 Hello and welcome. My name is Nancy Curdie and I sit on the Board of Directors for NACU. I'm also the founder and CEO of Patient Safety Innovations and very excited to be joining you today from Atlanta, Georgia. Now, I'm excited to introduce for you our next set of speakers. First, we have Alicia Cole. Alicia is an internationally recognized speaker and patient safety consultant. She is a survivor of hospital-acquired MRSA, sepsis, and necrotizing fasciitis. Alicia has endured nine surgeries, 11 blood transfusions, and nearly had her left leg amputated. While still recovering, Alicia co-sponsored and successfully lobbied for passage of two California laws, one in patient safety education for healthcare workers and the other for public reporting of hospital infection rates. Her passion is protecting patients by improving health literacy and self-efficacy while promoting safer care. Next, we have Dr. Donna Prosser. Dr. Prosser has been in the healthcare industry for more than 30 years and is currently the Chief Clinical Officer at the Patient Safety Movement Foundation. Prior to joining the Patient Safety Movement Foundation, Dr. Prosser worked as a healthcare consultant helping organizations across the U.S. to improve quality and safety, increase patient engagement, and reduce clinician burnout. Next, we have Dr. Ron Wyatt, who is an internationally known patient safety and health equity subject matter expert. He co-chairs the IHI Equity Advisory Group and his faculty for the IHI Pursuing Equity Initiative. Dr. Wyatt is a credentialed course instructor in the School of Health Professions at the University of Alabama Birmingham, teaching a graduate course in health policy with a focus on safety and quality. Next, we have Marty Moore, who is an executive with over 35 years experience, focusing on quality, patient safety, and advancing excellence in healthcare. She has chaired the Clinical Advisory Board for Continuum XR and serves on several advisory boards including the American Organization of Nurse Leaders and the Patient Safety Movement Foundation. She holds several patents and trademarks for healthcare innovation and leadership models. Last but not least, we have Patricia Mary Weather, who is an executive director of Project Patient Care, a nonprofit organization with a mission of improving healthcare quality and safety through collaborative initiatives with patients, families, caregivers, healthcare providers, and stakeholders. Pat has over 30 years of health and healthcare experience and currently serves on several quality and health boards. Now, there will be 15 minutes reserved for open Q&A at the end of this session, but you don't need to wait until the end of the presentation. Simply use the Ask the Question text box to submit your questions for the presenters at any time. So with that, I'll go ahead and turn it over to this amazing group of presenters. Thank you, Nancy. Hi, everybody. I'm Donna Prosser. I'm the Chief Chronicle Officer at the Patient Safety Movement Foundation. Today, our session is going to focus on how effective care coordination can better improve patient safety. There are five speakers today in this session and none of us has a conflict of interest to disclose. In today's session, we're going to focus on the dimension of patient safety and the specific competencies of assessing patient safety culture, applying safety science principles and methods, and collaborating to analyze patient safety risks and events. And so what we're going to talk about today is what effective care coordination looks like, how the COVID-19 pandemic has impacted our ability to do that well, and what organizations like yours need to do to better improve care coordination. So before we get started, I want to just start with a definition of what we mean by care coordination because there's so many terms for this out there. And I really like what the AHRQ has to say about this. They say that coordinated care effectively means that we take the patient's needs and preferences into consideration, and we communicate that to all of the care team members, and we use that information to be able to create a more safe and effective plan of care for patients. But the problem is that care is not always well coordinated across the continuum of care. Now, this has gotten a little bit better in the last several years with the advent of population health and the growth of accountable care organizations, but we still have a very long way to go and making sure that no care falls through the cracks for our patients in the outpatient setting. But even in the hospital, across the hospital stay from admission to discharge, care is not always well coordinated, and lots of things fall through the cracks which impact patients' aging. And so why is this? Well, care in hospitals is actually quite fragmented, right? We have healthcare professionals, very well-meaning healthcare professionals that are typically focused on one body part or function. There's typically not one person overseeing the care from the moment that the person is admitted until the moment that the patient is discharged. And so what that results in is that sometimes the right hand doesn't know what the left hand is doing. Now, I understood what this looks like on a personal note because back in 1997, I was a critical care nurse in Washington, D.C., and my first husband was diagnosed with cancer, and he had a bone marrow transplant. And for the next three and a half years, as I sat on the other side of the bed, I realized how poorly we really do coordinate care for our patients. And I understood then that as a nurse, they didn't have the same view that my patient and my family had, because nobody followed through the entire journey along with the patient and family. And so after my husband passed away in 2001, I decided to dedicate the rest of my professional career to improving quality and safety. And here we are 20 years later, and we're still talking about the same issues that I experienced on the other side of the bed. So we're going to talk today about why that is and give you some recommendations on how you can improve that in your organization. But before we get to that, I'd like to talk just a little bit about the history of how we got here. Now, you can't talk about the history of patient care without talking about Florence. She, as you know, is the founder of modern nursing. But she was the first person to initiate the practice of nursing notes and writing those individualized care plans for each patient. She also recognized how important it is to include family members as part of the care team, because they're the ones who are going to be caring for the patient post discharge. And so in the 20th century, those nursing care plans became the standard for communicating those individualized needs of patients. And in 1969 at the University of Minnesota, they started what we call primary nursing. What that means is that one nurse is responsible for coordinating care throughout the entire hospital stay. So a lot of organizations these days still believe that they have a primary care or primary nursing model. But if you don't have one person coordinating the care from the time of admission to the time of discharge, and your nurses are only coordinating care for the 12 hours that they're there on shift, then that's not the true primary nursing model. And you can see how easily things fall through the cracks when there isn't that oversight. Now back in the 70s and 80s is the cost of care increased. We started adding a whole bunch of different new roles. We added case managers, utilization review specialists and discharge planners, but none of those roles changed the fact that nurses were still responsible for coordinating care while the patient is in the hospital. And then in 1999, the Institute of Medicine report to Ares Human came and rocked our award. And they significantly, after that, our reporting