AHA's Rural Podcast Series

00:00:01:04 - 00:00:25:09
Tom Haederle
Welcome to Advancing Health. South Dakota-based Sanford Health is the largest rural health system in the United States. Yet even with its size and resources, there are many challenges to delivering the care that patients need, especially regarding behavioral health services and the threats to care posed by cutbacks to Medicaid.

00:00:25:12 - 00:00:51:27
Rebecca Chickey
Hello, I'm Rebecca Chickey. I'm the senior director of behavioral health at the American Hospital Association. And is my great honor to be here today with Dr. Jon Ulven, who is chair of psychology of Sanford Health, which is the largest rural health system in the country and covers North Dakota, South Dakota, Minnesota, and probably parts of the country that are very small and rural surrounding those states.

00:00:51:29 - 00:01:20:25
Rebecca Chickey
So, Dr. Ulven, thank you so much for joining us today for this very important topic: serving and meeting the mental health needs of rural Americans. And particularly the intersection of that with patients who are covered by Medicaid. So to set the stage, I'd love to have you share a little bit about Sanford Health, what it's like to really - I say rural - but you're in frontier states for the most part.

00:01:20:28 - 00:01:35:05
Rebecca Chickey
So the vastness of North and South Dakota and what that does to create challenges in terms of access and, the solutions that you've had to come up with but help the listeners understand the barriers.

00:01:35:07 - 00:02:01:07
Jon Ulven, Ph.D.
Yeah. So first of all, just thanks for having me. And I really appreciate the attention to this really important topic. You mentioned a few states, but  I'm just going to mention a few more states that we cover, Rebecca, because we're also in Wyoming, Iowa, Wisconsin and then the Upper Peninsula of Michigan. We have a very, very large footprint for our organization, and we serve about 2 million patients in that area.

00:02:01:09 - 00:02:26:05
Jon Ulven, Ph.D.
We do a lot of work with very rural areas, as you were mentioning, frontier type states. And North Dakota and South Dakota, most of those counties are known as behavioral health shortage areas. I practice primarily in Moorhead, Minnesota. And in the state of Minnesota about 80% - 80 to 85% - of our counties are known as a behavioral health shortage areas.

00:02:26:07 - 00:02:49:24
Jon Ulven, Ph.D.
So we have, just a very unique set of challenges when it comes to the trying to provide world class health care and behavioral health care to a footprint that size. And when we look at the rurality of the folks we serve. And so things that we often encounter, we counter pretty much persistent challenges with provider shortages.

00:02:50:01 - 00:03:14:10
Jon Ulven, Ph.D.
It's hard to recruit to this part of the country. We're in a perpetual state of recruitment. And we also know that a couple of unique things that happen with rural areas. We have people who can travel for literally some of...I've seen patients who travel across the state of North Dakota to come to an appointment on the eastern side of the state.

00:03:14:15 - 00:03:31:21
Jon Ulven, Ph.D.
So there are sometimes some very legitimate transportation challenges. And then, and then also, I think one of the things that is - when you are in a small rural community, and I know because I grew up in one, I actually grew up about 25 miles from where I am right here in Moorhead. I grew up on a farm.

00:03:31:24 - 00:03:50:22
Jon Ulven, Ph.D.
There's some nice opportunities for connectivity in a rural setting, but there's also you lose anonymity. So you have you have challenges with people who, might need behavioral health services. But, everybody knows everybody's business. So it makes it really hard to reach out and seek care.

00:03:50:24 - 00:04:10:09
Rebecca Chickey
I hear you, I grew up in rural Alabama. And it took 20 minutes to get to the closest gas station, and 20 more minutes from that to get to the closest hospital. So, perhaps not quite as rural as yours, but you got the fact and everyone in the little community I grew up in knew everyone else's business.

00:04:10:09 - 00:04:21:00
Rebecca Chickey
And with that comes the stigma of seeking care. It's incredible. That's one of the things we've been working on. So glad you're working on it, too. What about broadband? Can you speak to that for just a minute?

00:04:21:02 - 00:04:45:23
Jon Ulven, Ph.D.
Yeah. So to try to meet this behavioral health need, Sanford has invested a tremendous amount of infrastructure and time into a virtual care platform that we offer for this footprint, an area that I described a little bit earlier, where currently we have about 1 in 5 of our behavioral health visits are virtual at this time.

00:04:45:26 - 00:05:08:16
Jon Ulven, Ph.D.
So people can access this through their phones, through their computers at home. And we offer a confidential service where we are able to with the technology throughout that footprint, be able to deliver that type of care. And it's something that we are training our clinicians on a regular basis about, the effective ways to provide this modality of care.

00:05:08:21 - 00:05:17:06
Jon Ulven, Ph.D.
I think in all of our areas, this has just become a pretty common way of life for us to do care that we have a certain portion of it that's virtual.

00:05:17:08 - 00:05:20:23
Rebecca Chickey
And so you complement that with in-person visits, I assume.

00:05:21:00 - 00:05:46:17
Jon Ulven, Ph.D.
We do. Like I said, about 1 in 5 of our visits are virtual. I really have appreciated, some of the innovative minds that we've had here at Sanford to do some unique things. Like, for example, we have a very small community. The name of the town is Lidgerwood , North Dakota. And in Lidgerwood, North Dakota, which is like I said, I grew up around here, so I remember playing basketball in Lidgerwood, just a very, very small community.

00:05:46:19 - 00:06:08:06
Jon Ulven, Ph.D.
And if you head to that town, what they have is they had a clinic setting there, but it was nearly impossible to keep that staffed. So now what we've done is we have some bare bones medical staff in that area. We have some imaging capabilities and we have people to check patients in as they come in, and then they can do virtual care from there.

00:06:08:08 - 00:06:31:16
Jon Ulven, Ph.D.
And so they can do all different types of virtual care. They could be there for a checkup with their primary care physician. They can be there for a specialty visit for one of our other departments, and they can do behavioral health care from there as well. So we're trying to have both kind of this, this nice opportunity for people to have where they can go to a location if they need, if they have some difficulties with their technology

00:06:31:16 - 00:06:56:19
Jon Ulven, Ph.D.
and so they can't do the virtual care themselves, that we offer that up to people. And in this building that I'm in right here in Moorhead, we have 17 psychologists and master's level therapists. We have psychiatry here, social workers, nursing staff. And then within our building we have family medicine, internal medicine, women's health, pediatrics. We have a lab here.

00:06:56:19 - 00:07:20:28
Jon Ulven, Ph.D.
We have a pharmacy here. So we have this nice opportunity to provide just a really well-rounded, amount of health care. To tie back into the, connecting with what we're all here for, it's talking about the, you know, our ability to do that type of care, to think that way and to provide this platform of care.

00:07:21:00 - 00:07:37:26
Jon Ulven, Ph.D.
A lot of it has to do with in our country the ways that we pay for health care. And that's where we get into what has been a mainstay for health systems, and especially when we think about rural health systems is the services that are allowable by Medicaid.

00:07:37:28 - 00:08:04:18
Rebecca Chickey
I want to get back to that point. But before we go further about the devastating cuts that are being discussed right now, help the listeners with a couple of stories, if you can. What has been - so your ability to provide these services, your ability to provide access to care virtually or in person by being creative around that clinic that was probably on the verge of maybe closing and not being there in that community.

00:08:04:20 - 00:08:09:18
Rebecca Chickey
What are some of the personal stories you've seen that have impacted the lives and how?

00:08:09:20 - 00:08:30:08
Jon Ulven, Ph.D.
Many stories that that I could share around this. I've been here with, Sanford for 21 years. I'm a licensed psychologist, and as you were saying, I'm the department chair of our adult psychology group. So I often feel like, jack of all trades and a master of none. But what I do is I do some hospital based coverage from time to time.

00:08:30:08 - 00:08:56:24
Jon Ulven, Ph.D.
And so we have an inpatient psychiatric unit that I will occasionally provide care for. So a very common course that we would see would be somebody who is uninsured or underinsured. And they end up coming through our emergency department for a mental health crisis. And while they're there, the team, with our emergency department determines that the patient needs hospitalization in our inpatient psychiatric unit.

00:08:56:26 - 00:09:23:18
Jon Ulven, Ph.D.
Patient is admitted there. While they're there, we might uncover, for example, a first episode psychosis. So if you take someone who is a young individual in one of our communities who is having an onset that might lead to schizophrenia diagnosis, they're having a first episode of psychosis. And so we have the opportunity to assess the person there, start the person on anti-psychotic medications.

00:09:23:18 - 00:09:42:21
Jon Ulven, Ph.D.
And then let's say that we also uncover that this person has a substance use disorder. Well, we have had the opportunity to enroll this person in Medicaid. Perhaps this person is unemployed, underemployed, has a position where they just don't have the benefits to have, that standard type of health care that a lot of us are able to have.

00:09:42:23 - 00:10:07:29
Jon Ulven, Ph.D.
And so we get this person on Medicaid, and what we're able to do from our inpatient unit is set this person up with a primary care provider, a psychiatrist, a therapist, and we're able to do things like get this person started on some medication that might help with cravings for substance use. And we can we can also work with some of our community partners to try to get this person engaged in that care.

00:10:08:02 - 00:10:27:16
Jon Ulven, Ph.D.
What I often think about is just that if that early intervention that we know that if we can help this person out at that point on an early basis, we are really and in some ways, we're bending the trajectory for their health throughout the course of that person's life. And it is such an important time.

00:10:27:18 - 00:10:50:10
Rebecca Chickey
That's phenomenal. For the listeners: Statistically, by the age of 14, probably about 50% of the population if you're going to show or have a psychiatric or substance use disorder, those symptoms are showing by the age of 14. And correct me if I'm wrong here, keep me honest. But then by the time you're 21 to 24, we're up to 75%.

00:10:50:12 - 00:11:13:05
Rebecca Chickey
So that early identification and intervention and treatment, there's so many opportunities to improve the long term health of the individual, the ability to have a joyful life, to engage and be productive and make the most of the resources around them. It's just critically important. And you're being there, is equally so.

00:11:13:07 - 00:11:33:12
Jon Ulven, Ph.D.
Thank you for that. You know, as we're having this conversation that when we hear stories like this, sometimes the tendency as humans to just say, oh, that's nice. And it's important to hear about that. But we, it's a bit abstracted from us. If we don't have the ability to treat that type of individual, we see, as we see, diminishing services across the board.

00:11:33:14 - 00:12:02:13
Rebecca Chickey
Research shows that 50% of children and 18% of adults in rural communities are covered by Medicaid. Let that sink in, listeners. 50% of the kids in rural communities are covered by Medicaid and 18% of adults. Medicaid is also the largest payer for behavioral health. So speak a little bit more about the impact of these Medicaid cuts that are, currently being discussed in Congress and what that would mean for your community.

00:12:02:15 - 00:12:22:02
Jon Ulven, Ph.D.
Yeah, thank you for that. And just as you were saying that, just another I think another example just comes to mind for me, and that's the that's the example of that, something that I think a lot of people don't think about. And that's health care coverage for foster kids, for foster children. So, if you think about that for a moment, you're a family who's taking on a foster child.

00:12:22:05 - 00:12:46:25
Jon Ulven, Ph.D.
We  don't allow that those folks to go under the foster parents' insurance. There's a gap. There's a gap in care that is consistently filled by Medicaid. And if we think about some of the folks and even if our, you know, listeners can think about some situations where they think a foster child would come from a situation if they're obviously coming from a situation that is a distressing and challenging situation.

00:12:46:27 - 00:13:13:13
Jon Ulven, Ph.D.
Often there are there are lots of different health related issues, including mental health issues. Essentially, these folks would possibly be in a situation where they would have no care, no, no access to care. And we know some things about, looking at places, for example, where, Medicaid expansion has hit a certain area and we can we can take a look at some big numbers about like what's the impact of that?

00:13:13:13 - 00:13:39:27
Jon Ulven, Ph.D.
And we know, for example, that in one study they, looked at suicide rates, of the rate of suicide. And it was over the course of many years and found that folks who had access to Medicaid expansion that suicide rates go down. In the study that they looked at over a series of years, literally thousands of lives, they can see a reduction in completed suicides, which would suggest that there were thousands of lives saved.

00:13:40:04 - 00:14:08:14
Jon Ulven, Ph.D.
I'll also offer just a more pragmatic one. There was a study that was out of Montana that looked at a group of people who were participating in a tele-psychiatry practice. A large number of these folks were Medicaid recipients. And what they found was that, participating in this psychiatry practice, they had a 38% reduction in inpatient hospitalizations, 18% reduction in emergency department visits.

00:14:08:16 - 00:14:45:00
Jon Ulven, Ph.D.
So if you think about the higher cost elements of health care, when we can invest in ways that we know have evidence support, are effective, get the job done, we're actually preventing some of that higher cost care that that truly is. But I would much rather work on preventing something from getting worse than what ends up happening when people are at that level of distress, when they make it to our emergency department, or when I'm covering on our inpatient unit and I can see that I'm working with someone who has gone without care for a significant amount of time.

00:14:45:02 - 00:15:09:13
Rebecca Chickey
Again, going upstream, early intervention prevention, treatment, rather than waiting for the crisis, which might not only just impact the individual, but others as well, depending upon what the crisis is and how many people show up to the emergency room. So, as we draw this podcast to a close, is there a call to action that you would share with the listeners?

00:15:09:13 - 00:15:19:23
Rebecca Chickey
If there's something you would like to encourage them to do? Or, the last thing that you want to make sure that they that resonates as they click off to this podcast.

00:15:19:25 - 00:15:48:29
Jon Ulven, Ph.D.
My heart often goes to children. I only work with adults in my practice, but I but I mean, I'm a father myself. I think about that. Just that point you just made that earlier, we can intervene the better. And I think it's important that one study found that there children who have Medicaid coverage, they're four times more likely to have a regular visits with like, a pediatrician or get some of their health care needs met.

00:15:49:01 - 00:16:08:28
Jon Ulven, Ph.D.
And that that includes behavioral health and that they're 2 to 3 times more likely to receive preventative care. And then we think about when it comes to, adults who are enrolled in Medicaid, that they're five times more likely to have a regular source of health care and also receive preventative care. From the listening perspective

00:16:08:28 - 00:16:34:28
Jon Ulven, Ph.D.
I hope that what this has done is just increased an awareness to truly wide reaching effects that a change in Medicaid is going to it's going to have for the way that we deliver health. And I would say especially in rural health care. Rural health care systems are routinely much more impacted by non reimbursable care. And so you add to that, we're going to see some pretty significant reduction in services

00:16:34:28 - 00:16:51:12
Jon Ulven, Ph.D.
would be I think a reasonable guess. The thing that like call to action? I think one of the things I'm so I feel so privileged about in, in that, in North Dakota. I'm a citizen of North Dakota, I practice in Minnesota, I'm right on the border. Because we're in a small state of North Dakota,

00:16:51:15 - 00:17:30:05
Jon Ulven, Ph.D.
I have been able to work with our government support people and been able to testify. The last two legislative sessions, we have had laws changed in the state of North Dakota. That's been a great opportunity through connections of - here's me as a psychologist, working with our legislators. We all are responsible in a health care setting or our elected officials to improve the lives of the patients and the citizens of our states. And in a bipartisan way, when we can find some nice opportunities to get some things done that are truly meaningful for people in the states we serve, it's a win for everybody.

