Advancing Health Podcast

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

00;00;01;01 - 00;00;26;00
Tom Haederle
When a community health needs assessment was conducted in Hardeman County, Tennessee, it confirmed what most people already knew. Not only was obesity a serious health threat for adults and youth alike, but accessing food at all was a real problem for many county residents who lacked transportation and lived miles from a convenient grocery store. Fortunately for the people of Hardeman County, their local hospitals decided to take action.

00;00;30;26 - 00;00;56;11
Tom Haederle
Welcome to “Community Cornerstones: Conversations with Rural Hospitals in America.” A new series from the American Hospital Association. I'm Tom Haederle with AHA Communications. As part of its mission to advance the health of the community it serves, Bolivar General Hospital led the fight against food insecurity in Hardeman County, Tennessee. What they did, how they did it and what was the result is the subject of this podcast.

00;00;56;17 - 00;01;03;01
Tom Haederle
Their story is a window into the lives of leaders who took the necessary steps to improve the health of their community.

00;01;04;05 - 00;01;21;13
John Supplitt
Good day. I'm John Supplitt senior director of AHA Rural Health Services, and with me is Ruby Kirby, CEO of two critical access hospitals for west Tennessee health care, Bolivar and Camden Hospitals, and she's the recipient of the AHA Rural Hospital Leadership Team Award. Welcome, Ruby.

00;01;21;18 - 00;01;22;14
Ruby Kirby
Good morning.

00;01;22;25 - 00;01;37;07
John Supplitt
We are here to discuss how the team at Bolivar General Hospital collaborates with stakeholders across Hardeman County to feed their residents. Ruby, what is the origin behind the effort of a healthier Hardeman County?

00;01;37;14 - 00;02;17;15
Ruby Kirby
John, originally this initiative came from the results of our community health needs assessment and some of the CDC data. We actually have three entities in Hardeman County that does health needs assessment. We have FQAC, of course, a health department, and the hospital. And we bring all this data back to what we call now our health council, and we were looking at that and some of the things that jumped out at us quickly was our obesity rates for youth, which was like 44% higher than state average. Adults, was 40%, which our state was at 32 at that time.

00;02;18;05 - 00;02;41;13
Ruby Kirby
But interesting from our survey, 58% of the residents said they were either overweight or obese. So, you know, 14% said they didn't have healthy foods and 21% said they had to travel more than five miles to access food. And in a community like ours, where transportation is the issue, that was how we decided how to address these.

00;02;41;20 - 00;02;52;14
John Supplitt
So you gathered a lot of data over the course of your community health needs assessment, and then you tried to put them into action. You defined the need and had a strategy, but how did you put it into action?

00;02;52;21 - 00;03;18;24
Ruby Kirby
Well, we had the health council, and when we looked at the composition of the health council, we knew we didn't have the people we needed at the table. So we got some additional people to the table. And the first step that we decided was to address access to healthy food. So we was fortunate that we were able to collaborate with the University of Tennessee Agri-Stension Agency.

00;03;19;03 - 00;03;47;05
Ruby Kirby
And through the CDC, a $500,000 grant, cooperative grant that we could use on this program. So we established the “Healthy Hardeman County for Healthy Weight” or we finally call it the “H2O Initiative.” We identified food deserts in the county, and we work with our local farmers and farmers markets to set up produce bins all through the county. So they would distribute food in these bins,

00;03;47;05 - 00;04;16;10
Ruby Kirby
and it was open to anybody that needed to come in or anybody in the community could contribute. We had the Power Produce Club, which we called a Pops Club. We would give youth their own funding so they could go to the farmers market and pick out their vegetables and fruit. So that was really fun. We worked with the USDA Food Box program to create the Hungry Health and Hope Foodbank, and now we're off and running.

00;04;16;14 - 00;04;18;26
John Supplitt
And exercise is a part of this experience too, was it not?

00;04;18;26 - 00;04;49;19
Ruby Kirby
Yep. A lot of the community did not think they had anywhere safe to do the exercise. So what we did was start looking at how to increase the physical activities. People would come out with ideas. We got other entities involved. We built walking trails and walking paths. Additionally, we had new parks, crosswalks, bicycle safety programs and many of the neighbors just took part in what we call “Walk Across Tennessee” challenges.

00;04;50;05 - 00;04;51;26
Ruby Kirby
So we're still working on that.