requirements and our pain and structures significantly changed. And so suddenly care coordination became really important to hospitals. And so more new roles were created in response to this. A lot of our discharge planners became case managers. We also implemented care coordinators and nurse navigators to help patients to get through the care process. But very often those are focused on a specific service line. So perhaps oncology or cardiology or orthopedics, but not necessarily looking at the entire continuum of care and all of the problems that the patient might have. We also added clinical pharmacists to the bedside. Instead of being down in the pharmacy, they joined us in the care team to better coordinate medication. And the other thing that we've noticed over the last 20 years is how important care team collaboration and communication are. So a lot of organizations began doing interdisciplinary rounds and invited the rest of the care team to join physicians on rounds. But some of us have found this very difficult to hardwire and sustain because the logistics of getting everybody around the bedside at the same time can be quite complicated. And so as a result, very often the patient and the family are missing from these interdisciplinary rounds. And very often the bedside nurse is missing. It's generally the charge nurse or maybe even a nurse manager who goes because the nurses are too busy to leave the bedside. And so the nurse who's coordinating care isn't the person who is joining these rounds on a frequent basis. And all of these people in the care team each have a plan for care in the electronic health record. There are so many care plans. The doctor has a care plan. There's a nursing care plan. The social worker has a care plan. And so you can see how this gets very confused, especially with the way that our EHRs are built where it becomes really difficult for certain disciplines to see what other disciplines are recommending. But what about the patient care plan? There's no place in the electronic health record where all of these interdisciplinary plans converge. And patient portals which are great for an outpatient setting are very often inaccessible to patients while they are in the hospital. And then additionally patients don't often understand the language that we use in those portals. So they are a portal because they literally do just go into the electronic health record. But it still doesn't tell a story for the patient in words that they can understand of what is wrong and what is it that we're doing about each of the problems that you have. And so today in hospitals nurses are still expected to be the ones who are collaborating, coordinating and communicating across the entire spectrum of care while in the hospital. And as a matter of fact a nursing care plan is a CMS requirement. It's the only care plan that is required by CMS. But they're very rarely individualized and very often people see them as just a task. It's one of those silly things that those regulatory agencies are making me do. And we put it on the chart just so that we can have something to satisfy the survey rather than using them for the intent for which they were created, which is to document the plan for this particular patient. Now nurses say that one of the reasons why they don't plan care effectively is because they have too many competing priorities. Now in 2009 Beaches Kallish started looking at this and she developed the miscare survey. This is a survey where nurses consult report the frequency of care that they omit and the reasons why. And over the past 10 years there's been a lot of interesting studies that have been done and there's great data out there to show that consistently what nurses are telling us is that they're unable to plan care effectively more than half the time. And they say one of the reasons why this is so is because they often don't know the plan themselves. Now when I started nursing 30 years ago, nobody could come to see my patient without me knowing about it because I had the chart I had the flow sheet. And now that's not necessary. And so very frequently members of other disciplines can come and see patients and make rounds and the nurse never even knew that they were there. So that is definitely a barrier for nurses being able to effectively plan care. The other thing that these studies have consistently shown is those tasks that are associated with a reminder in the electronic health record are the ones that typically get none. Those critical thinking skills of nurses that is what we use to plan and evaluate is not a task and so therefore there's no reminder associated with it and it's more often missed. And then the COVID-19 pandemic happened where now the patient advocate is no longer at the bedside and so communication and coordination have become even more difficult today. So you're going to hear a lot from our panelists today with some great recommendations of what you can do in your organization to improve care coordination. But before we get there, I invite you to just do a quick self assessment. Think about care in your organization. There is no one metric that's going to tell you whether or not you're doing this effectively. You need to look at all of your data together and see if it tells a story. And more importantly, ask the patients if your patients are telling you that it seems like the right hand doesn't know what the left hand is doing, then there's some opportunity for improvement for you there. Now, before we get started with the panel, it is my pleasure to introduce Alicia Cole. You heard about Alicia and the challenges that she's faced earlier and she has been a strong patient advocate for many years now. She's worked with CMS, with the CDC and many other government organizations. She was also, she was appointed by President Obama to Presidential Advisory Council, but she served on for five years. And so Alicia's going to share a little bit about her story and then she'll moderate her panel. Hi, Alicia. Hi, Donna. Thank you for having me here today. This is a wonderful opportunity to share and give the patient perspective and I want to share some of my story and highlight some examples of good care coordination and then care coordination that could have been improved on. I've had numerous years of healthcare treatments after care. As you heard earlier, I've had nine surgeries, 11 blood transfusions. I just finished two and a half years of blood thinners for blood clots in my arms following central line infections in both arms. But I want to tell you how my healthcare experience got started and I'll just bring you forward with some examples of care coordination. So in 2006, I went into the hospital to get two small fibroids removed and I left the operating room with signs of sepsis. I had chills and I was nauseous and fever and the doctor thought that perhaps I was having a bad reaction to the anesthesia. And so he said, we'll just kind of wait and see and things will get better and you should start to feel better soon. But I didn't start to feel better. Now my nurses were some of the best nurses that you could ever hope for and they took responsibility for me. Just like you talked about with nurses being there for the 12 hour shift and they see all of the transitions that a patient goes through. So one of the nurses took it upon herself to take the lead and to take charge of my care. And she spoke with the doctor, the surgeon and said, would you like me to get a consultation with an infectious disease specialist because I think there's something else going on here. And he told her, no, no, I don't think we need that right away. And so she let it go. Another day later and I was deteriorating more and she asked him again. So I think this would be a good time to bring on infectious disease. And he said, you need to stay in your place. So by the fifth day, when I was completely just had deteriorated my abdomen was