51;28 - 00;17;05;10
Julia Resnick
Out of this original program grew The Center for Change, an organization that leverages community health workers and offers health coaching and self-management courses and chronic disease, amongst other opportunities to improve health.

00;17;05;13 - 00;17;34;21
Peggy Burgess
What we were actually doing was - and I'm so glad Orlando Health had the program designed where they had the bus available. They had the clinicians available and they were part of the program was requiring them to make sure that they go it. And for our end, it was no more than providing that extra push, that extra check in with them to see, are you doing okay?

00;17;34;24 - 00;18;07;26
Peggy Burgess
Are you following through? Why haven't you gone to check on this or that really doesn't sound normal to me. I would suggest that you check on this. You'll be surprised at the number of young mothers who are unaware of signs and symptoms and would say, Well, I have an appointment in three weeks. No. If you have swelling to this extent and is moving up your legs, something is wrong

00;18;07;27 - 00;18;36;01
Peggy Burgess
now. You need to have that checked. Sometimes just that motherly push is enough to say, okay, okay, I'll go. And they know that we're going to call back because we are their accountability partner in a way, because it is our responsibility to make sure that not only are we educating, but we're there for support and we're also there to listen.

00;18;36;04 - 00;19;20;11
Peggy Burgess
One of the biggest things that the community health workers  - and we train them to do - is please listen to what your client or your patient is saying to you. Listen, because they will give you all the clues that you need to help them. I love the program that we're working with with Orlando Health now, But if it was my goal, my goal would be for it to continue to grow so that not just a few of the mothers that are high risk, but all mothers that are high risk would have access to this.

00;19;20;14 - 00;19;31;20
Julia Resnick
The Center for Change wasn't the only community partner involved in this program. Dr. Boardman spoke to the other groups that have been instrumental in providing holistic wraparound services for new moms.

00;19;31;22 - 00;19;54;02
Lori Boardman, M.D.
I'm going to call out a couple that really have done a fabulous job, and one of those is Second Harvest Food Bank. So Second Harvest has been a partner with us through two of the grants that we've gotten from the Florida Department of Health. They've been able to identify those patients. They have a very streamlined process and they were able in the one grant, we enrolled about 1200 women about six months.

00;19;54;02 - 00;20;25;09
Lori Boardman, M.D.
They had touched 500 patients and their families with food boxes. They were 90 days of food boxes being delivered every other week. For families that really needed it continued. And then another group that we worked with, we've worked with a number of folks was Christine Certain who a perinatal licensed mental health counselor. She's been doing group counseling for patients who screened positive for the depression or anxiety, which is a very common side effect of pregnancy.

00;20;25;09 - 00;20;30;13
Lori Boardman, M.D.
And in the postpartum period, it manifests itself. But you can see it throughout pregnancy.

00;20;30;16 - 00;20;49;19
Julia Resnick
Addressing the medical, social and emotional needs of new moms helps create an environment where they and their babies can thrive. And the perinatal hypertension telehealth program has been incredibly successful in moving the needle on pregnancy and postpartum outcomes. Dr. Boardman shared the impact that it has had on their patient population.

00;20;49;21 - 00;21;14;01
Lori Boardman, M.D.
So when you look at participation from patients that have known hypertensive disorders, we recommend coming in for a visit in about 7 to 10 days. White women and Hispanic women, about 80% of those patients will go to them. About 25% of black patients will go to those visits. With the virtual visit platform, everybody participated in excess of 70 to 75%.

00;21;14;03 - 00;21;35;27
Lori Boardman, M.D.
So we didn't see those disparities anymore. And if a patient completed at least one of those two visits, the readmission rate was about half of what it was for patients who didn't do that. It's now become embedded in Winnie Palmer. It's part of what we do. It's not a pilot, it's not a study. It's really how we treat our patients.

00;21;36;00 - 00;21;39;13
Lori Boardman, M.D.
That's gone exceedingly well.

00;21;39;16 - 00;21;56;23
Julia Resnick
Everyone's needs are different. To get the best outcomes and reduce risk, hospitals need to design care with and around patients and create systems that make it easier for new moms to care for themselves and their babies. We'll wrap up with some closing thoughts from doctors Nwabuobi and Boardman.

00;21;56;25 - 00;22;32;17
Chinedu Nwabuobi, M.D.
Like I said earlier, pregnancy being kind of a stressor can mask this. So just be on top of your care, be very involved, be an advocate for yourself, speak up, ask questions. Those symptoms that you've read online, you've seen on Tick-Tock that you consider are normal should not be normal until it has been completely addressed by your OB provider. To make sure we care for women more before they become pregnant so that when they become pregnant, there's already that understanding of what the risk is, hopefully we've mitigated it, and how we can make for the best pregnancy outcomes of it.

00;22;32;19 - 00;22;55;10
Lori Boardman, M.D.
I know from thinking about even creating programs and all this kind of stuff, having the end user be involved in the conversation, and I think listening to our patients learn from our patients and then when you start to implement your whatever you're deciding they're going to do, make sure that it aligns with what they want to do because otherwise we're never going to be successful.

00;22;55;12 - 00;23;02;04
Lori Boardman
And I think they know better than we know what's going to work, for them and often for their communities.

00;23;02;07 - 00;23;27;26
Julia Resnick
Heart Month can be a catalyst for health care organizations to reimagine what it takes to create the conditions for a heart healthy pregnancy. And that will require going beyond the hospital walls to engage patients and collaborate with stakeholders who all share the same goal, healthy moms and healthy babies. By designing pregnancy care around patient needs, recognizing who is at risk of complications and reducing barriers to support,

00;23;27;28 - 00;23;56;06
Julia Resnick
hospitals can make progress towards reducing maternal morbidity and mortality. A big thank you to all of our speakers: Lori Boardman, Chinedu, Nwabuobi, Peggy Burgess and Crystal Wilson. I appreciate everything you do to support the health of your patients and community members. For more resources on improving maternal health visit www.aha.org/betterhealthformothersandbabies

00;23;56;09 - 00;24;08;17
Julia Resnick
Thank you for tuning in to this episode of Beyond Birth and Advancing Health Podcast. If you missed any of our previous podcasts, you can find them wherever you listen to your podcasts and please subscribe to the Advancing Health Channel. We'll see you next time.

Hospitals and health systems are rightly called cornerstones of their communities, and none take that mission more seriously than Advocate Health. The health system works with local partners to address a variety of community needs, providing nearly $6 billion in community benefits in 2023. In this conversation, Kinneil Coltman, chief community and social impact officer at Advocate Health, discusses Advocate’s wide-ranging programs and initiatives, including food insecurity, affordable housing and meaningful employment.


 

View Transcript
 

00;00;00;22 - 00;00;22;10
Tom Haederle
Hospitals and health systems are rightly called cornerstones of their communities. And as nearly 6 million patients spread across six states can attest, few care providers take that mission more seriously than Advocate Health. Headquartered in Charlotte, North Carolina, Advocate is the third largest nonprofit health system in the nation and takes pride in serving a large number of under-resourced patients.

00;00;22;12 - 00;00;40;14
Tom Haederle
Name a want or a need or a gap in community services, and chances are Advocate Health is already working with local partners to address it.

00;00;40;16 - 00;01;05;10
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. According to Dr. Kinneil Coltman, chief community and social impact officer, Advocate Health provided nearly $6 billion in community benefits in 2022. The funds supported a wide variety of programs and initiatives as leaders spent a lot of time thinking about where do we focus?

00;01;05;12 - 00;01;21;24
Tom Haederle
In this podcast hosted by Aaron Wesolowski vice president of Policy, Research, Analytics and Strategy with AHA, Coltman says certain priorities leapt to the top. They included addressing food insecurity, affordable housing and a meaningful employment.

00;01;21;26 - 00;01;31;13
Aaron Wesolowski
Dr. Coltman thanks so much for joining us. We're so excited to be talking today. Can you start by telling us a little bit about Advocate health and the patients and communities that you serve?

00;01;31;16 - 00;01;59;25
Kinneil Coltman
Advocate Health is the third largest nonprofit health system in the nation. We serve a diverse array of patients, nearly 6 million unique patients across six states: Alabama, Georgia, Illinois, North Carolina, South Carolina and Wisconsin. Many of our hospitals serve as the primary safety nets in their communities, so we serve a large number of under-resourced patients.

00;02;00;04 - 00;02;19;24
Kinneil Coltman
We're the number one Medicaid provider, for example, in Illinois and North Carolina by volume. But throughout our footprint, we also care for patients in about 68 rural counties, and that's about 3 million residents. So we're really proud of the work that we do around solving for underserved communities needs.

00;02;19;26 - 00;02;25;28
Aaron Wesolowski
Great. How does advocate think about community benefit across the system and across all those hospitals?

00;02;26;00 - 00;02;57;23
Kinneil Coltman
When I think about community benefit, I think about what are we doing that is truly benefiting society? We've noticed that sometimes those conversations may focus on one aspect of our community benefit, but we really look at it holistically. The pandemic really shined a light on the absolute necessity for us to focus on working even further upstream than maybe we would have in the past to really focus on disrupting those root causes of health inequities in our communities.

00;02;57;24 - 00;03;21;10
Kinneil Coltman
For us, we spent a lot of time thinking about where do we focus? so that we're going to have the deepest and most meaningful impact. And for us, we've kind of drawn a line in the sand around food insecurity, affordable housing and employment. When I say that, I mean meaningful employment, good wages, the provision of health insurance, career and economic mobility.