00;04;51;26 - 00;04;59;28
John Supplitt
So it clearly would not have been possible without the strong commitment from your community leaders. So what are the results? What are the outcomes from the experience?

00;05;00;10 - 00;05;26;09
Ruby Kirby
So we have improved food security. They've had 18 food distribution through the county. 27,000 boxes plus of food has went into the community. The obesity rate in Hardeman County has dropped. It was 40% when we started. We were down to like 35% within two years, and that was the adults. Amongst students it was 46% and now it's like 44%.

00;05;26;21 - 00;05;35;26
John Supplitt
So as a result of these efforts, you are recognized as a healthier Tennessee community by the governor. So tell us what's next for Bolivar Hospital, the Council and H2O?

00;05;36;03 - 00;06;04;26
Ruby Kirby
We are still adding individuals . Our work continues. Next step is to work with local industry. We are trying to engage them and their employees in eating healthy and exercising. We plan to engage the schools by visiting classroom, teaching children about healthy food choices and the importance of regular mobility and exercise. The Council and the H2O are working to raise awareness.

00;06;05;06 - 00;06;21;12
Ruby Kirby
That's, you know, the biggest thing in a community is people to be aware. So we're looking at having a poverty simulator that we would invite 50 community leaders so that they would understand what it's like to live in poverty and be able to stretch your dollars.

00;06;21;21 - 00;06;45;27
John Supplitt
Yeah. It's great to see you continue this very important work in your community. So thank you, Ruby. Your leadership is inspiring and the award is well-deserved. I look forward to learning more about the success you have improving your community’s health through healthy foods and physical activity. Your team has gone above and beyond providing inpatient care to improve the health of Hardeman County, Tennessee.

00;06;46;18 - 00;06;50;28
John Supplitt
I'm John Supplitt, senior director of AHA Rural Health Services. Thank you for listening.

00;00;00;26 - 00;00;57;28
Tom Haederle
For teenage girls, having access to period products is essential. Without them, they can miss school, be humiliated and experience health problems. Unfortunately, girls across America face what is known as period poverty, and they're suffering in silence. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Kathy Cummings, former communications director at the American Hospital Association, is joined by Dr. Angela Hawkins, an obstetrics and gynecology specialist at SSM Health St. Anthony in Oklahoma City, and Lindse Barks, executive director at Mid-Del Public Schools Foundation.

00;00;58;07 - 00;01;03;27
Tom Haederle
Their discussion addressing period poverty and its serious impact on school age girls.

00;01;04;23 - 00;01;34;21
Kathy Cummings
Dr. Hawkins and Lindse, thank you so much for joining me today to talk about what I find just extremely fascinating that's still happening in this country, this period poverty. You know, I host quite a few podcasts and covering a lot of different topics. But this one really hit me hard when we hear about some of the challenges that young girls are facing during very critical times of their life.

00;01;34;22 - 00;01;49;22
Kathy Cummings
So I just want to thank you for joining me and bringing this topic to our attention. I really appreciate having both of you here. So, Dr. Hawkins, let's start with you. Tell me a little bit about your role at SSM Health, St. Anthony.

00;01;50;08 - 00;02;06;14
Angela Hawkins
I'm an obstetrician gynecologist at St. Anthony's. I've been in private practice for about 11 years. I've just recently switched over to being what we call a hospitalist, where I work strictly in the hospital with women who are admitted or being evaluated at the hospital itself.

00;02;07;03 - 00;02;10;26
Kathy Cummings
And, Lindse, tell me about yourself, your role in your organization.

00;02;11;16 - 00;02;32;27
Lindse Barks
Hi. Thanks for having us, Kathy. Any chance we have to talk about period poverty I really appreciate it. So my name is Lindse Barks, I've been the executive director for the Mid-Del Public Schools Foundation for about five years now. The Mid-Del Public Schools Foundation exists to support Mid-Del Public Schools. We are the only entity that solely exists to support every Mid-Del teacher and every Mid-Del student.

00;02;33;10 - 00;02;40;02
Kathy Cummings
Well, Lindse let's start with you. What is period poverty and when was the first time you became acutely aware of it?

00;02;40;25 - 00;03;03;05
Lindse Barks
So to really simplify it, period poverty means families or individuals who do not have access to period products. That's the bare bones of it, is that. I had no idea, period poverty. I didn't know the terminology. I didn't know it was a thing until about two and a half years ago when I attended a grant check ceremony.

