 Good afternoon and welcome to Thoughtcast. I am your host, Nico Arsino, and I lead strategic partnerships at Kaiser Permanente. The work of strategic partnerships bridges technology and healthcare through meaningful partnerships that uniquely support Kaiser Permanente. Thoughtcast is an initiative designed to stimulate cross-industry dialogue on the topics that will define the future of healthcare and bring together thought leaders across disciplines to dialogue at the intersection of technology, business, and health. Today we're exploring the future of home care. Our session will be structured in three parts. First, we'll start with a fireside chat with Jody Lesh and Dr. Steve Prodi, examining the Kaiser Permanente perspective, followed by a video highlighting the home care nurse experience. Then we'll turn to an industry round table dialogue, including Susan Magsman of John Hopkins, Travis Messina of Contessa Health, Tom Lee of Galileo Health, moderated by palliative care physician AJ Miller. It is now my honor to introduce Jody Lesh and Dr. Steve Prodi of Kaiser Permanente. Jody Lesh is our Senior Vice President and Chief Transformation Officer. Dr. Steve Prodi is the Executive Vice President of the Permanente Federation and the Associate Executive Director of the Permanente Medical Group. Take it away, Jody. Thank you, Nico. Dr. Prodi, you and I have spent quite a bit of time talking about care in the home and the future of care in the home. I think there's very little doubt that more care is moving into the home and out of our hospitals and our clinics and other settings. And it's driven by a lot of different factors, certainly the pandemic has accelerated movement of care into the home. But also things like consumer expectations, which have changed because consumers are getting very used to receiving more services inside their home. I was struck the other day by a fact that I had seen that in 2014, there were seven adult caregivers for every person over the age of 80 in the United States, and by 2030 that's going to drop to four. So clearly the need is there. And we've also talked a lot about what will it take to move a substantial amount of care into the home. And we've talked a lot about the need for infrastructure and support and other things like technology. And in a recent survey that I saw, they were talking about the two biggest barriers to receiving care in the home. One of them was adequate staffing, something we've also talked a lot about. And the other was reimbursement. It's something that we're also going to have to work on as an industry to be able to increase reimbursement for care in the home. So I thought we could start with you telling us just a little bit about yourself, your role at Kaiser and your interest in care in the home. Yeah, it's great to be with you Jody and to be talking about this really paramount and important subject, because I think it really is part and parcel to how we'll be practicing and delivering care in the future. I'm an infectious disease physician by training and actually still practice and have a couple of roles within Kaiser Permanente. Within the Northern California region, I have responsibility for the hospitals as well as the continuum of care. And then on the national level, I have responsibility for external affairs and government relations. When it comes to my initial interest, I have it actually goes to the doctor. My dad was actually a patient back in the day. He was a hemodialysis patient. And his primary caregiver was, believe it or not, my mom. And they did home dialysis for 22 years. And what I got to witness there was the longevity of what can be achieved if you have good home care. The average life expectancy of a dialysis patient, even now, is somewhere between three to four years. And he lived for 22 years on dialysis and lived a good life. He was able to practice his dentistry. They were able to go on trips. And of course, they kept our family intact. And what I also saw, though, was it was a one-woman logistics system where literally all of the materials, the machinery, the coordination of care when it came to the social work or to the medical care was all done by mom. And I think what I'm convinced of is that it does work. It can work. But the infrastructure is going to have to be more than just what you were referencing. It can't be built on just people alone or moms alone. And so I'm so glad to be talking to you about this today. And Jody, why don't you tell me a little bit about your role at KP and your passion for this work? So my role at Kaiser Permanente is overseeing large innovation projects. And I find it so interesting, your personal story, because my interest in the home actually also stems from a personal story. My father had pancreatic cancer about 15 years ago, and my mom was also his sole caregiver. And he had kind of a different experience. I think she really struggled with providing that care. And at that point, when he became very sick, he had lost all contact with the health care system. And my mom ran into a lot of trouble, as people do, when they're trying to care for people in the home. And her only line of defense was 911 in the emergency room. And I really saw him suffer. And I saw her suffer too. And it really shows me, and why I'm interested in this, is that we need to be able to extend our care delivery system into the home, because most people spend their time in the home and not in our facilities. And we need to be able to connect to them in meaningful ways and be able to provide to them the support so that they aren't just one mom or one wife. And they can really provide that care that's so necessary. So Dr. Purdy, tell me what you think care in the home can be. I know what it is today. It can be a little fragmented and can be that single mom or wife in the home. But what do you think it can be in the future? You know, and I think when I think about Kaiser Permanente and what we've been able to do in the spaces where we have been, you know, traditionally, which is in the medical office buildings and in the hospital setting, and then, you know, expanding into the continuum of care, I think we have a tremendous opportunity to be able to bring together the integration of the entire health care team. And what didn't exist, you know, perhaps with our own individual experiences, you know, that may be predated by, you know, decades, is we now have technology to be able to scale into other spaces than having to be tethered to the particular building where we practice. And so what I mean by that is that we've got the ability to measure biometrics in the home and do that to scale, where you have a group of individuals that are trained to be able to evaluate those pieces of information. We have the ability to do video technology like never before. In fact, this COVID-19 pandemic has brought that to the fore, where we've seen massive expansion throughout the Kaiser Permanente system of being able to reach family as well as our patients and consumers, quite frankly. When I think about what it could be now, I think it's the opportunity to look at all the spectrum of care that we provide anywhere from the chronic medical care where we really excelled at, you know, producing or preventing complications from those disease processes all the way up to the acute care phase where you're in the hospital and actually replacing some of those hospital beds with care in the home. And I think it spans that entire spectrum. You know, Jody, you know, I was sort of touching on the idea that technology is here. And I'd be interested in hearing your perspective since you are sort of an expert in this field in terms of the technical and operational opportunities that you see for gaining a greater understanding of not only the care that we're providing, but the patient experience and a more holistic point of view on what's going on in the home. You know, it's a great question. Clearly, the technology is there and you've talked about some of that technology, like the ability to do remote patient monitoring or to be able to do a video visit. You know, those things are there. Our challenge now is, first of all, how do you scale that? How do you be able to do that for larger numbers of patients? And I think probably the greatest challenge is, how do we do it in a way that creates this very unique experience for patients in their home? Today, when patients receive care in the home, they're pretty disconnected from us. They might have a phone number. They might have a nurse come visit here or there, but they don't have continuous access to us. And one of the things that we've seen with technology is the ability to create a more continuous communication and connection to our patients. That might come in the form of being able to provide them information so that they can care for themselves, which is critically important because we can't be there all the time. And it also, on the other spectrum, can be there when patients get into trouble. Today, when patients get into trouble, they have very little option other than to call 911 or drive themselves to the emergency room. If we can use technology and build operational infrastructure, we can have people get in contact with us in real time should they run into problems. And that's the kind of things that the technology and the operations will allow for today that we don't have. And clearly, we can build in other things like the ability to have people come into the home and also understand people's non-medical needs, which are so important. And it gives us a unique opportunity to get an eye on the patient and then be able to provide different types of services to them. So it really is this opportunity to engage with the patient in a way that we've never done before. Technology can help us. Operational infrastructure can help us like 24-7 access. And it's just, it really can transform how we work with our patients and how they can support themselves in the healing process. I think that's so true. You know, when I think about the interface and I can just tell you from either clinical experiences that I've had or others have had, you learn so much when you do go into the home. You know what people are eating. You know what kind of social support. Or not. Exactly. And you actually really do, I like to talk about the idea of medication reconciliation. Real med rec occurs in the home. And I can tell you how many kitchen tables where I've sat down with a patient and said, oh, you're really taking this. And there's a whole host of different things that you discover. In addition to the social either inequities or issues that they're dealing with and realizing that there are other members of the care team that need to come in and help. And in some ways, you're also respecting the individual's personal responsibility, if you will, because you're on their turf as opposed to them having to come to you. And it really changes the dynamic of the relationship. And so where I see this in terms of the technology allowing us, rather than sort of having to go out with your own little black bag and go to the individual home, we can do this actually more effectively and more on the person's own time as opposed to the healthcare system's time. You mentioned, Steve, the caregivers or the providers in the home. And I think they're really an important part of this too because our nurses that go out in the home today, I mean, they're real heroes. It's a hard job. And they don't necessarily have the tools that they need to be most effective, including access to information or access to us, access to physicians when they need help. And I think a big part of the future infrastructure that we need to build are those systems, logistics systems, communication systems, documentation systems that give those providers out in the homes all the tools that they need to be most effective. They do an incredible job today with what they have, but there's so much that we could provide to them to increase efficiency and be able to allow them to focus more on the patient and less on how they're gonna download information or try to figure something out on their own with some work around. So I think that's an important part of this whole