00:17:30:08 - 00:17:49:16
Rebecca Chickey
That's phenomenal. Thank you. Your passion for this work, both for the patients that you serve, for the organization that you work for and with, and for having an impact work globally. It resonates throughout this entire podcast. So thank you for that passion, for bringing it to the work that you do. And thank you for sharing it with the rest of the field.

00:17:49:18 - 00:17:51:13
Jon Ulven, Ph.D.
Well, thank you very much.

00:17:51:16 - 00:17:59:27
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:01:06 - 00:00:22:12
Tom Haederle
Welcome to Advancing Health. In today's podcast, we learn how West Virginia University Medicine involves the entire clinical team: primary care physicians, virtual social workers and others to get children and young people the care they need before a psychiatrist is required.

00:00:22:15 - 00:00:53:12
Jordan Steiger
My name is Jordan Steiger, and I am senior program manager for clinical affairs and workforce at AHA. I'm really excited to be joined today by Dr. Adrienne Coopey from West Virginia University Medicine. Dr. Coopey is a child and adolescent psychiatrist who is extremely passionate about integrating physical and behavioral health services, which is, we know, something we love to talk about at AHA. And she is especially interested in doing this in areas of West Virginia where children and their families faced challenges in accessing behavioral health services.

00:00:53:14 - 00:01:14:17
Jordan Steiger
She and her team are doing lots of great work, not only to improve the outcomes for these children and their families, but also really trying to support the health care workforce, and clinicians who are developing behavioral health programs and delivering services maybe for whom behavioral health is not their specialty area. So, Dr. Coopey, thank you so much for being with us today.

00:01:14:20 - 00:01:15:29
Adrienne Coopey, D.O.
Thank you.

00:01:16:01 - 00:01:21:12
Jordan Steiger
So to get us started, please tell us just a little bit about you and your role at WVU.

00:01:21:14 - 00:01:52:13
Adrienne Coopey, D.O.
Thank you, Jordan, for that lovely introduction. I think the biggest thing is I'm really fortunate to have the support of West Virginia University to do this work, because I really enjoy it and it doesn't always pay well, right? Reimbursement can be an issue. So, I am currently a fully virtual faculty member in the Department of Behavioral Medicine and Psychiatry, and my role there at WVU is primarily in teaching psychiatry residents and the child and adolescent psychiatry fellows.

00:01:52:15 - 00:02:33:11
Adrienne Coopey, D.O.
So they can join the workforce, and help take care of our people. So teaching is a big role in my work, and it has been all along, which I didn't really catch on to. But, through integrated behavioral health, I've really done a lot of teaching all along. I think most of my, early career has been in-patient child and adolescent psychiatry, emergency departments,  doing consult liaison work in medicine and pediatrics, and then the integrated behavioral health work was just kind of like natural development that kind of happened, which is medical overlap, behavioral health

00:02:33:13 - 00:02:53:25
Adrienne Coopey, D.O.
in a lot of the work that I was doing. And I got really lucky. The hospital that I was working in supported me to implement, integrated behavioral health into primary care. Now, I've been at WVU for two years, and really I was hired to implement behavioral health integration.

00:02:53:28 - 00:03:12:21
Jordan Steiger
I love that WVU has made this investment in behavioral health integration. I think that speaks so, so much to the system and the priorities. And I love that you are completely virtual. I know we'll talk about that a little bit more later and how that helps you in your role. But I'd like to go back to, you know, you are a child and adolescent psychiatrist.

00:03:12:22 - 00:03:36:18
Jordan Steiger
You've practiced for a long time in this role. I know you're really passionate about the care that you provide. We know that there are not enough of you out there in the workforce right now. There are just not enough people going into psychiatry, and especially child and adolescent psychiatry. What does this mean for patients? What does this mean for the short term and long term outcomes for these kids when they can't see a psychiatrist?

00:03:36:20 - 00:04:02:19
Adrienne Coopey, D.O.
Right. So all of that is true. We are not able to produce enough child and adolescent psychiatrists to see every kid who needs help. But I would argue we don't need to. You know, our primary care providers are really seeing the kids who need behavioral health intervention. They're seeing them first, right? They're identifying their needs pretty early, right.

00:04:02:20 - 00:04:34:23
Adrienne Coopey, D.O.
We have made it important for screening tools to be implemented for depression and anxiety. So our primary care providers are seeing these kids right off the bat. If we can support our primary care providers to intervene early, we may not need as many child psychiatrists as we feel we do at this point. Treating behavioral health though, is so different than, say, treating strep throat, right?

00:04:34:25 - 00:04:57:04
Adrienne Coopey, D.O.
We don't have that one test that gives us that one answer and know that one antibiotic is going to be helpful. And so that can make it a little more difficult to just do. And that, is where I get to be a part of sort of distilling all the I've learned to support the primary care providers.

00:04:57:11 - 00:05:21:27
Jordan Steiger
So what I'm hearing you say, I think, is that we need to maybe shift our mindset around this a little bit. Not every child needs to be seeing a psychiatrist. And that early intervention piece is really important. And I know that that's something that WVU medicine is really investing a lot of time and resources in right now. So could you tell us a little bit about the work you're doing to empower that early intervention and get kids the care that they need?

00:05:21:29 - 00:05:46:12
Adrienne Coopey, D.O.
Yes. We have implemented three different programs already in behavioral health integration. That has been very exciting for me. One that I have continued today and it is a direct education with a primary care provider. I have a pediatrician that I work with in an area of West Virginia that has no behavioral health services as far as child and adolescent psychiatry is concerned.

00:05:46:15 - 00:06:12:13
Adrienne Coopey, D.O.
She primarily sees children with behavioral health needs. And I talk to her a couple times a week about patients. And we help implement those screening tools in a way that makes it easier for her to care for kids. I give her recommendations, but really, she's doing all the work. And often I am just saying, yeah, that sounds like a really good idea.

00:06:12:13 - 00:06:46:28
Adrienne Coopey, D.O.
And that has gotten a lot of children seen earlier and getting the care in their communities that they would otherwise have to travel pretty far for. Another program is primarily supported through our population health department. Really cool. It is a fully virtual collaborative care model. In general, the collaborative care model parks a social worker in a primary care office who then is the liaison between the patient, the primary care provider, and the specialist,

00:06:46:28 - 00:07:13:27
Adrienne Coopey, D.O.
the child and adolescent psychiatrist. I've worked in that model, it's super fun. It's great to have that collaboration with everybody in that team model. This model is completely virtual. The primary care provider can be in any setting. The social worker is calling the patient using the medical record to communicate. And I have direct conversations with the social worker.

00:07:13:29 - 00:07:45:06
Adrienne Coopey, D.O.
What that gives us is an opportunity to see patients in various practices that can be geographically quite separated. That was one of the difficulties with rural collaborative care is that the social worker may not have enough volume in one practice to really support their position. And so this really negates that issue. The third thing that we're doing that's super fun is, we call it E-consultation.

00:07:45:12 - 00:08:11:09
Adrienne Coopey, D.O.
It is an interprofessional consultation. So the primary care provider puts in an order and a question about a patient. It comes to me or one of our child psychiatrists electronically. We review the chart, review the question and send back an answer. This can be really great. Because we can give it an answer pretty quickly, and we can bill for it so it can support itself.

00:08:11:12 - 00:08:36:16
Adrienne Coopey, D.O.
The primary care provider and this child psychiatrist, are part of any kind of billings and review generation, so that can be helpful in supporting the program. That can give those patients who may not be appropriate for a collaborative care model, a more immediate answer before they can get to a child psychiatrist in specialty care.

00:08:36:18 - 00:09:07:01
Jordan Steiger
Wow, so many things you've mentioned I would love to just dive deeper and deeper into. I think that I mean, the thread I hear among all of these programs though, is the willingness to embrace that virtual care and the willingness to connect across a very large state with a lot of rural communities. You know, I think being a big anchor system in a state like West Virginia, there is such an opportunity maybe for other, you know, states similar to West Virginia, to kind of model off of the work that you are doing.

00:09:07:04 - 00:09:29:22
Jordan Steiger
One of the things you mentioned at the beginning, you know, talking about your different implementations is, you know, how you work one on one with this primary care physician in a rural community in West Virginia. I love this. I think this is such a smart way to just spread that knowledge and help - like you said - just bring that access to care to communities where it wouldn't maybe be.

00:09:29:24 - 00:09:51:18
Jordan Steiger
You alluded to this at the beginning too, but we know that behavioral health provision, you know, for services, is a little different sometimes than primary care. So how can other child and adolescent psychiatrists model kind of the work that you're doing and empower other primary care clinicians to be more confident in treating children with behavioral health needs?

00:09:51:20 - 00:10:23:15
Adrienne Coopey, D.O.
Great question. And this has taken time to develop for myself. Getting little bits of information about someone and formulating a diagnosis and plan can be really difficult and a little scary. So learning the ways that primary care providers can communicate with you in the same language. So sometimes our primary care providers and our psychiatrist are speaking different languages.

00:10:23:17 - 00:10:57:09
Adrienne Coopey, D.O.
One way that we can speak the same language and get the same information is if by using screening tools. And we are using screening tools in primary care a lot, right? We're using the PHQ. We're using the Gad seven and the scared for anxiety. We're using the Vanderbilt for ADHD. We're doing that. And that can be a great way to get the information that you need and communicate it with each other, primary care and psychiatry and follow the care. So we can use those to help support diagnosis.

00:10:57:11 - 00:11:17:18
Adrienne Coopey, D.O.
We can use those to help follow the care and see if we're getting better. Because one thing about psychiatry in general is that our responses aren't always immediate and they're not big. You don't go from sore throat to no sore throat, right? You have incremental improvement.

00:11:17:21 - 00:11:47:05
Jordan Steiger
Absolutely. And just making it objective, like you said, it's not like you have sore throat and no sore throat. It could be a lot of time, a lot of different interventions, a lot of different experimentation with lots of different things to get that person to that right care plan in psychiatry. So I think that that's a great takeaway message for our listeners is just figuring out what is that shared language and how can we come to kind of the middle and understanding each other between psychiatry and primary care

00:11:47:05 - 00:11:59:15
Jordan Steiger
so I love that. As we start to close, what advice would you have for other health systems who are looking to integrate behavioral health into their other models of care?

00:11:59:17 - 00:12:28:24
Adrienne Coopey, D.O.
Support it. I am super grateful to WVU for supporting my work. I am grateful to other hospitals that I've worked at for supporting behavioral health integration. It doesn't always pay upfront, but the improvements on the end in quality of life, hospital visits, hospitalizations and other needs are significant. So that prevention piece is really powerful.

00:12:28:26 - 00:12:34:16
Jordan Steiger
I absolutely agree. Thank you so much. Is there anything else you'd like to add?

00:12:34:18 - 00:12:57:24
Adrienne Coopey, D.O.
Thank you for having me. I really appreciate this. It is something I've been doing in the background for quite some time, and I know that individually, each primary care provider I work with is grateful their patients are getting what they need, and they are also grateful for this program. But I don't always get to talk about it.

00:12:57:27 - 00:13:06:12
Adrienne Coopey, D.O.
Because behavioral health can be something that we don't talk about a lot. So I really appreciate that you've given us this time and spotlight to do it.

00:13:06:15 - 00:13:17:23
Jordan Steiger
We are so happy to do so. I love talking about behavioral health and getting to help other people share their stories. So, we are really excited to keep following your work and see what comes next.

00:13:17:25 - 00:13:19:10
Adrienne Coopey, D.O.
Thank you.

00:13:19:13 - 00:13:27:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:05 - 00:00:23:09
Tom Haederle
Welcome to Advancing Health. In the face of today's multiple challenges, every hospital needs support and buy in for its mission of great care. Storytelling - sharing the right kinds of stories with the right audience at the right time - is a great way to build and maintain that support. This is particularly important for rural hospitals and health systems, most of which have razor-thin operating margins.

00:00:23:12 - 00:00:40:10
Tom Haederle
In this month's Leadership Dialogue, hosted by the American Hospital Association's 2025 Board Chair Tina Freese Decker, we hear more about the importance of advocacy and of all team members participating in telling the hospital story.

00:00:40:13 - 00:01:07:25
Tina Freese Decker
Thank you so much for joining us today. I'm Tina Freese Decker, president CEO for Corewell Health, and I'm also the board chair for the American Hospital Association. Last month we talked about trust and how our hospitals and our health systems can strengthen that trust with our communities and the people that we serve. Our rural hospitals are uniquely positioned to do this, as they are often the largest employers in their towns and communities, and frequently the only local source of care.

00:01:07:27 - 00:01:28:07
Tina Freese Decker
Rural health care is about being a family. We take care of each other in our communities as best as possible, and we're here to provide that care close to home, no matter what headwinds that we all face. I recently had the opportunity to attend the American Hospital Association's Rural Conference and you could really feel that sense of family and community in the room.

00:01:28:09 - 00:01:59:15
Tina Freese Decker
We work in hospitals in red states and blue states all across the country, but we are all focused on the same thing: helping our neighbors in our communities to be healthier. There are some big challenges that are facing real health care, but together with a unified voice, we can get what we need. As I have traveled around our country meeting with the American Hospital Association's regional policy boards and visiting the rural hospitals and my health system and others, the number one concern that I have heard from our hospitals, our communities, is access.

00:01:59:18 - 00:02:22:28
Tina Freese Decker
And that is why it is so integral to the American Hospital Association strategy and it is why it is so important that we come together as a field and that we're united as a field, because these challenges that we are facing are real. So today, I am pleased to have a distinguished leader in rural health care with us to talk about how we can all work together to advocate for the needs of our hospitals.

00:02:23:01 - 00:02:45:09
Tina Freese Decker
I'd like to welcome Lori Wightman. She is the CEO of Bothwell Regional Health Center, a 108 bed acute care hospital in Sedalia, Missouri. Laura has served in this role since 2019, but even prior to Bothwell, she worked in real health care as the president of Mercy Hospital Ada in Ada, Oklahoma. So, Lori, welcome. Glad you were able to join us today.

00:02:45:15 - 00:02:46:17
Lori Wightman, R.N.
Thank you, Tina.

00:02:46:19 - 00:03:03:20
Tina Freese Decker
And I wanted to start out with just telling us a little bit about yourself. I know you started your health care career as a nurse and then you made the shift to administration. Can you tell us about yourself and how you see that family aspect in the hospital and the community in our rural areas?

00:03:03:22 - 00:03:30:01
Lori Wightman, R.N.
Sure. Well, my father was a hospital administrator and my mother was a nurse, so I did both. And so it was a natural progression. And I think the foundation that nursing lays gives you all kinds of transferable skills that have been very helpful as I went into hospital administration. My career and dating advice has always been, you can't go wrong with a nurse.