00;03;21;17 - 00;03;46;16
Kinneil Coltman
So that's where we focus our energies, both in terms of the programs we develop internally, but also in how we invest in the community. But all in and in 2022, we we had nearly 6 billion in community benefit, and that includes free care for low income patients, but also the cost of educating the next generation of health care workers and research.

00;03;46;16 - 00;04;15;07
Kinneil Coltman
We have a huge research enterprise that extends across our footprint, but also investing in those safety net organizations that we know are really serving those that need it most in our community. We've invested in things like a medical clinic in an HBCU in Charlotte for really novel solutions like virtual care in community centers. And we have countless food pharmacies across our footprint.

00;04;15;07 - 00;04;21;10
Kinneil Coltman
So it manifests in a variety of ways, but all in service to disrupting those root causes of health inequities.

00;04;21;12 - 00;04;38;15
Aaron Wesolowski
That's really impressive and really exciting to hear, and I want to hear more about it. Before we go deeper into Advocate Health and all the good that that you all are doing, I'm curious to hear a little bit more about you and your career. How did you get into health care and how did you find yourself in the role that you're in now?

00;04;38;17 - 00;05;07;17
Kinneil Coltman
Yeah, so I actually grew up in a rural area myself. I grew up in the mountains of western North Carolina. I had some really profound experiences in high school and in undergrad that led me down this path of wanting to work on kind of institutionalized systems of inequality. And so that's what I've devoted my career to, is really helping to architect health equity strategies in large complex health systems.

00;05;07;17 - 00;05;26;22
Kinneil Coltman
And for me, it's very personal. I still have a lot of family members that live in very rural areas that have a lot of challenges around transportation and other social drivers of health. So I, I think a lot about the folks that I grew up with when I think about the energies that I bring to my work every day.

00;05;26;24 - 00;05;39;19
Aaron Wesolowski
Well, thank you for sharing that. What trends have your hospital seen in recent years in terms of patient and community needs? And how has that changed Advocate's focus on providing care beyond the four walls of the hospital.

00;05;39;22 - 00;06;10;03
Kinneil Coltman
You know, I think it all boils down to meeting people where they are and getting to them before they need us, right? That's the goal. And so a lot of our conversations with our leadership are around modernizing access. We know the access to care is is a dramatic issue that impacts health across the country. So we've tried to think about really creative ways to reduce that friction to access care and to make it easier for folks, no matter where they live, to be able to access care.

00;06;10;06 - 00;06;37;18
Kinneil Coltman
So thinking about things like our virtual strategy. If there are gifts around COVID, that is absolutely been one. It's helped us to kind of broaden our aperture around thinking about where and how we can use virtual care in the future. So we, for example, have made huge investments and had other investments from partners in school-based primary care and behavioral health in schools.

00;06;37;21 - 00;07;07;00
Kinneil Coltman
We are in 213 schools and that number grows every time I share that in 11 counties. And, you know, had just in the last year 26,000 patient visits with those. And we've been able to show that we can have a 32% reduction in E.R. visits once we create those kinds of interventions. We've also embedded virtual clinics in low income, affordable housing communities, in immigrant service centers.

00;07;07;03 - 00;07;40;13
Kinneil Coltman
We're thinking about all kinds of places where we can deploy these interventions in new and different ways. We also see it a lot of promise around the management of chronic disease. We've stood up virtual chronic care management programs for patients that have those tough chronic diseases to manage, like diabetes, for example. So enrolling patients in those programs, knowing that they don't have to access transportation and deal with some of the other friction of accessing care that they can access, that support virtually is a big deal.

00;07;40;16 - 00;08;06;11
Kinneil Coltman
And then the last one that I'll mention is our signature hospital home program, which we stood up virtually overnight during COVID. But since then we've been able to care for hundreds of patients at a time from the comfort of their home. And if you think about it, no matter how good of a job we think we do around care, our hospitals, people would always rather be in their homes than in a hospital.

00;08;06;11 - 00;08;25;28
Kinneil Coltman
And so we've been able to deliver hospital level care inside the comfort of someone's home. So we're still working on those solutions, but we are giving it all we've got because we know that our patients and communities are depending on us to kind of pass those traditional access points that we've relied on historically in health care.

00;08;25;29 - 00;08;34;20
Aaron Wesolowski
That's great. And I imagine that a lot of those local partnerships help you anticipate new needs that might be coming down the road at you as well.

00;08;34;22 - 00;09;03;01
Kinneil Coltman
Yeah, absolutely. So we've seen, for example, we obviously have a large footprint in Chicago, and Chicago has had, you know, a surge in immigrants and in recent months. And so trying to figure out how can we be part of the solution of delivering care in unique and different ways. But we're seeing that opportunity across our footprint to listen more deeply to our communities and say, where do you want to get care?

00;09;03;02 - 00;09;17;05
Kinneil Coltman
How do you want to get care? When do you want to get care? And then we have a wonderful strategy team that's guiding us to think about innovative solutions in terms of how we deliver that care differently than we have in the past.

00;09;17;07 - 00;09;31;10
Aaron Wesolowski
Stepping back, can you tell us why Advocate is committed to providing these services that that clearly extend beyond traditional medical care? Why is it important to impact health and well-being before someone even becomes a patient in a facility?

00;09;31;13 - 00;09;59;05
Kinneil Coltman
I think the answer to that question is, you know, a five-minute conversation with any emergency medicine provider that I've ever worked with, and I'm sure you have as well heard these stories that you think about in our emergency rooms. You may have someone who's unhoused and they may come two and three times a week sometimes. But as soon as that person secures housing, then we see their use of emergency rooms change for the better.

00;09;59;05 - 00;10;34;16
Kinneil Coltman
Right? And so you have all these stories that our providers collect and tell us about. And I think that creates a sense of urgency for us to be able to work further upstream, try to prevent that unhoused situation in the first place, try to get at those root causes that led to that incident of homelessness. So those are the things that we're thinking about all the time, that we've got to constantly work upstream because, you know, we have level one trauma trauma center  hospitals in so many communities that are in need.

00;10;34;19 - 00;10;53;27
Kinneil Coltman
We are the safety net. When all of the other safety nets break down, we see - we're at the very end of the line. So we see when all the other social systems fail, we're there to catch patients and community members when they need us so that that creates a burning platform, I think, to work upstream and be part of the solution.

00;10;54;00 - 00;11;16;09
Aaron Wesolowski
Building on that topic of of access, you know, ensuring that that all community members have access to care also means working to make care more affordable and make sure that patients have options around financial assistance. Can you talk about your work to improve financial assistance and the process around accessing it? And why is it important for families and patients?

00;11;16;12 - 00;11;40;01
Kinneil Coltman
So I mean, we talk about that all the time. In fact, when Atrium Health and Advocate Aurora Health came together just over a year ago, that was one of our big commitments was around affordability. And we already, in both legacy systems, had a lot of strengths, but we tried to, you know, curate the best of what each legacy system had in terms of building.

00;11;40;04 - 00;12;05;06
Kinneil Coltman
What I would argue is one of the most comprehensive and patient centered financial assistance programs in the country, because you hear a lot of discussions about federal poverty levels. And then, of course, we've committed to a very generous level of 300% federal poverty level gets full financial assistance, full charity care, and then up to 400% very, very deep discounted care.

00;12;05;08 - 00;12;28;22
Kinneil Coltman
You know, the devil's in the details on some of this stuff, that it's how we administer our program that I think is really meaningful for patients. So when you think about our patients who are under resourced and what may be going on in their lives, maybe working two and three jobs, we've really thought critically about how can we reduce the friction involved in qualifying for our financial assistance programs.

00;12;28;22 - 00;12;53;02
Kinneil Coltman
And so we have invested in a pre-qualification service that's really effortless, seamless to our patients. So I'm really proud of the way that we're working to reduce friction for patients and being able to access our policies. We also provide financial assistance for care that we know patients need. So it's not just for emergency care, but it's also for other essential care, primary care, behavioral health care.

00;12;53;02 - 00;13;14;17
Kinneil Coltman
So those are the things that we focused on. There's a lot of other players in the industry providers, insurers, drugmakers, pharmacy benefit managers. I can go on and on...that together, we need to solve for the affordability challenges in health care. We're committed to being part of that coalition that solves for this together.

00;13;14;20 - 00;13;26;04
Aaron Wesolowski
Absolutely. And that's that's great to hear. Last, what are you most hopeful about in health care? And are there things that you're really excited about in terms of innovations or patient programs that Advocate Health has planned?

00;13;26;06 - 00;14;12;26
Kinneil Coltman
There's so many big challenges ahead of us as an American health care system, right? But I'm also encouraged about what we can accomplish when we really focus. COVID taught us how much we can accomplish if we really focus on something. So for our part, over the last year, we've been standing at the Advocate National Center for Health Equity, and that's a really bold and ambitious strategy because it involves a national operating model that then will manifest interventions in all of our major service areas in different ways based on what the community tells us it needs, but also based on what we know from a public health data standpoint, is also necessary to improve health.

00;14;12;26 - 00;14;53;04
Kinneil Coltman
And so we are working on a very robust health equity analytics platform that will help us think differently about how we bring data to providers to intervene, but making sure that we have good clean data across our 6 million patients, but then also developing a framework of health equity interventions in our clinical environment. Soup to nuts. Every service line is then, you know, we have board approved health equity goals that we're cascading throughout the enterprise, but we're also looking at architecting national partnerships around those social drivers of health.