completely swollen and rock hard. And she asked him and he said, this is my patient. You need to mind your place. And at that point, she said to herself, I've got to engage this family. And so she came into our room. She closed the door. She pulled the drape and she brought my parents to the side of my bed and we didn't know what was going on. And she said, listen, I need to talk to you and it's urgent. And I could lose my job for speaking to you. So if you tell anybody what I'm saying, I'm going to say I never told you anything. This is strictly confidential. Your daughter is very sick and she needs a consultation with an infectious disease specialist. Now I'm just a nurse. I'm the low person on the totem pole. So this doctor doesn't have to listen to me. But if the family request a consultation with an infectious disease specialist, they have to get one. So can you remember that? And she used what's called the teach back and she had my parents and I repeat the words infectious disease specialist three times. And it's why to this day, I have a hard time saying the words infection preventionist because I'm so indoctrinated with infectious disease specialist. Well, unfortunately, before we got a chance to ask for the infectious disease specialist, my mother saw a black dot above my incision during the dressing change that day. And it was the first signs of necrotizing fasciitis or flesh eating disease breaking through to the surface. So we call the doctor back to the hospital. And by the time he got back to the hospital an hour later, that black dot had turned into a quarter size pustule. And then he had to do some heroic measures. My mother held me flat while the doctor took a scalpel and opened up my incision right there at the bedside. And when he and my mom finished, my dad said, okay, this is out of your hands now. This is beyond your scope. And we want a consultation with an infectious disease specialist. And so at that point, a specialist was brought in to my care. But even after that, there were weren't very many times when there was a huddle at the bedside when everyone was getting on the same page. And it took quite some time for that to happen. Then when I finally got better enough to leave the ICU, I actually had to go back to the operating room six more times had six more surgeries, almost had my left leg amputated and had an open wound that went from one hip completely to the other side of my buttocks. So I had a massive wound, and they had to bring in a wound vac specialist, and they did an in service training with all of the nurses in the ICU and they did a fabulous job. However, when I transitioned to the step down ward to the MedSERD department, they weren't quite as familiar with that level of complex wound. And so they were having some trouble with my dressing changes. Now, unfortunately, you would think that there would be a seamless transition of care, and that there would be teamwork among the different departments but unfortunately in that case there wasn't. And so there was sort of a competition and a resentment when the ICU nurses offered to come to the seventh floor and teach the nurses how to do my dressing change. And it was seen kind of as a slight as opposed to teamwork. And so my mother suggested that Bruce from KCI come and do an in service. And so that's how the nurses on the seventh floor learned how to do my dressing changes. Now, when it was time for me to leave the hospital, even though I had been assigned a case manager, and my nurses talked to me about which home care service would be good for wound care. When I got home, no one showed up for my dressing change. My wound was so massive that it took a three hour dressing change in the morning and then again a three hour dressing change in the evening. And there was so much drainage that if you didn't do the dressing changes, it would seep through my bandages onto my clothes, and then it would start to cause irritation and problems in my wound bed. And so for the home health care nurses to not show up was a very big deal. And we had to call back to the hospital. And when we finally did get someone the next morning, they had never done a wound that dressing change before. Coordination of care is extremely important. And sometimes people tend to think it's just about handoffs or it's just about communication or it's just about who's going to oversee, but it's so much more. It's making sure that people are properly trained. And if, if not, then you join together as a team to make sure that the person you're handing the patient off to is adequately trained for their condition. Now, unfortunately, in 2016, I had to go back into the hospital. I went to the emergency room with a sinus infection, which I never used to get. It's so funny in this time of COVID where people are wearing masks and social distancing. I am a high risk patient, of course. And I always wore masks on planes. And if I went into a large crowd, however, I went to a festival and I was feeling pretty good 10 years in, and I didn't have a mask. And I was out of hand sanitizer and I was talking with people and taking pictures of people with their phone. And the next day, I felt like I was hit by a Mack truck. And I developed a horrible, horrible sinus infection. When I went to the emergency room, they did everything right. The nurses and the doctor, they said, you know, you're a high risk patient. It seems you may have the early signs of sepsis. We're going to keep you here to make sure that you're okay. Well, unfortunately, the next day, that transition fell apart when the infectious disease doctor read and just glanced at my chart and said, oh, she has a sinus infection. That's no big deal. We're sending you home. And I tried to explain my history and I said, can we wait until the labs come back? And he said, ma'am, you have a sinus infection. I'm going to give you a prescription for antibiotics and we're sending you home. Well, when I asked for a second opinion, he didn't take that very well. And he left the room and did not come back for two days. And so the wonderful nurses there took care of me for two days while I deteriorated. And unfortunately, it took a call to the health department to a fellow committee member before that doctor would come back to my room and do cultures and labs. And I deteriorated and developed sepsis and again, necrotizing fasciitis. Now the good thing was, after all of this happened, they united as a team because they were trying to save me. So I was assigned a hospitalist who coordinated with the nurses and coordinated my care. I got a case manager and the director of patient safety and the director of patient experience came down. And so I had a great team at that point. And we were able to also transition to home care because I was such a high risk patient. We decided to set up a hospital at my home. And so things went much smoother. So even though I had a bad experience initially in that hospital, the care coordination team went into action and made the process much smoother. And my healing much better. And so I want to show you on the next slide the seriousness of what can happen when there isn't good care coordination and the balls are dropped. The picture you see from 2006 is the third surgery of seven after my hospital acquired infection. Mind you, I've never been sick a day in my life. And I developed MRSA, VRE, sepsis, pseudomonas, necrotizing fasciitis. And every other day, they would cut down further and cut into my thigh where they were going to sever my leg. And then the second picture you see what happened from a simple sinus infection not being taken seriously and the teamwork not happening properly between the nurses and the doctors. So I've had 13 years of weekly medical care. So that's a lot of care coordination. And thankfully I was allowed to participate in that and really act as the quarterback of my team. And what we want to do is make sure that we engage