equation. I think that's right. And when I think about it on the patient perspective, being able to access us in a more seamless way, because right now if you think about it, if you need equipment or you need an appointment or you're actually gonna do a visit virtually, sometimes that can involve three, four, five, multiple different systems or if I need to call a call center, that's yet another point of contact and somehow I've gotta sort that out and keep that all straight. And instead, I think we, again, have at our fingertips the opportunity, literally, either buy a smartphone, buy an iPad to actually make that more integrated and seamless, at least from the patient-facing point of view, they should be able to click a button or two and get what they need, as opposed to what it is right now. You know, you and I have talked a lot about logistics and we've seen a lot in other industries how advanced logistics have really transformed an entire business. And of course, everyone uses Amazon as the example, but there really is a lot to say about that, because as you said, there is a lot of logistics associated with care in the home, whether it be getting people there, getting equipment there, or getting other services there. Patients are sort of left on their own sometimes or they feel they are, because they don't have those advanced systems where they can order things and they can track things and they can troubleshoot. So I think, you and I have talked a lot about that. There's a lot that we can learn from other industries and a lot of technology and processes that we can leverage from the work that others have done and apply that to care on the home. I think that's right, Jody. And when I think about Kaiser Permanente and we have deep connections actually with a lot of logistics companies that are out there, in addition to deep connection with the supply chain. Again, another thing that has been at the fore these last six months in particular. And I think that there is a yearning, not just on behalf of our patients or even Kaiser Permanente, but a lot of the supply chain to try to solve for this issue. I mean, how do we more seamlessly and more efficiently get stuff into the home quicker? And actually at the speed of care, not at the speed of something else. Yes, I like that. I'm gonna steal that at the speed of care. I'm gonna take that from you, Dr. Prudy. You know, one of the questions that I've had for you, I mean, you've been a physician for a long time. How do you think this changes the healing process for people? You know, so I think that's such a deep and important question. I think for a person to be able to recover in their own space and in their own home and environment is critically important. From, you know, both a mental health perspective, from an agency perspective in terms of having control over the environment. And actually I think people are less likely to become delirious. They're less likely to be confused that actually less likely to fall. Again, with all the right structure around those folks, because they're in their own environment. So I think that's really key. I think in terms of doing training, you know, for whatever you might need to be doing to help your health condition, you're gonna be doing it in that environment. You're not gonna be doing it in a hospital room or even in a rehab environment in the outpatient setting. I mean, it's gonna be in your home. And so if something's gonna be more effective, that's where it's gonna be. And I'll give you just one example, Jodi. You know, we launched, and this is now almost a four to five year old program, something called Enhanced Recovery After Surgery, which is now spread throughout Kaiser Permanente, changed all the techniques for how we were treating pain, how we were treating nutrition before and after surgery. The effects of that program were so significant that types of surgery like total hip and knee replacements are now actually done on an outpatient basis rather than having a hospitalization. And what that required us to do is completely switch around, you know, essentially the dynamics of how we were going to provide the care and making sure that we had the follow-up on the outpatient side in the home and getting PT into the home. And what's the impact of that? The impact of it is that people have better outcomes. That's incredible for patients. I mean, having watched all of our family members, it makes me think too about, as people get older and living longer, just the process of dying at home, I think has changed or living with a terminal illness. And it also makes me think, we talk a lot about technology infrastructure, but there's sort of operational or human factor type infrastructure. And as our caregivers in the home are sort of freed up from some of the things that technology can address, they'll be free to, but will also need to learn skills of sort of dealing with people in this very human way because the transaction will be longer and it will be more in depth. And it really makes me think about all the training and just the, you know, all the different soft skills that will have to teach people in the future as they spend more time with our patients in their home, which is a tremendous opportunity for the patient and their families. When I think about my own family, if they would have had that opportunity that you're talking about rather than, you know, trying to heal in the hospital, it would have been incredible. Yeah, and I think you're speaking to something that's really important to call out here, which is that this is a new way of providing care. And so it is going to require simulation and training, simulation in the sense of, of course, the contact with the person to person, but also how to use the technology effectively. And how you connect with folks over video, it is a little bit different than, you know, in person. And so how do you do that? How do you take cues or understand social cues via these different modalities? So I think it's a good call out. You know, Jodi, one thing that I wanted to ask you about is, you know, what are the broader implications just from like an industry standpoint or marketplace standpoint? And we can think about that in the context of like Kaiser Permanente and other healthcare systems, or perhaps even bigger than that. Yeah. I mean, I think, you know, first of all, just from a kind of a market standpoint, we're just seeing just a proliferation of startups in this space. You know, as startups do, they see the opportunities and they see the gaps and that creates great business opportunities. So we've talked a lot, you and I, about those. There's a number of very interesting startups across the entire continuum of care all the way from providing hospital-level care at home to providing chronic disease, urgent care in the home, on demand, leveraging all kinds of different existing resources like EMS and other types of caregivers, even including sort of community caregivers like lay caregivers like promotoras. So it's just a proliferation of kind of interesting companies out there who see the opportunity. And we're also seeing a lot of more traditional healthcare companies try to build this into an ecosystem of care. And I think that has tremendous implications. I think it has probably the biggest implication I think it could have is really addressing the issue of affordability. Affordability is a crisis. Healthcare affordability in this country continues to be a crisis. Of course, Kaiser Permanente is probably moved along that spectrum further than most, but healthcare is still out of reach financially for so many people. And technology has been able to transform all kinds of other businesses, make services more accessible and make them more affordable. And I think that's the real promise here is that if we can get to scale, if we can leverage both care in the home on a face-to-face basis as well as on a virtual basis, we have this ability to shift care out of not only less convenient settings, but also a very expensive setting and really bend that curve significantly to make healthcare truly affordable for people. And I think that's the greatest opportunity here with care in the home. I think that's right. And we've got some early and burgeoning examples within KP. Another one that sort of comes to mind for me is the Connect to Care program that we have for a behavioral mental health, which in this is even pre-COVID up to 40% of the visits had become virtual rather than in-person. And we've actually gone back and surveyed those patients and been able to show that in fact, the satisfaction rates higher than even an in-person office visit. The reason I mentioned in the context of affordability is that we do have a crisis in the country in terms of access to mental health care and just a simple lack of numbers of mental health care providers in the U.S. And so I think you're right in terms of thinking about how do we scale healthcare in a much more affordable, but also accessible manner. I think about the other areas, and I'm curious on your opinion here when you think about rural healthcare or areas where you don't have as much population density and you can't have the same kind of subspecialty expertise, that appears to be a big opportunity and yet a challenge when you think about broadband and the other sort of just basic technical issues that the country faces. I mean, I think the sort of movement away from urban centers is a huge issue. And I think that COVID has actually probably accelerated a lot of movement out of urban settings, but one of the greatest challenges is access to healthcare in rural settings. It's a challenge for both the patient and a challenge for the provider, of course, because it's very difficult to have scale and accessibility. So this ability to combine care in the home and virtual care. So it has this great potential, I think, to solve one of the greatest problems that we've had. And our rural communities, I think are more significant sometimes than we think. It's interesting. I don't have to go that far out of the urban core to be in an area where there's healthcare access issues. So this idea of being able to come to the home, maybe periodically and augment that with different ways in which we engage, communicate and connect with our patients using technology, I think just is it just a really area right for innovation and could really change care in those very challenging settings. I think that's right. And the other thing that immediately comes to mind for me is that you actually don't even have to go out of an urban area to be inaccessible. There are folks that don't have access to transportation. So true. And like you said, there is a reduction in the number of people who can actually provide additional caregiving responsibilities. So you have a larger elderly population that doesn't have immediate family around because they've moved out. And so actually being able to reach those urban areas too, I think it's going to be. It's such a great point. And there's so many health disparity issues to people who live in communities that are challenged economically. And we see those disparities. And I know Kaiser Permanente is really committed to eliminating those disparities and care in the home could have a dramatic impact on that. It really could. So there's just so many opportunities here. It's exciting to be working on it. Yes, I'm glad to be partnered with you on it. Me too, me too. Dr. Proti, it is so exciting to be partnering with you on Care in the Home at Kaiser Permanente. It's just been an absolute joy for me. I've learned so much from you. And I just wanted to thank you for joining me in this conversation. Every time we talk, I learn something new and I'm more inspired every single time we talk about care in the home. So thank you so much. Well, and thank you, Jodi. I mean, I think that this is something that you and I and a whole lot of others share a lot of hope for. And Kaiser Permanente's no better place to make this happen. That is true. Thanks a lot. Thank you. I'd like to share with you now a video so you can understand a little bit more about what it's like to care for a patient in their home. This video features Isabel