00;14;53;06 - 00;15;19;18
Kinneil Coltman
But with all of our interventions, we have committed to studying them academically, right. In an academically rigorous way so that we can develop proof points, that we can educate other health systems that want to do this work, but also policymakers, elected officials on what are the solutions of the future around health equity, because we've got to have partnerships and a coalition to solve for these entrenched inequities together.

00;15;19;25 - 00;15;32;21
Kinneil Coltman
So I'm excited about that. You know, we're still in building mode, but I'm encouraged that we have a very ambitious board behind us that's very motivated around our health equity goals and ambitions.

00;15;32;23 - 00;15;44;29
Aaron Wesolowski
Great. Well, thank you for sharing that. It's really heartening to hear all that you all are doing and the scale of the benefits that you're offering the communities you serve. And so thank you for sharing it. Thank you for being with us today.

00;15;45;02 - 00;15;47;04
Kinneil Coltman
Yeah, my pleasure. Thanks very much.

Hackers and cybercriminals are targeting hospitals and health systems at alarming rates, disrupting operations and threatening direct patient care. In this conversation, Bryan Smith, recently retired section chief of the Cyber Criminal Operations Section with the FBI, discusses how the Bureau tackles the huge challenge of protecting the nation's caregivers from these attacks, and how partnerships are crucial in prevailing against cybercriminals.


 

View Transcript
 

00:00:00:29 - 00:00:28:12
Tom Haederle
If the steady rise in hospital ransomware attacks has taught us anything, it's that cybercriminals never take a day off. Life saving technology, CT scanners, MRIs and heart monitors can all be - and are - targets for cybercriminals every minute of every day, disrupting hospital operations and threatening patient care until a ransom is paid. That means that the good guys, the defenders against these threat to life crimes, can never take a day off either.

00:00:28:15 - 00:00:42:09
Tom Haederle
Well, they don't. And their constant vigilance is making a difference.

00:00:42:11 - 00:01:08:25
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I’m Tom Haederle with AHA Communications. Hackers are targeting hospitals and health care companies at alarming rates. It’s a continual cat-and-mouse game. When a cybercrime ring is arrested or shut down, new ones quickly pop up in their place. In many ways, the FBI is the tip of the federal spear pushing back against cyber criminals and their ceaseless assaults on the health care sector.

00:01:08:28 - 00:01:33:16
Tom Haederle
In this podcast, hosted by John Riggi, the AHA’s National Advisor for Cybersecurity and Risk, we hear from Bryan Smith, recently retired section chief of the FBI's Cybercriminal Operations section, on how the Bureau tackles the huge challenge of protecting our caregivers from ransomware attacks and how critical it is to partner with a private sector to prevail in the long game against cyber criminals.

00:01:33:18 - 00:02:03:17
John Riggi
Thank you, Tom, and thanks for everybody tuning in today. We've got another great special episode on cybersecurity issues. I'm really pleased and privileged to be joined today by my good friend and former colleague Bryan Smith. Bryan is the section chief of the criminal section of the FBI's Cyber Division, and he's been in the FBI since 2002. So just over 20 years, tremendous change in cyber and all types of investigations in the FBI since that time.

00:02:03:24 - 00:02:07:10
John Riggi
Bryan, welcome If you could, tell us a little bit about your background.

00:02:07:17 - 00:02:36:03
Bryan Smith
Great. Thanks, John. I really appreciate being here. And it's always good to have a conversation with you and looking forward to this talk today. Like you said, I've been in the Bureau for over 21 years. Prior to the Bureau, I did consulting work for Deloitte and Accenture, and then within the Bureau, I spent most of my time working white collar financial crime dealing with cryptocurrency and then probably for the last ten years, getting back to what I did before the Bureau, which was cyber.

00:02:36:06 - 00:02:52:11
Bryan Smith
Cyber is what white collar was 25, 30 years ago, and that cyber is just the new method by which folks are doing the same things that they've done since antiquity. They're stealing secrets, they're stealing money, they're trying to gain a competitive advantage. And so it's a really interesting space to work.

00:02:52:14 - 00:03:25:27
John Riggi
In as we realize the bad guys are evolving, just as technology is evolving, It's another way to steal money, much more effective and efficient way to steal money, steal secrets and commit crimes against the United States and our good citizens. But of course, the thing that we're most concerned about are these high impact ransomware attacks, which shut down medical technology in hospitals and health systems and really result in the very serious disruption and delay to health care delivery, ultimately risking patient safety.

00:03:25:29 - 00:03:53:13
John Riggi
Now, on the plus side, I can't have it all doom and gloom. On the plus side is that we as a field, as a hospital field, as a health care field, have come together just as we did during the pandemic, to exchange threat information and best practices and work with the government and very closely with the FBI in particular for the common defense, in the common good of the health care field and the nation, and most importantly, the nation.

00:03:53:15 - 00:04:05:06
John Riggi
Bryan, given your role as national leader for all FBI cyber criminal investigations, what do you see as the most significant cyber threat that is impacting health care today?

00:04:05:09 - 00:04:29:08
Bryan Smith
You know what I'd say is probably the biggest cyber threat that we're facing right now are I think the health care is facing right now is probably ransomware because it's immediate and it impacts hospitals or medical facilities ability to operate on any given day, which obviously has significant impacts on revenue, certainly has a significant impact on expenses as to we've got to still operate.

00:04:29:08 - 00:05:12:01
Bryan Smith
We can't bring money in because we don't have services that we can perform here. But as we've seen in a number of instances, it has a real life impact on individuals. And that the care that these individuals are needing, they are not able to get because of the ransomware attack. And so we've had some instances where, you know, you know better than I and people in this industry know better than I that the precision by which we get our medical care and the medications that we get are so precise in certain instances, be it chemotherapy or other specific ailments that we have, that if we don't have those records in front of us, we can harm

00:05:12:01 - 00:05:33:25
Bryan Smith
the patient. And so when an entity gets hit with ransomware and they're in a position where they cannot in good conscience deliver the care that the person needs because they can't tell what that amount and the dosage should be, that has a real life impact and can impact lives. And so it's critically important that we are all focused on that ransomware threat.

00:05:33:27 - 00:05:50:11
Bryan Smith
Yeah. And then on the economic side, there's the aspect of thinking about the long term intellectual property that's being stolen by foreign adversaries from our medical institutions that they're leveraging to create their own in direct competition with us.

00:05:50:13 - 00:06:32:23
John Riggi
Thanks for all that, Bryan. When a ransomware attack strikes a hospital and the encryption disables every piece of medical technology, shuts down our internal networks in our Internet connections, we have seen, unfortunately, time and again, a serious disruption in delay of health care delivery. So what does that mean? That means when there is a stroke patient enroute to the nearest available emergency department and that hospital is under a ransomware attack, they're going to have to divert that ambulance because they won't have the necessary CT scanners perhaps available to diagnose that stroke case.

00:06:32:25 - 00:07:06:03
John Riggi
Really very serious consequences. That's why we say and I know the FBI director Ray has publicly proclaimed that we believe and the FBI believes that ransomware attacks against hospitals are truly threat to life crimes. Given your role, national view, what do you believe are the most common vulnerabilities and methods being used by our cybercriminal adversaries to take advantage, to penetrate our networks, to steal our data and execute these highly disruptive ransomware attacks against U.S. health care?

00:07:06:06 - 00:07:29:23
Bryan Smith
Yeah. So by and large, the things that we see is the things that we've been seeing for the last 15 years, which is spear phishing or phishing emails, by which then they're able to gain access to somebody's system. Then they move laterally, escalate privileges, gain additional insight into the system, and then figure out what it is that they want to do while they're in there and what they can take advantage of.

00:07:29:25 - 00:08:11:03
Bryan Smith
We have seen some zero day exploits over this past year, and that gets into some of those scenarios where there actually were patches and some vulnerabilities that were identified that could have been mitigated had people been updating their systems. And so there's a huge learning curve on the user engagement and users owning the problem here. But there's also some really simple things, some fundamentals that can be done by organizations and by individuals to make sure that they're doing the rudimentary, fundamental activities that keep each of us safe on our own systems.

00:08:11:05 - 00:08:36:03
John Riggi
So as I always say, the bad guys simply hack before we patch. And in health care, sometimes it takes a while because we can't just patch a medical device quickly without testing it and understanding what the ramifications for patient safety are. Now, I'm going to get on my my soapbox a little bit here and say, look, yes, we've got to do a better job of patching, but the technology providers have to give us more secure technology.

00:08:36:06 - 00:09:01:26
John Riggi
And I know the White House has promoted the concept of secure by design and secure by default. So kind of shift that responsibility back to the technology developers versus the end user. Shared responsibility: You know, my belief is we've got to get the technology providers to give us better secured technology. Now, with that, we certainly understand that no organization, including the federal government, is 100% immune from cyber attacks.

00:09:01:28 - 00:09:13:04
John Riggi
Bryan, what do you believe are the top three, 3 to 5 best practices to help mitigate the risk of a successful cyber attack against health care or any organization?

00:09:13:06 - 00:09:48:16
Bryan Smith
Well, I guess the first one is doing the fundamentals. I love baseball and I love baseball is that if you do the fundamentals right, you do the little things right, then big things will happen for you. And you do that over time. And I think that's appropriate within the cybersecurity arena. Is that if you're patching, if you're running antivirus, if you have engaged personnel who are looking at this stuff, not on a quarterly basis, but this is every day activity and you do that well, you're going to catch a lot of the activity and or you're just going to make it harder for the adversary to get in there.

