how long she is in her disease process. Yeah, now we often discuss dementia in stages, which refers to how far a person's dementia has progressed. Defining a person's disease stage helped me determine the best treatment approach and helps me communicate better with you. Dementia is commonly referred to as progressing in three stages, mild or early, moderate or middle, or severe or late. Can you tell me from your past discussions with mom regarding her hopes or her wishes, what do you think she would be concerned about? What makes her happy? And what level of intervention does she want if she became even more seriously ill? Mike, I think that's you. Mom seems to be getting weaker with each hospitalization. And being in the hospital has not been a good experience for her. She seems to become more confused and combative and yells to go home when she's in the hospital. And the hospital doctors would give her more sedatives to calm her down. My mother has said in the past when she's lucid that she doesn't want to go back to the hospital. But I'm not sure that my sister, who's the primary caregiver in the home, agrees. My understanding from my conversations with mom is that she wants comfort-focused treatment. If she declines again, I think we would prefer hospice to another trip back to the hospital. My mom used to love to knit, and she worried about becoming a burden to us. She can't remember how to knit anymore and has lost whole interest in it. It's becoming difficult for me to take care of her. It's harder to redirect her and change her diaper without her becoming combative. She's yelling and swinging her arms. I haven't seen my own doctor in ages and not sleeping well because I hear get out of bed and wander around the house. I have a lot of guilt and anger. And while my brother does try to help, he doesn't have direct responsibility, and he gets upset when I call 911. That said, I agree that going back to the hospital is not the best thing for mom anymore. Can you help us? And I know this is hard for both of you. Let's talk about where I think your mom is with her dementia, and then we will discuss some options. Is that okay with you? Yeah. I think your mom is heading to the late stages of dementia due to her increased forgetfulness, aggression, incontinence, dysphagia, trouble swallowing, the pressure ulcers, and the weakness. The dysphagia can sometimes lead to aspiration, which is the accidental ingestion or sucking in of the food particles or fluids into the lungs. Aspiration is one of the end stages of dementia. And I have some difficult news to to give you. It would not surprise me if your mom passed away in the next 6 to 12 months. Well, what about a feeding tube? Well, that's a great question. But before I answer that, can you tell me what is most important to you in the care of mom given her current condition and moving forward? Well, I guess we would both want mom to be comfortable and minimize her suffering, giving her illness, and the likelihood her condition is not going to get any better, right? I'm sorry that I don't have a medication to reverse her mind, the dementia, and to make her mind work normally again. And she will most likely decline and become more physically and mentally weak in the days ahead. Can you give me an idea what is your understanding regarding a feeding tube for patients like mom? I guess not much except it can provide nutrition. Yeah, that's right. But there's research suggesting that two feeding in patients like mom with advanced dementia does not increase survival. It does not prevent aspiration pneumonia or prevent pressure ulcers. It does not reduce the risk of infection or improve functional status or even the comfort for the patient. A feeding tube can actually be a little bit uncomfortable and even painful at times. Your mom may need to adjust her sleep position, and you will need extra time to clean and maintain the tube and to handle any complications that may result from having a feeding tube. Yeah, that doesn't sound sounds like such a great idea to me. Plus, you know, with mom's aggression and combativeness, she might pull it out, right, and do more harm. I don't think I want to, I don't think my brother and I would want her to suffer. I know it was definitely something she didn't want. Yeah, let me know if you'd like to discuss the risk and benefit of a feeding tube some more. But based on what you told me and what your mom wanted, I agree with your decision. I think we're all in agreement about how to move forward. Would you mind sitting with me to summarize our conversation and also by filling out a pulse form? The pulse form is a decision-making process in a form that results in an order that's intended for patients like your mom who are sick, and they're at risk for life-threatening clinical events because they have serious life-limiting medical conditions, which may include advanced frailty and dementia. And we're going over the form together. How are you doing? We've talked about some very difficult things today, and I appreciate your willingness to sit with me. And thank you. Do you have any additional