Wilcox. She's a home health hospice nurse in Southern California working in and around Victorville and Apple Valley. Isabel is a very passionate and committed home health nurse. Kaiser and her patients are very, very fortunate to have her by their side. She's going to share with you some insight and color about providing care in people's home and describe the rewarding nature of this type of care. Working in the home versus working, for example, in the acute setting in a hospital is quite different. It's more challenging at times and more rewarding at the same time. The reason for that is because at the hospital we have cold teams. We have doctors to order emergency medication and we have resources, pharmacological or team resources that we don't have in the home setting. So you have to think outside the box. Patients react in different ways when you arrive at their home. Some patients are already expecting you and they are outside or they have a family member outside of their home. Like you said, you're coming between this time and that time and they are already like looking at the window. Like you're here, I need it. You thank you so much, you came. Here comes a nurse to the rescue. And some patients are more like private, more reserved like you are here at my home and you have to gain their trust and sometimes it takes time. Very important too that you are non-judgmental. When you're going to a patient's house, you have to meet their patient at their needs and understand that their environment is part of them. The future of home health is beautiful. I see nothing but positive, it's going to happen. It will be safer for the patient to be provided that care at the home setting, better quality of care for sure. It is such a pleasure to introduce Dr. B.J. Miller. Dr. B.J. Miller is a longtime hospice and palliative medicine physician and educator. He's been on the faculty at his alma mater, UC San Francisco since 2007 and he's worked in all settings of healthcare, including the hospital, clinics, residential facilities and even the home. B.J.'s career has been dedicated to moving healthcare towards a human-centered approach. Led by his own experiences as a patient, B.J. advocates for the roles of our senses, community and presence in designing a better ending. You may have seen his 2015 TED Talk, Not Weather but How, which has been viewed over 11 million times and I must tell you, I'm probably a good percentage of those 11 million people. It's so inspiring. B.J.'s latest project, Metal Health, aims to provide personalized, holistic consultations for any patient, caregiver or clinician who need help navigating the practical, emotional and existential issues that come with serious illness and disability. It is my pleasure to introduce to you Dr. B.J. Miller. Jodi, thank you for that introduction. We've heard from KP a little bit here from Steven and Jodi and thanks to that video. We have a sense that some big things are a foot at KP and beyond, and this is a very important space. There's a lot to talk about. Of course, the care delivery ecosystem is changing rapidly or it certainly feels rapid and this is changing the dynamics of home care. So we're also moving towards a consumer focus. All of these forces are going to affect outcomes, of course, efficiencies and the general experience of care for everybody involved. So there's a lot to talk about. Why don't we introduce our group here? We've got several different voices from several different angles to chime in. So we have Travis Messina from Contessa Health, CEO of Contessa Health, which provides a home hospital care. We have Dr. Tom Lee, CEO of Gailaleo Health, who are providing both virtual and in-person care at home available 24-7. We have Susan Magsum and founder and executive director of the International Arts and Mind Lab, the Brain Sciences Institute at the Johns Hopkins University. So that's our crew. Why don't we jump in guys? There's a lot to discuss. I'd like to organize this a little bit and this is informal, so we can all jump in together along the way. But let's maybe start with the current state of care second chunk would be to move into the future state and then lastly, we'll end on this sort of whole idea of care, the human endeavor of care. And see if we can dive in there because of course that is the main point of all this. So on this current state, like K.P. and others, there are legacy players. People have been doing this a long time and then there are of course, there are a lot of startups here too. Do we, a question is this a complimentary relationship or a competitive relationship? Where is the role for innovation in the form of disruption versus continuing on and continuing to build what already exists? To open this up, I'd like to turn to you startup guys, you CEOs of the startup world, Travis and Tom. So anyone, either of you want to kick us off here? Yeah, no, I think it's an exciting time in home care. There's a lot of new innovative entrance coming to this space. And I think I'm not sure I would view it as competitive versus complimentary. I think the healthcare ecosystem is so broad and it requires such partnerships that any type of collaborations typically gonna be more effective than any single player. You know, that being said, there are a lot of legacy processes and reimbursement that have hampered home care and we haven't had a lot of great, frankly, outcomes and services delivered from home care. So I think there's a huge opportunity. I think a lot of innovators like Travis are building these great concepts that should offer that potential. I think Tom makes some excellent points there and it's exciting to be here and talk about it today. So thank you guys for having us. And I would agree and really focus on the part that, you know, when Contesso started, its primary model is to operate hospital at home programs. So think of a patient that comes into the healthcare system and they meet that criteria to be admitted to the hospital, most typically for medical complications. So they're going to the med surge floor. Instead of sending them upstairs, we identify them, we send them home and we render those med surge like capabilities in the patient's home over an episode of care. And, you know, while the model has been around for a significant amount of time, Johns Hopkins is credited with inventing the model. There hasn't been that reimbursement. That's one of the primary challenges just as Tom noted. And without that, it's really tough to scale programs that can truly impact the patient in a setting that I think we could all agree they prefer. So looking at it through that angle or from that lens rather, you know, this legacy versus innovator dynamic, it really seems to be complementary because I think a lot of health systems in large providers that have more traditional models recognize the fact that to give a consumer-centric experience, they have to be able to execute at scale. And ultimately, that's how we view innovation. And so having that sometimes, it's tough to do that from within. And so they look to parties like ourselves to help them accelerate that effort. It's really interesting. In the early 70s, my sister had a serious accident and needed to be at home. And so in those days, we use the telephone. Do you guys remember the telephone? And what was really amazing was she had an amazing quality of care. She had a significant wound that needed to be treated that my mom treated because we lived in the country. And I think in a rural health and telehealth has been really innovative for a very long time. And now we're starting to see that happen more in urban settings. And so, you know, I don't think the parameters have changed in terms of why telehealth is so important, but that the ability to have a payer model really has been so limiting. But we see that at Johns Hopkins all the time. We have some really great ways to get to patients in their homes, and yet we really can't make the model work. So I think it's really exciting to see if there's been ever a silver lining in COVID, it has been that telehealth has now begun to look at kicking the tires on a reimbursement model that really is important to be able to build this field. Well, and does that spell, guys, is the limiting reagent at this point, the regulatory lattice work? Is there a big shift in policy happening at the Medicare level and elsewhere? Is that the primary focus that needs to change or is that too simple? I think I can speak explicitly for our model in terms of hospital at home. It definitely is a regulatory issue. And obviously to do hospital level care in a scalable manner, you can't be sending nurse practitioners or physicians into the home for every visit. Otherwise you'd need an army of clinicians. And while I would give tremendous credit to CMS and CMMI and HHS for all the efforts that they've done, especially in the face of a pandemic, understandably so, there is decades of regulations that they have to roll back. They've done a number of things. They implemented the hospital without walls, waivers, right as COVID hit. There's still some progress that can be made. I think it'll take a little bit more time because patient safety has to always be at the top of mind. And also with that, you wanna make sure that you don't allow for unnecessary utilization. And so the regulations that are in place, address those two issues. So while there's movement, still definitely some progress that we can make on that front, I think. You know, it's sort of one of the things that comes up. I'm assuming that remote patient monitoring is a big deal. I'm assuming that serves many masters. One is to really take, just to be up to the minute on what's going on with our patients. There's data tracking there as well. Are the, is the technology there in a reliable way? Is our people allowing themselves to be tracked? Are they seeking this? How is the remote patient monitoring going? I mean, I can hop in a little bit, which is maybe broadly framed. What are all the constraints and why is this, you know, how is innovation hard, right? So there's regulatory frameworks, obviously. There is some tech and privacy concerns, but I think ultimately, you know, this is really hard. You're taking a care model where people come to an office and it's one standard unit or you go to the office and it's a standard unit in terms of operations and finance. So you got over 50 years of legacy infrastructure, process and habits. And so to reconfigure to a home-based care model is a pretty radical shift. And so there are some regulatory hurdles for sure. There's opportunities to innovate underneath that. The tech is fairly commodity. So it's really just how do you stitch the tech together thoughtfully with patients who are all building up new habits, right? If you think about the habits from the regulatory framework, the system framework, the provider framework and the patient and caregiver and family framework, they're all not used to this type of a model of care and certainly not the economics and operations of it. So I think those are all friction points. I don't think technology per se is the friction point. Yeah, I can add to that. I think the technology is innovating so rapidly in terms of biomarkers and being able to get really consistent and reliable data. But the sociology and psychology of this kind of behavioral change is really a paradigm shift. And I think in some ways that's part of why this kind of health has not been implemented over the last 30 or 40 years in some form. Behavioral change is really, especially around healthcare, there's a lot of work with medical historians looking at this to understand sort of what are our perceptions and our mythologies around healthcare. And in this country in particular, we believe that healthcare is administered at institutions. And so we have this mindset around what quality healthcare is and where you get it and who you get it from. And so that flies in the face of some of the really amazing benefits around something like telehealth, including mobility and access, being at home, so being more comfortable. I think there are some privacy issues around that but they're easily surmountable when you think about things like the