00:09:48:16 - 00:10:10:11
Bryan Smith
And they may decide that they're going to give up and move on. The other thing is that we want people to think functionally. And when I say functionally, I go back to my earlier comments about what cyber being used for, and it's everything that people have been doing since antiquity. We want people to think of if someone gets into my network, what is it they can do here?

00:10:10:14 - 00:10:35:18
Bryan Smith
What can they take advantage of? How would they monetize it? Because that's what you're talking about here. At least with the cybercriminal actors, they are financially motivated and so if you can figure out how they make money based off the information that they have within your department, your division, your group unit or your work unit, and protect against that, you make it a lot harder for them to then monetize that type of information.

00:10:35:21 - 00:10:56:23
Bryan Smith
And that goes along with treating this like a business problem. I think far too often we've treated as an IT situation, so the business lines need to take some ownership of, Hey, I'm part of this, I need to be doing due diligence and making sure that what I'm doing on my network and what am I'm doing with our systems is not going to put the organization at risk.

00:10:56:26 - 00:11:15:25
Bryan Smith
And until we do that, it's going to be an arms war for the IT folks. So we've got to get that pulled together. And then the last thing I think is be prepared. Recognize that no matter what you do, you are likely going to be a victim of some sort of cyber attack. And are you prepared for what that means?

00:11:15:27 - 00:11:33:21
Bryan Smith
And that means do you have the partnerships laid out ahead of time so that you know who to call, what that's going to look like? Do you have a plan when there's an incident and let's say it's ransomware of do you have a policy of whether you pay or don't pay? Who's going to be helping you with the negotiations on it?

00:11:33:23 - 00:11:45:27
Bryan Smith
You want the game to slow down when you're in this event, which means that you're prepared for and you've already thought through what that's going to look like. And now it's just a matter of executing it and you're not having to think on the fly.

00:11:45:29 - 00:12:24:15
John Riggi
So gaming it, train like you fight, right, as we would say. So that will help reduce the stress level and make those decisions much easier. So, Bryan, as we've been chatting, I've been thinking, as I heard you talk about defensive measures, the basics, but we know that defensive measures can only go so far in reducing the risk of a cyber attack. And I believe, you know, based upon my experience in FBI cyber and counterterrorism, that's extremely difficult for the FBI to conduct law enforcement operations overseas, including arresting bad guys that are being sheltered by hostile nation states like Russia, China, North Korea and Iran.

00:12:24:18 - 00:12:47:05
John Riggi
So just like in terrorism matters, we may not be able to arrest our way out of the cyber threat. But I also believe there must be a whole of government approach to this, and that would include leveraging all the capabilities of the U.S. government to conduct offensive cyber operations to disrupt and dismantle these foreign bad guys before they attack us over here.

00:12:47:12 - 00:12:58:25
John Riggi
So, Bryan, can you tell us about how the FBI is going on the offense against these foreign cybercriminal organizations? And I know you've had some successes recently, so can you tell us about that?

00:12:58:27 - 00:13:19:12
Bryan Smith
We've broken that down in a couple of different areas, and then we target all of those areas, not just one of them, not just the finances, not just the infrastructure, not just the malware and the the marketplaces and forums by which they communicate, but all of them, and that it really becomes a targeting of the ecosystem. I would call this an ecosystem problem.

00:13:19:12 - 00:13:43:01
Bryan Smith
It's not a ransomware problem. Ransomware is a symptom of a larger disease. And what we're trying to do is eradicate the disease. In the process we may take care of the symptom, but we've got to go after that ecosystem. As we've moved forward with our strategy, we've also recognized that this is not going to be some sort of one knockout blow that's going to stop them from engaging this activity.

00:13:43:04 - 00:14:15:16
Bryan Smith
Just like any business, businesses don't go bankrupt overnight. They go bankrupt over time because they make bad decisions, they make bad investments, their expenses get too high over time. And eventually it gets to the point where they can no longer be a going concern. And that's what we're trying to do with the cyber adversary, is increase the expenses for them to engage in this conduct and expenses can be the risks of you might be going to jail, expenses can be it costs more because we're tearing down your infrastructure.

00:14:15:18 - 00:14:40:12
Bryan Smith
It costs more for you to get into the network. So that goes back to the defense side of this and that if you're prepped and you make it harder for them, that's raising the business costs on their end. And now what you're seeing across the board is that when we take actions, it's not just the FBI, it's the FBI with a multinational partnership with a number of different entities to include sometimes civil and regulatory entities.

00:14:40:13 - 00:14:54:18
Bryan Smith
Again, with the objective of there's not going be a knockout punch, but we can deliver body blow after body blow over time that will get us into a position where I think we can clean up the ecosystem in a much more comprehensive way.

00:14:54:20 - 00:15:24:10
John Riggi
Truly appreciate your comments, Brian. And I was thinking back again to my counterterrorism days, and it's the same problem. We knew there would not be one knockout blow, but you know, this continuous effort of what I call the enterprise theory of investigation: Go after the leadership, the communications, the finances, operational activity, the entire infrastructure that they might be using to ultimately increase risk and consequences for the bad guys as the deterrent and hopefully disrupt them.

00:15:24:12 - 00:15:51:26
John Riggi
So Bryan, victims of ransomware attacks or other cyber attacks often reluctant to work with the federal government, often upon advice of outside counsel, because they're concerned that the information provided to the FBI to further the investigation may ultimately be used against the victim in some future regulatory or civil liability matter. Brian, can you tell us how the FBI works with cyber victims to maintain confidentiality?

00:15:51:28 - 00:15:56:23
John Riggi
And also, does the FBI share information with regulatory authorities?

00:15:56:25 - 00:16:22:25
Bryan Smith
Yeah. So one of the issues that we have across the board is a reluctance by victims to report. And so we really need to change that reporting mechanism. Now, we don't say what companies got hit with it, but over time we develop that. We can't do that if people don't report to us. And so it's critically important for now and in the future that if you want to prevent these things to tell us what's going on, it begs the question of why not?

00:16:22:25 - 00:16:41:12
Bryan Smith
And I think some of it is that people don't know what to expect. What I'll tell you, we will not be showing up in the blue ray jackets with the yellow letters on the back. We're not going to make a scene at your office building. You call us. We will handle this in a very discreet fashion. If it's important for us to be out there, then we will do that in a discreet way.

00:16:41:15 - 00:17:01:29
Bryan Smith
We are not looking to revictimize folks. The other part is that there's got to be a value proposition for the victim of, Well, what do I get out of this? Well, one, you can help protect the ecosystem and which I talked about before as far as the intelligence that we can share. Just like us, criminals make mistakes. So we make mistakes and we let them into their network.

00:17:02:02 - 00:17:25:15
Bryan Smith
They will make mistakes. And the more victim data that we have that we can then identify instances where, you know, their VPN dropped or they reused a wallet ID or something that we can then latch on to make connections and then we can actually identify. And then once we identify, then we have a much better shot at doing something about the actor.

00:17:25:17 - 00:17:47:08
John Riggi
Thanks, Bryan. So obviously there's not only a benefit potentially for the victim to contact the FBI. You may be able to assist and guide them through the incident. Just as you said, you've got the experts, but also it's good for the nation. It's good for the nation and the rest of the sector. A victim cooperate and can help prevent future attacks against other hospitals or other entities.

00:17:47:11 - 00:17:56:19
John Riggi
Bryan, I just want to clarify in terms of sharing information with the regulatory authority, is investigative information shared with regulators for their purposes?

00:17:56:21 - 00:18:11:05
Bryan Smith
We are not regulators. And so when you give information to us, it is going to be held by the FBI. And we take the sensitivity of that information. We understand it. We're going to use it in the investigative capacity, but it's not going to be used for any sort of civil regulatory action against you.

00:18:11:07 - 00:18:42:19
John Riggi
And also, I'd like to point our listeners to a very helpful statute. It's called the Cybersecurity Sharing Act of 2015. I'm not a lawyer, but it does provide lots of robust regulatory and civil liability protections in that statute for victims and private entities to share information with the federal government. So have your outside counsels take a look at that statue, and I think you'll find that there are protections for sharing information with the federal government, cyber threat information sharing.

00:18:42:21 - 00:19:03:13
John Riggi
Right. So speaking about contacting the FBI, at what point during a cyber attack should a victim, hospital or health system actually reach out to the FBI? And what's the best way to contact the FBI? And let's say in an urgent ransomware situation, we've got we've got ambulances on diversion with stroke and heart attack patients who do we call in that situation?

00:19:03:16 - 00:19:36:13
Bryan Smith
So my advice is be prepared. And being prepared is to have the local FBI contact the supervisory special agent in your area that you can call and say this is what's going on here, that that's not the first time that you've had a conversation with them, that there's a relationship there. And so they can then help and walk you through. You know, let's say you haven't done that the earlier you call the local FBI office in the incident, the better because we're going to provide you with the help that we can. We will provide that to you and try and help out on it.

00:19:36:17 - 00:19:53:14
Bryan Smith
That includes whether or not we are aware of decryption capabilities. Sometimes those are ones that we have. There may be also ones that we know that maybe a private sector entity has. And so we will share that type of information with you to help you kind of deal with that incident as it's happening in the moment.

00:19:53:16 - 00:20:04:12
John Riggi
What can a victim organization realistically expect if they contact the FBI for assistance during a cyber attack? Does the FBI always have the magic decryption key?