patients, but we want to set up a system. We need to set up a system so that if a patient isn't able to do all of that like I was able to do, the system takes care of them and protects them. In the center, you see my mother at home preparing for a dressing change. She has PPE. She has gloves. In the top, you see my wound care specialist doing my weekly Wednesday shaving of my hypergranulation. I had five days of every five months of everyday hyperbaric oxygen chamber treatments, cupping, Reiki, acupuncture, ultrasound, scar tissue reduction. So coordination of care, incorporating the parents and the patient and the family, incorporating the nurses, the case managers. It's so important that the communication is there and that everyone works as a team. And so that's why I'm really excited to be here today and to moderate this panel so that we can share some experience and some practical takeaways and ideas for everyone to use in their facilities. So thank you for having me here today. Hi and welcome to the panel discussion portion of our presentation. I'm very excited to have some wonderful guests here today. We have Dr. Ron Wyatt, who is a internationally known subject matter expert in patient safety and care coordination. So we're excited to have him with us today. Marty Moore is a former chief nursing officer who also has a background in organizational management. So I think she's going to bring a very unique perspective to the discussion as well. And then we have Pat Meriwether and Pat has worked with the Medicare Quality Improvement Organization Program for years as well as partnering with hospitals, nursing homes, and physician practices. So we're going to be able to get a perspective across the continuum of care, not just in the hospital. So I'm looking forward to the information that they're going to share and I think it'll be some great useful things that you can take with you today. So the first question I'm going to ask each of you an individual question to start and then I want to go out a little bit broader. So Dr. Wyatt, Ron, I'd like to start with you. And the reason I want to start with you is because as you saw my wounds were pretty massive. And I read that when you were younger, you had an abscess on your shoulder and ended up having some wound care. And because of the way that doctor engaged you in the care and taught you how to take care of yourself, it was one of the things that influenced you to become a doctor. So can you talk with us and share with us? What did you learn from that experience about care coordination and involving patients and family that so inspired you to then become a doctor? Yeah. So thank you, Alicia. Thank you for your contribution to this effort. So I grew up in rural Alabama and serigated south and was spent summers in Harrisburg, Pennsylvania, where my grandmother lived, a place called Allison Hill. Summertime in Harrisburg, kids out playing and my arm shoulder felt strange and it got worse over a couple of days. Then I realized that I had an abscess and across the street was a house where there was a physician who actually lived in the house. The practice was downstairs and he and his family lived upstairs. So I'm thinking I was probably 14. And I just sat on the steps, the back steps of his house and got enough nerve to knock on the door. And I said I have something on my back and could you look at it? He looked at it and told me I had this strange word I had never heard, a carbuncle. And that sounded pretty bad to me. So I said, so what do I do about it? And he said, I'll show you what you need to do. He told me how I needed to lance it, how I need to clean it out, how I needed to keep it clean and let it with heal. And I have to press press and again young black guy from the serrated south. This was a white physician that was across the street from my grandmother's house. So I did what he asked me to do sterilize a needle and a razor blade. And I went upstairs and the attic where I lived used a mirror and I incised the abscess drained it. I took a tweezer. I burned the tweezer to sterilize it. And I pulled out the sack that was around the abscess as he instructed me. And then I put I would clean it daily with hydrogen peroxide and put what's called the cure chrome on it every day. And other than I still have a keloid where I did that. It healed up just as he said, I didn't take antibiotic. And I would have to say my grandmother really never knew about it. But I thought if someone can teach me at 14 to do something like that for a person, then that is a profession that I would need to pursue. So that was I would say my earliest memory of wanting to do medicine as a career. And how did you use that skill in engaging your patients? Yeah, so I think underneath all of this and what that physician showed me was first he was empathetic. And even as a 14 year old, he listened to what I was telling him. And he gave me clear instructions. And you mentioned a word that he used even back then. And that was teach back. So he so he asked me to tell me what you're going to do. And then he said, if you if you run into any problems or if you think it's not getting better, I'm right across the street come back. So so that was again shown empathy and interest in was I going to get better. So all of those things at one point or another has helped me through my entire medical career. And again, to your point, he and I became a team in the process. But I was in charge of my care. And he listened to a 14 year old black kid enough that I healed up. That's great. And he put the care in in health care for you. Yes. He genuinely showed you care. That's wonderful. Marty, I'd like to ask you a question also. You know, as I stated, during my second health care experience, I had a hospitalist who came on board in my team and and that's something right now health care patients are being taught that your hospitalist is sort of your primary care physician in the hospital. And so, you know, you're a former chief nursing officer. How can we build stronger relationships between hospitalists and nurses to facilitate good care coordination. Thank you. Yeah, you know, I had the most wonderful opportunity to model a model that came from Emory and it's called the accountable care unit or an ACU. And in it, we actually geographically assigned hospitals. So there was consistency in who was visiting you. And that's one of the challenges. The hospitalist role is a beautiful role. But in many places across America, there's inconsistency in who's going to see the individual that's that's needing care, but also how they interact with the team. And so when you start to think about how is it that we can bring people together, you have to design it to where that function happened. And that's one of the key things I think that we're missing a lot of times when we're looking at why does care coordination fall apart. If people will buzz in and they'll miss each other and they think they're reading each other's notes. And by the way, they're not. And so it's how is it that we can design this communication and bring it in in such a way that they can do it and function. And be able to communicate. So let me take that a little bit further. When we designed the ACU, we designed it to where there were known times that you had to be around. And you literally had to get a note from your mom to not be there. And I think that is part of leadership. Leadership has to be able to say it is non-negotiable that we do not communicate. And then we designed function to the rounding and we call them cyber rounds. So they drove the communication to be highly efficient. You knew what was coming so that your ears were listening for the key information that you needed. And then additionally, we designed in the sense of community and team. And it isn't so much that you need to develop an ACU. It's more so that you need to think about the function of how do you create communication? How