00:03:30:03 - 00:03:57:14
Lori Wightman, R.N.
And there's certainly served me well. And you talk about that family atmosphere. That is why I continue to choose rural health care. I've done the CEO position in a suburban hospital, and I sat at our senior leadership team meeting and thinking I was the only one on our senior leadership team that even lived in the area that we served.

00:03:57:17 - 00:04:23:24
Lori Wightman, R.N.
Everyone else lived in a different suburb, and I just thought that was strange and disconnected. And, so I returned again then to rural health care because it is like a family. And it's ironic because we just finished revisiting our mission, vision and values. And our new mission statement talks about together we work to provide compassionate and safe care to family, friends, and neighbors.

00:04:23:27 - 00:04:37:07
Lori Wightman, R.N.
Invariably, when I met new employee orientation, a significant number of people were born at the hospital. That's why I love rural. It's like that "Cheers" phenomenon where everyone knows your name.

00:04:37:09 - 00:05:01:02
Tina Freese Decker
Very true. I used to lead a couple of rural hospitals as well. And like you said, even just walking into a rural hospital it feels like family where everyone there knows your name and of course, protect things from a confidentiality and a privacy perspective, but that feeling that we're all in this together. So I love that your mission statement is about together, that you can make an impact on people's health.

00:05:01:05 - 00:05:13:28
Tina Freese Decker
I described a little bit about what it's like to walk into a rural hospital. Can you share a little bit about what is like to be a rural hospital, what it means in today's environment and why it's such a great place to work?

00:05:14:01 - 00:05:47:06
Lori Wightman, R.N.
Well, in many ways, rural hospitals are uniquely the same as our suburban or urban counterparts. Forty six million people depend on a rural hospital for their care. So we struggle with the same labor shortages, the cost of labor supplies and drugs is rising faster than our reimbursement. We have all of those same struggles. Unique is that family atmosphere, I think.

00:05:47:06 - 00:06:13:26
Lori Wightman, R.N.
And we have multiple generations working at the hospital. Now, you can't say anything bad about anyone because invariably they're somehow related. Or they were best friends in high school, or they used to be married to each other. So I mean, it's unique in that way. We have the same types of struggles that  our counterparts do.

00:06:13:28 - 00:06:18:03
Tina Freese Decker
What pressures are you feeling the most acutely right now?

00:06:18:06 - 00:06:47:09
Lori Wightman, R.N.
Well, you take all of those common challenges that I talked about, and you turn up the volume a little bit. Because for us, 78% of our patients and our volume is governmental payers, so 78% of our business, we're getting reimbursed below cost. You can't make that up in volume. So we rely on all of the governmental programs, you know, disproportionate share all of those things.

00:06:47:09 - 00:06:54:22
Lori Wightman, R.N.
And, 340B is doing exactly for us what it was designed to do, save rural hospitals.

00:06:54:25 - 00:07:11:22
Tina Freese Decker
Those areas are critical that they remain. And so that we can continue to provide that sustainable, high quality care in our communities and all of our communities. 78% being governmental. It's a huge portion of what we do and what we rely on for access and caring for people.

00:07:11:29 - 00:07:23:15
Lori Wightman, R.N.
Right. We are the typical rural hospital. We have razor-thin margins and aging plant of 18 years.

00:07:23:18 - 00:07:31:10
Tina Freese Decker
So those are challenges that you're trying to navigate right now with all of the other things that happen. And how is your staffing levels going? Are those going okay?

00:07:31:13 - 00:07:55:12
Lori Wightman, R.N.
Have the same labor shortage issues. We still have 22 traveling nurses here, but we have started being very aggressive in a grow your own program. And so as soon as the next month we're going to cut that number in half and then, within six months, we're hoping to have all of contract staff out.

00:07:55:15 - 00:08:02:04
Tina Freese Decker
Is that something that you're most proud of, or is there something else that you want to share that you're most proud of from a rural hospital perspective?

00:08:02:06 - 00:08:29:24
Lori Wightman, R.N.
I think what I'm most proud of is you get to personally view the impact of your decisions on people. I'm very proud of our all the talented people that we have here, from clinicians to community health workers. All of our physicians get to use all of the things they learned in medical school and residency, because there isn't a lot of subspecialists, so they are working at the top of their license.

00:08:29:26 - 00:08:50:21
Lori Wightman, R.N.
Just several months ago, one of our critical care physicians diagnosed a case of botulism. Now as an old infection control nurse I get very excited about that because I never thought in my career I would see botulism. But it was diagnosed and treated here and the person's doing well.

00:08:50:23 - 00:09:25:27
Tina Freese Decker
Oh, that's wonderful to hear. When you talk about all the different people that are part of health care in rural settings, or also another settings, it's quite amazing to see how many different areas we need to come together to take care of our community. When you think about an even larger scale, from rural hospitals to urban and teaching hospitals and others, how do you think about the whole ecosystem of our field and how we, you know, do we need all of us or and is there a way to form that greater fabric and social connection, or is there something else that we should be doing?

00:09:25:29 - 00:09:50:21
Lori Wightman, R.N.
We are all very interconnected and I believe we are all needed. And I especially feel that as an independent hospital, not part of a health system, this is my first independent hospital. I rely on my hospital association more than I ever did when I was working for a health system, because it all comes down to relationships.

00:09:50:21 - 00:10:18:13
Lori Wightman, R.N.
And so how do you develop, how do you get yourself in situations where you are meeting and now working with your partners around the state or the region? Because it comes down to relationships, you really need to know who your neighbors are in terms of other hospitals, who you're referring your patients to and develop that working relationship because it is all interconnected.

00:10:18:13 - 00:10:25:06
Lori Wightman, R.N.
And we rely on our partners that we refer to, and they rely on us, too.

00:10:25:08 - 00:10:43:23
Tina Freese Decker
One of the things I heard you say about the Rural Health Conference that the American Hospital Association just put on, and the value of the American Hospital Association is that we're not alone. And those values of relationships are really critical. So I appreciate that. The American Hospital Association also talks a lot about how do we tell the hospital story.

00:10:43:25 - 00:10:55:15
Tina Freese Decker
So how do you engage in advocacy to make sure we're telling that hospital story so that our legislative leaders and others know the value that we're bringing to the community?

00:10:55:17 - 00:11:22:11
Lori Wightman, R.N.
Well, we are surrounded by stories. And so the first thing is to always be picking up on what is the story that is surrounding us, and how can we capture that? Because the most effective way is to bring that patient or nurse or physician to the legislator to testify, because they are the most effective way of communicating a message.

00:11:22:18 - 00:11:49:07
Lori Wightman, R.N.
You know, the suits can go and talk about data, but nothing is more effective than what I call a real person telling their story and how a decision or a potential decision is going to impact them and how it feels. The other thing we do is every October, it's become tradition. We have Advocacy Day with our board, at our board meeting.

00:11:49:09 - 00:12:21:12
Lori Wightman, R.N.
We invite our state elected officials  - so people representing us at the state capitol - to come to our board meetings. On election years their challengers also come and I invite the hospital association and they all answer two questions: What do you hope to accomplish in the next legislative session, and what do you think might get in the way? That sets the scene for my board to understand that part of their role in governance is advocacy.

00:12:21:14 - 00:12:29:19
Lori Wightman, R.N.
And so I've had two of my board members...almost every legislative session I go and testify on on some bill.

00:12:29:21 - 00:12:50:01
Tina Freese Decker
That is really a good idea. Thank you so much for sharing that. Do you have any other final suggestions for us as AHA members, as other hospitals, whether it's rural or urban, that we should think about or do as we think about advocacy and access or also field unity?

00:12:50:03 - 00:13:22:11
Lori Wightman, R.N.
You know, having been on the board of two different state hospital associations, I get it. You know, sometimes members can be at odds with each other on a given issue. And my advice to AHA would be to play the role of convener, facilitating conversations between members to better understand each other's position. And if a middle ground can't be reached, then that might be an issue that AHA remains neutral on.

00:13:22:14 - 00:13:34:07
Lori Wightman, R.N.
But there are so many issues where we can agree on and that is very much the role and what all of us depend on AHA to play in advocating.

00:13:34:09 - 00:14:02:15
Tina Freese Decker
There's a lot that binds us together. Like you said, we're all caring for our neighbors and our communities, and that's the most critical piece of it. And we have to keep that front and center with every decision that we make and every action that we do. Well, Lori, thank you so much for being with us today on this AHA podcast, for sharing your expertise in rural health care and for talking about some new ideas that all of us can take forward to ensure that we're telling the hospital story in the best way possible.

00:14:02:18 - 00:14:21:09
Tina Freese Decker
So while I know that we have our work ahead of us, I know that I continue to be energized every time I speak with committed and passionate hospital leaders like Lori. Again, appreciate your work that you do every single day for the neighbors and for the people in your community that you serve. We'll be back next month for another Leadership Dialogue conversation.

00:14:21:13 - 00:14:23:01
Tina Freese Decker
Have a great day.

00:14:23:03 - 00:14:31:13
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:04 - 00:00:36:12
Tom Haederle
Welcome to Advancing Health and part two of the conversation on cybersecurity attacks against rural hospitals, and what can be done to protect against them. In this conversation between John Riggi, the American Hospital Association's national advisor for Cybersecurity and Risk, and Justin Spelhaug, corporate vice president of tech for Social Impact, Microsoft Philanthropies, we learn more about the role tech leaders can play in helping rural health care providers cope with cyber attacks and preserve their ability to care for the nearly 60 million Americans who depend on them.

00:00:36:14 - 00:00:45:02
Justin Spelhaug
So the impact is clearly disruptive on these hospitals, clearly disruptive. Now, John, what can these hospitals do to protect themselves?

00:00:45:04 - 00:01:04:21
John Riggi
So there's many things that they can do. There's many things they need to do. But again, it generally comes down to a resource issue. So we generally say start with the basics. Look at your tools and policies. We know that there are certain cybersecurity practices, basic practices that can help mitigate the risk of the majority of cyberattack.

00:01:04:27 - 00:01:33:13
John Riggi
So example: multi-factor authentication, unified identity management, cybersecurity training for staff. We know that most of the attacks still start with those phishing emails, a psychological technique versus technological. Another step: join the Microsoft cybersecurity program. You all have been very generous in offering free cybersecurityassessments, curated learning pass product discounts to all rural hospitals in the U.S.

00:01:33:16 - 00:01:53:03
John Riggi
And I mean, these are the type of things that we need to do together to help shore up the defenses of rural hospitals. Now, Justin, can you tell us more about the Microsoft cybersecurity program for rural hospitals in the role you see technology leaders having in addressing these challenges?

00:01:53:05 - 00:02:17:22
Justin Spelhaug
Yeah, for sure, John. And of course, the technology leaders in these hospitals are on the frontline of driving change, and they're managing everything end to end with really limited resources. And so we wanted to pull together a program that would provide them more capacity, more capability to respond to the threats that you've just highlighted. And really, there are three big buckets. New offers that help make our technology more affordable.

00:02:17:24 - 00:02:41:18
Justin Spelhaug
That's bucket one. Bucket two is capacity building services to help organizations respond. And then bucket three is new innovation to help rural hospitals have more impact, particularly with AI. So let me click into those just really specifically for just a moment. In bucket one, in terms of new affordable offers, we're providing those hospitals that typically have the least resources.

00:02:41:18 - 00:03:28:10
Justin Spelhaug
And so that's independent critical access hospitals and rural emergency hospitals, those that are not in a health system, they can access Microsoft nonprofit pricing, which can provide up to a 75% discount for things like Microsoft 365 off of commercial pricing. So that goes a big way in helping some organizations really get access to affordable technology. Now, all other rural hospitals in the U.S. that are using Office 365 or M365 can get access to one year free of our most advanced security suite, Microsoft 365, E5 security and EMS E3 for one year to ensure that they can take action on their infrastructure immediately.

00:03:28:13 - 00:03:55:22
Justin Spelhaug
We've also for everybody, we've extended one year of Windows 10 Extended Security update at no cost. So that's on the technology side. On the capacity building side, we're providing every rural hospital in America, over 2000 hospitals, free security assessments, through a pre-vetted Microsoft security partner to help them evaluate their risks and identify strategies to mitigate those risks.

00:03:55:24 - 00:04:19:08
Justin Spelhaug
We've also, in this bucket, put together curated learning pathways for both technical staff and non-technical staff. And then the third area is AI innovation. Now, John, you were highlighting how stretched the finances of rural hospitals are, and CHQPR reports - and you said, John, that 30% of all rural hospitals are at risk of closure - that's a real statistic.

00:04:19:10 - 00:04:46:20
Justin Spelhaug
And that means that funding is limited and funding is limited for security expertise and the services that they need. So to help tackle this challenge, we've launched a Microsoft Rural Health AI lab, which we affectionately call RAIL, that is developing tools to help improve both financial and health outcomes. The first tool we built, which is in testing now with a number of hospitals, is an AI tool to support managing denied insurance claims.

00:04:46:27 - 00:05:08:15
Justin Spelhaug
We know that's a massively manual process for many hospitals. We know that if we can manage that more effectively, we can improve hospital revenue, which improves all outcomes. We've also been working to deploy nuance to improve patient and physician nurse experience through AI. And we continue to look at how we can use AI to support hospitals for a number of other scenarios.

00:05:08:18 - 00:05:40:22
Justin Spelhaug
Since we launched it, nearly 500 hospitals have registered for the program. That's about 24% of all the hospitals in the country. And that's in about the last four months. Over 335 hospitals are participating in a cybersecurity assessment, and many are getting access to the offers as well. And this is, John, part of a broader commitment to rural communities. We've been investing for years, actually, in rural communities, both tackling the broadband divide in America, as well as investing in innovation in rural communities through our Tech Spark initiatives.

00:05:40:22 - 00:05:46:26
Justin Spelhaug
So this is just the next step that we're taking for this acute challenge that we're dealing with at the moment.

00:05:46:28 - 00:05:54:12
John Riggi
Since launching the cybersecurity program for rural hospitals. Let me ask you, Justin, what has Microsoft learned?

00:05:54:15 - 00:06:15:25
Justin Spelhaug
Yeah. You know, John, we've learned a lot. And, you know, as I mentioned before, we've engaged just about 500 hospitals. And our learnings really break into two categories. So if you're watching this and you are a cybersecurity professional, pay attention to this next section because I want to tell you what we're learning from the hospitals that we're engaging with directly.

00:06:15:27 - 00:06:42:06
Justin Spelhaug
Four key technical learnings that we're having. Number one, privileged account management is the top liability that we're seeing in many rural hospitals. Only 25% of rural hospitals adequately separate end user and privileged accounts, i.e. those accounts that have broader access to systems and data. Getting that segmentation is critical in terms of protecting your footprint. That's probably learning

00:06:42:09 - 00:07:11:20
Justin Spelhaug
number one. Learning number two is mitigating known vulnerabilities, running basic vulnerability scanning, doing timely patching, establishing processes to remediate those issues. Only 49% of hospitals that we're working with right now receive passing scores on being able to mitigate vulnerabilities quickly. That's because they're stretched. They're doing everything. They've got a limited amount of resource. That's really the truth. But it's a challenge nevertheless.

