 Good morning, everybody, and welcome to another Patient Safety Movement Foundation webinar. I'm Donna Crosser. I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. And today we're going to be talking about care coordination, most specifically focusing on those coordination activities that need to happen during transitions of care. So we have a lot to talk about today, as you can see by our objectives. We're going to talk about those typical gaps that are experienced during transitions, talk about potential solutions to improve that, identify strategies where we can engage patients and families so they can participate in coordination activities, and evaluate the impact that social disparities have on this, as well as looking at outcomes that we can evaluate to see how you guys are doing. So we, as always, are going to be providing continuing education credit for this webinar, for nurses, pharmacists, and physicians. This continuing education credit will be coming from MedStar Health. So if you have registered as one of these professions and indicated that you are looking for CE, then you should receive a webinar, I'm sorry, an email from MedStar within the next five to seven days with instructions on how you can complete an evaluation and get that information. If you are a respiratory therapist, depending on your state, you may be able to claim nursing credit that you can apply as well. This is an example of what the email will look like from MedStar so that you know what to anticipate. We will also be providing CE for healthcare executives through ACHE, so you can just lock that into your ACHE account, for CPPS and for board certified patient advocates, you'll receive a certificate from the Patient Safety Movement Foundation if you indicated that you are seeking that credit, and if you are a certified professional in healthcare quality looking for credit, then again, your attendance will be documented by NEHQ for that. So as you can see here, none of our speakers or any members of the planning committee have any financial disclosures to report. And so with that, I am so excited to get going and introduce our panelists today. So very quickly, I'm going to just run through who our panelists are and then we are, I'm going to let each of the panelists introduce themselves, but today we have Donna Gadson. She is a mother and a caregiver to her son with chronic illness in the U.K. Mark Williams is a professor and director for the Center for Health Services Research at the University of Kentucky and the Chief Quality Officer at U.K. Health Care. Misha Nair is a consultant and patient safety expert and the Senior Manager of Medical Affairs and Quality at Aster DM Health Care in the UAE. And Marty Moore, a patient safety consultant that's simpler, and he was previously the corporate Chief Nursing Officer at Medline Industries. So welcome to all of our panelists. I'm so excited to have you all here today. And so I'd like to just get started with Donna. Donna, I wonder if you could tell us just a little bit about your background and tell us about the gaps that you've seen in your experience and your coordination with your son. Yes. My name is Donna, obviously. I have a 32-year-old son who I've been a carer for about 12 years. And it's been a challenge. But we're getting there, it's things. So I'm sorry, would you like me to go through my first? Oh, no, no, just just tell us very briefly, you know, what are some of the things that you've experienced with your son and care coordination in the past? Mainly because of his long-term chronic care. That's when we find that sometimes it's difficult with different people coming on board, different teams that don't know. And that's where a lot of, you know, you have to start from the beginning. And that's when we do notice the gaps. Absolutely. Absolutely. Well, welcome to the panel. Thank you so much for joining us. And Mark, I wonder if you could tell us a little bit about your background and some of the gaps you've seen in care coordination in the past. Happy to do that. I think I obviously work as a physician, but I've also had the experience as a patient and also had family members as patients. And something I've witnessed quite frequently is with delivery of instructions to patients, there really often isn't the consideration that's needed of the condition of the patient. Both the personal family member had just had surgery, was literally falling asleep, dropping her head after the surgery as the residual of the anesthesia. And this earnest, friendly, wonderful nurse was providing post-op instructions. And then at the end of it, I asked, oh, did you have any questions? And I was listening intently, and so I knew sort of what was happening with my partner. And I said, no, we're good. I got everything. And then as I was wheeling her out, her comment as we got out, she said, what was that person talking to me about in there? And she totally was oblivious. And then my own personal experience, I had surgery. And I read in the post-op notes and so forth, I'd actually had a physical therapist who'd walked me upstairs and downstairs and said he's ready to go. And I remember seeing this person in the room showing me some kind of stretching exercise. I had no memory whatsoever of walking up and down the stairs. And so I think there's a lot that happens to patients and when they're sick, they're not ready to receive this information and the healthcare providers have to consider that and figure out, do we need to repeat this later when the person's awake? Or in the drugs have gotten out of their system? Or have ensured that there's a family caregiver who understands exactly what needs to happen? Well, Mark, thank you so much for bringing both your personal and your professional perspectives to this panel. We really appreciate you being here today. Misha, I wonder if you could tell us a bit about your background and the gaps you've seen and you're in the UAE, so you bring an international perspective to this. Hope you're on mute, Misha. Yeah. Thank you. So I've been into clinical practice for many years and also on the administrative side. So I would like to bring forward one of the major challenges that is exchange of patient information piece among all stakeholders. And this could include the patients themselves. And at times, you've been seen that patients seek out medical help when they reach to a vulnerable state. And