00;03;03;05 - 00;03;22;18
Lindse Barks
We had written a grant to a local organization, Junior Service League of Midwest City, and I was going to pick up a check for that grant. And when I was there, there were two teachers from one of our high schools, Del City High School, that they had also been awarded funds for their Sisterhood Project. And that was the very first time that I had heard the term period poverty.

00;03;22;26 - 00;03;35;10
Lindse Barks
And to be honest, I was blown away. I had no idea that this was something that existed and I didn't know the impact it was having on our students at Del City High School or in our district, for that matter.

00;03;36;09 - 00;04;03;09
Kathy Cummings
When SSM Health St. Anthony brought this topic to my attention, I too had to Google search it. I wasn't aware of exactly what it is and how it is affecting young girls’ lives, how it's spreading. The awareness is low. Why is that? Is it being shunned by the news, the mainstream media? Is it not part of the social media kind of trending conversations?

00;04;03;28 - 00;04;22;16
Lindse Barks
To answer this, I think it's twofold. I think one, I think it's just the lack of education. It's lack of knowing it exists.  I've been a menstruator for the majority of my life since I was 13. And the idea of not having access to what I needed has never been an issue. It's never something I've thought about.

00;04;23;07 - 00;04;43;25
Lindse Barks
And so I think part of it, it's just lack of knowledge, lack of education, of talking about it. And I think also there is still a stigma that is wrapped up in periods. Women have been taught that it's embarrassing. We don't talk about it. We sneak pads and tampons next to each other because nobody can see that we have to have a tampon.

00;04;44;03 - 00;05;02;11
Lindse Barks
We're not going to talk about it openly because it's something that we've almost been ingrained to be ashamed of. And that's a huge mistake I feel like we've made as a society. And I hope that talking about period poverty and talking about these things that we can teach this younger generation, that having a period is nothing to be embarrassed or ashamed about.

00;05;03;08 - 00;05;26;11
Kathy Cummings
Yeah, that was the first thing that came to mind for me too. I mean, I immediately thought about these young girls and, like you said, feeling embarrassed, not having a voice. Those who are most affected by period poverty, you know, keeping all of those feelings inside, you know, how difficult that must be. And Dr. Hawkins, can you share some of the facts that make this a national health issue?

00;05;27;06 - 00;05;56;20
Angela Hawkins
So in the United States, girls start having their periods around the ages of 10 to 15, sometimes even as young as 8 to 9 years old. So that's most starting having their periods in middle school. So if you add up all the days and years that someone has their period throughout their lifetime, that adds up to up to 8 to 9 years total of a person's life that's spent menstruating, so that’s 8 to 9 years, having a period within your lifetime.

00;05;57;08 - 00;06;22;10
Angela Hawkins
And menstrual products are expensive. They're taxed at higher rates. They're considered a luxury item or what some call a tangible individual property. Are not included in government benefits like SNAP or food stamps. In a national survey, it was reported that one to five girls struggle to afford period products and four in five missed school because they didn't have access to period products.

00;06;22;20 - 00;06;49;14
Angela Hawkins
So nationally, it's a big deal when you think about the fact that four in five girls miss school at least once a month because they don't have access to period products. It can cause physical, mental and emotional distress like we talked about before. It can cause shame and depression or anxiety surrounding periods. Young women experiencing period poverty have higher rates of depression than young women who don't have to worry about those kind of things.

00;06;49;29 - 00;07;16;19
Angela Hawkins
People unable to access products may use their products that are not recommended, like old rags, paper towels and newspapers even. And some will use their products longer than recommended because they don't have enough. And so they want to extend the amount of time that they're able to use the products that they do have. And that can lead to health risks like infection, irritation, even something as serious as something called toxic shock syndrome, which can be life threatening.

00;07;16;28 - 00;07;23;10
Angela Hawkins
So it's not just an issue of not having products. It causes lots of broader implications.

00;07;24;02 - 00;07;48;01
Kathy Cummings
You know, those data points are staggering when I think about so many of us just take it for granted, right. That the education around menstruation and periods is there and that access to period products is there. And then when you do hear those stats, you know, it really is mind blowing. So tell me about some of the conversations that you've been having with young girls who are affected by this in your communities.

00;07;48;07 - 00;07;50;02
Kathy Cummings
What are they telling you? What are they saying?