00:07:11:22 - 00:07:45:22
Justin Spelhaug
Number three, less than 65% of rural hospitals have implemented some of those basic cybersecurity best practices that you were highlighting, John. So email security, about 63% of hospitals. NFA, probably the number one thing we need to implement right now to protect against some of these threat vectors, about 64% of hospitals. Network segmentation, about 62% of hospitals. So A, it's good that we've got 60 something percent implementing these technologies, but we have 35-40% of hospitals that remain exposed and uncovered.

00:07:45:22 - 00:08:24:02
Justin Spelhaug
So that's what our program is trying to get at and get across. And then number four, while most rural hospitals scored well across the category of asset management, one subcategory, which is super critical, endpoint management is a substantial risk for rural hospitals. Less than 35% of assessed hospitals met the expert informed passing score for endpoint management. And if you remember what I said about ransomware, the ransomware is coming through those devices that do not yet have endpoint management comprehensively, you know, securing them.

00:08:24:02 - 00:08:46:26
Justin Spelhaug
So that's a real challenge as well. So there's a lot of work to do, a lot of work to do across the community. Now, the second category is that this challenge is enormous. And we're talking about over 2000 hospitals here in the United States. And it is going to take strong public private partnership with, I think, a real shared spirit both of collaboration

00:08:46:26 - 00:09:07:07
Justin Spelhaug
but John, like you have, urgency. Because this is a life and safety issue as you mentioned. This is people's lives at stake and livelihoods of communities at stake. And this relates to technology. Certainly we need to get the technology out there, but it also relates to funding, developing long term cyber skills, job pathways in these communities, broadband access,

00:09:07:08 - 00:09:25:22
Justin Spelhaug
there's a lot of different things that we need to get done. And, you know, Microsoft is all in. I know AHA is all in. And we're going to need more partnerships to tackle the size of this challenge. Another question here for you, John. You know, how can we collectively address the near-term risks of cyberattacks for rural hospitals?

00:09:25:22 - 00:09:29:07
Justin Spelhaug
Some of those issues that I just talked about from your vantage point.

00:09:29:10 - 00:10:07:10
John Riggi
First, I absolutely agree with all of those basic cybersecurity hygiene controls, procedures, policies that you've discussed. In fact, if hospitals are in fact looking for kind of a clear and concise list of these practices, starting with that multifactor authentication, unified identity management privilege accounts, you can go to, HHS' website - Health and Human Services website - where they have a list of ten essential cybersecurity practices and ten enhanced cybersecurity practices.

00:10:07:10 - 00:10:27:01
John Riggi
These are voluntary at the moment. They may become minimum mandatory at some point, but that's a good place to get that concise list, which includes all those recommendations that you made. And then ultimately, hospitals have to have the resources, not just a list to help implement these measures effectively.

00:10:27:03 - 00:10:56:13
Justin Spelhaug
Yeah they do, John. You know, we've also learned to remediate many of the risks that we're seeing to bring partner services in. If a hospital wanted to fund that, let's say they didn't have the staff, maybe between $30,000 or $40,000 per hospital to get those immediate issues addressed. You multiply that by 2000 hospitals. That's $60-$80 million, which in the grand scheme of things, and we're talking about rural America and rural communities, is a big number

00:10:56:13 - 00:11:16:03
Justin Spelhaug
but it's not that big of a number. And we need to be mobilizing all of the resources we can to tackle that. Now, of course, there's more systemic challenges, such as the skills in the community and ongoing challenges to maintain the environments and to upgrade the software and the hardware over time. That's going to require systemic, capacity building, systemic sources of funding.

00:11:16:03 - 00:11:37:05
Justin Spelhaug
But that has certainly been a learning we've had as well. So, John, as we kind of conclude the discussion, how are you thinking really about insuring rural hospital resilience long into the future? Sure, we're facing these challenges right now, but how do we create resilience over time?

00:11:37:07 - 00:12:23:28
John Riggi
Again, great question, Justin, because that's really what this is about. It's about the long game. If we just address the near-term tactical threat that will not secure our future against these threats, nor will it secure our rural communities in the future. So really, what we do need is this sustained support from both public and private sectors to kind of help bolster these resources and really this continuing partnership in innovation across the rural areas, these public private partnerships, and we need to continue to invest in innovative solutions, workforce development, collaborative efforts to address these both systemic challenges, these international challenges, the strategic threat and then ultimately which translates down to the patient care and safety

00:12:24:00 - 00:12:32:07
John Riggi
risk. Again, what good is needed this continued whole-of-nation approach, and we're proud to have Microsoft as a partner in that effort.

00:12:32:10 - 00:13:12:15
Justin Spelhaug
Now we're proud to partner with you, John. AHA has been just such a staunch supporter, first of the rural hospital community and really advocating for that community broadly, getting partners like Microsoft to the table, helping us formulate effective strategies that provide as much capability to as many hospitals as we possibly can. And, we remain super committed to this effort and look forward to working both with you, other public and private sector partners that want to come together, that are of like mind, that want to collaborate, that are feeling the urgency like we're feeling and seeing the urgency and support these essential hospitals and these essential communities all across America.

00:13:12:18 - 00:13:25:18
John Riggi
Thank you, Justin, and thank you Microsoft. It's been a great pleasure discussing this important topic with you today, and look forward to our continued partnership to help defend America's hospitals against these cyberthreats.

00:13:25:20 - 00:13:34:02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:04 - 00:00:45:24
Tom Haederle
Health care tops the list of critical infrastructure targeted by cybercriminals. These threat to life crimes hit every hospital hard, but rural providers even harder due to fewer resources and generally smaller IT staff. The average recovery cost from a ransomware attack is $11 million, a vast sum that leaves many rural hospitals one cyberattack away from closure. In today's podcast, we hear from John Riggi, the American Hospital Association's national advisor for Cybersecurity and Risk, and Justin Spelhaug, corporate vice president of tech for Social Impact, Microsoft Philanthropies, about the steps rural providers can take to reduce the risk and impact of a ransomware attack.

00:00:45:27 - 00:01:13:18
Justin Spelhaug
I'm Justin Spelhaug the corporate vice president of tech for Social Impact here at Microsoft Philanthropies, and I'm joined by my co-host John Riggi, the national advisor for Cybersecurity and Risk at the American Hospital Association. And we're here today to discuss critical issues of cybersecurity in rural hospitals, and how our partnership is coming together to tackle the challenges that so many rural hospitals are facing across America.

00:01:13:19 - 00:01:17:09
Justin Spelhaug
So thank you for joining us. And John, thank you for joining us. Good to see you here today.

00:01:17:12 - 00:01:20:24
John Riggi
Good to see you too, Justin. It's always great to partner with you.

00:01:20:26 - 00:01:30:09
Justin Spelhaug
Well, John, you know, as the expert in hospital cybersecurity, can you tell us why rural hospitals are particularly vulnerable to cyber attacks?

00:01:30:11 - 00:01:58:19
John Riggi
Justin, great question. There's really a number of factors about that. First, the impact of the physical distance on patient care and mortality when a hospital is shut down by a ransomware attack. For example, rural hospitals provide critical health services to about 60 million Americans, or nearly 20% of the US population. Rural residents already must travel more than twice as far as urban residents to reach the nearest hospital.

00:01:58:22 - 00:02:30:22
John Riggi
So when you have this increased travel distances, they are directly associated with higher mortality rates for time sensitive conditions like heart attack, stroke or trauma. And then you're diverting these patients during a ransomware attack, again just magnifying that risk. Then there are the resource challenges, financial constraints and skill shortages. Low operating margins due to patient volumes, high fixed costs relative to urban hospitals. And rural hospitals are more likely to have older technology and smaller IT support staff.

00:02:30:27 - 00:02:59:06
John Riggi
This impacts the resources to implement key cybersecurity measures, creating really, unfortunately, an ideal opportunity for exploitation for cyber criminals. The average cost of addressing cyber attacks - now this is the cost after you've been attacked - the cost to recover is almost $11 million. I mean, just an enormous, staggering amount for the average rural hospital. Thirty percent of all rural hospitals are already at risk of closing,

00:02:59:08 - 00:03:22:09
John Riggi
so they can be only one cyber attack away from closure. And then, of course, as I indicated, there's a skill shortage. Very difficult to get your best cyber security professionals to work in rural areas. The salaries are generally not as competitive as urban areas or even other industries, so you compile that...it's extremely challenging to get good experienced

00:03:22:10 - 00:03:53:22
John Riggi
IT staff to work in rural America. And then we have geopolitical factors making rural hospitals kind of unique targets. So over the past 12 months, cyber attacks against hospitals have increased about 130%, making them the top critical infrastructure that's targeted by cybercriminals. And make no mistake, they know when they target a hospital, lives are threatened. In fact there's now even evidence that nation-states are collaborating with criminal groups.

00:03:53:24 - 00:04:04:21
John Riggi
Justin, I know Microsoft keeps a very close eye on the evolving threat landscape. Can you talk to us a bit about the trends you're watching that might affect health care organizations?

00:04:04:24 - 00:04:27:13
Justin Spelhaug
I can and John, thanks. I mean, your feedback that hospitals are only, you know, one cyberattack away from closing, especially the rural hospitals that are very stretched, is just really eye opening. And when we look at the challenge facing hospitals, but frankly, many different kinds of organizations, one of the reports that we produced is a Microsoft Digital Defense report.

00:04:27:18 - 00:04:51:13
Justin Spelhaug
Now, we use about 78 trillion security signals a day from Windows and Cloud endpoint devices to inform this report. We've got security engineers and intelligence analysts tracking about 1500 unique threat groups all around the world. And the trends I'll talk about here are relevant for every industry. But as you said, John, it's impacting health care and it's impacting rural health care in particular.

00:04:51:17 - 00:05:32:03
Justin Spelhaug
So let's talk about a couple of the trends. The first one is that we're continuing to see a massive escalating intensity on password based attacks. When we look at our Microsoft entry data, we see organizations being barraged by about 600 million identity attacks per day, and 99% of those are password based. Now, advances such as zero trust architecture, conditional access policy, MFA have helped defend against this. But we're seeing hackers work around MFA, targeting infrastructure and applications and bypassing authentication altogether.

00:05:32:03 - 00:05:59:15
Justin Spelhaug
And that's why advanced monitoring and threat detection capabilities inside of an environment are so critical. So that's the first theme. The second theme that we see is nearly a 3X increase in year-over-year human operated ransomware attacks. They're attacking health care. They're attacking rural hospitals. They're attacking nonprofit. They're attacking schools, they're attacking sensitive government infrastructure. Now, on the good news

00:05:59:15 - 00:06:27:25
Justin Spelhaug
if there is any good news anywhere in this story, is we see a significant decline year-over-year in attacks reaching the encryption stage and locking up resources. And that's because of the deployment of automated attack disruption tool. It is also endpoint protection deployment 92%, 92% of all successful ransomware attacks involve the attacker going through unmanaged device on the network.

00:06:27:27 - 00:06:50:08
Justin Spelhaug
And it's also about increased training and awareness across the employee base in every organization. But we need to keep making progress because as you know, John, you said the average recovery was about an $11 million investment when they break through. It's devastating, for a rural hospital in particular it's devastating. We're also seeing a third theme and that's the ingenuity of fraud

00:06:50:08 - 00:07:20:26
Justin Spelhaug
tactics are quickly evolving. We saw growing sophistication of investment scams, tech support scams are particularly impacting hospitals and more. At the same time, we're seeing impersonation getting more sophisticated, in fact, and detection more difficult because of the access to deepfake technologies that cybercriminals are using. And globally, the World Economic Forum reports that scammers stole over 1 trillion in U.S. dollars from the global economy in 2023.

00:07:20:26 - 00:07:54:11
Justin Spelhaug
So the massive, massive impact. Then finally, John, something that you mentioned, nation-states. We're seeing actually blurred lines between nation-state threat actors and cybercriminals. They're partnering together to advance each other's objectives and in particular monitoring and see Iran, who appears to be the most active nation-state actor targeting health care organizations specifically. Perhaps the most acute impacts and the biggest headlines have been in the health sector, certainly over the last 12 months.

00:07:54:13 - 00:08:13:15
Justin Spelhaug
And when you talk about a small rural organization or a rural hospital, John, as you just did with less resources as you just talked about to protect themselves and respond. We know why, you know, hackers are targeting these organizations and why it is such a huge challenge for us here in the United States. So big challenges all around.

00:08:13:17 - 00:08:25:04
Justin Spelhaug
Now, John, those are the challenges. Can you talk a little bit about the impacts you're seeing these cyber attacks actually have on hospitals and maybe even more importantly, the communities that they serve?

00:08:25:06 - 00:08:56:17
John Riggi
As you know, the AHA has been a very loud voice signaling what the impact is of these ransomware attacks on hospitals. Unfortunately, this isn't just about the protection and privacy of data. It's very important, but most importantly is the disruption to patient care. These attacks have caused significant disruption and delay to health care delivery when hospitals are attacked directly or through some third party attack that results in a disruptive effect.

00:08:56:24 - 00:09:31:09
John Riggi
And we all know that when there is disruption and delay to health care delivery, patient safety is placed at risk. Lives are threatened. The bottom line: these attacks are not just data theft crimes. These are threat to life crimes. And again, they're not only going after hospitals, but after our mission critical third party providers. For instance, the Change Healthcare attack: the largest, most consequential cyberattack against health care in history, compromised the health care records of 100 million patients, 100 million Americans, costing the sector $100 million a day.

00:09:31:12 - 00:09:57:23
John Riggi
And then ultimately disrupting health care delivery. But it's not just the big organizations that are attacked. And of course, when a rural hospital is attacked, there's an outsized impact to the community they serve. Because these attacks, as we have seen, are not just attacks on the hospital as an organization. It's an attack against the patients inside the hospital and against the entire community

00:09:57:23 - 00:10:26:11
John Riggi
that depends on the availability of that hospital. A couple of years ago, we had an attack on Sky Lakes Medical Center in southern Oregon. Their 90 bed hospital serve about 120,000 people across 10,000 square miles. Their next nearest hospital, 72 miles away. And when this attack occurred and encrypted their systems forcing them to shut down many of their services, it was very, very significant disruption.

00:10:26:11 - 00:10:54:01
John Riggi
And that disruption lasted about 28 days. They had to use 60,000 sheets of paper for clinical documentation. Fortunately, they did not have to pay the ransom. They had the capability to recover and restore independently. But again, significant impact to patient care delivery. And even after it hired extra staff, it took some six months to input all the paper records into the system.

00:10:54:03 - 00:11:23:00
John Riggi
So the organization spent about $10 million, a huge expense that was not covered by insurance to overcome this attack. And we have to thank Skylights Medical Center for coming forward to share best practices and lessons learned so we can all help prepare for the impact of these attacks. Unfortunately, I have many examples of how these attacks affect the patients in these rural hospitals, but also threaten the safety of the entire community.

00:11:23:03 - 00:11:45:10
John Riggi
A couple years back, I got a call from a hospital in the Pacific Northwest, and they were talking about an attack that they were experiencing, but there were two other hospitals that were also under attack. And so their natural diversion points no longer existed. And they said, John, we are very, very concerned because our next nearest emergency department is 125 miles away.