connectivity to the elderly or inability to be able to travel and distances. So I think one of the things that we're really gonna need to grapple with maybe even more than the technology is this idea around how do we think about change and what is quality healthcare and what are the benefits and what are the challenges around that. So practitioners are gonna need to learn a new way to connect via internet or other kinds of technologies because it's not the same as one-on-one. So, you know, developmentally, cognitively, we are not connecting in a three-dimensional world when we're doing what we're doing right now. But how can we create intimacy and connectivity and a sense of trust and relationship is really gonna be the hallmark of how and why this becomes successful. Susan, I think you hit it right there at the end in terms of the clinical or the clinician's adoption of those types of behaviors because, well, understandably, the consumer's got a real role in this. What we've found is that patients trust their clinicians. They trust their doctor, they trust their nurses. And so when they say, hey, you can receive appropriate level care at home, they overwhelmingly understand and listen to that caregiver. To us, it's really been our providers and our partner providers who are candidly doing something that flies in the face of everything that they've been trained to do. It was, oh, you know, historically, everything I've been taught to do is to treat this patient in the hospital. And now you're asking me to send them home. That's a radical mind shift. And a radical training shift, too, right? Because that's not how doctors are trained. Absolutely. So I think that that's an excellent point. And that's what we've encountered the most. Now, it's so fascinating. We see it at a very interesting level in thinking about the military. So we do quite a bit of work with Creative Forces, which is a group, the Veterans Administration, the DOD, and the National Endowment for the Arts. And what they have seen is that in the healthcare setting, appointments have gone from 30 minutes to 10 minutes. So the reality is that in order to see enough patients to, within a day, patients are getting less of the physician, but in telehealth, they're actually getting more clinical care and higher quality clinical care because they're not having to move through so rapidly. So there's even an economy of scale in how you can use multiple practitioners for multiple reasons within a telehealth setting, which I think is super interesting, too. Yeah, I've noticed that I do some telehealth myself, clinic at UCSF, and now I've started this little thing called metal health. And I'm starting to see clients in a palliative care way online. And in some ways, it feels like we get to the point more rapidly. There's sort of a built structural efficiency. I've noticed our conversations move along more rapidly, not because we're cutting, trimming something off, but perhaps maybe we're not as distracted. I'm not sure, but I have noticed that we are able to get to the point a little bit more quickly than I remember in the clinical setting. Susan, I wonder, I'm fascinated by neuroesthetics. I feel like we could talk about that for hours. And perhaps you tell me what you think here, guys, but maybe one of the things we're describing here is that this feels different and this perception of how it feels. It feels, that seems like a really important, this is not just, telehealth is not just a transmission of information, per se. We've got to convey care, empathy, love, even all sorts of things. That is one thing in person when you can see and touch and feel and smell a person. But what is your work, Susan, from the neuroesthetics point of view, telling you what are we losing in this online platform and are there other things opening up in terms of the visceral aspect of care? No, that's a really interesting question. So neuroesthetics is really looking at how your body and brain changes on aesthetic experience and to what end. So what is possible when you really can really understand those things. And so when you think about the human built environment, like a hospital or rehabilitation center or other kinds of places where you might go, there is a certain aesthetic that's expected. And there's a certain induction around space where you, how you enter, how you go through those processes. There is an ethos and certainly you're giving those things up. But I think as you said, you're almost cutting to the chase in terms of the interaction, the relationship between the clinician and the patient. And so things like facial movements and gestures, body language, what your setting is as a physician or a clinician, how you're welcoming the person, all are types of aesthetic cues. And thinking about the pauses and sentences or even the language, the linguistics that you're using, how you bring a concept or a topic forward, all those become part of your aesthetics as you're conducting something within telehealth. So the refinement and the complexity of that actually allows for the potential for more attention, more focus, better understanding of what's happening in the way that that's getting set up. Even the colors that you use, that your backdrops or what you're wearing are communicating in an aesthetic so greatly. I think someone was talking about perception. So sensory systems and the way they work is one thing, but our perception really is based on our genetics and our life experiences and our conditioning. So being able to really understand how someone's perceiving you from their point of view is enormously important when you're trying to build that kind of rapport. So what I think is from a medical education point of view, we're gonna be seeing more educational programs looking at what is that aesthetic experience between the patient and the clinician and how can you really enhance that for things like compliance and connection and access and looking at things like recovery time and overall quality of life are hugely important for overall health outcomes. And that is something we perceive. I mean, we need to perceive our health. We need to sense it. We need to feel it. And we wanna have it. You know, if you're mood is low or you're depressed or you feel like your life does not have value, then you're not gonna be interested in compliance, right? So to be able to have your clinician assess that from sort of an early stage of a call and then be able to evaluate that, I think mood also ties to aesthetics, right? So we use a lot of art experiences and modalities to enhance that, you know, whether it's music or dance or visual arts or writing from a telehealth point of view. But this is about helping someone really feel like their health matters. Right, we wanna not only be alive, we want to feel alive. And those are slightly different things. Well, that's a good maybe lead into this future state. Do we see that technology in a way will begin to somehow condition or allow for a more three-dimensional experience? I mean, what are you guys seeing in the technology front? What could we improve as we look to the future in terms of the experience? I mean, just building off of Susan's comments a bit, you know, people always get nervous about tech and robots taking over healthcare and kind of getting the humanity out. I actually think, you know, it'll allow us to increase the humanity of care in some areas. So, you know, the technology enables so much that I think it's a pretty powerful factor. Then it allows humans to do a lot more human connectivity and things that are really important, kind of from a human to human connection perspective. The nuance that I would say only is that there are some people that prefer the technical medical approach. And so there's always gonna be a segment that says, just give me this and give me that. And I only want it through the data. But I think if you're really, truly designing a healthcare or a provider organization that's, you know, a patient-centered, you know, you kind of have to meet them where they are. So for some, there always may be a, just give it to me in data cohort. Right. For personalization, right? I mean, in fact, that's what you're able to do. You're able to really look at what personalized medicine looks like when you have the ability to look at the human side of healthcare along with the technology and what can be brought forward. You guys know this better than I do, but it'd be really interesting to think about in the next 10 years, what does technology look like? You know, are there gonna be holograms that you can send it to homes? You know, I always wanna be beamed to the next city and then get on an airplane. Like, what will technology really be in 10 years, 15 years, 20 years? And is that an opportunity for greater humanity, greater empathy, greater compassion that we know leads to greater outcomes? And on that note, how do we see the interdigitation of this sort of online tech-driven experience versus the in-person experience? Obviously, the health system's gonna need to evolve in a way to accommodate all of the above. The certain things are gonna need to happen in person. Are we seeing, do we have enough experience yet to see how that transition works? Are there gaps people fall into? Do they act one way at home online? And then when they're in their clinic, they act a different way. I guess my question really has to do with both, is there technology that's gonna help us or smooth these transitions between in-person, this sort of analog space and the digital space? Or is that to remain to be seen? Any thoughts there? Mejia, I don't think that there's much more advancement necessary to have kind of a truly revolutionary insight into that setting, because some of the clinicians that I was speaking with the other day noted the simple fact of, hey, having a telehealth visit with a patient in the home, I can sit there and ask him, hey, can you move the camera around and just let me see what's going on? And the provider was just stunned by what he saw. He just said, look, just having that simple glimpse into their home told me so much and that I never would have known by having that visit in the hospital, in my clinic, wherever it may be. And so I don't think that there needs to be that much more advancement on the technological side, but that we're there, it just now needs to be more adoption of it so that we can realize those benefits, if you will. In a way, what you just described, Travis, is a greater intimacy. I mean, here we are in some ways divided from each other, removed from each other, but as you just described, we have these windows into the patient or family's experience that we wouldn't otherwise have and that can spell a kind of intimacy. And that's also gonna start pointing us to these social determinants of health as well. Do we think anything to talk about there? I mean, maybe one way to focus that question is really about how do we imagine training future clinicians, given these dynamics, given these forces? We know Kaiser's just kicking off their medical school. I wonder how their curriculum will change. From your guys as perks, are you seeing any, would you love, if you were in charge of the medical school curriculum, do you know what you might change versus the traditional curriculum to accommodate this new experience? I would add that I think there's some ethical issues around the access into people's homes that we really are gonna need to think about. So people are letting you in their homes. There's a vulnerability in that and you're also collecting significant amount of information that a patient may or may not wanted you to have. There's the doorknob moment for the clinician where they're leaving, the patient is leaving and they say, oh, and by the way, I think my dog has fleas or whatever, or my husband abused me. I just will talk to you later, right? And so what is that limit of privacy and how much does that information get shared? And that I think will translate into medical education. We've been doing a lot of work at Hopkins fourth year medical students with neuroesthetics training and helping them use art observation to be able to be better observers and better listeners