00:20:04:15 - 00:20:30:14
Bryan Smith
Unfortunately, we don't. I wish we had it every single instance. But if we did and this wouldn't be such a lucrative business for the adversary to be in. So if we have it will provide it to you. But what you can't expect is that we're going to have any indicators of compromise about the group. Unless it's a new group, we will share what we know about how that group operates, our experience with them in the negotiations, what you can expect on the back side of it.

00:20:30:17 - 00:20:44:13
Bryan Smith
And so that just that kind of insight of this is what and how they do this. Is really helpful for you understand what you can expect and then you can make decisions based off information, not based off what you think might be happening.

00:20:44:15 - 00:20:56:28
John Riggi
So could you could describe to us a little further on what your role is at the FBI and how you work with CISA, HHS and the intelligence community, even state and local agencies on cyber issues?

00:20:57:00 - 00:21:17:14
Bryan Smith
Yeah, I think if I could sum this up in kind of one phrase is that we're all in this together. And that is government, that's private sector, that's international partners. I'm really proud to work at the FBI. We have some incredible people here. But as good as we are, we can't do this alone. And so we need partnerships.

00:21:17:14 - 00:21:49:00
Bryan Smith
And that's why we have engaged with HHS and CISA and the IC community and Secret Service and foreign partners. If you look at any of the operations that we've had, there's a good 12 to 14 different flags on there, and that doesn't even count then the fact that there may be three or four different agencies within each of those countries that are working on these things together, so that we can have the maximum impact in a bunch of different areas against the adversary.

00:21:49:03 - 00:22:03:13
John Riggi
It's just great to hear that. Again, that same philosophy, one team, one fight force multiplier is being leveraged in this fight against these cyber adversaries as well. So, Brian, as we close out here, any final thoughts for our listeners?

00:22:03:16 - 00:22:27:18
Bryan Smith
Yeah, just a couple of things. There's not going to be, as we've talked about before, one knockout punch on this. But if we can deliver body blow after body blow, then that will have an impact. One of the lessons that we've learned is that we're all in this together. And so one of the best practices that I've seen across a variety of industries is partnerships between related entities.

00:22:27:18 - 00:22:42:07
Bryan Smith
And whether this is in the financial services or in other industries, is that when we share information and we collaborate with each other, we are making it harder for the adversary to attack any of us.

00:22:42:09 - 00:23:00:09
John Riggi
Thank you very much, Bryan. Thanks for all your thoughts and for being here with us today. Thank you and your team for what you're doing to help defend the nation against cyber threats. And thanks to all the men and women in the FBI for what you all do every day to defend the nation against cyber and physical threats.

00:23:00:11 - 00:23:13:10
John Riggi
And special thanks to all our frontline health care heroes for what you do every day to care for our patients and serve our communities. This has been John Riggi, your national advisor for Cybersecurity and Risk. Stay safe, everyone.

In 2023, the U.S. Surgeon General issued a shocking 80-plus page advisory declaring loneliness and social isolation as reaching epidemic levels in American society. Ready to act, Indiana University Health was among the first large health systems to develop a care network to spark social connection and community. In this conversation, Jay Foster, vice president of spiritual care with Indiana University Health, and Shadreck Kamwendo, director of the Congregational Care Network, talk about the difference the network is making in the lives of Indiana residents and beyond, and the resources available for those in need.


View Transcript
 

00;00;00;22 - 00;00;23;20
Tom Haederle
In 2023, the Surgeon General issued an 80 plus page report that shocked and dismayed many people. It found that loneliness - social isolation - is epidemic in American society and carries very real physical as well as mental costs. The report compared the effect of loneliness on health to smoking 15 cigarettes a day. With locations all over the state of Indiana,

00;00;23;23 - 00;00;43;14
Tom Haederle
Indiana University Health was among the first large health systems to recognize and act on the healing effects of social connection and community.

00;00;43;17 - 00;01;09;08
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. "We are made to be in community." That philosophy is the guiding force behind Indiana University Health's Congregational Care Network created to address loneliness and social isolation. In this podcast, hosted by Jordan Steiger, senior program manager of Clinical Affairs and Workforce with the AHA,

00;01;09;08 - 00;01;24;06
Tom Haederle
Jay Foster, vice president of Spiritual Care with Indiana University Health, and Shadreck Kamwendo Director of Congregational Care Network, talk about the difference the program is making in the lives of area residents. Let's join the discussion.

00;01;24;09 - 00;01;42;03
Jordan Steiger
So I'd like to start the conversation just by learning a little bit more about IU Health and really what the role of a chaplain is at IU health or in a hospital system, just in case there's a listener out there that doesn't really know. So Jay can you tell us what a chaplain does in your organization?

00;01;42;06 - 00;02;06;13
Jay Foster
Hey, Jordan, thanks so much for having us. And I like to think of it that there's things that chaplains do and things we try to be. And I'll start with the second one. It turns out that spirituality is really important in how people understand and cope with their illness. When folks are in the hospital, some people find that their faith is the most important thing to them, however

00;02;06;14 - 00;02;36;07
Jay Foster
they define that faith. Others find themselves questioning that. And so chaplains try to be someone who can walk with a person of whatever faith, religious tradition or not they may or may not identify with. But to accompany them on that health journey. Some of the things we do, some of them are kind of obvious, maybe. We get called to most deaths to be with loved ones of family members who are breathing.

00;02;36;10 - 00;03;12;04
Jay Foster
We get called the most traumas when loved ones show up and are understandably distressed. Some are maybe a little less obvious. We do things like advance care planning. We help with ethics consultation, work with persons who are having difficulty adjusting to their illness and help them identify their spiritual, emotional resources for coping with their illness better. And then finally, we provide a lot of support for our team members because we're embedded with team members.

00;03;12;06 - 00;03;30;08
Jay Foster
They find that they can have a level of trust, and sometimes we can help that team member get to the right door for more help. Maybe we can walk them to if they need to work with a therapist, if they need work with someone in H.R. or someone on our legal team, we can help them get to the right door.

00;03;30;10 - 00;03;50;17
Jordan Steiger
It's a really important role within the hospital system and the care team. And you know, what I'm hearing you say is that you are really that emotional guidance. You are there to help people walk through this, this experience. And we know that some of the experiences that our patients and families can have with health care can be a little bit isolating and a little lonely.

00;03;50;20 - 00;04;05;00
Jordan Steiger
And we know that people are lonely in the community across the country. So, Shadreck I was wondering if you could tell us a little bit more about the issue of loneliness and social isolation, and then also tell us why hospital leaders should care about it.

00;04;05;02 - 00;04;32;17
Shadreck Kamwendo
Yeah, that's a great question there. I think social isolation and loneliness has been found to be associated with hospital increase and hospital readmissions. Jay and I and others always talk about that. You know, patients come here to get treatment and they go home to get well and if they don't have those tools or things to make them well like community, they'll come right back to the hospitals.

00;04;32;19 - 00;04;46;21
Shadreck Kamwendo
So it is in the interest of all health care systems, hospital leaders. We are made to be in community. And for us to do better is to have everything and the community around us who wishes us well to get better.

00;04;46;24 - 00;05;14;13
Jay Foster
Thanks, Shadrack, for for making that point. I'd love to amplify just a bit. Two things. When we were trying to figure out where we as a spiritual care department would focus our work, we chose to focus on social isolation and loneliness because it's something that chaplains know how to do well, as you were saying, Jordan, But it's also something that congregations excel with and that's providing care for the sick and the shut-in.

00;05;14;16 - 00;05;41;21
Jay Foster
But the second thing and this was this is now much more well-known in our community, but as the surgeon general pointed out in recent studies, this is an epidemic in our country, isolation and loneliness. And it had it's a biological condition. I mean, it has actual impact on our spiritual and physical health. He compared it to smoking about 15 cigarettes a day.

00;05;41;23 - 00;06;09;21
Jordan Steiger
So really, you know, affects physical, mental, sociological, all of those outcomes. It's an important thing that we should all be focusing on. And I know at IU Health you have created a program that really has focused on reducing loneliness and social isolation in your community. And that's why we're here to talk today about your congregational care network. So Shadrack, I'd love for you to tell me a little bit more about the program, how it got started, how you fund it.

00;06;09;24 - 00;06;11;20
Jordan Steiger
Just anything you want to share.

00;06;11;22 - 00;06;38;20
Shadreck Kamwendo
Yeah, I'd love to do that. Our ill health care system. One of our goals is to make Indiana healthier, a healthier state. And one of the things that they see IU health system established in 2018 was a community impact investment grant. So when we thought about starting this program, loneliness and social isolation is one of the things that we'll focus with the partnership with the chaplaincy.

00;06;38;22 - 00;07;08;18
Shadreck Kamwendo
So we got funding from the IU Health Foundation through this grant, a community investment grant to start this program to study it here in Marion County, in the Indianapolis area, to find eight congregations and two congregations in Monroe County, Bloomington area. So we got started and Jay and others thought, how are we going to train the congregations? Who is going to be journeying with our neighbors?

00;07;08;21 - 00;07;38;21
Shadreck Kamwendo
So we chose a pathway training called Companionship Training that we provide to their congregations that are part of our program. This is a four-hour training. We talk about hospitality, just active listening, just being present is a deliberate admission of being present. And they ask for us to the connectors who are part of this program is to just to make phone calls about an hour a week for about 12 weeks.