00:11:45:16 - 00:12:02:21
John Riggi
Said John, we've got a medevac parked in the parking lot, but we already are in the state. It actually snows in the winter quite a bit, and we're expecting a storm to come in. If that happens, our medevac can't fly. And if we get a stroke, heart attack or trauma patient, that patient's going to have to go ground transport if it's even safe.

00:12:02:23 - 00:12:21:20
John Riggi
And unfortunately, we don't think that patient would make it under those conditions. That's how deadly serious these attacks are. And that's why we always say and tell the federal government that these attacks - make no mistake - the bad guys know what they're doing in the hospital. They're threatening lives. These are threat to life crimes.

00:12:21:22 - 00:12:39:29
Tom Haederle
Thanks for listening to part one of this podcast. Please join us on Wednesday for part two as we continue this important conversation on cybersecurity for rural hospitals. Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcast.

00:00:00:09 - 00:00:21:21
Tom Haederle
Distance and lack of transportation. Obtaining a prescription and then paying for it. These are just some of the challenges that make accessing mental health and addiction services especially difficult in rural communities.

00:00:21:24 - 00:00:43:01
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Access to quality care in rural communities often presents problems that defy easy solutions. Still, there are workarounds, as we learn in this podcast hosted by Rebecca Chickey, the AHA's senior director for clinical affairs and workforce.

00:00:43:04 - 00:01:06:17
Rebecca Chickey
Indeed, it's an honor to be here today with Brenda Romero. I have known her for over a decade now. She is a past member of AHA's Committee on Behavioral Health, our national advisory committee that helps us with our advocacy and policy, as well as resource work. And that's why Brenda is here today as a CEO of a small rural hospital in New Mexico.

00:01:06:19 - 00:01:31:21
Rebecca Chickey
She has a great deal of experience, some of which she's going to share with you here today about improving access to mental health and addiction services in a small rural community. So, Brenda, welcome. Thank you for sharing your time and expertise. My first question to you is, what are a couple of the biggest challenges to accessing behavioral health in a rural community?

00:01:31:25 - 00:01:37:09
Rebecca Chickey
For those many, many listeners who live in an urban, metropolitan area, help them understand.

00:01:37:11 - 00:02:09:20
Brenda Romero
The first issue is access to the care in that rural communities don't usually have taxis. Transportation is an issue. And for people who are suffering from this illness, they're usually couch surfing or living out in the streets. And so finding them and getting them to the care is usually the first issue that we encounter. And the second is getting them the medication. The cost

00:02:09:20 - 00:02:38:15
Brenda Romero
of the medication can be up to $500 a month. And getting them the prescriptions is one thing, but then getting them the medications is another. Usually people with that presentation don't have a payor source, and so then it would require somebody giving them that money and willing to support that every single month. In order to increase compliance with medication treatment

00:02:38:20 - 00:03:03:26
Brenda Romero
we have started using some medications, like Brixadi, that we can give in the ER or in our infusion center, and it'll last a whole month. And we're using that type of medication for pregnant women that present and that we're not sure if we're going to see again for some time. And so that's been helpful.

00:03:03:28 - 00:03:27:15
Rebecca Chickey
So I'm going to hit home with a couple of things that you said for people who live in Chicago or New York or even Nashville, Tennessee, where I lived for a number of years. The fact that there's not a taxi is really sort of like, what? And I suppose that same lack of transportation services, you don't have an abundance of Uber drivers or Lyft drivers in your community either, right?

00:03:27:16 - 00:03:53:11
Brenda Romero
No, it's not available. And when you're talking about where these patients need to come from, we are in Espanola and there's about, there's less than 10,000 people that actually live in the city. And then there's Rio Arriba county, and it can be 100 miles to one of the borders. So we're talking about they come from surrounding communities. So it's not like somebody can walk there.

00:03:53:13 - 00:03:55:13
Brenda Romero
They need to find a ride.

00:03:55:15 - 00:04:18:17
Rebecca Chickey
And so that means relying on family or friends who may or may not also have transportation services. So just that physical capability of getting to the hospital or the emergency room is a challenge that many of our listeners probably can't imagine, but I can. Having grown up in rural Alabama, when EMS tried to get to my father, they couldn't find the house because there was no GPS at that time.

00:04:18:19 - 00:04:49:26
Rebecca Chickey
The next thing that you mentioned is the cost of the medications. So that's not unique to mental health. There always seems to be an article in the news or a discussion somewhere about the cost of medications, but these medications are for our most fragile patient populations because they often, and please correct me if I'm wrong, but they often have physical comorbidities as a result of or perhaps one of the reasons that they may be self-medicating with substances.

00:04:50:03 - 00:04:56:29
Rebecca Chickey
So their physical health and their mental health are often fragile and being challenged. Is that an accurate statement?

00:04:57:01 - 00:04:58:09
Brenda Romero
Yes.

00:04:58:11 - 00:05:16:02
Rebecca Chickey
And so because of that, tell me why it's so important to be able to provide a medication that lasts for a month. Is that to know that you don't have to worry after that because of compliance issues, because the patients are actually going to, they don't have to worry about that then.

00:05:16:05 - 00:05:48:23
Brenda Romero
Yes, it's not only compliance, but it's actually getting the medication. And so usually they don't have a payor source so they don't have Medicaid. And if they have Medicare due to a disability, they usually haven't signed up for part D or any of the other parts that they need to get payment for the medications, for prescriptions. And so if they were to try to go get their medications and be compliant with that, most times they wouldn't even get the medications because they can't pay for them.

00:05:48:26 - 00:06:07:24
Brenda Romero
And if a family member is willing to start them on it, like pay for the first month, it's pretty hard to get somebody to commit to just continue to pay for that. In order to get them on Medicaid, they would have to then get all the paperwork in order to apply. And they can apply online.

00:06:07:24 - 00:06:28:24
Brenda Romero
But some of these older folks don't have the capacity to be able to do that. They don't have the phone. They don't have the experience with getting on a website and filling in all the information that they need. And some of that information that they might need is to upload a copy of the birth certificate, and they might not have the birth certificate.

00:06:28:26 - 00:06:37:12
Brenda Romero
So the barriers are huge for them. They can't get there. And so I think that...

00:06:37:15 - 00:06:40:28
Rebecca Chickey
So what's your solution? What have you been creating, what have you been innovating.

00:06:40:28 - 00:07:01:18
Brenda Romero
So what we've done is we've started the treatment in the emergency room and then following them up in the clinic. And if we can get them started on medication, then we can buy more time to work with peer counselors, to work with case managers to help them get what they need in place in order to continue the treatment.

00:07:01:21 - 00:07:29:00
Brenda Romero
We are also encouraging the homeless shelters to work with the homeless population and to get them to our E.R. if they can do that. Presbyterian Healthcare Services, organization I work for, is now also asking if our paramedics can start giving out some of the medication when they respond to a call, if the patient is willing to start the treatment at the time.

00:07:29:07 - 00:07:37:17
Brenda Romero
So we're trying to figure out how to get the medications to folks where we can, even if they can't afford to do it.

00:07:37:19 - 00:08:04:08
Rebecca Chickey
So it sounds like you're taking advantage of every opportunity where there's a touchpoint with a patient that has this need. Yes. That's phenomenal. It's, I think, a broader sense of patient-centered care. You're going to where the patients are and providing the services. So do you think this innovative idea is replicable? Can it be implemented by other organizations in a similar crisis situation?

00:08:04:08 - 00:08:11:23
Rebecca Chickey
I would say because the challenges that you described almost seem insurmountable. But do you think others could replicate it?

00:08:12:00 - 00:08:35:21
Brenda Romero
Yes. Also, keeping in mind that, especially at the beginning, they're not going to have a payor source, right? So we're going to have to start that and not be reimbursed for that. But it makes a huge difference, not only most importantly to that person's life. Right? Like, who wants to be suffering like that? And then it starts improving their participation in society

00:08:35:21 - 00:09:02:27
Brenda Romero
and with their family members. And in our area it's a very family-oriented area, and most people who don't have a place to live will have a place to live if they sober up. And so reuniting those patients with their families is just, it would be an amazing thing to do. And then their reentry into their communities would be another win for everybody, right?

00:09:03:00 - 00:09:25:08
Brenda Romero
And makes it a safer place for the patient and for the communities that they live in. And so I think it's very, very important. I think it's worth it to everybody. There's something in it for everyone. And I think that one way to start is to assess what the barriers are, what are the barriers that those patients in your community are experiencing.

00:09:25:08 - 00:09:37:07
Brenda Romero
Because as you said, bigger communities have transportation. They have other ways to get around. So the patients in their community might not have the same barriers that we have in ours.

00:09:37:14 - 00:09:59:26
Rebecca Chickey
Yeah. As you were describing the long-term impact of this, if an individual gets on a medication that helps them remain sober for a month, then that gives them hope, then they may be able to get traction to go back and live with their family. Then they may be able to get a job. And that is something that is priceless, right?

00:09:59:29 - 00:10:26:15
Rebecca Chickey
You can't really put a price on giving someone their humanity back. But at the same time, the reality is that often no margin, no mission. So I realized that this is a new innovative initiative that you undertake, and so you probably haven't, you don't have hard data on that. But I would assume that what you're hoping is that you're going to see fewer emergency room visits, which we all know are costly.

00:10:26:17 - 00:10:54:12
Rebecca Chickey
I assume that you're going to have less use of emergency services outside, sending someone out to rescue someone who is in a crisis from a substance use disorder. And perhaps even you will see a reduction long term in things like cirrhosis, in things like congestive heart failure, in wound care for individuals, depending upon what the substance is. Is that what you're hoping for in the long run?

00:10:54:15 - 00:11:21:19
Brenda Romero
Yes. But most importantly, saving people, saving people's lives, right? They are at risk of death every day, premature death every day. And there's a lot of violence that's, you know, associated with this diagnosis. And so not only the patient's life, but their family and friends and other community members walking around. I mean, it would improve all of that also.

00:11:21:21 - 00:11:33:08
Rebecca Chickey
So it's a population health approach, I agree. Thank you. So much, one, for the work that you're doing. Boots on the ground, making a difference in individuals' lives. And thank you for sharing that inspiration with us here today.

00:11:33:10 - 00:11:34:27
Brenda Romero
Thank you.

00:11:35:00 - 00:11:43:10
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:15 - 00:00:24:23
Tom Haederle
In 2022, more than 49,000 Americans took their own lives. Beyond the tragic loss of someone who might have been saved by seeking help in time, suicide has a domino effect, leaving devastated families and communities in its wake. Suicide happens across every sector of society and there are resources available to help. But for farmers in rural areas, accessing those resources is especially difficult.

00:00:24:26 - 00:00:39:10
Tom Haederle
That's why Farmer Angel Network in central Wisconsin has stepped up to help.

00:00:39:12 - 00:01:07:26
Tom Haederle
Welcome to Advancing Health, the podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Farmer Angel Network is a support group founded to tackle suicide prevention, as well as assist loved ones who are coping with it after the fact and steer them to resources that can help. In today's podcast, hosted by Jordan Steiger, senior program manager of clinical affairs and workforce with AHA, we learn more about the group's important work and how area hospitals are contributing to the effort.

00:01:07:28 - 00:01:22:14
Tom Haederle
Jordan's guests are Brenda Statz, cofounder of Farmer Angel Network, Carey Craker, who handles marketing and volunteer services at Reedsburg Area Medical Center, and Christy Updike, transformation program manager with Sauk Prairie Healthcare.

00:01:22:16 - 00:01:45:12
Jordan Steiger
Brenda, Christy and Carey, thank you so much for joining us today on the Advancing Health podcast. We know that it is Suicide Prevention Month. We really want to shed light on the work that our members and our communities across the country are doing to bring some awareness about the issue of suicide, and I think the work that all of you are doing in your community in Wisconsin is really exceptional.

00:01:45:15 - 00:01:57:27
Jordan Steiger
So, Brenda, I'd like to start with you as one of the founders of the Farmer Angel Network. Could you please just tell us more about what the Farmer Angel Network is and what inspired you to start this initiative in your community?

00:01:57:29 - 00:02:16:21
Brenda Statz
We are just a group of people that started out at our church. I had lost my husband to suicide, maybe six years ago coming in October. And we started a support group of people to come in through our church. The president of the men's club, who was a friend of my husband's, wanted to do something.

00:02:16:21 - 00:02:38:05
Brenda Statz
And so he said, I just want to call people together to come in and talk, and that's how it started. And so the ladies of the church did a soup and sandwich luncheon, and we did it from noon to two, because that's when farmers usually come in to eat. And we put it out to Pam Jahnke on Channel 3 News and said, hey, we're having this gathering at Saint Peter's Church in Loganville.

00:02:38:07 - 00:03:04:05
Brenda Statz
Anyone who wants to come and talk or just needs someone to listen, or just wants to find out what's, you know, if something's going on in their life that they want some help with, they should show up. A lot of events we go to, we show up, and our main goal is to provide resources to the rural communities. Because when I went through it with my husband, everybody afterwards said, well, you could have gone here, you could have gone checked into this.

00:03:04:07 - 00:03:30:00
Brenda Statz
I didn't know any of that existed. And so I thought, this is some way that we can help other people and other families. And that was another big key to me was, for me, was to support the families, supporting those going through the crisis because they're already in trauma also. And that trickles down to the kids, all the way down, because it is a domino effect that affects everyone.

00:03:30:02 - 00:04:00:21
Brenda Statz
And so we try to bring resources to everyone to support the whole family. So, if the person does have to go into a treatment facility, by the time they come home, we can have the families supported. Because, like on a farm especially, somebody still has got to do the work whether you're there or not. And so if that person, like when my husband would go, that fell on me and my sons to do the cropping and get everything done while he was in the hospital. And the guilt that they have of not being there. But yet, they can't function where they're at.

00:04:00:21 - 00:04:18:18
Brenda Statz
So, that's what I always told them. You need to go where you can get help because we can't help you here on the farm. So that's your job now, to go get help. And so then he would agree to go, and we would take care of what needed to be done on the farm. But sometimes that can cause a lot of resentment to the other farm members

00:04:18:18 - 00:04:48:03
Brenda Statz
if it goes on for a long amount of time, because everybody gets tired; everybody gets stressed out. And if you don't teach them how to handle that stress, by the time that person comes home, they might be in a good place. Everybody at home is not, and that can just spiral out again. So, if we try to get everybody on a good place before they come home or whatever the situation they have going. That is our biggest goal that we have is just to bring resources, so people realize they are not alone.

00:04:48:06 - 00:05:16:23
Jordan Steiger
You've brought up so many important topics, I think within suicide prevention and just that introduction of the work that you do. I think, you know, surrounding the family and making sure that other people are empowered to take care of themselves as they're taking care for their family member that might be struggling. But one of the things that you really brought up, that I think maybe people in urban areas don't know as much, is just that stress that farmers face and those risk factors that come up for farmers and their families.

00:05:16:25 - 00:05:25:21
Jordan Steiger
So, I'm wondering if you could expand on that a little bit and just tell us about some of the unique things that farmers and farming communities face when it comes to mental health.