and understanding different aspects of the same picture so that you're becoming a better observer and third party. We're also, we have an app now that when a primary clinician works with someone, this is primarily in mental health, they'll identify an image, a song, a poem that is a metaphor for that patient. And the team will look at that and say, oh, I understand what you're saying. So it's a deeper understanding of the person than symptoms. And then that work gets shared with the patient to say, you know, we were saying this, how do you see this? So using an art experience to help deepen an understanding of someone. And that's the kind of thing that I think you can do in telehealth too, but it also ties back to training and how you're really thinking of these other things that are available, other ways of knowing besides the DSM. So I think there's a lot of promise there, but it's very new and it flies in the face of traditional medical education. How uphill a battle is that Susan? How hard is it going to be to convince deans of curricula to bring in this other way of thinking, this added way of thinking, this more rounded way of seeing people? You know, before COVID, I'd have said it was a steep mine, a steep hill, but physicians and clinicians are on their knees. PTSD is higher among clinicians and nurses and doctors than almost any other population first responders. And I think they have a need to use these tools as well and to help heal themselves. And so I think there's so much more openness to shifting systems and to having a more human approach to healthcare and what happened pre-COVID. And so I'm much more hopeful. And I think we're seeing it all over the country and I think we're seeing it in other countries, especially where there is more of a payer model that is aligned with federal policy or government policy. So I'm optimistic that we'll see more of this. I think we're seeing a lot of organizations move towards it and meaning healthcare settings. So I feel good about it. I think medical education and these med schools are in a very interesting predicament because obviously our healthcare system has been greatly impacted but obviously the education system is greatly impacted in terms of how they're appropriately educating their students and I mean, ultimately there's a vulnerability for those medical schools as well in terms of if the students don't get the training that they want or desire, they're possibly not gonna pursue education at those institutions. And so I think they'll be forced to adapt even more quickly than others because we've seen clinicians discuss pretty vocally how much they support this new type of medicine and some of our partners have big academic components, Mount Sinai, Ascension and Marshfield Clinic and they are incorporating home care delivery into their education curriculum. So it's a unique position that they're in because they're kind of getting hit from both sides, the education side, as well as the healthcare delivery side. Yeah, fascinating. What about on the physician side? You know, Travis, Tom, are you guys seeing, what are you hearing from your clinicians? Yeah, I mean, I think a lot of what Susan and Travis mentioned about the ecosystem and where the current model's broken and there are a lot of people that are looking for a change. I think that's quite apparent. I think it's hard to shape that environment still and then to design and execute it. So I think there's a lot of hope and desire for these models to work, but you got to work out a lot of the details, a lot of the kinks. And so, if you think about medical education, even up until recently, it's mostly been focused on the bedside manner and then the science of care. It's very rarely talking about office flow or kind of interaction design through other modalities. And so as the modalities have accelerated, it used to just be the office plus a scratchy-scrally note mailed to the patient. Then it became email. Now there's video and text and now home-based care. So the modalities of care are changing exponentially and you need a new methodology and a training system to understand how to interact with patients thoughtfully. So with us, with Gale, we have this digital first model and then this home-based care model. And most of what we're doing is just working out the kinks. You know, there are a lot of kinks to work out. Like when patients are texting, you know, the fidelity of the information is different. The anonymity is a little bit higher. And so you have this intimacy, but you also have this ability to misshape data, you know, and you're not sure how high fidelity the data is in a virtual world. In a home care environment, at least for our physicians, they're able to do what they always fantasize could be done. You know, every clinician, even though none of us have ever trained in this model, romanticizes this home care knocking on the door model. And so for our clinicians to be able to do that and really start to figure out, well, geez, what happens if there's a dog and I don't like dogs? And, you know, so there's a lot of little kinks to work out. But overall, I think that the directional trend is very motivating for the docs in our system. Absolutely, I think, you know, you always have the administrative or technical glitches that they encounter. And pretty much everyone's been a good sport about that because they realize it's new and we're gonna have to do something different and just like anything else in our life that's different, you know, it takes some ironing out. I hate to bring it back to the first topic that we discussed in terms of the regulation, but the biggest issue that we run into is the fact that they can't apply it to all of their patients, right? Because of the lack of reimbursement for some things and how do you get them to change behavior when they can only apply it to some fraction of the panel that they have? And so they say, hey, I love it. I've seen the patients truly respond to this care model, but it's 5% of my patient population or 15% of my patient population. And that's, you know, it's tough and understandably so, like how do you change your daily practices when you're only touching the subset of your patients? Are you surprised by any unintended consequences or hypothetically concerned about unintended consequences, whether for your patients or for your clinicians? Well, I mean, I think, you know, it was alluded to in some comments prior, I don't know if they're necessarily unintended consequences, but there are, you know, new contours to the patient care environment that add new obstacles, challenges, opportunities to more thoughtfully caring for the patient. So, you know, if you're walking into a domestic abuse situation, this is not stuff that you would experience necessarily in an office-based encounter. So if you have clinicians that are focused on solving the broader problem, I don't think you have unintended consequences, but you do have, you know, unexpected new issues that you need to address so I think that's the biggest issue. I do think that, you know, almost by definition, any innovative frontier is going to have, you know, some set of unintended consequences. And so what that really probably translates to in this context of home-based care is, geez, you know, we're gonna try this out at home, but sure, all things being equal, you know, it might be safer to be in the hospital or otherwise. And so there always is gonna be a trade-off on probabilities and so I think as long as you're open, explicit with patients about the options and letting them kind of participate in the decision, I think you're gonna mitigate the number of unintended consequences. I think two things to think about there. One is access cuts both ways. So clinicians have access to their patients at home but patients have access to the clinicians. So, you know, how do you manage email and texts and the kind of bi-directional communications and how can, you know, so now you're, you potentially have a 24-7 relationship and so how do you begin to think about information management and time management and because it's a different kind of time management, that's one thing. And then from an administration point of view in healthcare, there's a real facilities question. You know, how do you redesign facilities to allow for these different kinds of care models? Maybe someone doesn't need to be in the hospital. Maybe they don't need to come to the outpatient clinic or maybe there isn't so much office visits. So what happens to the physical environments that were there and, you know, what does that mean for capital expenditures and what does that mean for how you can use some resources to go towards more telehealth work? So I think there's a facilities and resource management question that's gonna come out of this. That's super interesting. The only thing that I've had here on unintended consequences is the excitement around some of these capabilities in these models and the desire from those to be new entrance into the market. And by that I specifically mean, like if you take hospital at home, for instance, like hospital medicine is very unique and not all people are capable of rendering that level of care. And so when you have certain providers saying, hey, I want to be in the hospital at home space or the sniff at home space or the palliative care space that probably can't meet the level of quality that those legacy providers are able to render their patients, I think that creates a concern around patient safety. And so it's just seeing new entrance that don't have that level of experience that's a bit of a blessing and a curse. There's excitement for the model, which is great, but at the same time, patient safety is always paramount to everything that we do. Do you know Wendell Berry? He's an author from the South. I want to say it's from Tennessee and I'm probably wrong, it might be a Louisiana, but he wrote a story about an older man who was dying and his family brought him into the hospital and they hooked him up to all this equipment. The family knew that that's not what he wanted, but they said, well, we can make him better, we can make him better, then we can make him comfortable, then we can help him die easily. And it makes me think about telehealth and palliative care and if someone is dying, what are those ethical issues around how someone wants to die and what's the health care facilities responsibility and what's the family's role and what's the patient's role in making those decisions? And I think from a palliative care point of view, this is a whole other ethical domain of thinking about who owns someone's health at the end. And I think that's gonna be another issue that's gonna come forward too. I think you're darn right about that. I'm feeling it myself and that is the Pad of Care is my world. And the hospice guys are there to kind of, in so many ways have been doing this and making care at home work for a long time. Some of the struggles while we're on this note is really once folks are at home with hospice, I can generally rest easy. It's turning those corners, getting them into that safely ensconced place with the systems in place, with the mode of care clarified, et cetera, families' roles are clarified. Because a lot of folks are surprised to have learned that the hospice isn't in their home with them 24 hours a day, still 23 hours a day what's left up to the family. So I think hospice as an institution is a lot to kind of teach us on this note. And as ever, I think a lot of the struggles are going to be the transitions getting to that final station. We shall see. But how about guys have sort of a little shift here to cost. So in the one hand, it's easy to imagine that this, that in-home care saves money, right? No bricks and mortar, et cetera. But is that really true? I mean, and do we run, is there a risk of hanging our hat for these models on cost per se, on cost savings per se? What are any, are you guys seeing any sort of as we get into the weeds, is it really gonna be sort of ultimately cost neutral once you factor in the tech and the different roles that are required, et cetera? Or do you guys, are you feeling this is gonna end up being really a big cost