this scenario we've commonly seen in case of migrant workers or maybe for global travelers. And here patients may provide only limited information about their health status or they may not have access to the details. So this has a potential to cause delays in treatment. And this may also call for repeat assessments, diagnostic tests, again, leading to more stress and more financial burden. Then from the provider side, I would like to mention that we've been seeing that there have been a lot of concerns related to handoff communications, more often on medicine reconciliation, lack of resources to coordinate, and also about the follow up care during transition. Wow, it sounds like no matter what country we're in, we're all seem to be having the same challenges. Well, welcome to the panel. Thank you so much for being here today. And then finally, Marty Moore, thank you so much for joining us and tell us your background. And I know that you are very passionate about this topic. You know, Donna, I've been a chief nursing officer for almost 25 years. And so I've been over health systems, magnet hospitals, and then as you shared, I was on the corporate side. And so it's always been a passion of mine. But now it is even more so because it's personal. So way back in early 1990, I was doing barcode medication administration long before people were realizing that it could be done working with the Institute for Safe Medication Practice. And so it's been part of my leadership. But now, now it's personal. And, you know, my father fell in the summer of 2020. And it articulated that he had incredible pain. He was scanned once, said he was fine, said that it was just a demotest ligaments. And there were seven points, seven touch times where he saw a provider. He was in the emergency department. He was hospitalized for severe neck pain. And no one rescanned, even though it was asked. And at the end, because the neck was unstable, he ended up having to have a pretty extensive surgery. And it was the causation of his death. And so, you know, when you're in side health care and you can't get people to listen, we've got problems. We've got problems. Absolutely. Well, you know, again, thank you all so much for being here today. And let's go ahead and get started with our content then. And again, here are all of the members of our panel today. So, but let's go ahead and get started talking about the different support systems in the community. And Donna, I believe that these are your slides. Oh, no, I'm sorry, Nisha, my apologies. My apologies, Nisha. Yeah. Yeah, so let's start talking about the support systems that are available in the community. Thank you, Donna. Yes, I would love to talk on this. So community care coordination systems, you know, they are gaining momentum for promoting prevention and improving health outcomes across. They've been instrumental in connecting individuals to a comprehensive area of health promotion services. And we see that they are coordination methods. They may vary on the objective they wish to support. Some may begin with a population in mind, such as chronic disease management, or supporting developmentally challenged people. Others may begin with some priority in mind, such as homelessness or food insecurity. And yet others we find they may start with some geography in mind. So we have health care organizations. They should come forward and actually collectively agree on the roles of care coordination for each of these sectors. And the partnership should be promoted with examples of how each provider can benefit from the association. So they can envision themselves utilizing the resources available across the community to the advantage of their patient care. We see that many community resources have been supporting logistical coordination. They've been supporting advocacy, identification of personal goals and motivators, as well as education. As health care workers, we can encourage as well as coordinate the participation of patients in these activities and also make them aware of the available resources. Then it's also fascinating to see how technology is beginning to transform care coordination. And it's helping individuals through common caregiving challenges. We see nowadays a lot of systems and apps providing information on health and community resources. They can help address different barriers of engagement, ensure the establishment of sustainable ongoing care plan for the patients. They can also support patient self-management. And one can also coordinate transportation, make appointments and reminders when needed using these resources. So we can move to the next slide, please. So as we see the new technology which is available, it's providing us with a lot of information which is there and people should be taking advantage of it. It's available across now and we can explore all these apps and systems which are available. Next slide, please. So the WHO framework proposes five interdependent strip strategies that need to be adopted for better responding to people's needs throughout their life course. Now each of this technique is meant to have an impact on a variety of levels. Now from how services are offered to individual families and communities to how organizations, care systems and policy making operates. But then the key of success of this framework will depend on various factors. For example, it much largely depends on leadership support, the governance structure we have, the staffing levels we would have, the network and community resources and the partners which are around and the screening tools that we are using, patient communication and do we have a closed loop referral mechanism, the interoperability of the systems that we have. Also a lot depends on quality improvement initiators being taken up and also important as a funding to support. So those establishing the sustainable system based on this framework, it requires a lot of effort from both the healthcare providers and the community at large. But overall if we see the benefits are enormous. For example, it's next slide please. For example, it can offer better coordination of care that fills gaps in the services. It can promote effective communication among providers, social service agencies and it can increase effective utilization of resources. It also promotes quality of care, builds community awareness and perception. It can also support growing your patient