questions? No, I think we're okay. Yeah. If you think of additional questions, I'll be back to check on your mom in a few weeks. I'm going to do everything I can to honor your mom's wishes. We will call in hospice when it is appropriate. In the meantime, I will send you some caregiver resources, and I can provide a referral to a social worker who can help you through the caregiving process. I'm going to check on your mom now, and we can talk more after I'm done. Thank you, Dr. Chang. All right. Thank you. Okay. Think about what transpired in the role play and how you might have done things differently. And also, to have a note here to have the learners go to the Ask, Tell, Ask handout. I think that's on, is it on 30? Here we go. On 32, page 32, advanced care planning and discussion tools. All right. All right, Ina. All right. Okay. So, we'll keep moving forward to talk about advanced care planning. I think the main thing, so if you want an advanced slide, I can pass this. Okay. Yeah. I think the advanced care planning, you know, it can't be done in one day. Sometimes, I don't want people to be set up for two lofty goals here. Sometimes, you know, you have to build trust with the family. You have to have the discussion multiple times to really kind of figure this out. And it might not just be with one family member, right? It could be, you know, they could have eight kids and you might have to, you know, have it multiple times with, you know, different permutations of the children. So, you know, advanced care planning is really just starting to figure out, you know, what the patient's values are, their life goals are, and really start them to really kind of look at what their goals of care should be. It should really never be about filling out a paper. I think we often like them to fill out some paperwork, but that's really not the goal. The goal is really just to start having that discussion. Okay. So, next slide. Okay. So, I think we kind of talked about that. It's really not about filling out paperwork, but again, looking at what their goals are. So, next slide. So, you know, so there's different things you do if you are moving towards a document. You know, you want to look at like living wills, you know, designation of health proxy agent, and, you know, Dr. Chang talked about post forms. The thing about, it's great. I mean, I believe in living wills. I believe in all of these things. And so, you know, what I often tell families is that, you know, as we're having this discussion, you should write it down. You know, you should fill out a form to make sure people really understand what it is that you want. So, that might be in a form of living will. Oftentimes, like I really try to push them and say, who do you want to be your spokesperson? And I can't believe you tell you how many times like people look at me like, what are you talking about? And I'm like, you're 85. You should have, you should have a spokesperson in your life. And they're like, you know, they turn to their, to their spouse, who's like, you know, 88. I'm like, okay, well, besides your spouse, who else, you know, and sometimes they really have, like, they haven't really thought about it. And I'm kind of always surprised, like, you really haven't thought about this. And they haven't. And so, you know, I'm like, well, maybe you should think about it. And oftentimes, what I often hear is that, well, my children would know what to do. And I'm like, do they really know what to do? Because have you had that discussion with them? Because it's not a conversation you bring up like a Thanksgiving dinner and say, hey, this is what I would like to do if I'm about to die. I mean, it's not a conversation most people are comfortable having, even with their own children. So I'm like, did you I mean, you assume your children will know what you're buying. But do they first of all, do they know that you're actually asking them to be your spokesperson? Have you had that just that conversation? If you haven't, you should probably let them know. And then when you tell them, you know, I want you to be my spokesperson. You should probably also tell them what you actually would like to have done because kids assume things that maybe should not be assumed, right? And sometimes because they don't know what their parents want. They they do everything because they don't they don't want to have that, you know, burden of not doing what mom wanted. So because they didn't know what mom wanted. Well, we're just going to do everything and cover everything. Right. And so I often tell them, it's like, you know, you actually take the burden off of your children by actually really dictating what you want, because then even if they have conflicting feelings about it, they can have something that they can read black and white and say, oh, this is what mom wanted. And, you know, even though I feel this way, I think, you know, she said this, so we're going to do this because we're going to honor mom's wishes. So I tell them, I was like, it's really not only doing it for benefit for you, but it's also doing it as a benefit for