00;07;38;23 - 00;07;57;08
Shadreck Kamwendo
And in that, you get to learn a little bit about what's going on in just being a friend and showing some love and saying, hey, we're not always about the disease that you have or a diagnosis you have. You are a human person, you're a neighbor, and we want to support you through this process.

00;07;57;11 - 00;08;20;07
Jordan Steiger
Wonderful. And I know just from speaking to both of you and learning more about your work, that the outcomes from this program have been unbelievably great for your workforce, for your patients, and for the volunteers that are part of the congregations in your community. So Jay, could you tell us a little bit more about how this has positively impacted your workforce at IU health?

00;08;20;09 - 00;08;51;19
Jay Foster
Maybe the main way is that it provides our team members with a sense of purpose. We are a values based organization and one of our core values is is connecting to purpose and spirituality. We actually find that the more persons are connected with their with their purpose, their North Star, the healthier they are. So that works well for our team members that we're helping patients connect with a higher sense of purpose.

00;08;51;21 - 00;09;11;27
Jay Foster
One of our hospital presidents said to me recently, said Jay, I just love this program. And here's the reason why: hospitals really aren't set up to be wellness communities. Now, we could argue that one way or the other, but that was his perspective. He said, But the community is where folks need to focus in order to really work on their wellness.

00;09;11;29 - 00;09;34;23
Jay Foster
But what you've managed to do here, not me, Jay, but you the CC and team - is help build that bridge way so that we identify a patient. One of our physicians connects with a patient that they love and they see that this person is lonely or isolated. Connects him with the chaplain. The chaplain connects them with a congregation in their neighborhood.

00;09;34;25 - 00;10;00;18
Jay Foster
And over that 12 week period that Shadreck was talking about, that individual find some companionship and hopefully gets really strongly connected with a broader sense of community and ultimately with something bigger than their than their illness. It's like, okay, I'm not just my illness, I'm all these other things. And how can I actualize that even while I'm coping with this particular illness?

00;10;00;20 - 00;10;20;04
Jordan Steiger
I love that you are connecting this back to purpose. And I think, you know, health care providers and people that work in health care really are drawn to that sense of purpose in their work. And so having this avenue, I think, is a really smart, beneficial program, I think, for your workforce. But let's talk about patients, because that's really what this program is about.

00;10;20;06 - 00;10;25;11
Jordan Steiger
So, Shadreck, tell us about some of the positive outcomes that patients have seen.

00;10;25;14 - 00;11;02;03
Shadreck Kamwendo
Yeah, So most of our patients is their stories that we we tend to hear coming from the our connectors, you know, in the companions, the relationship that are being formed. I'll give you an example. We had a companion that was being followed by a congregation and we were delivering food on her porch, you know, raw food on her porch, and she confided to her connector and say, you know, you're providing me food, but my stove does not work.

00;11;02;05 - 00;11;24;10
Shadreck Kamwendo
So the congregation was able to get the men from the church on a Saturday morning, went and got her a new stove. And she was able to get that nutritious food that we have. We wouldn't have known some of the struggles that are going on into her household. So that program, supported by their own neighbors, makes a difference.

00;11;24;12 - 00;11;55;20
Shadreck Kamwendo
Another example was a companion that we met here at the hospital that had moved from St. Louis because she has been widowed for several years and she came to live here in Indianapolis with her daughter. But she said I had and haven't made friendship with anybody. Can this program connect me to a friend? And we said yes. She said, Because of all the friends I have on my daughters friends, I live my life, 50 years of life in Saint Louis, and I'm in the new city.

00;11;55;20 - 00;12;15;11
Shadreck Kamwendo
So I needed support and care. And now she has friends that will go to farmer's market with her. And that makes a difference. That's the wellness we are talking about. And we have other companions in our program. They have all the resources. They just want somebody to talk to. You can only watch TV for so long.

00;12;15;14 - 00;12;36;14
Shadreck Kamwendo
So as I said earlier, we go home to get well. And those are the things that will make you go well, because if you don't have those things, you're going to return back to the hospital. So we have seen a lot of positivity coming from the companions, the patients that I, you know, program. But also let me add the transformation that is taking place for those connectors.

00;12;36;14 - 00;12;55;23
Shadreck Kamwendo
The volunteers now, they are starting to learn what's happening in their neighborhood, that they have friends that are food insecure, they have friends that have transportation problems to get to the appointment. And how are we going to come alongside making sure that they get to the right care at the right time in order to be well?

00;12;55;26 - 00;13;24;00
Jordan Steiger
I think you bring up some great points, you know, individual outcomes that are improved, community outcomes that are improved. None of that would have happened without IU health stepping in to make some of those connections. So I think that's a really good lesson for others listening and that hospitals really can serve as that social connector in communities. Jay, I was wondering if you could talk a little bit about how your partnership with local congregations has strengthened the services you're able to provide to patients?

00;13;24;00 - 00;13;32;27
Jordan Steiger
Because I don't know if all of our, you know, member hospitals and health systems would think maybe to go to a congregation for this kind of program.

00;13;32;29 - 00;14;19;11
Jay Foster
So a couple of ways. The first is a recognition that many of these congregations have been in their neighborhoods for decades, sometimes hundreds of years. They are trusted sources of information, of wellness in many communities where people go to to to learn about all of their needs, including their health care and social needs. And so an operating philosophy of ours is to really partner with congregations and let them teach us: How do we provide better care for your neighbors, help us help you do that, rather than coming in and saying, let us tell you what we as a health system can do for you or can't do for you.

00;14;19;13 - 00;14;41;09
Jay Foster
So we begin from that that point of view of appreciative inquiry. Second, you know, we talk a lot and health care about physician extenders or provider extenders. And so in that way and this model, the chaplain is up and the outpatient clinic is an extension for that provider. And the congregation is an extension of that chaplain.

00;14;41;11 - 00;15;01;11
Jay Foster
And here's the way that works. Quick story. We had a patient was just loved by her physician and they had a great relationship, just loved by their social worker, growing relationship with their chaplain. But it was their connector who they said, you know what? My oldest son has moved back in with me and my expenses are going up, so I've cut back on my medications.

00;15;01;14 - 00;15;25;11
Jay Foster
So it works both ways. The connector then reached back upstream to be able to say to to that physician ultimately and that social worker, hey, here's the problem. And they were able to come in and make adjustments so that her medication wasn't compromised and her budget stayed on track. The other thing is, is it more of a relational level?

00;15;25;11 - 00;15;44;29
Jay Foster
Our system, like all systems or like many health care systems, struggles to be a trusted source of information in the community. As we build these person to person relationships with clergy and the congregation of all faiths, they know they can pick up the phone and call Shadrach or their connector or their chaplain and have somebody on the other end to listen.

00;15;44;29 - 00;16;04;07
Jay Foster
So the pathway works both ways. The physician is a extender for that congregation. The other thing I would come back and amplify from your earlier question, if I could, I'm surprised that my friend Shadrech didn't jump all over this. Shadrach is like the only non-chaplain on our team. He's got to put up with a bunch of us.

00;16;04;09 - 00;16;36;04
Jay Foster
He's a population health MBA guy, but thanks to Shadrech, we've developed some really strong utilization metrics that he's built a Power BI dashboard with our population health team. This has now been vetted through our pretty rigorous statistician and we're comfortable saying that we've been able to see a 4% reduction in hospital readmissions for CCN patients compared to our control group.

00;16;36;04 - 00;17;13;20
Jay Foster
And we've seen remarkable reductions in ED utilization and a complimentary rise in family medicine and other appointments. That's just the thing you want to see after an intervention like this. We've also provided pre and post inventories of a validated instrument called the care field, Loneliness Scale. We use the abbreviated version. This demonstrated statistically significant improvements in a person's sense of feeling connected and less lonely.

00;17;13;20 - 00;17;20;00
Jay Foster
I feel like someone's on my side. I feel like I know who I can call if I get in trouble.

00;17;20;02 - 00;17;47;27
Jordan Steiger
Absolutely. And I was going to ask about any data that you had to share. And so that is a perfect explanation. And I think, you know, across the country, we see, you know, hospitals and health systems struggling with things like ED utilization with readmissions. So I think that's something that resonates and it's, I think, incredible that you've been able to reduce some of that utilization because we know people seek those services or go to the hospital because they don't have other places to go.

00;17;47;27 - 00;18;08;06
Jordan Steiger
It's not necessarily that they're needing care all the time, sometimes, but not all the time. So as we start to wrap up our conversation, Shadreck, if you and Jay have inspired anybody out there to think about how they could maybe adapt your program to their community or their hospital or health system, what kind of advice would you give them?

00;18;08;08 - 00;18;37;10
Shadreck Kamwendo
I think the choice of working with chaplaincy was really profound because they have a little superpower of being gentle and bring trust to their room. And if hospitals can, making sure that the chaplains are at the table as they develop some of these programs, because usually they will have a little bit of time to sit in their room with the patient and the really deeply at least seen what's going on.

00;18;37;12 - 00;19;07;27
Shadreck Kamwendo
So that's what we have done here into making sure that the chaplains are at the core of all the strategies of how we can help our communities. So they bring that that power. So I would encourage different health care systems and making sure that they are really bringing their chaplains to the table as they develop new programs to figure out how they can help to communicate, but also to encourage patients to be part of them.

00;19;08;00 - 00;19;24;11
Jordan Steiger
I think that's great advice. The chaplaincy and social work and all of those those professions I think are so powerful when they are used in the right way. So I think that's great advice and something to consider. Jay, as we close out anything you'd like to add?