00:05:25:24 - 00:05:46:24
Brenda Statz
Stress is one of the number one things, but the biggest stressors they have is the weather. We can't change the weather. YouÕve got hay to make, youÕve got corn to plant. Everything relies on good weather or it's too dry. Last year we had a drought. I mean, we had half the crop or less because it wouldn't grow once you put the seed in the ground.

00:05:46:26 - 00:06:07:15
Brenda Statz
The other stressor we have is markets, totally out of our control. We have to take the price that is offered unless you work for a contract[BM1]. You know, there's ways that you can do that. But there's a lot of farmers that don't have access to that or just don't understand how to use the systems. And then other stress too, is just, having time to yourself. Time away,

00:06:07:15 - 00:06:30:18
Brenda Statz
time to get away from the farm, trying to relax somewhere. Because when you live where your job is, you never are off the clock. When you live in town, you work your job, you go home. When you're on a farm, you're at your job all the time, and you can never walk away. And so you have to teach people how to take time for themselves.

00:06:30:20 - 00:06:33:00
Christy Updike
I would add to that, if that's okay.

00:06:33:08 - 00:06:35:20
Jordan Steiger
Yeah, absolutely. Jump in, Christy.

00:06:35:23 - 00:07:05:29
Christy Updike
Couple additional things, are the transitions in farming. So many are family farms, and that transition to younger generations or having to sell or get out of farming are huge stressors and crisis moments for many people. That's a big risk factor that they're going through that. Another is access to guns or deadly weapons. So that is a standard part of living on a farm.

00:07:06:01 - 00:07:34:02
Christy Updike
It is a tool that we have to utilize. And unfortunately, that can be a risk factor in the farming. And the last one is isolation. So much of what farming is with the animals and the fields, and we don't have as many opportunities for fellowship. And that's one thing that Farmer Angel does, is to help bring farmers together to help address that isolation.

00:07:37:06 - 00:07:55:17
Jordan Steiger
I'm really glad you brought up isolation, because I was just going to ask Brenda about that. That was the first word that came to my mind when she was describing, you know, putting together this, this meal and, kind of fellowship at the church, you know, is just having that opportunity to come together, we know, is so important for mental health.

00:07:55:19 - 00:08:20:19
Jordan Steiger
It sounds like that's something that doesn't naturally always happen for people in farming communities. So, I think that, again, underscores the importance of the work that you guys are doing. So, I'd like to transition now and talk to our hospital leaders a little bit about how this actually works within the community. So, Christy and Carey, both of you represent two different hospitals, who work together as part of the Farmer Angel Network.

00:08:20:21 - 00:08:37:17
Jordan Steiger
I love to see when hospitals kind of come together for a common cause, and work across the organization to do something good for the community. So, I'd love for you to explain the role that hospitals play in this greater kind of network of work and the types of services that you provide.

00:08:37:19 - 00:09:07:24
Christy Updike
Sure, I'll start off with that and then Carey can jump in. To start with, Carey and I are both part of farming families as well. So, we have our professional roles and represent our organizations, but then also have our personal roles in being part of farming. And many of the people that we serve in both of our hospital service areas are either farmers, farm families or farm workers.

00:09:07:24 - 00:09:37:06
Christy Updike
They're part of that agricultural community. So, what we do as hospital partners with Farmer Angel Network is to offer our own resources as a part of our professional roles, to help the network coordinate the activities to achieve their mission. So, for example, in my role, I serve on board for the network and bring in the resources we have from the hospital. Whatever

00:09:37:06 - 00:10:18:26
Christy Updike
that might be, my time, the tools and resources, other experts. We also are able to support with expenses or resources like materials and printing materials, which Reedsburg Area Medical Center has done, as well as Sauk Prairie Healthcare. And we cohost and comarket our events. We have also trained our health care providers. So, with the collaboration with Farmer Angel Network, we've brought in different trainings for suicide prevention and for caring for farmers.

00:10:18:28 - 00:10:50:21
Christy Updike
And then we offered a continuing medical education collaborative with our entire county. So, all health care providers and behavioral health care providers in our county that are working toward suicide prevention on how they can best understand the farmers they care for, and practical strategies to help with suicide prevention, mental health care. So, I think with that, Carey can jump in as well.

00:10:50:23 - 00:11:26:19
Carey Craker
Sure. Just to expand a little bit on what Christy said. We help get the resources out there to our rural communities. As with any support group, you have times when things don't get better or when things escalate beyond what our group can help with. Reedsburg has both emergency services for crisis that's available 24/7 and a dedicated and growing behavioral health team thatÕs comprised of people from the rural community who understand rural living, farmers and rancher perspective.

00:11:26:21 - 00:11:51:09
Jordan Steiger
One thing that you both just brought up was that kind of cultural awareness around, you know, making sure that your providers and your behavioral health providers are aware of some of these things that we're talking about, you know, that could really affect farming communities. I'm a licensed, clinician myself. I'm a social worker, and I can tell you I did not learn in social work school how to care for these types of communities.

00:11:51:09 - 00:12:17:18
Jordan Steiger
And I think it's something that is really important to understand if you're going to be in that situation. So, I think that offering the CME credit, like you mentioned, offering that training at lots of different like lengths and, you know, over different times, I think is really probably very effective for, for you. Carey, I'm wondering if you have any advice for other rural hospital leaders who might say, like, wow, this program and this work is incredible.

00:12:17:18 - 00:12:20:24
Jordan Steiger
I want to start this in my community. What would you tell them?

00:12:20:27 - 00:12:48:04
Carey Craker
I think the biggest thing is going off of what we call our community needs health assessment. It's done nationwide and for the last, I don't know how many years, mental health has been at the top of the list. And so between us, Sauk Prairie Healthcare and the other hospitals in the area, it's the top of our conversation whenever we're looking at what do we need to do to help the community?

00:12:48:08 - 00:13:03:05
Carey Craker
So, the biggest thing, I think, would be, you know, to come together. We're not standing alone where hospitals in small communities who need to band together to help this mental health need.

00:13:03:08 - 00:13:32:17
Jordan Steiger
I think that's great advice. Again, just, you know, we're not in silos. I guess that's kind of a farming pun. I didn't mean that, but we should be working together. Not even just with other hospitals, but, you know, other community organizations, other groups across your, you know, your county, your region. I think that you guys have really done a great job of not staying just within the hospital or staying within a church or staying within these small entities, but really coming together.

00:13:32:20 - 00:13:49:14
Jordan Steiger
As we wrap up, I'd like to just turn it back to Brenda. I want to thank you for starting this and having the courage and the foresight to say that this is something that your community needed and using the loss that you endured to help other people. I think itÕs a really beautiful thing.

00:13:49:16 - 00:14:10:03
Brenda Statz
When it comes to this, like we are a network and that's why we are called the Farmer Angel Network. I always say, if one of us doesn't know something, we might know somebody who does. So, we all work together to get to the end result, which is to help the family or to help those that are struggling. And there is a lot of training. I've done mental health, first aid responder and safe talk training.

00:14:10:06 - 00:14:29:05
Brenda Statz
And that's what we've done with the hospitals. And the one thing I give them as advice is when a farmer finally decides to come in, don't just brush them off because it's going to take 15 minutes before they finally come forward with why they're there, because it takes a lot [BM2]for them to leave the farm because they've got 100 things to do.

00:14:29:05 - 00:14:44:06
Brenda Statz
So, they have to be in a really bad place before they will come in. And I said, they're going to walk in your office and they're going to talk about the dog, the weather and everything else. And then when you'll say, well, I guess our 15 minutes is up, and then they'll say, wait a minute, I've been struggling with this.

00:14:44:06 - 00:15:22:17
Brenda Statz
It takes time for them to gain your trust because a person with mental health, like with my husband, it takes a long time before you can trust someone to tell them that they're struggling with something like this, because farmers are fixers and they try to fix it themselves, and they wait so long to go in. But once they get in and they get the right tools or medication or whatever they need to help them navigate what they've got going on in their life, they do respond that much better once they've let it out, that they need help. And we just need to just, really, just listen because sometimes they just want to be heard.

00:15:22:19 - 00:15:39:12
Jordan Steiger
Sometimes just a very easy conversation to say, hey, I'm not doing okay. It's just the gateway that you need. I think everyone listening to this is going to be able to take something away, and we really appreciate the work that you're doing on behalf of all of our hospitals and all of the people that you serve. So, thank you.

00:15:39:16 - 00:15:40:21
Christy Updike/Brenda Statz overlapping 
Thank you. Thank you.

00:15:40:24 - 00:15:42:16
Carey Craker
Thank you, Jordan.

00:15:42:18 - 00:15:50:29
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:00:18 - 00:00:20:26
Tom Haederle
Experts say at least one in five children or adolescents in a pediatric waiting room is dealing with a significant mental health problem — everything from serious eating disorders to suicide attempts. Nationwide, there has long been a critical shortage of trained care providers to meet the needs of kids struggling with these issues. And the problem is especially acute in rural areas.

00:00:20:29 - 00:00:42:06
Tom Haederle
So it's encouraging to see that the most rural academic health system in the U.S., New Hampshire's Dartmouth Health, has created one of the most innovative and effective programs anywhere to provide the tools to help.

00:00:42:09 - 00:01:09:27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Sitting near the border with Vermont, Dartmouth Health serves a population of nearly two million people across many small towns in northern New England. Backed with a federal grant, Dartmouth has created a five-part virtual behavioral health training program for children and adolescents that offers care providers effective tools to engage and help guide young people through their challenges.

00:01:09:29 - 00:01:37:00
Tom Haederle
The program is called Keeping Students Safe: Supporting Youth in Mental Health Distress. In dialogue about the program with Jordan Steiger, AHA senior program manager for clinical affairs and workforce, are three experts from Dartmouth Health. Dr. Julie Balaban, child psychiatrist, Jackie Pogue, research project manager with the Dartmouth Institute for Health Policy and Clinical Practice, and Barbara Dieckman, director of Knowledge Map and patient education.

0:01:37:02 - 00:01:53:18
Jordan Steiger
Julie, I'm wondering if you can kick this off being that you are a child and adolescent psychiatrist, but we know it's been all over the news that since the start of the pandemic, a lot of children and adolescents are really struggling with their mental health. So could you kind of just paint the picture for us of what that's looking like right now?

00:01:53:25 - 00:02:21:09
Julie Balaban, M.D.
Yeah, I think there's actually been a problem with meeting the needs of children and adolescent mental health for a long time, because there's always been a critical shortage of mental health providers in general, and specifically for children and adolescents in that area of specialty. And then the pandemic really highlighted that the kids that were coming into the emergency room were seriously ill.

0:02:21:11 - 00:02:43:17
Julie Balaban, M.D.
Significant eating disorders, very serious suicide attempts. That's what was showing up during that time. And I think that really brought to light that this was an area of great need for a long time. So it's been well known that historically, that one in five kids in a pediatric waiting room, for example, will have a significant mental health problem.

00:02:43:17 - 00:03:10:14
Julie Balaban, M.D.
That number may now be higher, maybe one in four. And depending on what region you live in of course. The other piece that the pandemic played into is of course the general workforce shortage. So nursing shortage, for example, is a problem that's been affecting things like inpatient beds for kids who might need a psychiatric hospitalization. So hospitals have had to decrease their bed size.

00:03:10:14 - 00:03:34:05
Julie Balaban, M.D.
And so that led to a backlog for kids who were seriously ill, having to be in emergency rooms or even waiting at home. At Dartmouth, we had the luxury of being able to put some of those kids, at least up on a pediatrics unit, so they were around other kids and not in a general emergency department, which can be a scary place for a kid.

00:03:34:07 - 00:03:58:09
Jordan Steiger
Absolutely. And I mean, I know that this is a problem that is affecting communities, hospitals, health systems across the country. We hear it all the time at AHA. You know, we need to provide support to children and adolescents. I know you mentioned some pretty severe things like suicidal ideation, you know, severe and persistent mental illness that we know can continue to get worse when they are not treated.

00:03:58:11 - 00:04:14:27
Jordan Steiger
What I love about the work that you all are doing is that you're not just sitting back and saying, this is bad, what are we going to do? You've taken the steps to do something about it, and kind of brought your entire community and state along for the ride with you. So I would love to hear kind of what you're doing.

00:04:14:27 - 00:04:25:11
Jordan Steiger
I know that you have a virtual behavioral health training program for children and adolescents, and teaching people how to respond. Is that correct? Jackie? Can you tell us a little bit more about it?

00:04:25:11 - 00:04:49:09
Jackie Pogue
Sure. So we received a grant from HRSA around training rural behavioral health workers, very broadly defined. And we knew we wanted to focus on youth mental health. But, you know, we can't, like, grow a bunch of new psychiatrists in three years or, you know, things like that, we're trying to think creatively about where might be points of intervention that could have a bigger impact.

00:04:49:12 - 00:05:32:04
Jackie Pogue
So we met with a lot of different stakeholder groups, a lot of people from schools. So school counselors, school principals, other folks hearing about how youth mental health was impacting kids at school. So it could be things like really disruptive classroom behavior, kids who are kind of languishing, like just showing up but not thriving, right. A lot of kids wandering the hallways and hearing some of those stories, and also educators and people on the school staff, like really trying to work together for the increased severity and number of kids who were in having mental health challenges.

0:05:32:05 - 00:05:55:22
Jackie Pogue
So through those conversations, we developed, five-series training called Keeping Students Safe: Supporting Youth and Mental Health Distress. And we designed the program so that way to kind of fill some of these gaps that we heard from the schools. So they're like, well, they said they're very sick, but they went to the hospital and they sent them home.

00:05:55:24 - 00:06:17:06
Jackie Pogue
Like, why didn't they admit them? They're still so sick, or, oh, they went to the hospital and they came back and they're still really having problems, like what's going on. And so we realized there were, there are these kind of siloed systems, and to be able to share information and, you know, sort of promote more collaboration and give people more tools.

00:06:17:09 - 00:06:45:11
Jackie Pogue
What's been interesting is sort of helping people learn about all the skills they already do have, you know. I think there's a lot of fear from people that they're gonna say the wrong thing or that they don't have the tools, and not everybody is going to administer like a Columbia scale around suicide severity, right. But like especially school staff, I mean, they're amazing, you know, they're like, yeah, I talk to this kid every day.

00:06:45:11 - 00:06:55:27
Jackie Pogue
We do a check-in. We do these things like so just helping them feel more confident and that there's more details on it left out. Julie or Barb, what what else would you add?

00:06:56:00 - 00:07:26:16
Julie Balaban, M.D.
I think you did a great job, Jackie, of describing. I think what I would add is each time that we do the program, we learn from what our experience is, so that we can fine tune the content to better address what's coming up from the participants as what their needs are. And I think the other really nice aspect of the way the program runs through the I ECHO format is this all teach, all learn model.

00:07:26:19 - 00:07:55:04
Julie Balaban, M.D.
So not only, as Jackie said to people already innately have a lot of skills that they can bring. They just don't realize that it's useful. But they also all have a lot of help and support for each other and very practical resources. You know, we'll hear schools from the northern part of the state talking about something that they're doing, and then someone in the southern part of the state will connect with them offline to find out how they could implement the same thing in their school.