do you assure that people understand the rules? Otherwise they're going to function the way that they want to. And then lastly, you have to be very clear about what are the key pieces of information that have to be transferred, have to be shared. And by the way, it isn't necessarily what we think. And that's where the patient comes in, the individual. The individual should state, here's the most important thing for me today. I want you to know this. And when we did that, it was amazing because the team was going this way. And the individual who was really the recipient of that care and should be the designer of it or a partner in it was laying there going, but I'm worried about this. That's the part of function that you also have to be thinking about. How can you design the voice? The voice of not only the individual who needs to care, but the support of those that love them. Absolutely. Absolutely. I like that. And you said a couple of things. One, I want to come back to later on when you talked about function, because function also goes into social determinants of health and social disparity. And as we're putting together plans, are they actually doable? Are they actually able to be implemented? Can a patient get to that follow-up care? Do they have transportation? Can they afford them? And so one of the questions, and I do, we're going to come back to that. You said something else just before we get to that that I want to also mention. You talked about specific times that the doctors were in the room to meet so that everyone knew when the other person was going to be there so that they could all get together at the patient's bedside. And I can tell you that makes such a difference when my dad was in the hospital recently for his cancer care. We knew what time the oncologist would be there and everyone was going to be in the room. The nurse navigator for his patient care, the oncologist, the regular nurse. And so as a family, we could be there. I have a sister-in-law who's a nurse practitioner. And when she could not be there because she was at work, we had her on speakerphone so that everyone in the family who needed to be informed about the care could be there. And we could have that phone ready. And something like that is so important, especially now in a time of COVID when a patient cannot have their family member in the hospital with them. If they know that the doctor is going to come at a certain time or the nurse will be there at a certain time, they can have that phone charged and ready so that their loved one or their patient advocate can be in on the call on speaker and hear exactly what the doctor is telling them to be a part of that team. So I think there's some excellent points that you brought up and we'll definitely come right back to that. But I do want to pull Pat, Maryweather, into this discussion. We're so happy to see you, Pat. And, you know, you've worked across the continuum of care. And so you've had a perspective of bringing team members together. So I was curious to find out from you in your work with everyone, have there been any policy or administrative barriers that kind of affect good, effective care coordination among the stakeholders? And what can we do to improve that if there are? Thank you. And thank you for your presentation. I really enjoyed it. And it was breathtaking. It really was. I think, you know, when we're talking about the continuum of care and looking at care that's being provided in different settings, you know, first it's in the, you know, a lot of the continuum of care issues start right in the setting where you're at the original setting, and then it spreads out from there. But we have many policies and legislative initiatives that affect the continuum of care. For example, and I'm going to give a few examples. One is when we talk about dual-eligibles. Now, there's a dual-eligible demonstration right now, and that is wonderful. Dual-eligibles are those patients that are typically under Medicare and Medicaid. They tend to be those with any types of disabilities as well as many of the seniors that are in nursing homes or settings. So think about that. You have two organizations that want to reduce payments, and the patient is in between those. So having the dual demonstration program right now, it's offering up some opportunities to change legislation and policies going forward. And that's a demonstration by the Medicare as well. Another one is, one that has really, you know, you mentioned disparities. It has to do with chronic kidney disease. And in Chicago, and I'm going to use Chicago as the example. Well, it's about 30% of the population is black. It's 62% of the patients on dialysis in dialysis centers are black. So part of the disincentive that we have right now is we haven't been encouraging clinicians, primary clinicians and physicians to look at the CKD scores. And to do it early on so that people can change, you know, if it needs a change in medication or change in pattern, life pattern. But to have so many people on chronic kidney disease that could be avoided if they only knew. And that goes with the rest of the population, about 14% have CKD and 4% know about it. So that's another one where our incentives are on providing dialysis and providing dialysis in a center. And then if you look at Korea, South Korea, about 85% of their patients on dialysis are at home. We have them in centers. So, so again, financial incentives. And then I'll just leave you with one that has me really still taken aback during this COVID-19 with pay with persons that are in a nursing home because it's an emergency and I understand the emergency. Many long term residents were given three days to move to another nursing home. So residents with dementia with Alzheimer's had three days and they moved them to nursing homes that were not of their choice again, or their families choice. The families were sometimes the last to know that this was even going on. And so what was the result? What we sometimes refer to is preventable early deaths. So again, I think when we talk about COVID-19, 5% of all the nursing home residents have died. It's a startling statistic. It's heart breaking because that statistic represents people and those people have families and lives and histories attached to them. And that's at the heart of why we have to have better, more effective care coordination. So let's just throw this wide open with regards to the social disparities right now and the race racial disparities. And that also goes into the culture, you know, a culture of how do we overcome some of these social determinants of health and social disparities? And how do we also touch the hearts and minds of those clinicians who don't feel that it's a family's position or a patient's position to get involved? I'm the expert. I'll determine that. And then the family's the last to know, like you gave in the one example. So I'm going to throw it wide open and if someone has something they'd like to elaborate on with that. I can start and then I think my my student colleagues certainly have much more to add. You know, in the work that I was talking about with the ACU, one of the things that we really came to understand was how much bias plays into our decision and our actions. And so the first question, I think leadership has to ask themselves. And I do a lot of work around confirmation bias because we look for what we know to assure us that what we're thinking is right. And we really have to kind of step away from that. So when you're looking at social disparity, we have to ask ourselves, why don't we know? And what do we think we know? And really explore that and understand that because we're designing systems in a vacuum and we're designing care. And we're looking at it through different kinds of lenses that are very much myopic. And by doing that, it really created just this incredible change. So one of the example I can give you is that we were