00;07;50;22 - 00;08;11;24
Angela Hawkins
In Oklahoma between the ages of 12 to 44, one in five women are below the poverty line. And that's just in Oklahoma. So like we talked about, it can cause physical and emotional changes in addition to concerns for depression and health issues and missing school. Young girls talk about the fact that it affects their grades when they miss school.

00;08;12;05 - 00;08;36;13
Angela Hawkins
Older students may miss work, which then affects the income that makes them able to buy those products. Some students even drop out of school due to embarrassment or in order to work and be able to afford the things they need to do. And let's not forget, we still have a homeless teen population who struggle with access to products and toilets and showers and just being able to clean themselves up.

00;08;37;02 - 00;08;57;18
Angela Hawkins
And so we have all types of girls who come in discussing issues with periods. Who come in, asking, how can I just stop having periods all together? This is something I can't deal with every month and still be able to do school and work. It affects when you think about this happening every month, and for some girls it can be as little as three days.

00;08;57;18 - 00;09;08;29
Angela Hawkins
But for some girls that can be as long as ten days to even two weeks. So when you think about that, every month for these young women, it is a huge issue for them.

00;09;09;21 - 00;09;16;08
Kathy Cummings
Lindse, tell me about what you're hearing and seeing in the schools and what is the role that teachers are playing?

00;09;16;28 - 00;09;34;21
Lindse Barks
Oh, that's a great question. So when we first when I first heard about period poverty, the teachers at Del City said that the way that they noticed there was a problem is that they noticed that there were students on average per month were missing two to three days per month just because they didn't have access to period products.

00;09;34;21 - 00;10;05;00
Lindse Barks
And that's when they started asking for donations and stocking. They had one bathroom that they would stock with period products for those students. Missing two to three days at a time every month. Like how far behind can somebody fall and how hard is it to catch up, to get picked back up? And then we had there was a there was a TikTok that a teacher at Oklahoma City public schools videoed that they left their classroom and they walked to the front office, got a period product and then went back to their classroom.

00;10;05;00 - 00;10;28;00
Lindse Barks
It took eight minutes to walk one way to the office to get a period product. So eight minutes one way. And then you go to the bathroom and then you walk back to your student. So you can miss anywhere from 20 to 30 minutes of one class. And classes range from 40 to 50 minutes per day. So, I mean, we're talking about a lot of missed class time that students are falling behind.

00;10;28;23 - 00;10;52;22
Lindse Barks
And while period poverty specifically talks about students that can't afford products, what about the students that can afford it? But they started early or they started unexpectedly, or they just forgot to put their products in their bag? Because I qualify as that. Like I've been caught several times in my lifetime without the products that I've needed. So not having access to it, well, maybe they can afford it, but they don't have it with them.

00;10;53;00 - 00;10;56;25
Lindse Barks
That's another impact that we've seen with our students.

00;10;57;22 - 00;11;18;14
Kathy Cummings
And that eight-minute walk. You know, you think about, you know, again, a young girl hoping not to be embarrassed. What if people know, you know, I mean, all those feelings that they could be feeling during that time when they're unprepared, unready, and not sure what to expect as they're trying to, you know, get that access to those period products.

00;11;18;24 - 00;11;32;15
Kathy Cummings
I was so excited then to hear about this incredible partnership between SSM Health and the Mid-Del Public Schools Foundation. So tell me about that. How did you guys meet and come together to address this issue?

00;11;33;10 - 00;11;54;11
Lindse Barks
So this whole program, I feel like if everything just aligned like the stars aligned at every part for this program. So when I had learned about the Del City Sisterhood Project, immediately I said this is something that the foundation can help champion. We can come in and we can make an impact right now. What do we need to do to see this go district wide?

00;11;54;12 - 00;12;17;14
Lindse Barks
Del City has got a great handle on it. How do I get it at all of our schools? And initially I was just thinking secondary high school and middle school because I was under the misconception that most of our students were in middle school before they started their period. Like Dr. Hawkins said, that's not the case. I actually learned that over 50% of Mid-Del students will have started their period before they leave elementary.

00;12;17;21 - 00;12;36;21
Lindse Barks
50% of our girls. That was staggering to me. I had no idea that so many of our students were leaving the fifth grade, having already started their period. So I knew this was going to be a district-wide initiative. And so I partnered up with a couple of women organizations and the community to do a small fundraiser. I said, okay, let's start small.