00:07:55:10 - 00:08:17:04
Julie Balaban, M.D.
So it's just been a wonderful way to build connections and networks that otherwise would never have happened, and all in the name of supporting youth in their schools. And our hope being that with those added resources and support, that kids will do better sooner and won't get to that severe level where they need to go to the emergency room or need to access things.

00:08:17:12 - 00:08:23:21
Julie Balaban, M.D.
But we also tell them how to handle that and what they have available to support them if they should need to.

00:08:23:23 - 00:08:52:06
Barbara Dieckman
I would agree with both of you. You know, I think that the ability to intervene in a kid's life earlier or in their where are you beginning to see some problems at school and having people that have those natural relationships with kids actually do something or be able to reach out and touch them is really helpful. I think just to decrease the demand on the whole acute care system.

0:08:52:08 - 00:09:17:26
Jordan Steiger
Absolutely. And I love, you know, through this program, you've kind of addressed some of those workforce issues that we hear about, maybe not directly, you know, but bringing people in like a coach, like a school nurse, like a principal, people like you said, Barb, that have contact with these children every day, that know them, that know their lives and can intervene, I think, takes so much stress off of the local health care system, as you all have mentioned.

00:09:17:29 - 00:09:37:07
Jordan Steiger
And I think that's so important because as you said, Jackie, we can't grow psychiatrists on trees. That's going to take a little time to build the workforce. So this is, I think, just such a great example that others can emulate and really implement in their own states. But I'd love to hear a little bit, maybe about some of the positive outcomes that you've seen.

00:09:37:15 - 00:10:21:23
Jackie Pogue
So we've done this five, it's a five-session one hour Zoom like every couple weeks. Usually. So we've run that five times. We've probably had 500 total people participate. It's been very, very popular. And some of the outcomes that we've heard, we do a pre/post course survey and we do a follow-up three months later. So things that people talked about are feeling more confident that they could intervene with a student in distress, that they knew the resources that were available and that they felt more confident interacting with youth's families as a resource and also other community resources.

00:10:21:26 - 00:10:57:29
Jackie Pogue
One outcome that we're really proud of is that, like 100% in every session, people talk about having a decreased sense of professional isolation. And so that is really powerful for us, knowing that people are, you know, just like in health care, school staff are very stressed. They've had a really hard time from the pandemic and now, and to be able to provide an opportunity for people to connect, to not feel so alone, right, that there's resources and there's hope has been really very meaningful I think for our team.

00:10:58:01 - 00:11:15:28
Jordan Steiger
That's great. I think, you know, sometimes we all get in our own bubbles and lanes and think, oh, we are the hospital. We can only solve problems for patients and families once they walk through the doors. But I think this proves that there are a lot of ways to partner with your community and to really improve the way that we respond as a whole.

00:11:15:28 - 00:11:28:20
Jordan Steiger
And I think that's really, really powerful, especially when we're talking about maybe smaller rural communities that we do know have some issues sometimes with workforce, with access, with things like that. I think this is just such a great example.

00:11:28:23 - 00:11:56:13
Jackie Pogue
Yeah. With youth mental health, it's just, it's such a crisis, right. And it's really an all hands on deck situation. And there's so many areas where people can act. And so that's really you know, when I think about the stats, it's really sobering. And then I think about all the caring school staff and community youth supporters and other folks that I have, that we've met through our Project ECHO.

00:11:56:15 - 00:11:58:09
Jackie Pogue
It really gives me a lot of hope.

00:11:58:11 - 00:12:19:09
Julie Balaban, M.D.
Yeah, I think one of the things that was an unexpected outcome for me, anyway, was hearing from the community, you know, we know this is a crisis and I come at it particularly from a clinical perspective. And what are we doing and how are we seeing these kids, and what kinds of things can we do to increase access to specialty care and all of that?

00:12:19:12 - 00:12:45:19
Julie Balaban, M.D.
And then talking to not just the schools, but particularly when we did the community programs, town libraries, we had a lot of librarians participate, and the stories that they tell about what they're doing and how they're trying to hold these kids together and what they have to manage in their setting with even less support than a school setting would have

00:12:45:21 - 00:13:09:21
Julie Balaban, M.D.
for example, it really opened my eyes to how this problem is just not just pervasive, but is really affecting people in the community so strongly, even if it's not the family member of the kid or the school trying to educate the kid. Like everybody is experiencing it, everybody is struggling. It was really something.

00:13:09:24 - 00:13:16:22
Jordan Steiger
That is. What other types of professionals were involved in that community ECHO that you ran?

00:13:16:24 - 00:13:57:03
Julie Balaban, M.D.
So we had some faith leaders from the community. We particularly ended up with our panel trying to include more of the community members for that reason, because we previously had had a lot of school people because we were dealing with school. And then of course, the hospital psychologists and myself and the typical sort of providers for kids. But we've very much have learned that if we're doing a program for a particular group of stakeholders, you need to have representation from that group on your panel, or you'll miss the boat in a number of things, even if it's just like when to schedule the sessions.

00:13:57:05 - 00:14:12:07
Julie Balaban, M.D.
So we had faith leaders, we had the coaches, we had rec department people, we had a daycare provider participate. People from some of the like, family support centers throughout the region. Those kinds of people.

00:14:12:09 - 00:14:37:15
Barbara Dieckman
You know, I would add to that, what is so good about doing this in a virtual way is that people didn't have to come to a meeting, central location. We've got mountains and you know everything else, right? And like every other rural community, there's distance, right? And there is hardship in terms of transportation and getting time off. None of that had to happen.

00:14:37:23 - 00:14:53:13
Barbara Dieckman
I mean, what we were able to do is to bring these people together from very disparate areas geographically to talk about something that they all cared about, and they all had very similar themes of need and solutions for each other.

00:14:53:15 - 00:15:12:10
Jordan Steiger
I think that's really powerful and especially like you mentioned, just, you know, addressing some of those, you know, transportation, some, you know, that distance between people, I think is something that I think many people will resonate with that are listening, you know, finding easier ways to connect people. And I think you guys have done that really, really well.

00:15:12:12 - 00:15:22:20
Jordan Steiger
As we wrap up, if you maybe have inspired somebody that is listening to, you know, implement something like this at their own hospital or health system, what advice would you give them?

00:15:22:23 - 00:15:49:00
Julie Balaban, M.D.
I would say do it. You know, we used a particular program that I ECHO program because Dartmouth has joined that group. But you can do this without any sort of a formal program. In our presentation, in our handouts, we particularly put a lot of that information because we want people to be able to emulate it within their own setting with whatever they can do and whatever resources they have, and it doesn't have to be costly at all.

00:15:49:03 - 00:16:14:16
Julie Balaban, M.D.
So I would say just jump in and do it. And I think, again, I think the important pieces are to go to the group you're trying to reach and hear from them. As Jackie talked about what they see as their needs, because we had guesses about things. But I think we did a better program because we worked from their perspective and what they were telling us.

00:16:14:19 - 00:16:24:18
Julie Balaban, M.D.
And then also to keep that good representation on your planning committee and on your panel so that you're really keeping a nice, well-rounded group going.

00:16:24:20 - 00:16:29:12
Jordan Steiger
Great, thanks Julie. Barb, Jackie, any advice you'd want to share?

00:16:29:14 - 00:16:43:01
Barbara Dieckman
Know that you can make a difference. Know that you can make a difference and just keep keep doing it. Keep improving. Keep looking for ways to hear from the people that are your audience. You can do it.

00:16:43:04 - 00:17:05:29
Jackie Pogue
I would add, you know, I think Project ECHO is a really great training platform and format, but like Julie said, you don't need to do Project ECHO to do a good program. And the things that I really value about ECHO and what we've been doing is you don't need to have a bunch of fancy experts like talking, talking, talking, right?

00:17:05:29 - 00:17:33:11
Jackie Pogue
The beauty of a more interactive, all teach, all learn there is the sense that you're relinquishing some control over your program, but it ends up providing space and being more powerful, I think. And that is, that's just how adults learn, right? Like giving each other advice and ideas and stuff that you can apply right away. So, you know, I've facilitated all the sessions.

00:17:33:11 - 00:17:52:11
Jackie Pogue
It's super fun for me to just, you know, don't know what people are going to say. And, in that way, yeah, it's just it's really rewarding. So I would say even if you're not going to use Project ECHO, I would encourage you to if you're going to do a session, have half of it be something where the audiences interacting and sharing with each other.

00:17:52:14 - 00:18:10:20
Jordan Steiger
I love that all teach, all learn model. I think that is so effective and just want to thank all of you again for joining us. I think the work that you're doing across your state is truly phenomenal. And like I said, something that others can really learn from. So we appreciate you sharing. And Julie, I know you mentioned you put some notes in your presentation.

00:18:10:20 - 00:18:17:03
Jordan Steiger
We can make sure maybe to add those to the podcast description so others can also learn from that. As long as that's okay.

00:18:17:03 - 00:18:18:01
Julie Balaban, M.D.
That would be great.

00:18:18:01 - 00:18:21:12
Jordan Steiger
Wonderful. So thank you so much again.

00:18:21:15 - 00:18:29:23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00;00;00;19 - 00;00;22;29
Tom Haederle
Imagine getting an email or a phone call from a total stranger with this message: "I have your medical information and I know that you had surgery on this date." Pretty scary stuff. We've seen a sharp uptick this year in the brutal tactics of cybercriminals, who are now directly contacting and threatening patients during ransomware attacks, pushing the boundaries as never before.

00;00;23;01 - 00;00;48;26
Tom Haederle
As always, the bad guys demand payment and if a victim resists, they may threaten to publish sensitive photos online, take advantage of stolen patient records, or even send phony incident reports to the local police to trigger a harrowing visit from a SWAT team. Yes, that's happened too.

00;00;50;06 - 00;01;20;19
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA communications, John Riggi, AHA’s national advisor for cybersecurity and risk talks over with two experts how this latest despicable tactic in the arsenal of cybercriminals should be managed starting with updating incident response plans. As John notes, if there were ever any question that the intent of these gangs was to harm patients, it is now clear that is their fundamental intent.

00;01;20;22 - 00;01;45;21
John Riggi
Hello everyone, and thanks for joining today. I'm John Riggi your national advisor for cybersecurity and risk at the American Hospital Association. Today we'll discuss a new cybersecurity trend. Cybersecurity criminals are contacting and threatening patients during ransomware attacks. And there is a need to update incident response plans to adjust for the uptick in this despicable criminal behavior.

00;01;45;24 - 00;02;31;11
John Riggi
Unfortunately, last year was the worst year on record for data theft attacks and ransomware attacks. Foreign-based bad guys, primarily Russian ransomware gangs, are continuing to evolve their despicable tactics to increase the likelihood of payment by victims, including calling victims directly based on information in their stolen health care records, demanding payments from them directly, and/or conducting swatting attacks, dispatching local police to fake armed incidents at those homes of patients, which is very, very dangerous for the patients and responding law enforcement, and also threatening to publish very sensitive photos of patients online.

00;02;31;13 - 00;02;56;11
John Riggi
So, as you can see, they are pushing the boundaries directly, threatening patients. If there was ever any question that the intent of these gangs was to harm patients, it is clear now that is their fundamental intent. Today I'm joined with Jake Milstein, chief marketing officer at Critical Insight, and Johnathen Inskeep who was the former CIO at Caribou Medical Center.

00;02;56;13 - 00;02;59;12
John Riggi
Jake and Johnathen, thanks for joining the podcast.

00;02;59;15 - 00;03;00;14
Jake Milstein
Thanks for having us, John.

00;03;00;14 - 00;03;01;21
Johnathen Inskeep
Yeah, thank you.

00;03;01;23 - 00;03;12;00
John Riggi
Jake and Johnathen. Let's jump right in. Can you help our listeners understand what cybercriminals are doing during ransomware attacks and how they affect patients?

00;03;12;00 - 00;03;38;09
Jake Milstein
I think you, you know, you hit on some of the attacks that just occurred, but I want to go back actually a couple of years here, and recognize that this has been a criminal tactic in sort of a spotty way. You know, you go back 3 or 4 years and there was an attack on a school district in Texas, and that attack on the school district in Texas, the school district, I don't know, they either didn't pay quickly or decided not to pay.

00;03;38;11 - 00;04;02;20
Jake Milstein
And the criminals started calling parents and emailing parents and saying, oh, I know your son's name. I know your daughter's name. And of course, the parents started calling the school district. We saw it in health care a couple of years ago, but it was kind of spotty. The big change here is at the end of 2023, we saw it several times.

00;04;02;20 - 00;04;27;10
Jake Milstein
We didn't just see it one time. We saw it at a health care organization in Oklahoma, and then we saw it at Fred Hutch Cancer Care Center, which you talked about, which is in Seattle. And in the Fred Hutch case, the criminals went so far as to threaten these swatting attacks. The swatting attacks are when the criminals would, you know, they threatened to call 911 and say, you know, this person has kidnaped me and I'm in the basement.

00;04;27;10 - 00;04;48;27
Jake Milstein
Send the SWAT team, right? So the SWAT team would come. And you know, how might it affect patients? I mean, wow, can you imagine getting an email as a patient? You know nothing about cybercrime. And all of a sudden, you know, somebody emails you and says, I have your medical information and I know that you had surgery on this date.

00;04;48;29 - 00;04;52;05
Jake Milstein
You know, I mean, that's pretty scary stuff, right, Jonathen?

00;04;52;07 - 00;05;11;17
Johnathen Inskeep
Oh, absolutely. I just try to put myself in the shoes of, like the patient. If you're receiving those phone calls, you start to wonder. It's like, is this really happening to me? And then you start like, how did you get my information? And, you know, they point back to the hospital and you immediately lose trust and value in the health care service provider that you were going to.

00;05;11;18 - 00;05;21;13
Johnathen Inskeep
It's just devastating. And then a lot of people, it's like, I don't really have any problems, but I don't want any problems that I've had shared with anybody. So it really just leaves you vulnerable.

00;05;21;15 - 00;05;42;15
John Riggi
Just think about it from the patient perspective. As you said, you're getting these calls. And of course, the first thing that patients are going to do is call the hospital. Now the CEO is getting calls. . . . word that these patients are being directly extorted. Imagine again the pressure on the hospitals. Nobody wants to pay ransom. And again, of course, we at the AHA strongly discourage the payment of ransom.

00;05;42;15 - 00;06;06;07
John Riggi
It will only encourage these groups to continue to conduct these attacks and fund them for perhaps other, more serious crimes as well. But you know what I was confused about, I should say, wondering about in this latest, highly publicized case when they were contacting patients directly for demanding a ransom payment from them, they were only asking $50 each.

00;06;06;10 - 00;06;08;13
John Riggi
I don't get that. That's a lot of work.

00;06;08;14 - 00;06;28;01
Jake Milstein
You know, it's super interesting. It's super interesting. And, you know, I've seen a debate and actually been part of a debate on this. So folks know what this is. And I might have the exact figures wrong here, but basically what the criminals said was pay us $3 and we'll let you know if we have your records. You can see your record for $3.