loyalty as well as the volumes. And community care coordination can also support reducing duplication of services which is also a major challenge. It can help improve reimbursement and position the hospital for population health for the future. Thank you. Thank you so much, Nisha. Again, it's so interesting how the, we all have the same challenges no matter where we seem to be in the globe. And Marty, I know that you understand what Nisha was talking about from a healthcare systems perspective. But what are some of the patient needs that you're seeing in healthcare systems and how can we restructure them so that we can help patients better? Yeah, you know, it's fascinating because as I was preparing for today's webinar I went out and I Googled coordination of care and I looked at all the images that came up and every single one, every single one had the hospital as the largest image. Some of them had the hospital in the middle. And if you think about it in the lifespan of an individual the time that I've been hospitalized is just a blip. It's just seconds within my life. And so we have to kind of reframe. And so many times we're doing things that are trying to kind of create these bridges. And I call them stereostrips and people have said, well, they're band-aids. You know, they're really and truthfully kind of band-aids except if you think about what is the role of a band-aid it is to heal. And in truth, what we're trying to do by putting in coordinators and navigators is we're trying to bring disparate areas together. And that's why I call them stereostrips. But the issue with stereostrips is they rattle up. And that's what we're also finding. So many hospitals have put in systems and or roles and or programs to try to think about how they bridge in and how they bridge out. But in true fashion of a stereostrip as it starts to roll up that's when the system starts to fall apart. Let me give you an example. Many times we will discharge coming out of the hospital. And by the way, discharge means that I am done with you. If you look at the definition, it says, I'm done. I'm discharging. I have nothing more to do. And that's actually one of the fallacies that we have. But if you look at discharge and you look at then that fact that somebody is being referred into home care what the system doesn't do is to say and what's happening there. We just do this kind of here you go kind of a moment. What we don't know is, is there a coordinated plan of care? Are they even gonna be able to get there within 24 hours most cannot? And then if you think about it and you go upstream and you start to look at, what are these points of intersection that we have designed into our systems such as primary care? Primary care hands over to a hospitalist and there's this discount. Now, the stereostrip that we're putting into that is the EMR, the electronic medical record. We're counting on people looking and understanding. Guess what? They don't. So if you think about and look at from a system standpoint health really is, is not about the hospital and yet our biases bring it in that it is about the hospital. It is about really and truthfully everything that Nisha did a beautiful job of bringing forward. And that's the challenge that we have because as system leaders, as a healthcare leader I will tell you that I lived in the big box and I thought about care coordination from the big box outward. And I think that's a challenge for us and I put in stereostrips. Wow, that is so well said. I love that thought because when I was a hospital administrator, I had the same thing. I thought, you know, the box was at the center. You know, it's a, so Donna, I know, you know over there in the UK, you've been, you've been, oh, I'm sorry, like actually before we get to that do you have any suggestions, Marty, about how we can restructure the systems? Yeah, I think, I think we need a revolution, you know and, and I think a little later in the webinar I'm going to talk about maybe doing some design thinking and kind of bringing it out. But the first thing I would encourage people to do is to ask themselves fundamentally what do they believe about health and wellbeing because as a leader, it wasn't until I had to reframe kind of my thinking and then I needed to influence and engage others around wait a minute here, we are a moment. What is our role? What is our scope as a hospital, as a health system? Do we hold people's health and that we are the bearers of it or is it truly their individual health and we're partners? And when you start to uncover that you really do pull back a lot of layers that I think is very beneficial to have conversations about and to make sure that you've got that alignment in your strategic plans and additionally within your executive leadership and all the way through. Good point, good point. So, Donna, I know the UK has been trying this. They've been really working hard to improve care coordination across that entire continuum. So, you know, what has happened, what's been happening over there at the NHS? Oh, right, okay. As with every country in the world, the UK is wanting to improve the quality of service within patient care. If care coordination is not conducted with precision and unity, mistakes can be made that have devastating consequences for the patients. The latest framework to emerge only last month in the UK was in connection with patient safety and it's called the Framework for Involving Patients in Patient Safety. This came about from a review from an advisory group chaired by Don Berwick in 2013 after a spate of serious incidents in one hospital. The result was this, as we can see, a promise to learn, a commitment to act. It's called improving the safety of patients in England. In this review, this is what I'll be talking about. So, what's the connection between this and our topic? It's refreshing for me to sit, read this and that it's been recognised. What you have in the NHS is a unified system of care that is completely capable of identifying its problems, admitting them and acting to correct them. And yet even with a robust, unified system, there are still gaps within that system. The two most important times when care coordination are at their most critical, where problems could occur are during the admission and discharge processes. Both involve movement and information sharing. Both stages have the influence of claiming success or producing difficulties. One