your children. So they know very much what you want done. So, you know, designating health care proxy, you know, a spokesperson, formalizing that to a DPOA is it would be wonderful. And I often tell family members and, you know, I have patients who don't want to designate DPOA because they feel like once they designate the DPOA, that they've lost control of their lives, that their daughter's going to make all the decisions for them from now on out. And I'm like, that's not what's supposed to happen. That DPOA doesn't get activated until you lose capacity, until you cannot make decisions for yourself. I was like, it doesn't activate the minute you sign it, right? That's not how it works. So sometimes there's myths around that, that you really have to dispel. The post most forms are great. They're called physician orders for life-sustaining treatment. They're really to be filled out, to be placed in the patient's home. In Delaware, we have pink envelopes that we stick them in and tell patients they put it, they have to put it somewhere where the, the paramedics can easily see. It is a legal document. So whatever the patient's wishes are and how they fill it out, the, it does, the paramedics have to, by law, obey it. So, which is great. So if a person says, do not resuscitate, you know, and no transfer to the hospital, the paramedics cannot do resuscitation and cannot transfer. I love this form. And sometimes people ask, well, when should we start filling out this form? And I tell them, like, you should, I mean, really it should be used for the last year of your life. And sometimes people are like, well, how do I know it's the last year of your life? And I often, this is a great question to, you know, kind of carry around in your brain. But if, and the question is, would you be surprised if this person was dead in a year? And, you know, and I know that's kind of like, you know, grim, but if you look, and you know this, when you look at a patient, if you ask yourself, you were like gut feeling, probably not. And your gut feeling saying that they're probably not even last year, you should be filling out a pulse form or, you know, a mulch form. Does, you know, you should be filling out that form and getting them ready. So, so that's often sometimes I think about, like, kind of what propels me to fill out that form is that question. Will the, will they be dead in, will you be surprised if they were dead in a year? All right, next, next slide. So advanced care planning, you know, we talked a little bit about the benefits of this already. You know, you want to, you know, one of the benefits of this is all, all of a sudden knowing their goals. Hopefully you can reduce some hospitalizations and unwanted procedures. You know, a lot of older people don't want to be, you know, poked and prodded a lot more. So that's great. Like if they don't want it, we shouldn't be doing it. But, you know, when they go to the hospitals, that's just like standard. So if they don't want it, then they shouldn't, shouldn't get it. And then you can talk about palliative care. You can talk about hospice care. Next slide. So the other thing about, so the steps in discussed advanced care planning, a lot of this was what Paul already talked about is steps in prognostication. That is a long word. And earlier, so actually the first, I was like going through it. And actually I think the first seven steps are kind of the same thing. So I'm not going to review it. It really kind of differentiates really only in bullet like eight and nine. And which is really to talk about, you know, your advanced care plan preference and really being specific. And this is, you know, again, talking about like, what do you want? Do you want CPR? Do you want defibrillation? Do you want intubation? Do you want IV fluids? Do you want tech tubes? And really, you know, and sometimes, you know, families really don't know what, what, you know, each one entails. You know, it's sometimes hard to say, well, I want CPR, but I don't want intubation. Sometimes it's like, well, you can't, you can't really separate the two because like, once you go down that pathway, you kind of have to like start doing everything. So sometimes I really try to say like, you know, if you want one, then you kind of have to have it all. So if you don't want to be intubated, then you really shouldn't want CPR and defibrillation and kind of back them out that way. Peg tubes is a, is a conversation that, you know, Paul, I think already addressed, not really appropriate for end stage dementia patients at all. Evidence has really shown that. So I really, you know, very much, very strong. I come down very strong that it should not be, be recommended for end stage dementia patients. Peg tubes should not be recommended. IV fluids is always tricky, right? Because people want IV fluids, like why not? Why can't you just give my mom some fluid? And then you really have to kind of be like, well, what are you trying to do with the fluids? You know, like what are you trying to gain from it? And so, so that's always, you know, kind of a longer conversation about that