00;12;36;21 - 00;12;53;24
Lindse Barks
Let's see how long this is going to take us. And we kind of did the math of, you know, because we have other programs that the foundation we have to fund. And so I knew that a little bit at a time. Slow and steady wins the race. And so my timeline was five to 10 years, we would have dispensers in every bathroom.

00;12;53;24 - 00;13;21;18
Lindse Barks
That that was my goal was to have it done within five to 10 years. A few weeks later, I was part of a group with the Midwest City Chamber of Commerce for leadership in Midwest City, and we got to tour SSM Health St. Anthony's in Midwest City. They had purchased Midwest City Hospital about a year or so ago and we were excited to see the changes that were taking place. In that we learned about SSM health, their commitment not just to the hospital but to the community of Midwest City.

00;13;21;18 - 00;13;39;21
Lindse Barks
And they talked about how they want to come in and they want to invest in their community and they want to make a difference. And the light bulb went off like, oh, I've got a great project for you. Let me tell you about what we're doing with period poverty. And every meeting that I had with the different executives and the different the marketing teams at SSM Health, they all jumped on it.

00;13;39;21 - 00;14;00;18
Lindse Barks
They said, this is fantastic. It's something we didn't know what was a problem, and we know that we can help make this happen. So between talking with SSM Health and talking with our district, our superintendent said if the foundation can provide the dispensers, the district will provide the period products, we'll keep them stocked. And so that was kind of what we came up with SSM Health.

00;14;00;21 - 00;14;31;23
Lindse Barks
And they gave us a grant for right under $38,000 to purchase 207 dispensers to go in every bathroom across the district. So every site in our district has dispensers and we're talking at our performing arts centers, our field houses, at our football stadiums like we've got on all of our high traffic areas. And so for our secondary locations we have tampons and pads available because we want our students to feel that we have what they what they need and what they want.

00;14;32;04 - 00;14;52;08
Lindse Barks
And then at our elementary locations, we have in our fourth and fifth grade hallways, pad dispensers. So they've only got access to pads. But we want our students to have access to what they want. And all of our products are organic and so they're healthy and they're comfortable. And we worked with Aunt Flo, which is a great company to buy our products from.

00;14;52;16 - 00;15;10;14
Lindse Barks
And they also they look cute and trendy. And so our students feel, we want them to feel valued. We're not buying the bottom of the barrel products. We're not getting the cheapest products we can find. While Aunt Flo is absolutely affordable and it's maintainable for us, we wanted them to know that we value them and that they're worth the investment.

00;15;11;07 - 00;15;27;10
Kathy Cummings
That's wonderful. And Dr. Hawkins, tell me a little bit about how you personally got involved and do you see this program expanding beyond the schools and the school facilities you mentioned, you know, the issue among homeless people. How can we get more products out there?

00;15;27;25 - 00;15;55;07
Angela Hawkins
Well, and that's a big part of period poverty is that it's great that we're focusing on elementary school and middle school, but we do have other populations that have issues. College students struggle to afford period products. They're just trying to buy their books and get lunch and dinner and pizza occasionally. So college students are struggling. So this is something that I think could be expanded to our colleges in the state.

00;15;56;11 - 00;16;28;14
Angela Hawkins
Incarcerated women. There are 38 states, including Oklahoma, who have no laws requiring period products to inmates. And so this is a much broader picture that we're looking at. And it's going to take a lot of normalizing the conversations around periods and for people to start realizing that this is an issue that spans a woman's lifetime. And these are things that we need to start looking at to figure out how we can help improve access for all women, young girls and women.

00;16;29;08 - 00;16;51;24
Kathy Cummings
So let's start with you, Dr. Hawkins, and we'll throw it to Lindse. Based on that, what do you think needs to happen to put not just a bigger kind of community spotlight on this topic, but a national spotlight on this topic? You know, how can we help increase awareness and the support and resources that need to come along with that?

00;16;52;25 - 00;17;20;09
Angela Hawkins
We've got to what she talked about earlier. We've got to start reducing the stigma and shame associated with periods in general. People need to feel comfortable having these conversations and talking about this topic. And then we need to start some nationwide campaigns that actually start talking about these issues like we talked about at the beginning. A lot of people just don't think about this being an issue because a lot of people haven't had to actually deal with it.

00;17;20;22 - 00;17;47;01
Angela Hawkins
And so normalizing the conversation, getting the word out, educating the public that this is an issue. Other countries have already starting addressing it. It's time that we do as well. And then figuring out ways that we can build programs within our states to help tackle this issue. We have three bills in the Oklahoma legislature this year to discuss period poverty, and unfortunately two have already failed.