savings to the system, a total cost savings to the system? You know, it's a delicate topic, right? Because you're bringing in cost with care, obviously. That being said, so Contessa only contracts on a risk-based arrangement with health plans. So we can't treat Medicare fee for service beneficiaries. So all of our contracts are with predominantly Medicare Advantage institutions. So we cap the spend. And so we guarantee those savings upfront. The way in which we approach it is that if you have a high quality provider that has a truly engaged patient, the cost savings will be a factor of that. And so you are able to eliminate a lot of waste that's in the system. But if you're kind of dollars focused first, that's gonna have a bad outcome. And so if you can get the patient engaged in their care, that's how you get them back onto that road of recovery, which then leads to the savings. I might address it a little bit differently in terms of thinking about an economic analysis. And what are the variables that you're looking at? So I think it depends on how you think about what the costs are to society and what the benefits are when you're able to help someone at home. So I'll give you just a couple of examples. If you're working with someone at home, does that mean that their family members can go to work as opposed to bring them into the hospital? Are you able to reduce different types of economic issues around transportation? You know, there are primary, secondary, and tertiary costs and benefits when you think about this kind of complex system. And so if it's really dollars in and dollars out, I think that's not the right way to do an economic analysis. I think you really have to look at the overarching economic value within a community. And it depends on the age of the person, the kind of disease or disorder, whether it's physical or mental health, whether you're working with children or adults. And so it's a complicated model to really look at from an economic view. And I think to just cut down to say, we're saving money would be the wrong way to come at it. We've talked a little bit of how we bump into this sort of social determinants and social needs. What do you guys feel your responsibilities are? What is the responsibility as physicians to these social issues that come up? What are you guys seeing at Galileo and Contessa? Are you needing to hand off to someone else? Is there a triage moment? Or are these social issues things that you guys can tend to yourselves? Or how is that playing out for each of you? Yeah, so our care team incorporates social workers. And it's an integral part of our healthcare model because of the fact that we are in that home and we can't identify those needs that are most important to helping that patient recover. That being said, we can't do everything. I mean, we're trying not to boil the ocean. And so we say, and basically everything that we do, what is our highest and best use of our skill set? And if it's something that we can't address, we do have partners that come in and can satisfy those needs, specifically around food deficiencies and things of that nature. And so it's a critical component. And if we can't deliver it to the standard that we think is necessary, then we have to find the right partners that can provide that for us. And so we just act as a convener in that regard for those type of services, but they are essential to all of our patients, pretty much. Well, I was gonna say, what sort of infrastructure? We've focused, we've talked to a fair amount about the technology, but what other infrastructure needs are you finding that come in? How do you set up the right infrastructure for home care beyond just the tech? Is there anything to say about conditioning that work in a certain way? What infrastructure needs do you find you need? Well, I think the most obvious thing is not everybody has great access to tech infrastructure. So that last mile problem for a lot of patients, particularly in rural or lower income environments is not there. So I think that's the biggest obstacle. Once you have wiring to the rest of the ecosystem, there's still a lot of custom work, but that's a little bit more within a manageable control set. And in terms of the clinicians, if a lot of this work may be virtual, are you guys getting the clinicians together to bond for self-care and support? And do we know enough yet to see how this kind of work is affecting things like burnout among clinicians? Yes and no. I mean, I think there's pros and cons to any form factor. I think overdose in any environment is probably unhealthy for us all as we speak in a virtualized conference forum. So I think finding the right balance of activities, trying to get people into flow state is kind of what we always try to do, but it's hard given the nature of the job and the intensity that's required at times. But if you have thoughtful operations and experienced designers that think about the patient experience as much as the provider experience, I think you can get certainly better than how it is today in a pretty broken environment. Susan, I wonder if you can touch on the potential here for in-home care to tend to mental health specifically. The sort of psychological stressors, again, we're gonna have windows into people's homes, things that may be sources of stress. Is there more that we can be doing for the mental health of our patients and our providers in this space as far as we can tell so far? Yeah, I think there is a lot more that we can do related to mental health. A couple of projects that I've seen that I think are really good exemplars. One is something called the Unlonely Project and it's really looking at isolation and loneliness. And this is across the lifespan. So you might not think that college students are lonely or folks that are working from home or lonely, but this project uses film. Oftentimes it's folks that are creating small films on their own or identifying films that they think really address different aspects of loneliness and isolation and they share them. There's an online film festival. So it brings lots of folks together. There's another program that's being used for called Creative Forces with the military and looking at mental health and well-being through chorus singing. Also online dancing. Looking at creative writing as ways to really look at depression and anxiety and stress. So there are all kinds of really great self-expressive or expressive arts that can be used to really help identify and also work through that. And then of course, I think the mother of all art forms for this is music. It's an instant remedy for helping folks feel better. And so we're seeing a lot of work there and there are many studies that have been done. We just finished a study on music and serious mental illness and identified in the last 10 years over 12,000 studies looking at different aspects of mental health and music. And that's from being the player of music to being a listener of music, both live and recorded and as well as preferential music. So there's a lot of really great things that you can do through the lens of telehealth and mental health. I wonder how difficult it will be to integrate the modality describing which might fall into from a traditional medical point of view auxiliary or complimentary or integrative per se. Would you imagine that we could train in-home providers whether it's like Tom's guys at Galileo or Travis's guys at Contessa or beyond. Would it be a matter of training these guys to bring in these other modes into their work or would you imagine we're expanding then teams to include art therapists, et cetera? Yeah, I think it's yes and. There's a spectrum of care and outcome. So some kinds of creative arts therapies really are clinically based and they have a clinical outcome around the integrated and complimentary health models. But NIH has really been standing up over the last several years as being a really important aspect of health and well-being along with traditional therapies. But there are also arts and health or other kinds of art experiences that can be done, the lighter touch that really look to prevention and lifestyle and well-being. And so I think it depends on the population and the goals of that art modality or that intervention. And so sometimes I think it can be trained within a system and that's great. You can also look at bringing in partners or thinking of some hybrid approaches to that as well. So I think that's an area that I think is actually an unintended consequence of this work too is how do you expand the services that you can provide that you might not have been able to provide in a traditional healthcare setting? As you're talking and realizing I'm thinking about my own experiences, at least on this online version of in-home care. And yes, I'm realizing I'm getting windows into their world but they're often seeing windows into mine in new ways. And there's something perhaps about the times or whatever else that patients seem more comfortable asking me about my life often because I'm sitting in my home or my cat walks by the screen or whatever else. And what might feel like mistakes or somehow unprofessional at least in the palliative care world which admittedly is a little bit more emotion and touchy feely base. I am finding that I am in a self-disclosing mode one way or another more often and that that's feeling really good actually. I don't have to prop up this white coat version of doctor. I get to be a little bit more human with my patients. I don't know if that's my experience just because of palliative care but Travis, Tom, are you guys hearing anything from your clinicians along these lines is self-disclosure coming up? Is there in a way an encouragement for your providers to share something of their life? No, absolutely. I mean, I think that type of vulnerability and I think it's okay to use that word is necessary. And because that just makes that care experience with that patient that much more productive. And for the clinician. Yeah, exactly. So I think we have seen it and I encourage it. I mean, we had an all-hands team meeting yesterday where I talked about that exact thing. So noting that it's okay to have that type of human element to it, right? Yeah, yeah, which is lovely. Well, okay guys, I think we are about out of time. Anyone have anything else? I don't want to cut us off prematurely. Anyone else have a burning issue that they want to squeeze in here or anything else? Well, can I just say that to round this up in some ways, I think this last conversation, this is really about connection, right? Connectivity in all its levels, whether that's technology connection, but personal connection, clinician patient connection. And I think the more we don't apologize for being vulnerable and human, but we actually use those as assets to health and healing. I think we're going in the right direction. Amen. I'm just going to say thank you not only to K.P. and those of us on the panel, but also just to anyone that's working in healthcare and those caregivers for what you're doing today. So I just wanted to say thank you and we greatly appreciate it. Thank you, Travis. Well, thank you guys, I echo that. Thank you everybody involved in this new brave world. It's daunting, but also pretty darn thrilling too. So anyway, thank you guys for sharing with your experiences so openly. It's been a lovely conversation. Thank you. Now I'll turn it over to Gary Wehmeier from Kaiser Permanente to take us into the Q&A. Thanks, BJ, and thanks for moderating our panel today. We really appreciate it here. So we've had a pretty steady stream of questions coming in. So I think we should just get started and start asking them to the panelists. So the first question I have is here from Jeanie. I think I'll give this one to you, Dr. Proti. We already deliver a lot of skilled nursing and PT and various other kind of home health into the home today. What are some of the other sort of farther reaching services that you see maybe coming into the home? And in fact, what about OB, for instance? So it's a great question. And I really do think what we talked about earlier with the other couple of panel discussions is that we're going to have