thing that's abundantly clear, healthcare professionals do not set out wanting to fail. In fact, completely the opposite. When things do not go according to plan, it is normally down to a chain of events and not just one factor alone. So, let's have a look at some of the reviews recommended for identifying the problems. Next slide, please. The first one, incorrect priorities do damage. Other goals are important, but the central focus must always be on patients. And this is very true. We have all experienced when other factors have made circumstances difficult for staff as well as patients. When responsibilities are diffused, it's not clearly owned. With too many in charge, no one is. How often is work delegated? Sharing the workload is good, but if it's shared without the responsibility, we generally say once you've handed something over, then it's their responsibility, but is it? And fear is toxic to both safety and improvement. How many times are we confronted with frontline staff that are blamed if things do not go according to plan and then again, when they are reluctant to act? For as a family member, it can be difficult to witness when you know that they are a very small cog in a very big wheel. Next slide, please. So, if we look at a brief overview of some of the changes necessary that we've addressed in the UK for these problems. Recognize with clarity and courage the need for wide systemic change. Systemic change also needs conviction, determination and the backing of people using the system, which is all of us. Healthcare professionals are not alone on wanting change. For the benefit of everyone, everyone needs to be involved. Reassert the primacy of working with patients and carers to achieve healthcare goals. So this is regarding the state, the importance of working together. Collaboration is achievable for reducing and removing the gaps within the healthcare goals when both parties are working towards the same goals and recognize that transparency is essential and expect and insist upon it. To demonstrate transparency, it requires two other factors that have a strong association and that is openness and honesty. If all healthcare professionals demonstrate this, it should not only assist in improving, improving the standards of care, but strengthen the working relationship with patients. And lastly, engage, empower and hear patients and carers throughout the entire system and at all times. For me, this is a powerful statement. How difficult would this be to incorporate empowerment with hearing patients and caregivers within your working day? Or even using the same strategy with your peers? Next slide, please. One recommendation that should happen from this, a promise to learn, a commitment to act says, patients should, when they wish, advise leaders and managers by offering their expert advice on how things are going, ways to improve on and how the system works best to meet the needs of the patients. The standard of healthcare has never been better than it is today. However, there is still room for improvement. The complete inclusion of patients in their care decisions is still in its infancy with many people embracing the joint decisions to be made whilst others appear skeptical and resistant to change. This would not be undermining the medical profession, but providing a long-awaited balance that is especially vital in all aspects of care coordination. Thank you. Thank you, Donner. Thank you so much. And it sounds like you guys are doing some great work over there in the UK, but again, everybody in the world is trying to improve on this. So, Mark, I wonder if you could help people to understand how are organizations, how are they able to meaningfully measure how they're doing and why is it that more organizations don't measure this as well as some? Yeah, well, I think a key factor driving a lot of the work around care transitions was the Affordable Care Act and its inclusion of something called the Hospital Readmission Reduction Program, HRRP. And there was an article published with some colleagues, Eric Coleman, who I think everyone knows is a leader in care transitions nationally and was a MacArthur Genius awardee. He focused on this aspect of the hospital is a tiny, tiny part of people's medical care and health throughout their lives. It's what happens in their homes and in the community. But this is what was promoted as a way to try and improve care transitions. And we found in our study that was about almost 20% of Medicare beneficiaries were re-hospitalized. When these threats of penalties started coming out, you can see there's a pretty significant decline in hospital readmission rates for Medicare beneficiaries in the US, but they've been staying pretty stable. And currently about 50% of hospitals are receiving penalties related to the Hospital Readmission Reduction Program. And there's clear recognition now that one of the reasons or a major reason for hospital readmissions is not just the patient's medical condition, it's their home setting, their social determinants of health. Do they have electricity to cool things off in the summer? Gas or electricity to warm things up in the summer? Do they have food? Do they have transportation? Do they feel safe in their homes? Do they have community support? These are the key factors that are driving a lot of it. If you go to the next slide, another key measurement being used in the US is the hospital consumer assessment of healthcare providers and systems. So every patient or a large sample of patients when they're discharged from the hospital or surveyed, CMS collects this data. And again, based on the results, they will penalize hospitals for low scores compared to the rest of the US. And I think it measures some important things. It asks the patients and or their family caregivers if they're filling out the survey, which actually happens quite a bit. Were the nurses and physicians treating you with courtesy and respect? Were they listening carefully to you? Did they explain things to you in a way you could understand? These are all individual questions. And then from the hospital perspective, these patients and their family caregivers are asked, did the hospital take my preferences and those of my family or caregiver into account? And did they, you have a good understanding of the things that you as a patient are responsible for and managing my health? So these are things that