stuff. So it's really, you know, trying to really tease things out because it matters at the end. And really kind of having people think about what their, you know, their choices are at the end. And, and hopefully, you know, kind of depending where they are in their life cycle, that can change, right? And so sometimes when you're having these discussions and the health, you know, they're healthier, they might want to say, I want it all, you know, and then, you know, as they move through and they're getting weaker and weaker, and they maybe had way too many hospitalizations, you know, you have this conversation again, and they might say, you know, I don't want any of that, right? So it's also static. I mean, not static. It's also fluid in the sense that, you know, depending on where they are, they might have different ideas about what their goals of care are. So it is important to revisit this issue, you know, as, as you get to know them and as they kind of move through their life. Okay, next slide. All right. So the last, next slide, the last slide is really just the ask, tell, ask approach. So this is very, you know, well taught in the palliative care world, in the hospice world. And it's basically, you know, you ask the patient or the caregiver, basically what they know about their condition, you know, so you tell me what you have heard, what you know. And, you know, and, you know, and any questions you have about your condition. I'm always surprised. Well, I'm surprised either way. Sometimes I feel like a patient knows a lot. And then when I asked them, they don't know a lot. I'm like, whoa, there was a total knowledge gap, you know, between what I thought you knew, what you really knew. And there's times when, you know, some of my silent patients, I'll ask them and be like, I don't think they're getting it. I really don't. And then I asked them, and they totally know what's going on. I'm like, oh, all right, great. That makes it easier. So you don't know. And so I've been humbled many both ways, that I don't know what they know. And so I ask, you know, you ask, what do you know? And they like, let them tell you. And then you basically tell them what you know, what you know, the condition, and what, you know, kind of what the prognosis is, kind of what the future path is. And, you know, again, in layman terms, as Paul talked about, it's easy to get really locked down into the medical jargon, really try not to and make it, you know, make it easy. And then you ask them again, they'll be like, do you have additional questions? Do you understand what I just said? You know, basically, you tell me or you, you know, I asked you, but you tell me back, you know, what you understand from this. And so that's really the format of, you know, having these conversations is the ask, tell, ask approach. And it's nice to have a little format, just because sometimes these conversations are tough. And, you know, I know, there's times when I go in, I'm like, I feel like I'm floundering, like, you know, there's just so much to digest and talk over. And this kind of grounds me to be like, all right, ask them first, like, what do they know? And then tell them, and then ask them if they understood everything. So all right, next slide, I think that comes to the end. Yeah. Okay, so great. So, you know, prognostic information, I just want to kind of go back to one thing. Prognosis is important. Families will ask you how much more time, right? And that is, I mean, we get that. And, and I tell people, like, I don't have a crystal ball, right? I wish I did. But I can give you a best guess, you know, and I think that helps people. I'll tell you, I'm not, I'm not magic there. And that's why I'm humble, because I have given my best guess. And sometimes my best guess is off the mark by, you know, two weeks. One time I was like, I was like, oh, two days, woman live for another two weeks. I was like, the daughter like looked at me like, I was like an idiot. And I was just like, I'm so sorry. Because I apologize. And like every other day there are, and then mom just like held on. She was like, well, this tough bird, she's like, held on. And so I don't know. And so it's okay to be upfront and to say, I don't have a crystal ball. I have a best guess. And but even a best guess gives people a peace, peace of mind. And I think you have to say, and I don't know, we have a discussion about hospice and dying. But one thing I did learn from my hospice counterparts, and I really want to impart to you, because it was really, it's a really great teaching point from the hospice nurses was that if you are, if somebody is near the end of life, you do have to use the word dying. Okay, I know it kind of sticks in your mouth, like it's hard to get it out. But you have to force it out of your mouth for patients and families to really maybe not a patient, but for the patient and family to really understand, you know, time is near, you know, because you don't want them to miss calling, you know, Bob, Uncle Bob, who lives in Colorado, to come visit or have a phone call with mom, one more time, you know, because if