00;06;28;01 - 00;06;50;23
Jake Milstein
And if you want us not to expose your record publicly, then it's $50. And so some people have said that really this is just a pressure tactic that I personally think that that is more advanced than a pressure tactic. And I actually think that the bad guy - this is just a new revenue stream for that. It is the what is the triple extortion?

00;06;50;23 - 00;07;09;13
Jake Milstein
The quadruple extortion. I think you know, this is the you know, we're going to tier your payments. I actually think it's a revenue stream because, you know, you know, criminals are you know, they're good at math. We know this. You know, let's say you have what, 100,000 patients and everyone pays you $50,000. I mean, you know, it's real money.

0;07;09;15 - 00;07;33;00
John Riggi
Right? And, you know, as I'm thinking this through, ransomware as a service has proliferated dramatically the past couple of years. And people are assuming, wow, if they're demanding millions from the hospital victim, why would they go after patients for $50? Well, maybe this is a separate department within the ransomware as a service. Said, you guys can have the patient aspect of this.

00;07;33;03 - 00;07;54;12
John Riggi
There's others we know that are making money off stolen credentials. So we have the initial access brokers. This is truly a very efficient underground economy all around ransomware where there are multiple components making money off different aspects of the attack. So this is my theory only there's probably some groups said, hey, whatever you can collect from the patients you keep.

00;07;54;15 - 00;07;58;11
John Riggi
And that helps apply pressure to the victim organization as well.

00;07;58;16 - 00;08;32;17
Jake Milstein
Yeah. I mean, rewinding back to that Texas attack on the school district. There was no demand for money from the parents. That was strictly a hey, call the school district and, you know, get them to give us $5 million or whatever the ransom was. This new thing is different. Now, I will also say there's another case in, I believe, the Los Angeles area - plastic surgeon, bad guys got the pictures and both extorted the plastic surgery clinic and demanded $500 per patient from the patients.

00;08;32;19 - 00;08;47;01
Jake Milstein
Now, I will say that is an actual moneymaking scheme. And, John, if you're right, you know, what we're looking at here is these criminal enterprises, and they are enterprises are now developing a B2B wing and a B2C wing. Like this is ridiculous. But that's what we're starting to see here.

00;08;47;03 - 00;09;07;26
Johnathen Inskeep
Yeah. The other thing I would say, too, is when you have a victim called like that, what are they preying upon? The reaction of the victim, right? So as the victim...oh my gosh, they have my information. I'm going to pay the $3. Well, that's a great way for that victim to be victimized again, because you put in through their paywall your information to be able to pay that.

00;09;07;26 - 00;09;22;05
Johnathen Inskeep
Now they have your financial information to take advantage of your debit card, right? So a great way to snag the person once again, unfortunately, it's just a great way to prey upon a person, which is just unthinkable.

00;09;22;08 - 00;09;25;01
Jake Milstein
Are you saying the criminals don't accept cash, Johnathen?

00;09;25;04 - 00;09;29;10
Johnathen Inskeep
I've never got one to accept cash. I would try to get him to do monopoly money once, but he told me no.

00;09;29;12 - 00;09;30;05
Jake Milstein

00;09;30;08 - 00;09;58;00
John Riggi
Wire transfers? No, that's no good. Digital currency? I recently made a provocative comment on social media, in a sense. And I said that digital currency is the root of all cybercrime. And ultimately, if it wasn't for crypto digital currency, it would be much more difficult for bad guys to conceal, transfer, anonymize the proceeds of crime and certainly would take a massive reduction.

00;09;58;00 - 00;10;04;12
Jake Milstein
Yeah. I mean, I think that that is definitely true. I'm not sure I agree that it's the root of it.

00;10;04;12 - 00;10;05;07
John Riggi
They're meant to be thought-provoking.

00;10;05;07 - 00;10;25;20
Jake Milstein
I understand. You know what, I don't know if it's the root of it, but I do think that it brings up an interesting question for folks like it is. I understand deeply that the AHA tells people not to pay a ransom. I don't think people should pay a ransom. Some organizations make the business decision to pay the ransom.

00;10;25;23 - 00;10;47;14
Jake Milstein
And one of the things that folks need to do in building an incident response plan is to come up with, are we going to pay the ransom? Under what duress would we pay the ransom? Would we never pay the ransom? And I will say, if you come to the possibility that you might pay the ransom, think about how you're going to do that before you're in this situation.

00;10;47;17 - 00;11;02;23
Jake Milstein
If you're going to have to buy Bitcoin, how are you going to do that? If you're going to use a firm, how are you going to do that? Again, do not think anybody should pay the ransom. But this is all part of it. I will tell folks, I was in a fascinating tabletop with this guy, John Riggi, who's joining me on this podcast.

00;11;02;25 - 00;11;18;12
Jake Milstein
There was, hospital exec and the hospital exec said, I'm never going to pay the ransom. I'm never going to pay the ransom. John, I don't know if you remember this. And John got to, you know, all your systems are shut down. No, I'm not going to pay the ransom. You're on divert. I'm not going to pay the ransom. 00;11;18;16 - 00;11;26;08
Jake Milstein
And then John said, the criminals have started calling your patients. And this hospital exec said, okay, I'm paying the ransom.

00;11;26;10 - 00;11;46;04
John Riggi
Exactly right. There is a boundary. They know what the pressure limits are to extort these payments. These are equivalent of violent crime extortions. So you know my background, 30 years in the FBI - dealt with a lot of bad guys, including Russian organized crime bad guys, and terrorists as well. They know what the pressure points are, apply pressure to get whatever their objective is.

00;11;46;04 - 00;12;08;10
John Riggi
They claim these are financially motivated crimes, the bad guys, but really financially motivated, under threat of harm to patients, under threat of harm to patients again is why we always say these are threat to life crimes. There is a whole network now. Again, I said a whole industry around how do we creatively find ways to extort money out of the victims?

00;12;08;10 - 00;12;37;03
John Riggi
We extort the patients. We also have data leak sites that if the organization, the victim organization has not reported the attack publicly, the ransomware guys publicize it on their public web leak sites, notifying the government. So they have all types of issues there. Again, trying to maximize pressure on the victim to pay. Again, we discourage payment. We know that ultimately, even the FBI says this is a business decision.

00;12;37;06 - 00;13;01;11
John Riggi
And if patient safety is at risk, that is a consideration of whether to pay or not. Now, the best way is you talked about being prepared. Cyber insurance companies now actually generally come with their cyber policy methodology is to pay the ransom in digital currency. They actually have ransomware negotiators. There's a whole industry on the good side that's developed around ransomware.

00;13;01;14 - 00;13;22;12
John Riggi
So all these things have to be thought out. But ultimately we say, look, just don't get yourself into that position if at all possible. Offline secure backups that are immutable, that you can use to restore, know where your data is. But ultimately, if your data is encrypted, the bad guys can't use it. Even if they get to it, they can't use it.

00;13;22;14 - 00;13;48;28
John Riggi
Quite frankly, I think that there is not enough attention being focused on data mapping and encrypting the data. All these layers of technologies, millions and millions we spend are around protecting data, ultimately to protect patients. So let's start at the bullseye. Let's encrypt the data at rest and in transit. Even the government says if the bad guys get to your data and it's not readable, you don't even have to report it.

00;13;49;00 - 00;14;10;15
John Riggi
So again, let's start with some of the fundamentals and the basics. So speaking of vulnerabilities right? Which lead to these attacks for both of you. So are there common vulnerabilities in hospital systems that you see that cybercriminals, especially ransomware groups, are most frequently exploiting? Maybe Johnathen, you could take that.

00;14;10;18 - 00;14;31;04
Johnathen Inskeep
I think they take advantage of obviously the patient care aspect, right? But what they're finding is a lot of these real hospitals and stuff like that, maybe lack a little bit of direction and don't have the securities in place to be able to handle those type of attacks. And then what happens is that can either come in through a third party.

00;14;31;06 - 00;14;46;09
Johnathen Inskeep
There's a lot of risks that's there. There's a lot on the plate for the hospital, and it just puts them as a prime target, right? They've got all the medical record information there on the patient. They know they can hit a bunch of people all at once. And so it's actually kind of a scary scenario. You're just you were talking about targets.

00;14;46;09 - 00;15;00;25
Johnathen Inskeep
Hospitals are the prime target. And so to try and find a way to curb that, I agree with the encryption process. I also think that you should be following a security framework to help narrow that gap, to be able to identify risk. Yeah. Ultimately you're always going to be a target for the bad guys to hit.

00;15;00;28 - 00;15;23;21
Jake Milstein
And I think there's a basic unfairness here. There's a basic unfairness in that you can do everything that you should do to build up your defenses, and yet the bad guys only need to be able to get in one way. And when you look at that and you look at how they're getting in, it used to be the number one way bad guys got into hospitals was through email.

00;15;23;23 - 00;15;58;01
Jake Milstein
That's no longer the case. So when you look at the HHS data, you know, the number one way that they're getting in is through vulnerabilities and through third parties. What's a vulnerability? So a vulnerability is every time Chrome tells you to update or your iPhone tells you to update or whatever, because there's a vulnerability. If you look at all of the devices, if you look at all of the software a hospital is using, all of them, there are vulnerabilities that need to be patched, and those patches need to be treated as urgent incidents so that bad guys can't get in.

00;15;58;03 - 00;16;21;13
Johnathen Inskeep
And I would add to that, the other thing that's really makes it difficult is you to patch your home computer pretty easy-peasy, right? For some of these hospital systems, for them to be able to implement a patch, whether it's an EHR patch or even just a simple Microsoft patch, it takes a lot of coordination to make sure that that patch doesn't have a profound effect on other operating systems, right?

00;16;21;13 - 00;16;39;13
Johnathen Inskeep
So there's a lot of times that those patching processes take proper planning, like how do we have time to be able to have downtime for the network to be able to restart and implement the patch, do a little bit of testing. And so when they drop, unfortunately, we can't just immediately go run and patch it and come up all good, right?

00;16;39;20 - 00;16;44;11
Johnathen Inskeep
There's a little pre-planning that has to take place which leaves you exposed.

00;16;44;13 - 00;17;16;09
Jake Milstein
And you know we mentioned third party. So I want to break third party vulnerabilities into two buckets. Bucket number one is third party is holding patient data or employee data. And bad guys get it by getting into a third party system. And that's the data theft. The other is the third party has a door into the hospital network, and then the bad guy uses that door to get into the hospital network, and then is able to launch a ransomware attack on the hospital network.

00;17;16;09 - 00;17;22;02
Jake Milstein
Those are two different kinds of third party vulnerabilities, and both are getting bigger and bigger.

00;17;22;03 - 00;17;52;21
John Riggi
Yeah, I agree, and is actually even a couple more. So not only do they hold the data or they are the electronic pathway in because how does that all that data move through electronic transmission, but also that the third party themselves maybe become victim of a ransomware attack, which then disrupts hospital operations? You have some mission critical or as I often say, life critical third party that immediate patient care depends on - is then struck with ransomware.

00;17;52;21 - 00;18;14;21
John Riggi
And the bad guys are strategic and intentional. They know if we hit this particular third party, it will disrupt care in 100 health systems, placing massive pressure on that third party to pay tens of millions of dollars in ransom, tens of millions of dollars in ransom. So and then there's the other third party risk of their technology risk, third party technology that has vulnerabilities in it.

00;18;14;21 - 00;18;21;19
John Riggi
Right? We don't write our own operating system code very often I would assume. We don't build our own medical devices. We rely on third parties.

00;18;21;21 - 00;18;41;05
Johnathen Inskeep
Yeah, absolutely. I can't remember the last time I broke down the code to build something, right? So we have all these dependencies. And I think one of the biggest things centered around that is proper risk identification, right? If you take a third party on for operational purposes, how much do you know about either of that product? Where was that product made, manufactured?

00;18;41;05 - 00;19;01;02
Johnathen Inskeep
What's the risk of it coming into your environment and third parties you work with? Like what's the obligation? How strong is your business associate agreement with that third party vendor? Did you identify things that are related to risk in your environment that you're talking about in your business social agreement? Because I tell you, if you don't have it listed, they're not going to be held accountable for it.

00;19;01;05 - 00;19;23;02
John Riggi
Quite frankly. You know, we don't want to alarm folks too much here, but really it's third party risk management and fourth party. So, who are the subcontractors for those third parties? That should be part of the evaluation. Where are they based? Are they based in the United States or overseas? China's ofering a lot of good deals these days to get into our health care sector.

00;19;23;09 - 00;19;26;26
John Riggi
Unbelievably good deals, related to the Chinese government.

00;19;26;26 - 00;19;28;24
Jake Milstein
We saying that deals are too good?

00;19;28;27 - 00;19;53;23
John Riggi
They're too good to be true, right? As we always say. So take a close look at that. What type of technology are they using? Is that technology vulnerable? Third and fourth party risks? Some of it you can control, some of it you can't. But that's where we have to be ready with that incident response plan that not only takes into account if you are the direct victim, but what about if our mission critical third parties are attacked?

00;19;53;28 - 00;20;05;14
John Riggi
How does that disrupt our operations, disrupt and delay patient care, risking patient safety. And the IT department has no control. Right, Johnathen, your third party gets hit. What do you what can you do about that?

00;20;05;21 - 00;20;23;26
Johnathen Inskeep
No control because you have to function. I think one of the most interesting things was this like our EMR vendor that we had - American company, right? However, when we went to do updates at night with the HR vendor, they were people from India that we worked with. And what was interesting to us is we had a geo blocked on India.

00;20;23;29 - 00;20;41;28
Johnathen Inskeep
So they had to call me and say, hey, we can't connect to your system. Can you make an allowance on your firewall? And that wasn't a risk that we thought we would run into because we're working with the American company that's here in America, and they outsourced their technical deployment out to India. And it was just this astonishing.

0;20;41;28 - 00;20;47;26
Johnathen Inskeep
Like we didn't factor that in when we committed to the HR program. And it's things that hindsight we should have looked at.

00;20;47;27 - 00;20;53;03
John Riggi
Right. And of course, the time you discover that is in the midst of a crisis.

00;20;53;05 - 00;20;54;05
Johnathen Inskeep
Absolutely.

00;20;54;07 - 00;21;26;15
John Riggi
You know, I do a lot of media. Talk to a lot of reporters. I explained to them in these terms, hey, these are foreign bad guys being sheltered by hostile nation-states, attacking us, putting us at risk. They're very sympathetic. They understand and generally do want us want to help by promoting good, accurate information. So just as when we face the threat of terrorism, the media was very helpful to distribute alerts to really show what the impact of these threats are and help folks prevent attacks.

00;21;26;17 - 00;21;54;17
John Riggi
Thank you both, Johnathen and Jake, for sharing your thoughts and insights and joining this podcast with us today. For AHA members, for our listeners, if you would like to learn more about AHA's cybersecurity programs, please visit aha.org/cybersecurity. This is been John Riggi, your national advisor for Cybersecurity and Risk.

00;21;54;20 - 00;21;57;23
John Riggi
Stay safe.

00;21;57;25 - 00;22;06;07
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.