technology that can enable greater capabilities beyond what we do now and do it at a speed that's much faster, where we can deliver care in the concept of hours rather than days when it comes to actually getting either a person into the home virtually or actually on the ground. And it's going to require different personnel to do that and stretching the different capabilities of a given clinician. So I think that when I think about what we do right now, what we actually put into buildings that are labeled skilled nursing facilities or hospitals, a lot of that will be done in homes. And I don't think that's like in the far future. I think that is here and now. And there's clearly a call across the industry, across consumers and then payers to make this happen. And especially with the pandemic having taken front and center this past year, I think we are on a journey to make that happen soon. That's great. Thanks, Dr. Proti. I have a question here from Keith. Maybe I'll give this one to you, Travis. Who and how are clinical indicators being developed that determine when a patient is really stable enough to be cared for at home? I think that's a great question from Keith. As we think about it in the health systems and provider partners that we have throughout the country, I think the best way to think about it is just still relying upon the clinical judgment of that caregiver that is right there interacting with that patient, whether it be virtually or beginning with an interaction that takes place in an actual clinic or hospital setting. We rely upon those partnerships to develop sort of the protocols and clinical criteria because they know their patients best. And so we still rely upon that pretty heavily as opposed to relying upon strict algorithms because again, clinical judgment plays a great role in deciding what is appropriate for a patient wherever that setting may be. That's great. Anyone have anything you wanna add to that? All right. Well, we have a long list of questions. So I have plenty to keep firing away at you. This one's from Michael. I'll give this one to you, Jody. With all the different aspects of care in the home that we've been talking about, the different kinds of services and whatnot, how do we integrate these into a single experience for members and patients? That's a great question. And I know, Gary, you and I have done quite a bit of work together on this. I think that as we add more modalities to how people receive care, whether it's virtual or on the ground in the home or even things like chatbots, we're going to have to create an end and experience for people. We do run the risk that we could have all these individual things and from a patient perspective, it's just confusion and repetition and trying to re-explain and re-explain. And it's our job to look at this as an end-to-end experience. And we've talked a lot about this. I know you and I, Gary, about creating kind of a platform that allows information to seamlessly move with people as they move from one venue to another. And it's also going to require that people be able to communicate with us in new and better ways because we won't get it right and people will run into problems and they'll need to be able to talk with us much more real time and in a way that's much more consumer friendly. I think the healthcare industry has put itself in a position of kind of come to us and there's one way to do it and that's simply not going to work when there's just more and more ways in which people are engaging. So while it's wonderful that we'll have these new, these new modalities, it does present a real challenge of creating an experience for people that's intuitive, that's connected, and that engages patients very differently than we have in the past. Yeah, I agree. This next question came in from Anonymous. And I think I'll send this one to both Tom and Travis. Maybe Tom, you can take it first. How do you think about the balance of kind of the high touch home visit with the sort of highly efficient virtual visitor, virtual healthcare? Yeah, I think we've alluded to it in the discussion, but I think the two work hand in hand. The more effective and efficient you are through the tech-based systems, the more human and high intensity you can be for the human and home focus systems. So I think they work pretty well in complementary with each other. But I appreciate the question, Mr. Anonymous. I think Tom said it well, and like we had discussed just a minute ago in the panel discussion, I mean, innovation is the ability to execute at scale, right? And if you rely more heavily upon the face-to-face interactions, then you're never going to achieve scale. And we're never going to be able to make this kind of the pervasive model that we, I think we all want to see come to fruition. And so I think Tom just said it extremely well in terms of relying upon that tech component to the extent that you can as you gain that comfort, you will see less dependency upon the face-to-face interaction. Yeah, it sounds like for both of us, it's something we learn over time really, and it'll start this model or merge and become clear as we go forward. I've got a question here from Jennifer, and I'm going to direct this one to both Susan and BJ. Maybe Susan, you can go first. And I know this is right up your alley, so what can we do to enhance the human-touch emotional connection when we're delivering care in the home? It's a great question. I think one of the things that feels like a throughline through a lot of this is this ability to have agency around your own story. And so being able to create that kind of communication and conversation about story and narrative is so important, so we know where people are coming from, we know what's important to them, we know what matters. And so I think more than anything, this ability to listen to other stories and to be able to remember that. And I think that can be part of this continuum of care that Jodi was speaking about with this end-to-end is where is the agency and where is the storytelling and how do we continue to see that story unfold over weeks or months or even years? That's great. PJ, what do you think about this emotional connection? How do we enhance that when we're in the home? Yeah, thanks for the question, Jennifer. It's a good one. That's a million dollar, zillion dollar question. I think as ever, I think the idea is as a clinician, as a provider that we excuse the sound here is that we have some ability to be present. And you might say that that's in some ways harder when you're in the home. The work of getting to the home, whether in person or online with the tech, in some ways, there's just challenges to being present with someone. So as Susan's saying, really the innovation here is listening and listening very well and generously. And last comment there, that's always difficult. That's always our task as clinicians. And doing that in someone's home, navigating the distractions, but also priming our eyes and ears to different cues and different things that we wouldn't see in a clinical setting traditionally. These can be wonderful insights into the person's personality, what they care about, et cetera. So it's being present, but being present with more cues around you. You know, Gary, I just wanna add that I think a lot of this is also gonna come down to how do we respond? You know, one of the things that's wonderful about caring in the home is we have the opportunity to see more and learn more, but then we have an obligation to do more. And this is gonna be very, very difficult because we don't necessarily have the mechanisms to do more when we see many of these social non-medical issues and we're gonna have to build out the system better. You know, in the United States, we don't have a robust infrastructure to deal with social issues and the healthcare industry is faced with them on a daily basis, but we're gonna come face to face with them when we come into people's homes and we're going to have to probably build more than our medical network and our medical care services to address these. And of course, there's all kinds of challenges in terms of adequate infrastructure and capacity as well as reimbursement, but I think it's gonna be hard to not address what we see. You know what I liked about BJ's comment is that we are sort of flipping the tables on what a classic provider patient relationship is. I mean, we need to fit into their home as opposed to them having to fit into our healthcare system. And you know, it's a huge demand for that. And actually, I think it actually gets back to the root of what we all went into this field for was to actually be able to be there for that person. And so there's just such a tremendous personal connection that can be made, even if it's virtual or it's somebody else that's virtually examining on my behalf, incredibly meaningful compared to maybe the traditional way we practice. Yeah, that's good. Thanks. Here's a question that came from Zana. This one is kind of the flip side of what we've just been talking about. And I think I'll direct this to Travis and Tom because you both kind of face this, I think in your businesses. What strategies do you employ for overcoming perceptions from facility-based providers that home care-based clinicians are less capable? I'll go ahead and try this one first. I don't know that it's an issue of whether or not they're less capable. I think it's just whether or not it's the highest and best use of their time. And so I think that if you look at, I would say the overwhelming majority of not close to all of facility-based providers do have the capabilities to stand up to these types of models that we're referencing. It's just hard to do off the side of your desk and the need to invest adequately so that you have a proper program takes serious time and commitment in dollars. And for better or for worse, the financial component does come into play when making that decision. And so how do you cannibalize for lack of a better description that facility-based business? But I think we've seen a number of instances where they've done just that over the last several decades. And I think we referenced ambulatory surgery centers as a perfect example of that. They've historically relied on the inpatient setting for surgical procedures and now you have hospital outpatient departments and surgery standards that are freestanding. And so they have that ability. Candidly, I think it's important for the providers that are a part of those specific systems and then naturally the patients and those communities that will, I think, accelerate the push for them to do so in a more timely manner. And the only other comments I would add is, and it's hard to understand the question fully because I'm not sure if there's a perception or misperception about home care because it's still kind of in its early days in terms of how we design it. But all I can say is, if you look at the content of home care, it is as challenging if more challenging if not more challenging than traditional institutionally-based care because you don't have all the data points from a medical perspective, you've got many more social data points. And so the practice of medicine in the home is much more challenging and also more fulfilling. There's a separate issue which is, do you have the right talent and the right systems in the home? And I think Travis and I would agree that it's still early and premature. So if you're evaluating folks on the current outputs, I think it's not really kind of apples to apples. We've over-invested in the institutional infrastructure and under-invested in the home-based infrastructure. And so I think with a little bit more systems design and talent focus, I think you can get comparable if not superior outcomes in the home. If I could add one more comment, specifically related to the strategies, I think a tactic that we have seen be successful in these efforts is the proverbial crawl-walk-run approach. If you go in and try and talk about you're going to move a drastic percentage of the historical volume that was institutionally based to the home, there's a fear factor there. And so talking about identification so that you can get the care