you don't say it, they're not going to think mom is really dying. They're going to keep thinking, oh, we still have more time with her, right? Whereas you're like thinking, no, you don't. But if you don't say dying, they're not going to get it. So, so you have to say it as it's getting closer that they're dying. Okay, and it's not comfortable, and it sucks to say it. But it has to be said. Okay. So just want to impart that little nugget that my hospice nurses have told me and I keep remembering to do. All right. So I kind of all right, we came a little bit under time. So, any questions, maybe two minutes for questions for us. I know it's a long day. But the good thing is you're going to end with self care and avoiding burnout. So I think that's a great way to end the day. Yeah. I have one question. I just, it's just a personal experience. I've had some patients who really, like, they know what their wishes are, and they defer to their children. And their children may disagree, or sometimes they're like, kind of disengaged, like, they literally don't want to be a full coat anymore. But they are because their children aren't on board with their decision. I was just curious if there's any approach to dealing with that, like disengaged or, or, or like, almost too engaged family members who kind of can't disconnect from their own wishes. Yeah, I'll tell you, I come across that, too, where I feel like almost the kids are like, Mom, you will be full coat, you know. And I'm just like, she just said she didn't want to be full coat. I actually really try to intervene in that space and be like, um, that's, I will say something like, that's not what I heard what your mom wanted. You know, I think what I heard your mom want was that she didn't want, you know, to go to the hospital more. And, you know, so on and so forth. So I do try to, you know, push back on that. Because it is hard for the mom to stand up to their children sometimes. And so I start trying to stand up to them, you know, in a gentle way. And sometimes it works, sometimes it doesn't, I'll be frank, you know, but I do try to push back and be like, that's not what I heard, you know, from your mom, you know. Okay, um, all right, I think we'll end the day now with Amanda. Thanks, everyone. Thank you, Paul and Ina and Michael. I just want to remind everyone to complete your learning plan. We now have our last session for the day with Amanda speaking on self care and avoiding burnout. Hey, guys. Okay, so I propose here, here's my proposal. It's been an awesome day. super excited. I propose we turn on our cameras. Let's ask some live questions. Some of you sat through my self care last time. There are a couple slides in that we're going to talk a little more about grief, loss and burnout more in depth, kind of the systemic stuff. And my counterpart, or my other proposal here is that, well, wait, let me back up, I guess we at 430. Some of the faculty are going to stay on if people have questions and kind of want to just talk. So I, and typically, if we were in person, and we would be in or in Florida right now, because we were supposed to be in Florida, we would be going to happy hour. So I propose for this talk, if you imbibe, you go get your glass of wine right now, don't feel shamed at all for turning on your camera, get your glass of wine and talking about burnout. How's that sound? And then stick around for a few more questions. All right, guys, some thumbs up. All right. Well, except it's two o'clock in the afternoon in California. Same here. I know. But you know what? You know what we you guys started so early. I know. It's five o'clock somewhere. It is five o'clock. Yeah. You've earned it, you guys. Five o'clock on the East Coast. Yes. All right. Awesome. Awesome. Oh, 1pm. Oh, in Alaska. Okay. Oh, gosh. Wow. So, all right, let's talk a little bit about burnout and stress. So today, we'll just talk about, you know, common stressors. I'm going to say generally health care and facing, you know, facing home-based medical practice. And then, you know, what are some operational administrative strategies? Now, like I said, there are a couple. Did I did I do something? I can hear you. Does anybody else see the changing screen? Or is that just me? Yes, it's being presented. Oh, okay, we'll just keep going. So, let's see, where was I? Oh, like I mentioned, in the essentials class, I talked more about like personal self-care, how you think about and I tried to introduce the concept of burnout earlier, really because of COVID. Because, you know, I think COVID is pushing our health care system, you know, structurally and emotionally to the max. And, and then what I also did in this talk is I added a couple of slides in addition to our learning objectives here around grief and loss. And so, you know, share as much as you want to share. But as I have thought about it all day, and as people have shared stories, we've shared such heartwarming stories, and funny stories and things that are really touching and all of the why's behind it, but it's incredibly draining work. And, you know, there are these moments and we'll