00;17;47;21 - 00;18;05;01
Angela Hawkins
So again, it's a matter of starting the conversation, getting people to talk about it more, and then talking with our legislators about it so that they understand the importance of this. The fact that two of our bills already failed is a sign that we are not doing a good job of letting them know why this is such a critical issue.

00;18;05;23 - 00;18;15;02
Kathy Cummings
Right, Right. Yeah. Lots of stakeholders need to get involved and invest and support this. And Lindse, any additional thoughts from your perspective?

00;18;15;24 - 00;18;40;06
Lindse Barks
Just to echo what Dr. Hawkins was saying, we need to normalize this conversation. I will say all the different programs and projects that the foundation has done since 1989 when we were first established, this has been the most positive feedback we've gotten. There hasn't been a single negative thing. And that happens when you do things, you always find the negatives or you find somebody that wants to complain or that they aren't happy.

00;18;40;12 - 00;19;00;14
Lindse Barks
But that hasn't been the case with this program, and it's because, for starters, periods aren’t political. It's not a political thing. It is an everyday thing that we face and we have to come together to help fight this epidemic that we're facing. We've got students that are facing these issues and it's a problem that we can make a difference in.

00;19;00;14 - 00;19;17;19
Lindse Barks
There's a lot of things that we can't, we don't have an impact. I can't do anything about the teacher shortage and I can't do anything about the bus driver shortage. But this is something that the foundation can step in and we can do, this is something that our community can step up and we can end this problem. Keep having those conversations and contacting our legislators.

00;19;17;27 - 00;19;36;27
Lindse Barks
I've been overwhelmed with the positive feedback that we've gotten. And one thing that I hear over and over again, it's something that you've said more than once Kathy, I had no idea. I had no idea this was a problem. And the women in our community have come out in full force to support our students in our district. They have donated money, they've donated products.

00;19;36;27 - 00;19;48;09
Lindse Barks
They've said, how can we help? And then they brought their friends along to do the same. So the more we talk about it, the more we can spread the word and make people aware and the more, the bigger impact we can make together.

00;19;49;00 - 00;20;12;11
Kathy Cummings
So we have a pretty broad audience of these podcast episodes. You know, you have an opportunity to speak to hospital and health system leaders, to health care professionals across the field, to policymakers, to community groups and leaders to the general public. What do you most want to say to them right now? And where can they go for more information?

00;20;12;29 - 00;20;37;24
Lindse Barks
It's a great question. I think just to keep it going, let's get rid of the stigma. Let's have these conversations. What you can do right now is buy a package of period products and donate it to your local shelter or to a school. We've got a great nonprofit that has been around for about two years in Oklahoma, and it's Period OKC and all they do is collect donations of period products and then donate it in different areas.

00;20;38;14 - 00;21;01;18
Lindse Barks
70% of what requests that they get are from schools. So the need is there. So you can do something immediately by buying and donating it. You can also help by contacting our legislators. This is something that we can actually do something about, like we can actually make an impact and we can do it right now. You know, I said I thought it would take us 5 to 10 years to reach our goal.

00;21;01;18 - 00;21;21;25
Lindse Barks
But but thanks to SSM Health St. Anthony's, we did it in six months. In six months we essentially ended period poverty in Mid-Del within our schools because students have access to period products whenever they need them. And then they also can take them home with them over breaks. I'm really proud of that, but I feel like it's just the start in Oklahoma.

00;21;21;25 - 00;21;34;06
Lindse Barks
It's just the start in our community because like Dr. Hawkins said, we've got homeless and we've got our colleges. So it's just the beginning. So let's keep the ripple effect going. Let's keep having these conversations.

00;21;35;03 - 00;21;56;10
Kathy Cummings
Well, I can't thank you both enough for bringing this issue to the forefront, having this conversation with us and doing the great work that you're doing and you're making such a big difference. We're so happy to be able to share your story with others. So once again, I can't thank you enough for your time and for this important conversation.

00;21;57;01 - 00;22;05;05
Lindse Barks
Thank you again, Kathy for having us. And for shining this light on period poverty. We're so proud of the partnership we have with St Anthony's and the work that we're doing.

00;22;05;05 - 00;22;13;04
Angela Hawkins
Thank you all so much for having us. We appreciate starting this conversation and helping build a community of advocates for young women.