are happening right now. One of the things that a collaborative team that literally involve people from across the US from California to Louisiana to Kentucky to Boston to Philadelphia was something called Project Achieve. And the next slide, this was funded by the Patient-Centered Outcome, the Research Institute. Achieve is a little clunky, but we came up with the acronym Achieving Patient-Centered Care and Optimized Health and Care Transitions by evaluating the value of evidence. What we attempted to do was literally study patients and their family caregivers as they went through the hospital discharge process. And we ended up surveying almost 8,000 patients and approximately 3,000 family caregivers. Next slide, it shows you some of our results. And another key aspect of this is we started off by conducting focus groups. It was the largest set of focus groups ever done with patients and their family caregivers related to the hospital discharge process. And the patients and their family caregivers, this is what they told us. They look for certain services and provider behaviors that really achieve what matters most to the patients and the family caregivers. They want the providers to communicate using empathetic language and gestures. In other words, sit down when you talk with the patients. Don't stand up at the door with your hand on the door handle. They say, you know, this is a new experience for me being a hospitalizer. I've only been hospitalized maybe a few times and I don't know what's gonna happen when I leave. You've been taking care of thousands of patients with these issues. You should know what's gonna happen. Make sure you anticipate what are gonna be my needs and help me as I transition to home. They wanna be involved in the discharge planning. They don't wanna be told this is what you need to do. And then if you're gonna provide information, honestly, patients and their family caregivers, they don't really care about the pathophysiology of disease. They wanna know what is the actionable information they need to take care of themselves. And then as was mentioned very clearly by Donner is that they want continuity. They want minimal handoffs or that there's a handoff. They wanna feel that the handoff has actually occurred and they know there's gonna be accountability from both the person who handed off and the recipient of that handoff. Next slide. So these are the things that they said mattered most for a successful transition of care. They wanna feel cared for and cared about by providers. That needs to be, I think, measured a little bit more explicitly. They wanna see that there's unambiguous accountability from the healthcare system. Not that they got sick. They called their primary care provider. There was a voice message, call 911 if you're feeling bad. So they do, they get transferred in. They see somebody they don't know in the emergency department. They then get admitted to the hospital to somebody they don't know. And a lot of times the primary care provider doesn't know what's happened. Maybe there is a scary strip of the EHR, but we found in previous places I've worked that you needed to have that phone call, that accountability to make sure that the hospital providers, whether it's emergency medicine or hospitals, talk to the primary care provider. And I think they need to be involved actually in the discharge process without question. They, the family, caregivers and patients wanna feel prepared, confident and capable of implementing these care plans. And one of the things that has now come out of our research that we have submitted for publication is the importance of trust. If the patients and the family caregivers trust the health system, they actually are less likely to be re-hospitalized from what we could see. So I think this is how we need to figure out how we measure trust among patients. And if it's not there, something needs to be done to establish that trust. Next slide. I think that's it, yeah. Thanks. Well, that's great, Mark. Great, wonderful solutions. And we've got several questions about some of this in the Q&A. So please keep the questions coming. We'll have about 15 minutes at the end to answer some of those. But in the meantime, Marty, Mark's brought up some really great ideas about how we can make those, we can create those solutions and systems. But what's the mental shift that has to happen in order for that change to take place? You know, the mental shift is hard. That's the bottom line. If your life's work has been in healthcare and you know how to run health systems in hospitals or home care, it's really hard to reframe. But I want to kind of give a model to you. And you know, Mark did a beautiful job. And one of the things they talked about is, is what's trust? And I define trust as an outcome based on actions. And so when you start to think about, okay, what is trust? Trust is an outcome. Well, if there's low trust, then what are the actions? When you start to ask those kinds of questions, it then really kind of uncovers. And you know, the model that I use to help me reframe and to think differently is I personally had the opportunity to be trained in human centered design thinking, we're gonna be sending out information around that. I would tell you, put it into your repertoire of how you approach problems because it opens your eyes to really very different kinds of solutions. But the questions that you've got to ask yourself is do you believe in the three S's? And as you're doing design thinking, if you design the system to fit into its current system, you're gonna get continuously what we're getting. And so you've got to back out and you say, do I fundamentally believe in the three S's? And S one is self-management of health and wellbeing. Do I believe that individuals, those that I serve, those that I walk alongside in my communities are the ones who should self-manage their health and wellbeing? Or do I see it as part of my job and accountability once they land in whatever place they land in? The second S is advocacy of self and others. So when we look at that second S, one of the things that we have to think about is are we willing for people to be advocates? That takes active listening. And as Mark said, empathetic capabilities and empathetic presence. And then the third is, are we willing to blow up our systems to where we can allow and have self-navigation? Now, what does that mean? And