kind of talk about but there are these moments that are, you know, you get so attached to a patient and you are so intimate being in their home that grief and loss is probably applicable as a covered topic in this topic going forward even beyond COVID. So those are the learning objectives for today. Slide. So let's talk about a specialty review. Not all of you, many of you are internists, family medicine, and this is a burnout, depression and suicide report from 2019 Medscape. So sometimes you see cited articles, this is from last year, you're talking we're talking about almost 50% of these specialties and you have what over 40% of the specialties are 45% or higher have experienced burnout. And I'm going to extrapolate this data to all of those who work in healthcare around these specialties. I'm going to say this applies to, you know, nurse practitioners, it applies to administrators, it applies to those nurses, social workers who are working in these spaces in healthcare. Slide. So what are some of the top stressors? And I'm going to, you guys think about them, start throwing them in the chat. What are we missing here? So, you know, mediating patient family conflict. I can tell you we have certainly had a patient and family interaction that has gone absolutely great and perfect and we just nailed it and everything's great. And like I said, that son in San Francisco calls us up is on, you know, is a decision maker in here and throws a wrench in everything. Right. So now the family has this conflict, you know, sometimes you have mentally ill family members. My favorite thing about working in healthcare is the number one thing that providers do is they diagnose everyone around everyone. And so, you know, well, you know, I've talked to a provider, maybe something didn't go quite right or whatever. They'll say, oh, they have depression, you know, and, oh, okay. They're not our patient, but probably maybe they have depression or, oh, they're, you know, they're bipolar. Maybe, we do not know. But they certainly, we certainly understand how others are dealing with grief and loss. And when you add the mentally ill family members and you add conflict, it becomes quite a lot of burden. Electronic health record and paperwork complexity. We talked about, you know, even if everyone on this call could just get access to their local health system, Epic, McKesson, Cerner, you know, EHR, wouldn't that be awesome? And you add in then even if you have access, how do you navigate it? How do you get all the paperwork in right? How do you keep fixing the system? You know, the system and the infrastructure put in place to get your work done. Financial pressure, inadequate funding for the complex works that occurred. And so, Brianna will talk tomorrow about how we maximize the funding as best we can ethically and legally, but there's still not enough money in this field. And that's why we talk more tomorrow about value based care is how do we start taking what you're already doing and putting more money to that and maybe less of a widget fee for service function. But that financial pressure is real. I want to keep my lights on. I want to pay for my child to go to, you know, college. And I'm so vocationally rewarded by this work, right? Patient adherence. I told them how to do it all. I laid it all out. We had this great conversation. We hugged at the end. And sure enough, they didn't do it. My goodness. You know, how do you push that push past that every time? You know, how do you put your heart and soul into it and kind of get burned? That's a tough, that's a tough road to be in and to continue to have that happen. So, you have these bright spots and then you have some dark spots as you go along here. The scheduling and logistics of providing care and home care. So, we open today with how do you make things more efficient? But just if you think about the numbers that Tom shared of the number of people in his opening video of how many people need our help, there will always be someone who's just five miles down the road, five miles down the road, who needs your help. And sure enough, you're driving a hundred miles just to get to that patient. And it's a long burden, rewarding, but exhausting. You know, and finally, you know, how do you, you're feeling unsupported in the field, especially sole providers or just a couple of providers. There are a lot of complex issues. You're running your own business. You have to keep track of all the clinical pieces, all the clinical documentation. You take all the risk and, you know, it's just you doing it. So, I mean, there's a lot of components that again, put these, these stress things together. Now, as we talk about stress in our lives, we all have a level of stress that we deal with, right? And it's just a, actually, I think if you go to the next slide, I can have a definition. So it's just a body's reaction to change and we all carry it in all different scenarios, right? And, but that over time is what we call burnout. And so often we hear people say healthcare workers are burnt out. That's different than the system is stressful. You