working with a family and the family didn't have technology. And I remember saying to somebody, well, then how do we fix this? And it was more, I was going down the lane of technology. And others came up with just brilliant ideas of how we can engage that family and meet them where they're at, not make them come to where we're at, I promise. I'm going to turn it over to my other colleagues. Absolutely. I was on a project recently. It was about a two-year project with the Society to Improve Diagnosis in Medicine. And one of the things that we did is we worked with about 24 patients or family members to talk about what was going on, because each of them either themselves experienced harm or lost a loved one. And it was where there was, there was this perception as the person presented themselves that there was a conclusion made already about their condition. And so when we talk about teach back, I always like to talk about bi-directional teach back. So say back to me what I'm telling you are my symptoms and conditions. And that really does make a difference because we sometimes, again, when somebody walks in, there's sort of a picture of what their patient is. And then in just a few sentences, sometimes it's already concluded what their condition is without really listening. So thinking about teach back is not just one way but bi-directional, especially when it comes to diagnosis. Yes, absolutely. So, you know, when I talk about this topic, usually I tell people kind of prepare to get uncomfortable because it's such an important topic. And I'll preface it just with a brief story. My brother was diagnosed with a malignancy about six weeks ago and will also need a bone marrow transplant at some point. He was admitted to hospital last week with inceptic shock. Put an ICU, put on a presser to keep his blood pressure up, went into acute kidney failure. After multiple attempts to talk to his care team, I finally talked with hospitalers who I'd have to say barely knew the data but certainly didn't know the person. The next day I talked to a nurse practitioner who knew the data but didn't know the person because they didn't take the time to know the person. It was interesting to me that when I asked the nurse, when could I talk to the hospitalist, the intensivist, she said that he had not made his rhymes. That was 8.30 at night. For a patient in an ICU and acute renal failure on a lever fed to keep his blood pressure up. But the intensivist had not made his rhymes. So that's a failure. That is a failure of professionalism, teamwork, leadership, accountability. It's a failure of a culture. Then my brother was discharged to the floor two days later after the nurse practitioner told me that he would need temporary dialysis. After one day on one day on the floor, he was sent home. His wife called and said he was in tears. My brother works for the IRS. He sends his blue jeans to the laundry. If he gets a nick on his shoes, he gives them to me. He won't wear them again. And he was upset for her to see him because as she put it, when he left the hospital, he was filthy, which is so unlike him. And when I asked, did you see a nutritionist? No. Did you see a social worker? No. Did you meet with the pharmacist? No. Did you meet with the case manager? No. Did you meet with physical therapy? No. So another day when I sent over the type of renal failure diet that he should be on because after being told that he needed temporary dialysis, he was not seen by nephrologists. So I sent her a renal diet and lo and behold, she was giving him all the foods and liquids that he shouldn't be getting for a person in kidney failure. So when I talked to him, he said after he said after I left the hospital, they should have just told me that I was dead. And I would have been better off. So that is the system that we're dealing with. And it is a system failure for leadership, for teamwork, for communication and for accountability. So what COVID has done is shown us what WB DeBose said in 1899 as relates to black people, there's a peculiar indifference that persists. COVID didn't cause it, COVID uncovered it. It uncovered the mistrust, the distrust, the lack of trust that I would say black people have had since 1619, because that is when the pandemic for black people started. So COVID is telling us that what we have failed at. So when we talk about social determinants and disparities to your point, Pat, what I describe it as is the stuff that's killing too many black and brown people that needs to stop. It is the evil on the bridge that throws people in the river, and then we fish them out downstream and we call those things chronic conditions. So back to your point, up on the bridge are the things that are preventable. And we have to collectively say, why are we continuing to throw people off the bridge instead of working to save people with eliminating poverty, decreasing incarceration and over-policing, giving people livable wages and fair housing and eliminating food deserts. That's the stuff that's killing people. And then the downstream expression is failures and care transition when my brother goes home and has no idea what to do. Then he internalizes this bias. And his expression of internalizing it and too many black and brown people do is, I'm dead. And they give up. So why should I keep an appointment? Why should I go get my blood work? Why should I take this medication? Because you don't care enough about me to coordinate my care, to understand who I am as a person, to allow me to invite you in. Pat, as you said, bi-directional, let me invite you into my house through my gate, not through yours, so that you'll understand me. You'll understand that I've never been in a hospital. I've never been an ICU as a patient. My wife doesn't know what to do. And you send me home without talking to us, without allowing us to invite you in so that we can trust you, so that we can build that relationship so that I can live. So we show too many people, especially black and brown people, and we don't need to go through the data because we know the data. This peculiar indifference that is expressed itself in racial bias and racism and implicit bias and all the things that take place even within a team. Even when a nurse knows that it's wrong, the way a person is treated, spoken to, or dismissed and for fear and a safety culture for fear will not speak up. Or if they speak up like within my case, they know that they run the risk of losing their job because we have those better angels who say no. And even if they have to pull you to the side and say, hey, listen, ask for this, speak to that person. So I want to make sure that we, from this, because that's so powerful. I mean, I apologize for being overcome, but so many of the things you were saying I've experienced so many of the things during my father's cancer care. Recently, my dad, anyway, we know that we know the story. I'd like to say, okay, what are some some practical right now suggestions, recommendations, guidance that we can give people watching this to overcome these barriers to overcome these situations because we have to a put the care back in healthcare. We have to overcome these biases, because they don't stop magically at the hospital door or the nursing home door. They go right the baggage goes right in with the person. So how can we set up systems, how can we incorporate education or what can we do what are some practical right now steps that anyone listening to this can use to examine their culture and their and their organization and then ways to overcome this. So if we could each just try to quickly give some some of that and then we can go back in with a deeper dive on the next round of that. We'd like to go. Well, I can start again. And, you know, Ron, thank you. Thank you for sharing such a personal and powerful in you spoke to culture. And, you know, the one thing I'm going to share with you is you have to have courageous