00;19;24;13 - 00;19;45;04
Jay Foster
So one thought, we focus an awful lot on social isolation and loneliness, and that is absolutely the primary intervention is that we give an hour of time or more during this intensive 12 week period to try to help people find community. But if I spent an hour listening to you, I'm going to learn all kinds of things. I'm going to learn that there's food insecurity.

00;19;45;04 - 00;20;06;18
Jay Foster
I'm going to learn that that there is domestic violence. I'm going to learn that there's substance misuse. And so what we've really worked hard on is to provide training and encouragement for our connectors and resources to know how to help people get to the right door and then stay connected with them after they've made it to the right door.

00;20;06;20 - 00;20;20;21
Jay Foster
So if they get to a behavioral health therapist, they get to the kind of food and security concerns that they need, but then they stay connected because the ultimate intervention is around providing that love and friendship as there is our coping with your illness.

00;20;20;24 - 00;20;44;20
Jordan Steiger
I think that's a great place to conclude and thank you both for your time today and for sharing your story with other members of the American Hospital Association membership. I think this is a program and an approach that could be used in a lot of different communities and kind of adapted to that community need. Jay, as you mentioned, you know, taking that that approach of like letting the community tell you what they need from, from that, I think that's a huge takeaway.

00;20;44;23 - 00;20;55;13
Jordan Steiger
So thank you so much. We will make sure to link some information about the Congregational Care network so people can learn about it if they're interested. And again, thank you so much.

 

In U.S. health care there has been a significant increase in the number of chief wellness officers (CWOs) employed by hospitals and health systems. CWOs are an essential part of a health care worker's mental and physical support structure, providing opportunities and resources whenever needed. In this conversation, Jonathan Ripp, M.D., senior associate dean for well-being and resilience and chief wellness officer of Icahn School of Medicine at Mount Sinai, discusses his role as one of the nation's first chief wellness officers, and how the importance of employee wellness has evolved in hospitals and health systems in the last decade.
 

 

View Transcript
 

00;00;00;26 - 00;00;21;04
Tom Haederle
If someone at a party should ask, "What do you do?" And you reply, "I'm a doctor," most people get it right away. But if your answer is, "I'm a chief wellness officer," you might very well be asked, "What's that?" There is a growing group of chief wellness officers, sometimes called
chief well-being officers, currently employed by hospitals and health systems in the U.S.

00;00;21;06 - 00;00;37;21
Tom Haederle
In a nutshell, their job is caring for those who care for patients, and there's a great need for their services.

00;00;37;23 - 00;01;03;17
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Today, we hear more about the important role that a chief wellness or well-being officer can play in support of the mental, emotional and physical wellness of doctors, nurses and other health care professionals. Dr. Jon Ripp is among the first people in the country to hold such a position and can truly be called a definer of the job.

00;01;03;19 - 00;01;15;11
Tom Haederle
The very idea of a chief wellness officer has evolved and come a long way in the past dozen years or so. As Dr. Ripp explains, we were building the ship as we were sailing it. Let's join the discussion.

00;01;15;14 - 00;01;34;25
Elisa Arespacochaga
Thanks Tom. I'm Elisa Arespacochaga, AHA's vice president of clinical affairs and workforce, and today I'm really happy to be joined by Dr. Jon Ripp, dean for well-being and resilience and chief wellness officer at the Icahn School of Medicine at Mount Sinai and the inaugural president of the Collaborative for Healing and Renewal in Medicine. More commonly known as CHARM.

00;01;34;27 - 00;01;53;21
Elisa Arespacochaga
Today we're talking about the role of the chief well-being officer, chief wellness officer, depending on where you are. And Jon, you are if not the second or third, one of the first chief well-being officers in the country. So can you tell me just a little bit about yourself and your role and how you got there?

00;01;53;24 - 00;02;20;10
Jonathan Ripp, M.D.
Sure. Yeah. Thanks. Thanks for the opportunity. Thanks again. It's great to be with you and have this opportunity to chat. So that's correct. I am the chief wellness officer here at Mount Sinai in New York City. I've been in this role coming up on on six years. I am a practicing general internist. I originally came to Mt. Sinai for a residency training in internal medicine and then pretty much been here ever since, going on well over two decades now.

00;02;20;12 - 00;02;51;19
Jonathan Ripp, M.D.
And when I got started as after residency in working as a general academic internist, I began, like many of us do in academic medicine, exploring possibilities for career interests, for a career focus. And it was around that time in the very early 2000s that I became interested in well-being, specifically of residence was where I got started, and specifically from a scholarly pursuit.

00;02;51;19 - 00;03;20;06
Jonathan Ripp, M.D.
I was sort of fascinated about the very nascent literature at the time and thought this might be something interesting to do and really got started in that way. And so I began doing some small studies, and then as I grew my my career, my academic focus, I began doing some multicenter studies and probably around a dozen years ago or so, my interests kind of were following what was going on nationally.

00;03;20;06 - 00;03;48;23
Jonathan Ripp, M.D.
And a lot of us were starting to say, you know, well, we don't want to just study a problem. We want to try to be part part of the solution. And increasingly, health care systems, schools of medicine and so forth, recognize, okay, we've got a problem here and we should we should do something about it. And it was around that time that I began working more closely with our office of graduate medical education, looking at the well-being of residents across our pretty large system we have.

00;03;48;26 - 00;04;13;21
Jonathan Ripp, M.D.
So I began as an administrative role addressing well-being in that group, in residence and and fellows, and began as an associate dean and was in that role for a little while when about, I guess, seven years ago or so now, I was approached by the dean of our school of medicine, who really had the foresight to recognize that this was not going to be a challenge limited to any one group within the constituency, the school of medicine.

00;04;13;24 - 00;04;30;01
Jonathan Ripp, M.D.
And it was right around the time that this idea of a chief wellness officer was was being developed — Tait Shanafelt at Stanford typically gets credit for being the first. I was probably within the first four or five. You know, there's many now, there's probably 60 or 70.

00;04;30;03 - 00;04;51;03
Elisa Arespacochaga
That's great. And I really do believe that a lot of this work really did start in looking at small groups and then expanding out and realizing, wait, if this group is experiencing this, maybe this other group is as well. And I know that's been part of your work and focus is to understand in small slices where the challenges are.

00;04;51;03 - 00;05;08;11
Elisa Arespacochaga
But then to take a look at that slice and say, okay, where else is this happening? So as you have really, you know, been one of the definers of the role of a chief wellness officer, how do you explain it to people and how it fits into the organizational structure of the typical hospital?

00;05;08;19 - 00;05;29;26
Jonathan Ripp, M.D.
Yeah, it's a great, great question. One that I that I would say I deal with all the time because part of the role actually is explaining to people who you are and what you do and why there's a need for you and, you know, I think it still remains that there are those that recognize the importance and there are the naysayers for sure.

00;05;29;29 - 00;05;57;05
Jonathan Ripp, M.D.
And I will just say, by the way, in followup to your previous comment, I mean, I think in addition to, so part of the need for chief wellness officers to address the well-being concerns of a large group of individuals and and each health care system or school of medicine is a little different in terms of the constituency that a chief wellness officer might be connected with, but ultimately the health care professions and health care professionals.

00;05;57;11 - 00;06;23;21
Jonathan Ripp, M.D.
You know, we're all interconnected. We work. There's a very large amount of team-based care, right? And so and similarly, we train our future health care professionals, our students and trainees. In that context, you can't really pay attention to one group isolated from the other. The interconnectedness is key. So what is a chief wellness officer?

00;06;23;24 - 00;06;48;10
Jonathan Ripp, M.D.
I think it's pretty fair to say that those of us who have been doing it, dare I say, as long as I have, which is not that long, but it's still very new, we're part of a cohort that kind of you know, we were building the ship as we were sailing it, so we recognized that there was a need for a leader who was responsible for overseeing a large effort at the institutional level.

00;06;48;10 - 00;07;09;29
Jonathan Ripp, M.D.
I mean, that at its base is, is why we believe there's a need for a chief wellness officer, because there's a level of work here that requires some unique expertise. So you need you need an individual that brings that. It's a volume of work that can't be absorbed in some other existing position. There's just too much of it.

00;07;10;04 - 00;07;34;20
Jonathan Ripp, M.D.
And it's distinct work. It's distinct from those other areas. Those principles, I think, underscore why there's a need for a distinct position. And that's, I think, what got a lot of us, those of us who had already developed some of the expertise involved to be named in these positions in the early years. So that was kind of, you know, sailing the ship and we've been building it.

00;07;34;22 - 00;08;13;17
Jonathan Ripp, M.D.
And I'd like to think that we're kind of at phase two, you know, 2.0 now, where at least in broad strokes, we have a sense of what the core functions are of a chief wellness officer. And the way I describe those and I do it regularly here, you know, we are the individuals that bring the expertise that's needed to measure the problem, to really understand how do you take the pulse of of how a given group of of health care professionals and trainees are doing and perhaps more importantly, how do you measure the drivers that are impacting how they're doing?

00;08;13;19 - 00;08;33;25
Jonathan Ripp, M.D.
And then it's that you can't just gather information. You have to be able to disseminate it and disseminate it in a meaningful, digestible fashion. So that's a critical part of the role, which I think is often not given enough attention that, we now know how to collect, do surveys where we collect these data and understand the drivers.