team, the administrative team comfortable with the model and then slowly progressing to a more right-sized balance of patients. I think that that's a strategy that has typically been pretty successful for us. Dr. Proti, do you have anything that you wanted to add to that? I thought maybe you were going to say something. Yeah, the only thing I would add is there is a skill set to doing this well. And so I would say actually we're just starting to test the bounds of what that needs to look like. Perhaps if you go back 100 years back to the future, maybe most of the clinicians had the skill set to be in the home and now we're actually reversing that and saying, in fact, that's what we need to be doing now. But we're finding that you have to do training around this, you have to do simulation even just with the current pandemic response we've done and put together a whole training module for all the clinicians, regardless of whether you're seeing people in the home or just doing your regular clinic visits via video that there's a whole etiquette to it. And so having that up to speed. So I would sort of push back on the fact that if you're working in the home that somehow you have less skills. I think if anything it's a different set of skills and probably more sophisticated like we were just hearing. Well, Xania will be happy to hear that it's a maybe more optimistic view of care in the home than what she perceives. Here's a question from Ren. Susan, I think I'll send this one your way. What are the information and knowledge needs for patients now specifically for them to be more successful with care in the home? And I guess this would include their caregivers. I will throw that in as well. Well, I think this is a little bit about what we were talking about earlier that for a patient to really be successful at home it does require a level of agency and engagement on their part. And I think that that actually is part of the healing process as well. And so to really feel as if they have some control and some ability to be part of the decision-making process in their own health and well-being. I think that's really important. And that's a shift. I think that's definitely a shift in the way care has been delivered in the past. For caregivers as well, I think the ability to be able to observe and to listen and to document and to be able to be reliable witnesses for the folks that they're caring for is also really important. So those relationships become a bit more nuanced. And I really like BJ's term, the idea of being present and really paying attention because that's what's really required from the physician level, but it's also going to be required from the patient and also from the caregiver. That's great. Anything to add, anybody on that? Role of the patient themselves or their caregiver? You know, it's interesting. I think the role of the patient will change a lot. I think that a lot of patients feel that they haven't had the agency. And I think that when they finally do this may present its own set of challenges in terms of engagement and their own health. We even see this on the flip side of people who are trying to keep people well and sort of put positive behavior change and things like that. This is not easy. It's not easy to be part of your own healthcare and to be able to be active in that process. And so the patients themselves, I suspect will change dramatically. The question is, how will we support them in that? We can train clinicians. We can't necessarily train our patients. But I think that over time, we'll have to kind of ease them into that level of engagement that will be very, very different. So that sort of hand on the knob when they're leaving, you know, I think we'll change. We want it to change, but I don't think it's an easy change. And we'll have to think about the role that we can play in helping that along. Jodi, it's a little bit like the, it's not flipping a switch, but it's turning the light dimmer switch, right? To bring the light up, it will definitely take a time. I think that's a really, really good point. Okay, well, since our session is being sponsored by IT, I think we need to get some technology questions in here. So I've got a few stacked up for us here. I think the first one, I'll just leave open to everybody. This is a question from Antonio. His question is, what are the kind of opportunities for really advanced technologies, be it augmented reality, AI, these kinds of things in this space? I'll leave it open to anyone. I mean, I think there's going to be a big role for sort of predictive analytics of trying to get in front of problems when people are not in front of us and trying to be proactive in that, understand where the needs are, and then being able to, you know, engage without people necessarily coming to us. So this ability to understand the situations that people are in, predict what might happen, intervene in an intelligent way, I think provide just significant opportunity even in the ability to reduce costs, right? To get in front of somebody who's at risk of hospitalization or going to the emergency room. So I could really see over time that we really are using data in a much more sophisticated way in order to get in front of those and be able to sort of predict what might occur. Anyone else want to weigh in on the kind of advanced technology side? I mean, I can speak to the intervention side in terms of thinking about AI and using virtual reality for pain management, as example. There's some really nice models that we're seeing where, especially for patients who have chronic pain, to be able to use virtual reality for a form of attention and distraction. And I can see that being a really great tool to use here as well. Yeah, and from the AI standpoint, I was just gonna say that, you know, it's not just the actual development of the clinical care, then it's the evaluation of a program and then predicting where you need to go next. So that's clearly already starting to happen outside of this space and it's clearly gonna need to happen here. And when I think of augmented reality, I mean, think about being able to go into a home and evaluated and determine do you need a ramp or two or what and being able to model that out or for your patient right then and there or at least be able to come back like you would, like an architect would come back and show you what the model needs to look like and do it in a much more personalized way rather than just sort of ordering the DME equipment and sending it out. I think there's also a huge role for home monitoring. I mean, we're already seeing a lot of that, you know, understanding if somebody hasn't moved in a while, if their patterns have changed, if they're at risk of falling. I think, you know, our homes are getting smarter. Obviously not everyone has homes that are, you know, wired in that way, but I think over time as this becomes more ubiquitous, they'll have more and more sort of ability to use sensors in the home to understand people's nutrition and all kinds of things. I see a huge role for home sensors. There's obviously a lot already, but just a growing body of kind of evidence that that will work. I think there'll be more of it. I'll jump in with one. I love the potential for VR to be helpful for sort of sensory distraction and things like that around symptom management. One other that's come up is the idea of a virtual reality for folks who are at the end of life who are trying to say goodbye to the material world, but maybe didn't get that last trip to some place that I always wanted to go to or whatever it may be. And the idea that you could visit other worldly places through technology, I can imagine, I'll be very interested to see how that, something like that plays out. I could imagine that being a wonderful experience for folks. I could also imagine that being very triggering for folks, seeing all the things that they're about to leave behind at the end of life. So that one, well, like all these technologies are going to need to be used thoughtfully and carefully and they're not going to be all good or all bad. A related question that's come in, maybe Travis or Tom, you guys have some experience in this. What technologies are needed, specifically for the clinicians in the field to just augment and enhance their work and ability to deliver care? I guess I can maybe merge a little bit of the prior question in this, when it comes to some of the tech, I think it's still premature. The tech is actually much more sophisticated on the consumer side and we still don't have really great use cases for VR and AR today. So I think it's going to be a while before we have it in the field in the home. I think there's definitely a lot of potentials. It's just, we don't even know how to choreograph work in the home still. So I think it's still going to be a physical process for quite some time. I think my personal advice is, I think for clinicians, it's the same kind of thing. We still need to kind of figure out how to involve home care providers and physicians into a coordinated body of work and the tools that exist in a very simple office-based environment are extremely crude. And to think that we need a more sophisticated lightweight tech in the home-based environment where there's low Wi-Fi and a bunch of other challenges, I think is still, again, a huge challenge. So when we talk about how do we kind of operationalize home care, that is going to be a key component of it, whether if the physician is remote or in person. And I think the demands on tech are actually much more extreme. So I think there's a lot of design and work to be done there, but it's all possible. I mean, the great thing is the bits and the hardware are all there. It's how you design and choreograph it into a provider model that is economically sustainable. I think Tom hit its spot on. And I acknowledge that it's a bit contradictory to what I stated a minute ago in terms of the ability to scale requires a reduction in the dependency on in-person visits. But in terms of the adoption curve and advancing that in a more timely manner, we often do rely on it early on. And again, our patients are hospital eligible. We're treating them in the home. The hospitalist is rounding on that patient virtually, but it often relies upon a nurse being at the bedside for some period of time while they're rounding so that they are comfortable knowing that there is a clinician within close proximity. And so, as Tom said, the tools are all there. We just need to ramp the adoption curve if you want more comfort. Well, that's great. Thanks, we are out of time. I wanna thank everybody, Dr. Proti, Joey, Tom, Travis, Susan, BJ, you guys were awesome today. I wanna just share one quick thing. I got this, came in the Q&A while we were on and it said this, somebody asked Mark, is this a new service? My dad passed away from Alzheimer's in 2008. This was not even an option then. All care was delivered through the hospital. And I'm assuming by that, Mark sounds like this might have been a great option, possibly for his dad, especially with Alzheimer's and the challenge of introducing them into new environments and moving them around. So hopefully it is a new service, Mark, will become, as we've heard from our panelists, a bigger and more significant service and something that we can address things like Alzheimer's with in the future. So thanks again, I'm gonna send it back over to Nico to wrap us up and take us out. Thanks. Thanks, Gary. Thank you all for coming. We hope you enjoyed the digital experience today. I'd like to thank Jody Lesh and Dr. Proti for a great dialogue, as well as Isabelle Wilcox for the inspirational video of her day in her life. I'd also like to thank BJ Miller, Susan Magsiman, Travis Messina, Tom Lee, and of course you again, Gary, for moderating the Q and A for us. These events take quite a bit of effort and I'd like to acknowledge amazing team behind Thoughtcast from dialogue to left field labs, the Office of Transformation and my team's strategic partnerships for making this possible. Please stay and connect with your fellow colleagues on the chat application. And finally, we look forward to seeing you again for our next Thoughtcast. Thank you.