that's when it gets fun because that's when you involve individuals outside of healthcare who think wild. They are wicked, wicked wild thinkers. And you encourage them to ask the questions challenge and to say, why can't we do this? And that's when we can fundamentally start on what I call this revolution of how is it that we can create health systems that are safe, that people feel comfortable navigating through. I like it. I like it. I want to be wicked. I want us all to be wicked thinkers. Nisha, any thoughts from your perspective about how we can do that? How can we all be these wicked thinkers and improve that holistic patient care and improve that patient engagement across the continuum? Yeah. Thank you, Donna. So what I would talk would be repeating most of the things what Mark mentioned. I believe for holistic patient care and engagement, the most vital thing is the empathetic hospital culture that values patient care and engagement. And this can thrive only when employees feel empowered and valued. Physicians feel that their patients are getting great care and patients feel that their services and the quality they are receiving are extraordinary. Next slide, please. Now, coming to the specifics, I would like to mention one important component is to focus on patient provider communication during pre- and post-discharge interventions. These would include risk assessments for adverse events or readmissions, medication reconciliation, patient engagement, patient counseling, tagging of red flags, which is so essential, and making disease-specific management strategies. It is also very important that we look into resources for addressing post-discharge issues, you know, especially related to communication when it comes to outpatient services, including the rehabilitation. Enabling skilled staff to aid appropriate follow-up is also going to add a lot of value for care coordination. And this is something very, very important that organizations should look forward to, that we do have skilled staff, that post-discharge, we do take care of our patients for communication. We should take care of reaching out to patients either through telephone calls or through home visit so that, you know, we ensure a safe transition and facilitation of a proper clinical follow-up, wherever it is applicable. And at all levels, I would say that it is very important to ensure that information is transparent and the organization that is providing care is accessible. We need to be available for our patients. And we all would acknowledge that with this pandemic, the digital technology has taken a lot of prominence as a means of enabling patient-provider interactions across the continent. We see more and more healthcare organizations embracing the healthcare technology like telemedicine, teleconcentrations, and all these. Lastly, I would like to add that privatizing quality outcomes and ongoing monitoring is also very, very essential, as Mark mentioned. And the stat tree should include measuring outcomes like the 30-day read-measurement rate, which was mentioned, you know, measuring adverse drug events, medication errors, patient-reported outcome measures where you understand, you know, what's the perception of your patients for the care that you're giving, plus enhancing on electronic health records and telehealth communications, as I already mentioned. Thank you. Thank you so much. And so, Donna, I wonder, you know, you've been dealing with this for many, many years and, you know, been very involved in the care of your son. What are some tips and some strategies that you can provide to others that, you know, can help patients and families be more involved in their care transitions? Yes, I have. And, you know, it's been a huge learning curve. And what we found is, I use the same strategies for care transitions as with every aspect of my son's care. And we mainly simplify everything because everything else in his life is so complicated that it's most important that we find the most effective way of dealing with stuff. And these are just four points which, you know, it's going to be a very brief overview, but this is what we use to design for maximum benefit. Greatest advantage of using strategies such as these is that they are easily adapted and they meet individual's needs, you know, and you can change them or add, it depends. So the first one, be honest. And that means with the professionals too. Honestly, it can be a difficult one to achieve, especially if identifying gaps in care coordination needs to be brought to staff or sometimes even the patient's attention. But this should always be a two-way street for communication. To be honest with, you know, both sides need to do this. Alleviate anxiety and fear. These are possibly two of the most negative traits as human beings we possess. Overthinking can occur to the most level-headed of us when we find ourselves in vulnerable situations beyond our control that renders us unable to fully engage. Fear is generally created by the unknown. It's left to build, when it's left to build, it then turns into anxiety and then, you know, complications do set in. But the more you deal with the fears and the anxieties and the triggers that cause them, the less they appear and they do become reduced. So both of these can be crippling to a person and yet they're both able to be managed. And the next one, insight, use it. Oh, sorry, not the next slide, sorry. Insight, use it. The one common factor between many patients and their carers is the experience and knowledge that they have accumulated from the medical conditions, their experience, the treatment that they've received. By information sharing, everyone benefits. And then the last, expect the unexpected or the human factor. Just as it doesn't matter how much planning or goal setting is prepared prior to any form of patients transition, life as a habit of throwing a curveball, no one expects. And this is the human element. And as we are all human, it affects all of us. In times such as this, I find that I just have to pause, I take a step back and breathe. I process the situation and this is usually when I find myself to say expect the unexpected as a patient could deal with these type of situations every day or even several times today. Next slide, please. And finally, I would like to leave you with this statement from the World Health Organization. This demonstrates that the clinical