know, work, being a working adult in the world is stressful. This constant grind is burnout. I want to make sure that I don't skip out on some of the other notes here. Red tape, insurance. Oh, can you imagine, can you imagine building the healthcare system from the ground up today and saying, I'm going to bring in a third party entity that's going to dictate exactly how I do, but not really understand anything about what I do and sit behind a desk. That would drive me nuts. You wouldn't build it today, would you that way? Family frustration. Yep. So all of these things are real, right? They're coming at us. We're dealing with stress, home life, you know, school, whatever those things can be. And then this burnout, as far as I can tell is there's really no agreed upon definition. And so I turned to a couple of these research entities to try to say like, what does that look like? It's long-term stress reaction. It's emotional exhaustion. It's this depersonalization of I can't make a difference anyway. Oh, well, I, you know, oh, I'm trying as hard as I can, but I'm not, I'm not there. Right. So now I start to step back a little bit. I really haven't ever accomplished anything in what I'm doing. It's just these symptoms where your energy starts to decrease. And as the Harvard report says, and they're all quoted at the end of my presentation is, it's a public health crisis. So as you think about these things, it's really important to be able to understand them for yourselves, for your colleagues, and for the other coworkers and partners, community partners you have inside of the field. Because when we get to this point, then we start getting into that suicide territory. And just for context of the Medscape report, 80% of the people in 2019 that were surveyed had never thought of suicide. Each 20% had either thought of it, did not comment, or had tried it. So we kind of use that Pareto's rule of 80-20. We're right on that cusp right now, and we have choices that we can make to start turning that tide. Slide. The outcomes of these, you'll start to see. Those individual health outcomes, right? I have depression, exhaustion, dissatisfaction, higher rate of addiction, suicide, career change, sense of failure, that it's never gonna get better. Those things, when we actually build them into our psyche, start to impact the other things around us. Now we have patient outcomes, lower patient satisfaction, lower quality of care, higher risk of malpractice claims, right? I'm sure we could list a number of other things, but when you aren't fully present and authentically you, other people can feel it. Your family can feel it, your loved ones feel it, but certainly the patients then feel it by extension. And at a global sense, the system really never gets better, right? If we start to feel that sense of burnout where I can't make a difference, I really haven't ever accomplished anything, then we never actually improve anything. We start to stall innovation. And as we bring up new talent behind us, they're unprepared for the real world. And so as we think about the opportunity to move past this and in a few slides, we'll talk more about how to kind of think around at a systemic level, burnout and these high stress situations, we all benefit if we're all part of the solution. So slide, I'll take a few minutes to talk about grief and loss. You know, grief and loss is a natural part of working in healthcare. Everybody experiences trauma, grief and loss in your own way, right? And you know, these five stages, you've probably repeated them to others. You certainly have learned them 10 times over in your clinical schooling, denial, anger, bargaining, depression, acceptance. They're not linear. You can start anywhere, you can stop anywhere, you can pick back up anywhere, right? How do we take all of these stages as we understand loss and grief and push and move ourselves through these stages? So I'm actually gonna use COVID. It's kind of a perfect example. And it's been a great 2020 punching bag, right? So let's talk about some of the feelings around these five areas around COVID. How did you find yourself in that situation and how did you mentally move yourself past that situation? I'll open up the floor. Hi, this is Fran. For me, I had to make up my mind that I got to leave. I know there is COVID, but it has to be me making up my mind, you know, take out the precautions that are out there, but I can't live in fear. I got to leave. Sure, absolutely. I mean, how many of us went through an extended period also like this summer, right? So to your point, you're like, I'm stuck here, I'm stuck. I can't, and right, this acceptance of this is happening and I have power and I'm walking away, right? How many went through the summer where it's like, I think we all probably remember early March. Did we all think we'll be back in three weeks? It's, you know, I remember I went to the Target and I bought a bunch of board games for our five-year-olds. And I was like, I come home and my wife's like, why do you have all these board games? I said, we've never really had to entertain him for three weeks. So