00;08;33;27 - 00;08;56;25
Jonathan Ripp, M.D.
But there's a lot of data. So we need to be able to digest it and provide that to given stakeholders that are enabled to act on it in, you know, in every health care system and school is a little different. We're all matrixed and there's lots of different leaders at different levels. But in the end we need to deliver that information at the unit level, whatever you want to call that unit, because there's going to be variations.

00;08;56;25 - 00;09;27;10
Jonathan Ripp, M.D.
We need to be able to give that information to surgeons and primary care doctors and, you know, procedural lists, but also, you know, to trainees, to students, we need to break it down, slice and dice it, and give it to the leaders who can act on it in a way that's action-oriented, that's solutions-focused. The other big piece of what we do is we lead by influence and we try to direct the development of solutions that we think might and we've studied and we know are likely to have impact on those drivers that we identify.

00;09;27;10 - 00;09;49;01
Jonathan Ripp, M.D.
So measuring, measuring the data and the drivers digesting and disseminating and providing it in a way to leaders so that they can act on it. And usually the last piece I should add is that a lot of us now are overseeing what we call well-being champions or directors. These are individuals embedded in and associated with a given unit.

00;09;49;03 - 00;10;13;05
Elisa Arespacochaga
So a lot of what you just said makes it sound like your critical partners are basically across the organization. But can you talk a little bit about who are those folks that you really, in addition to well-being champions or directors who are working as sort of part of the team, who are those critical partners in your leadership circle that really help this work move forward?

00;10;13;08 - 00;10;49;01
Jonathan Ripp, M.D.
So I frequently say that chief wellness officers are leaders who lead by influence in the truest sense. We can only really be effective if we're able to influence those individuals who are at the helm of given system-level responsibilities that are likely to have dramatic impact on the well-being of the workforce. And it's important to take one step back and and really speak to how we think chief well-being officers, chief wellness officers should focus, right?

00;10;49;01 - 00;11;05;26
Jonathan Ripp, M.D.
So actually, I think there's been some work in the last several years as chief wellness officers that come about to help us define our focus, because actually, in the end, well-being can be all things to all people. I mean, just about anything can be construed to influence one's well-being. So we need to have some focus.

00;11;05;26 - 00;11;37;20
Jonathan Ripp, M.D.
And those of us who are chief well-being officers, largely we ascribe to the idea that we need to try to impact the system. We're more about kind of creating the environment that enables our health care workforce to flourish and thrive. And maybe preventing those barriers to thriving. And so really our focus tends to be on the system and therefore our partners who we try to influence through collaborative relationships, are going to be situated in relationship to some of those drivers.

00;11;37;20 - 00;12;01;27
Jonathan Ripp, M.D.
So what do I mean by that? Well, clearly your operational leaders right? The folks that help enable work to be done, folks that are in the quality work space that already have an improvement mindset. Well, a lot of well-being work is just improving work conditions as opposed to quality, perhaps where the output is some kind of metric of, you know, patient care.

00;12;01;29 - 00;12;26;26
Jonathan Ripp, M.D.
The metric for us in improvement is some measure of the well-being of the workforce, and they're intimately interrelated. So, you know, our operational leaders are quality leaders, are continuous improvement leaders, but also, as you know, no stranger to the audience that's listening, no doubt is, you know, the relationship with the electronic health record.

00;12;27;00 - 00;12;46;20
Jonathan Ripp, M.D.
We have to partner with our IT colleagues, our electronic health record colleagues. There's many others, quite honestly, who we need to connect with. Our mission, the way we've kind of designed it in Mt. Sinai is we want to, you know, enable all our workforce to be able to efficiently and effectively do their work in a place where they feel valued.

00;12;46;20 - 00;13;13;26
Jonathan Ripp, M.D.
And so our belief that if we can do that, then they're going to be able to unlock the inherent meaning in the health care professions. So anyone involved in cultural work, leadership trainers and folks, even folks in human resources, even though they do a lot of work that's distinct from ours, they're often involved in onboarding and sort of critical times of of providing content that help influence the culture a bit.

00;13;14;04 - 00;13;25;16
Jonathan Ripp, M.D.
A lot of the work of the chief wellness officers building those relationships with these individuals so that when there is an ask that we ask of them, they understand who we are and why it's important and we can move forward.

00;13;25;20 - 00;13;56;18
Elisa Arespacochaga
Absolutely. Nothing at this leadership level gets done by yourself in a room. So really being able to have those connections is key. For organizations that either don't have this role yet or are thinking about how to do it or are still figuring that out, what are some of the ways that you've seen people start to champion this work and really bring about a focus, if not necessarily a position at first?

00;13;56;20 - 00;14;30;18
Jonathan Ripp, M.D.
You know, I often speak about what I'm speaking with you about today in various venues and settings across the country. And this is a common question. Well, it's great that you're a chief wellness officer and you have a team and a budget and you have all this work that you're doing. But I'm at an organization that is not going to commit to that, and what I will say is I've been doing this work for 20 years and it's been a journey and every institution is at a different phase in terms of their level of commitment.

00;14;30;18 - 00;14;55;08
Jonathan Ripp, M.D.
And we're all moving in a direction towards making this work more standard. So if you don't have a chief wellness officer, I'm not sure my recommendation would be to put all your stock in trying to get one or trying to get one approved. It's more about actually understanding some of what we've already discussed in terms of what are the outputs of a chief wellness officer, what are the roles and responsibilities.

00;14;55;10 - 00;15;21;16
Jonathan Ripp, M.D.
And if you don't have one person on the team that's dedicated to that, well, maybe you do it in parts, or maybe you don't do it for your entire health care system. Maybe you start with one constituent group where there's greater buy-in from some some local leaders. So maybe it's about just gathering some survey data for one of your large departments or one of your health care professional groups. Is it physicians,

00;15;21;16 - 00;15;43;26
Jonathan Ripp, M.D.
is it the nurses? Maybe it's just about starting some some of the basic programming and solutions that we think have impact at the system level. So you just focus on bringing well-being-centered leadership training to your institution so that more of your leaders understand the  ways in which they lead are going to impact the well-being of your people.

00;15;43;26 - 00;16;08;20
Jonathan Ripp, M.D.
So the difference is that a chief wellness officer actually is getting, there's enough of a commitment tangible for meeting the metrics that are associated with the roles and responsibilities of the position. So if you're at an institution that doesn't have that level of commitment, well, then maybe you're just going to take on some of that. There's basically a lot of places that are at those stages, and that's okay.

00;16;08;22 - 00;16;21;02
Jonathan Ripp, M.D.
It's actually really important to try to understand where your institution is at, what the level of commitment is, where you're likely to have impact, who your partners are that are going to work with you. So that's that's how I would think about it.

00;16;21;05 - 00;16;50;28
Elisa Arespacochaga
That's wonderful. And I really want to thank you and your colleagues at CHARM for the work we've done thus far and hope to publish very soon. That really highlights some of the learnings that you all have gotten through. I guess just blood, sweat and tears, because you didn't have a manual to do it. Just to wrap up, I have one more question, which is just briefly, where do you see this role going in the future, at least maybe just for you, maybe for the field?

00;16;51;00 - 00;17;11;03
Jonathan Ripp, M.D.
I think I'll answer from the standpoint of the field. I feel very fortunate that, you know, I'm able to do the work that I do and I've been able to reach this position. I can remember being on a panel some years ago. I think someone said, how do you get to to where you are? And one of the panelists said, well, you can just, you know, just follow

00;17;11;04 - 00;17;34;10
Jonathan Ripp, M.D.
the chief wellness officer track that Jon followed. And I remember thinking, I don't remember this track. I kind of just followed my passion and, you know, and sort of advocated that certain things be be put into place. And I had the fortune of being somewhere where leadership valued this and put me in this position that I've been so fortunate to hold for the last several years.

00;17;34;17 - 00;17;57;03
Jonathan Ripp, M.D.
The kind of aspirational state, the ideal future state, is one in which this work is recognized. Yeah, as I mentioned before, as being part of the standard operations of health care systems and health care professional schools. I'd like for it to be reflexive that this is part of the standard group of of leaders running a health care system.

00;17;57;10 - 00;18;26;16
Jonathan Ripp, M.D.
One interesting dynamic of that is that, you know, it should be so standard that when you're doing improvement work, for example, when you're trying to enhance the function of your health care system, that there are a few outcomes that you're looking for. You know, you want to be able to deliver high value care. You want to be productive and efficient and and provide high quality care that, you know, is well received by the patient population.

00;18;26;20 - 00;19;00;11
Jonathan Ripp, M.D.
But it also should be, should be that the work is done to improve the experience of the workforce and that it's just part of of what's done. Some of us feel a little antsy about that because maybe it means like we won't be necessary down the road. But I would argue that even when that, you know, let's say that in that ideal future state, it's standard that we have, you know, well-being, that we always pay attention to  the well-being of the workforce as one of the outcomes of our work.

00;19;00;13 - 00;19;19;03
Jonathan Ripp, M.D.
You know, you'll still need folks who understand how to measure it, who understand how to track the drivers and who can be those partners with the other, you know, the other leaders who are responsible for their priority. You know, for the quality and the patient and the value of the health care delivery.

00;19;19;05 - 00;19;43;17
Elisa Arespacochaga
Absolutely. I don't think in any way we need fewer of you. We need more of you. And I'm really excited for where this role may go from the advocate to really being a integral part of the system and how it operates. So, Jon, thank you so much for sharing your expertise and your just your deep knowledge about this topic with us today.

00;19;43;20 - 00;19;44;25
Jonathan Ripp, M.D.
Thank you. It's been a pleasure.

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