and patient aspect of care are two halves of which we're all responsible for bringing together. The term transition of care is broader than clinical handover because it encompasses the clinical aspects of care transfer and other factors such as views, experiences, and needs of the patient. By embracing patient involvement at every point of the clinical process, this will be one less factor being the cause of breakdowns in care coordinations. And I'd like to thank you. And that's it. Thank you, Donner. I really appreciate you being with us today and all of our panelists. It's time for us now to get to some questions. Before we do that, I just wanna wrap up just a few more housekeeping items just to remind everybody, if you were here in the beginning, you saw this. If you are interested in receiving CME or ACPE credit for this, then it'll come through MedStar Health. And again, respiratory therapists may also qualify for nursing credit for this. You'll receive an email from MedStar if you registered as one of these professionals indicating that you would like to seek the CE. And if you are any of these folks, if you're seeking ACHE, CPPS, BCPA, or CPHQ credit, then if you indicated that, then you'll either receive a certificate from us or you can log it into your system for ACHE or NHQ will take care of it for CPHQ. Here at the Patient Safety Movement, we are so very, very excited to be able to offer these webinars on a monthly basis for free. But we could certainly use your support. So we are a nonprofit organization. So if you would like to help us to continue to be able to provide this education for you of charge to everybody, then please visit our website at patientsafemovement.org slash donate. We would really appreciate any support that you can provide. So thank you everybody, but we're gonna move ahead onto our Q and A session. And there are lots and lots of questions going on here in the chat. I think one of the big questions that I'm seeing here is related to how do we, well, first of all, here's a great question and maybe Nisha, you can start is, is there anybody that's doing this right? Is there any healthcare system in the world that has successfully figured out how to manage care appropriately across the continuum? Nisha or anybody? If you know the answer, please tell me. Exactly. I don't think there's any organization across the world which is the perfect. There are learning from each one of them, you know? Yeah, yeah. Well, and I think what we've all learned is, there is no healthcare system that is gonna fix this without involving patients and families. But there's a lot of questions in the chat talking about how do we adequately prepare patients and families who don't know how to do this? Mark, I saw that you answered several questions in the chat. You wanna expand on some of those thoughts? You know, I think a key aspect of all of this is that Gabe's getting reputed over and over again is that one, we've got to involve the patients and their family caregivers. You know, I grew up working in a family gas station and I remember hearing Don Burwick comment that basically hospitals are big repair shops. And so look at what's happened now with cars that they don't go in the repair shop nearly as much. And as we are about to make this transition to electric cars, I don't know if anybody's seen this, there was a company in Southern California that bought a whole bunch of electric cars and they thought it would be a novelty. But one of the things that they found it out is that these cars were still running 500,000 miles later and really just needed their windshield wipers and tires replaced. So I envision a time where we begin to design our system so that people get good education and good food as they're growing up and they're taught how to take care of themselves. Instead of this, let's wait for them to get sick. And I remember when we published our original health literacy paper way back in 1995, there was this incredible editorial by a PhD educator. And what he basically said was that trying to deal with this when patients are 65, 70, 75 may be too late and we need to invest in making sure patients know how to read and I completely agreed with them. And I would agree more as I've gone through my career. Unfortunately, we just can't negate the idea that we still need to address these other individuals who are now, they are 75, they're sitting in front of us. But we've got to begin to undertake if you will, some preventive care. And there was the original slide that talked about the different steps and it was mentioned the hospitals in the middle of a lot of these graphs. Well, that diagnosis and treatment steps, those are gargantuan from a financial perspective and it would shrink if we invested more in the education and prevention components. And there's no doubt about that, but this has been, I think one of the difficulties we talked about, all this new technology that's coming out in medications that cost $100,000 a year and so forth. I was gonna also share that at least here in the US and our payer system is many times now jumping over hospitals. So many of our insurance companies have said, listen, we've got to figure out how to help our covered lives, our individuals that we care for to where they self-navigate and they can make the right choices and their advocates for themselves. So remember the three I talked about, we're sitting down in the payers. Now, what's fascinating is is many times health systems are not part of those conversations nor are they part of that plan. And so they're really kind of still over here. And I would encourage you, and I saw one person say, hey, I think health premiums many times are kind of influencers of that. I would sit down with your top payers and let's do a pilot and let's talk about, let's be wicked and ask those questions about how can we can design it? I can tell you one payer is sending food to identified covered lives. They have exercise programs that they're bringing in via the women from Chicago. And there's just so many things that they're doing to really create this health and well-being, this self-navigation. Partner up, I would encourage you for the partner up. I would agree. I would absolutely agree. Donner, there was a question in the chat about whether or not we could use virtual reality to train patients. I wonder if you could give us your perspective on that. And what are some of