leaders who are willing to get in there and deal with things. I mean, early I talked to you about systems processes and functions. But what I'm going to say to you is this is hard work. This is not a program. This is not something you delegate to the quality department. This is you as a leader looking in the mirror every day and saying, What do I need to work on today? What do I need to change? And I'm going to share with you. Sometimes you have to look in the mirror and look back at yourself because you carry biases. You're upbringing, your background, your experiences all influence who you are. And you have to step back and question and reflect and be open and transparent in your own transformation. Very good. Absolutely. Absolutely. Pat. I think there's several ways you can look at it. One, there's data in every organization and they should be looking at the information because, again, it's there. It's there. If they look at their community and they look at their population, it's there. I'm on a hospital board where it's a very, very challenging community. The life expectancy of the population in the community is 60 years old compared to going up north in Chicago where it's 90 years old. So that's a glaring. I mean, that's glaring, but everyone has data and information they can work with. The other is to observe each other because sometimes we take these courses, these online courses, and we think we've got it nail down, but let somebody observe you. Let somebody observe you of color to make sure that, again, you understand what you may be saying or how you're interpreting it. And then the other is code development. We should be designing our programs around code development with the patients involved. And I just came off of one where we did a guide for patients, what they were saying and caregivers about why they weren't returning for follow-up care, hospital care. And the data today said 55% of patients are not returning for care. And part of it is listening to the patients, what was important to them? It's about going into the facility, but it's also about what do I do after I leave the facility? Is my loved one going to be with me? It was a series of questions, and we put it out there so that people can understand these are the challenges that are in the minds of patients and families and caregivers. So code designing opens up windows and opportunities that people have never thought of before because, again, it comes from the patients, families, and caregivers. Absolutely. And Ron, you do a brief, and then we're going to come up here. So I agree with Marty and Pat, but I'll start by saying it's hard work. And that's where it begins. After that, when I was at the Joint Commission looking at some events, there were three root causes. Failures in leadership to Marty's point, failures in communication, and failures in teamwork. So those are three areas to look for solutions. And leadership, I think, is crucial at this point in time. Many health organizations have gone out and paid millions to learn quality improvement, patient safety tools, and methods when they should spend time on leadership. That's going to build a safety culture that's going to impose standards of professionalism on the clinical staff in a just way. So what is blame-free and what is blame-worthy, for instance? And then work with the community, patients and families, to build that trust that's been lost, that maybe was never there. What that means then is we have to value our communities. And how do you value a community if you don't know the community? And then next, you've got to make a tough decision as a leader to say, we're going to redistribute resources. We're going to allocate resources where they are most needed, not where they're most wanted, but where they are most needed. And that means looking at your status as a nonprofit and saying, am I putting resources in the right zip code based on something other than need? Or is it a marketing ploy to get a population that maybe has higher insurance rates or highly insured? So I'll pause there, but I think it comes back to leadership, communication, and teamwork. Absolutely. Absolutely. And for me to just sum it all up, leadership, absolutely. But also bringing in patients as part of that leadership, like, do you have patients on your boards, your advisory boards? Do you actually have patients who sit in on some of those planning discussions to be a part of and to get that feedback from your community? Also, I tell providers and hospital leaders when they're saying, how do we find these patients? Well, you know what you can do? The patients who have written you letters, good or bad? Take those letters because those are engaged people who want to see your facility get better. That's why they took the time to write that letter. It may not be what you want to hear, but it's where you need to start the improvement. If someone writes you and says, hey, you dropped the ball here, or we fell through the cracks over there, that's where you want to start that heavy lifting and that work. So reach out to the community, reach out to those people you've harmed, and find out what went wrong. Where did the care coordination, you know, lack? Where was the lack of communication and follow through? And then you want to look at the makeup of your community and does it match the makeup of your staff and your doctors and your team members in your facility? Are you reflecting back to your patients who they are and really opening up to, as you say, invite them in your door and get to know them and let them get to know you? So we encourage you to bring patients on as a part of your team. Take a real strong look at your leadership. And just, I hope that we've given you all some great information and made you think about things you hadn't thought about before and realized as it relates to the coordination of care in our facilities and outside of our hospitals that continuum of care. Because care coordination affects everything. It starts with good communication, strong leadership, and having a heart and a mind to really put the care back in care and be there for your patient. All patients, because all patients deserve the right care at the right time for their condition. And we all just want to make our patients better. So we thank you for being here today with our panel discussion and we look forward to the questions and answer section. Thank you. Thank you so much for your content rich and passionate presentation. Our virtual audience has provided great feedback, especially about the role of the nurse, the coordination and care and empowering patients. So we're going to move right into our Q&A. And our first question is from Sheila and Marty. I'll ask you to answer this one. Why is care coordination under supported and underfunded in hospitals? That's a great question. So there's a couple of things you have to think about. The first is that has the mind shifted, you know, the viewpoint of how they look at care coordination shifted from the traditional discharge planner kind of seen as a necessity, but not seen as actually that pivotal hub of the wheel. So first have that conversation with your executive leadership about how they view care coordination and then take it beyond your walls. So you've got to start to develop coalitions and working about with your community health leaders to demonstrate the value of where core care coordination reduces costs, elevates care, and then you've got to expand it out. But the first thing you have to do is really and truthfully think about what are the biases that are withholding people from funding care coordination. Typically it's all models, all mental models that they have in their heads. No, thank you so much. I think that's great answer. And our second question now is for Alicia. And why didn't the nurse go up the chain of command was she listened to what needs to happen to empower nurses and this is from