these technologies that we can use to better train patients to participate? Well, that is a very good question. I mean, with technology and the way it's going. We do have in the UK videos and films that use like a virtual tour around the hospital and what they're actually, you know, will come up against, you know, from entering into the hospital and they work through the process. So yes, that could be something that could be looked into. But yes, it's very interesting because it's not just the health care professionals that need information, it's the patients. And yes, and family members because a lot of people come in and they don't know what to expect. You know, they see there's so many different people, so many different grades or uniforms and anything. And, you know, it's very confusing. It's very daunting. So yes, I think we do have a lot of scope there, but it's just actually finding something that is going to be suitable for the wider audience, you know, the higher, bigger patient thing. Yeah, so that's going to be interesting to see where we go from there. Yeah. Well, I think it's, you know, it's really interesting, Donna, because you bring up that different perspective of the patient and I think there's also some thoughts in here in the chat about how healthcare professionals, healthcare clinicians are dealing with patients that may be quite, you know, or patients' family members who may be a little bit aggressive, probably because they are very afraid and they're very overwhelmed. But, you know, Mark, I wonder, Mark, do you have any thoughts about, you know, how do healthcare clinicians who are very overwhelmed in this very complex care setting, trying to do everything they can, how can they better deal with these families that are overwhelmed and may be perceived to be overly aggressive? Yeah, no, no, I saw this pop up a lot of times. This has been a frankly troubling issue that's coming up more and more. In a way, it can be almost even equated to what we're seeing happen on airplane flights where passengers basically lose their sanity. And I think there's a lot more just stress in the world with everything that's going on, certainly with COVID-19. And, you know, when I see family acting out, it just tells me that there's a huge amount of stress that they're experiencing and there hasn't been the resources to begin to address those issues. You know, again, I think, you know, there's a difference between somebody being a Q-Leel, needing true emergency and critical care and trying to address that versus somebody with a chronic illness that may have a little bit of difficulty but there's really no other place but the repair shop at the hospital. And I think if we're able to maybe get this care delivery out of the hospitals and into people's homes, even especially before they're sick, that would be a truly transformative change. I mean, the information on hospital at home, it's staggering. And the thing is, you know, people, Bruce Leff at Johns Hopkins, I mean, he showed this 15 plus 20 years ago. I mean, there was a systematic review 10 years ago that was published showing its effectiveness, shorter length of stays, even though the patients at home, they literally need hospital care for a shorter length of stay, reduced readmissions, huge increases in satisfaction. And so the key factor in a lot of this is that I've been realizing quite well actually, the funds flow has got to go towards better care for the patient that is more, you know, encompassing of the community and not rewarding more surgeries, more procedures, really super expensive pharmaceuticals and so forth. But it's gonna have to be balanced. I mean, there are some expensive procedures that have astonishing life-saving outcomes and we now know that. The issue is we're gonna have to have, and I think Don or had this, we've got to begin to be honest. There's a cost when we decide to pay $100,000 for a medication that has marginal, if any benefit to patients or maybe it benefits one patient and to a thousand that you give it to. And we're then depriving thousands of people of something that we know works. Yeah, that's very, very true. You know, and I think we also have to recognize somebody had asked a question about lean and when a hospital implements lean and everybody is now pulled in so many different directions and so much to do. And I think that's a fairly interesting question because yes, our clinicians are overwhelmed, our patients are overwhelmed, our administrators are overwhelmed, everybody is overwhelmed. That's not the definition of lean, right? Lean isn't supposed to lead to, everybody is too overwhelmed and too busy to do what they need to do. So, you know, any thoughts there about how we can improve that? Or Marty? Yeah, I mean, I would jump in and say, you know, the principles of lean are good, but they lay on the foundation of, you know, a system that is fundamentally strong. And so you've got to step back and say, wait a second here, you know, as we're looking at the principles of lean and we're utilizing that in whatever system we're looking at, this conversation we're talking about care transitions, we have a fundamental system that is strong that we then can move efficiencies out and then we can bring it in. If it's not strong, then you're gonna do stare districts. I mean, that's what you end up doing and that's what I've watched with, and you know, I've done Kaizen Advanced, Malini, I've done tons of them. And we just take a little bit and we bring this and we bring this and we put a stare strip on. But we didn't step back to ask the question of fundamentally is the system strong or what is it that we need to fix here? And then go forward from there. Well said. Well, we are right at the hour now at 8.30 here on the Pacific coast. So, you know, we didn't get to all of the questions in the chat and in the Q&A, but as always, we will download that content. We will confer with our wonderful panelists here today and we will make sure that we post those along with this video, the PowerPoint. And I believe there was a question, Mark, you brought up an idea by Eric Coleman and you can make sure that we post any references that anybody made to here on our YouTube page. So thank you to all of our panelists. Honor, Nisha, Marty, and Mark, it was a pleasure to have you here today. Thank you. Thank you. I'm here for everybody have a wonderful day and we'll see you next time.