Sue. Okay, wow. Well, actually, he did go up the chain of command. And later that she number one she spoke with the my surgeon several times three times she tried to speak with him. She spoke with her nurse manager, and got pushed back. It turns out that this particular doctor this surgeon generates a lot of revenue in the, you know, obstetrician gynecology department. And so unfortunately, when you stack that up against a nurse, you know, advocating for patients, they chose to support him in his position and she was pretty much, you know, she got a lot of pushback up the chain of command. This is something we have to work on and that is a top down starting with the CEO, the trustees appreciating that everyone on that medical team has the ability to save a life. It's not just the surgeon who can save the life. It's the nurse. It's the housekeeping person that walks in and sees that the patient is sliding out of the bed and can speak up and say hey, this patient is sliding out of the bed and about to have a fall. Can someone get in here? Every member of the staff is there to save the patient. And we've got to start that from the top down with appreciating the skill set and the expertise that every person brings to the table. And whether that's a nurse challenging what's happening with her patient that she's watching for 12 hours, you know, and being able and empowered to call for a consultation with infectious disease. So that's what we need to do is empower everyone. Yes, empowerment and that interdisciplinary care process. Everybody knows their roles. Yes. Yes. Yes. And our next question is from Bridget and Donna. I'll ask you to take this one. Today, the role of care coordination still exists as a previous care coordinator myself. I found it difficult to just get all of the disciplines and medical specialists at the same table to discuss overall plans of care for patients. What solutions would you recommend for this ongoing issue? That's a really great question. And I want to echo what Marty said before about, you know, changing the paradigm of how we think about what, you know, what we used to do and what we need to do moving forward. And so I think that, you know, first of all, we need to think about about cure coordination as a patient centered activity. So when we're designing new processes, we need to start with the patient and family first and then figure out how we're going to get the other other clinicians to the bedside. I think, you know, we also need to make sure that we're using standardized tools during that that time where, you know, if as I mentioned earlier that, you know, there is no one place where there is a patient care plan with all of the components of care that we need to have a conversation about with all of the different disciplines. So having some kind of tool for us to use as a, you know, a guiding principle, as well as, you know, aligning this with bedside shift report and bedside handoff and nursing. All of this should be part of a larger discussion for interdisciplinary collaboration. So, you know, as we don't necessarily all have to be physically present every moment of the interdisciplinary rounds, we just all have to be in the know and have access to the tools when the majority of the folks who can get to the patient at the right time are there and and updating them. Thank you so much. And question number four is Dr. Wyatt. This will be your question. Thinking about the dismissal of patient and caregiver perspective and assessment. Ron brought up race thankful the doctor listened to a 14 year old black kid. Are the facilities you work with addressing the latent root of cultural racism and other isms and this is from Deborah. Yeah, thank you for the question and the easy first answer is, many organizations are beginning to. And part of that beginning, I think is that organizations from the board level to the sweet suite is beginning to get more comfortable with these areas of the the isms, whether it's race or poverty ism or sexism able ism as we go down the list. And I think a big part of that from the board level is for the board and the C sweet to reach out to the community serve and ask for that help, be that partner and do that in a courageous way, because I think underneath this is a fear. And if I borrow the phrase from Edward Deming is replace the fear with knowledge and the knowledge means when we reach out to each other and the people that we serve to say help us with this and then say we will commit to looking at where we are and how the isms operate in our system based on our community's needs and then build that into your strategic plan as a priority begin there with the board and executive leadership with with a clear genuine transparent commitment to addressing how we eliminate these isms that so many of us see in the healthcare systems. I love that point about integrating into the strategic plan and being transparent that way. You know, that's the way you'll get it done is put it all in the top and have a part of the strategy. That's terrific. And I think we'll have time for one more question and Pat I will turn this one over to you. And it's from Jean and what she's asking is what's the one thing that you would want leadership to do. Great way to end. How can you amuse your mind. It is a great way to end and I truly believe that the group that has the most vested interest in healthcare are the patients and their families and caregivers. And so integrating the patients families and caregivers in all the areas within a hospital setting, you know, from the governance the patient family advisory councils, as well as as some hospitals have done into all the committees. But the voice of the patient is is as Ron had said, you know, the the deming approach is making sure that you've got the right voices there, and also being proactive, because again, you want to make sure that you're representing all patients, not just a particular sector, but you want to make sure that there is representation. So it's the ability to have them engaged and be transparent with them. And I'll tell you, they are very interested in participating because it is their health care that they're most concerned about and the health of others. That's so true. And I am such a huge deming fan. So thank you for bringing him up. Any last words from anyone before we wrap up. I like to just throw out there really don't be afraid to reach out to patients who have been harmed in your facilities. Because they want to be part of the solution. They, you know, we have this fear of the angry patient. The thing is, you're so happy to be alive that you just want to make sure that nothing like that ever happens to anybody else again, and you want to be a part of the solution. You want to share your experience. You want to give your advice. And so reach out to those people in a real sincere, honest, transparent way and an empathetic way. Listen without defensiveness and find out because the best way to find out where the cracks and the chasm in your system is is to talk to the person who fell through the crack. So I think Marty, you wanted to say something too. I can't top what Alicia just said, because that was what was in my heart is, is you, you know, when, when we fail in health care, we really have to be willing to listen and to hear and to understand. And then to be totally transparent with everybody, everybody, not just the family, the caregivers as well, and all of those that were involved. And from that, commit to changing, improving and growing and never look back. Beautiful. Well, that's a wrap. Thank you so much to our speakers for a very moving and wonderful presentation. And for our virtual audience. Please join us for the next session presented on engaging patients and families for safer care. And that'll begin at 1205 central time. And if you'd like to contact any of the presenters, their info is at the end of the PowerPoint handout. Thanks again.