we better figure out a way to like, keep him entertained for three weeks. And at the end of the three weeks and out of board games, I was like, what are we going to do now? Other stories. I think the hardest part for me is getting through the initial wave. I'm in the San Francisco Bay area. So we, the initial surge, then there was like this hope kind of, sort of at the end of the summer and we had, you know, we moved from our purple tier to, you know, down to red. And then with this latest surge and everything shut down and they're talking about, you know, sheltering at home and not going out for anything. It, I, it's, you know, it's times I feel like it's too much, which I'm sure a lot of people do. I also am trying to find the small positives in it. That I'm connecting with people that I would not normally connect with because of it. You know, family that's, you know, that I wouldn't normally be talking to every month on Zoom. You know, finding those small positives or small blessings or whatever you want to call it through the midst of it all. Yeah, no, I'm, you know, and as you experience that and the reality keeps setting in and we kind of, you know, we call them these COVID surges, right? But there's also these emotional surges and it's, I'm certainly not that it's a self-fulfilling prophecy exactly, but we keep, we, you know, for months we've said the fall is going to be bad, the winter is going to be bad, right? So we've been telling ourselves psychologically how bad it's going to be. Well, we're here and it's bad and it weighs even heavier on our shoulders, right? You know, I can tell you, you know, so we have 180 employees in our practice, 60 providers, and we do SNF and assisted living and home-based medical practice. But, you know, as we have lost, we have seen over a hundred or over 1,300 COVID patients. We have lost roughly 30% of, have a run rate of around 30% mortality rate. So every time our providers get a phone call that someone has COVID, it's about one in three chance that they're going to die, okay? And we have one provider who has lost over 75 patients in the last eight, nine months. We had one provider who in the span of four days lost, had to call a son because his mother and grandmother at the same facility died within four days of each other. Right, and so this, what comes of this is anger, you know, this bargaining of trade-off. Well, you know, what can I trade for anything? What does this look like? This depression and, you know, and as you start to come to the other side and we're all not there, we're not coming to the other side yet. You know, I think what you're saying is so real and that you have to find that meaning. And it actually perfectly leads me into my next slide, if you would. Is, you know, if we all experience grief, trauma and loss differently, how do we find, like, do we all find a meeting differently? And I'm not trying to be esoteric. I was really serious, right? Like, do we all come to a different spot of finding meaning and how do we think about that? And in all my research on this, it really was finding meaning and moving away from grief is totally personal. It's totally individual, but there are some of these universal things, right? These find and express gratitude, right? I'm thankful for this. I'm leaning into community. That can be your faith, family, friends, fill in the blank, you know, four-legged household pets. I start to create action. I'm part of the solution. I will be part of the solution and I will be doing X, Y, Z. And it could be on a personal level, right? I'm gonna, a friend shared, I'm gonna walk away now. Right, my action at this moment is walking away. Or it could be bigger action. I'm gonna start writing letters. You know, I'm gonna start, you know, part of mine is I'm gonna go do, you know, I'm gonna start volunteering at a homeless shelter. I'm gonna do some of these things. And that action is gonna start to shift me out of this space of grief and loss and into this space of, you know, finding meaning in my work, which is really what I'm asking you to think through is, how do we go from everything is stressful, I'm completely burnt out, to I start to see the flip side of this as everything is positive and I'm part of that solution. And finally, this display of love and acceptance as we move forward, we have to be very careful with ourselves and others during this sensitive time. We don't know what other people are truly going through. We never did. But as we look towards a global pandemic, as we continue to look towards the work that we do, and I think you heard such a great expression of that in the caregiving discussion today, you know, of we display this love and acceptance for others and in return, we get that back. And that's, that again, is another way to find meaning. I have one more thought about grief and loss if you go to the next slide. So as I was preparing a talk for my company to try to, you know, see if I could motivate people to kind of feel just even a slightly bit better and know that I'm with them, I wrote down two things. And my end of my talk was, I'm sorry, and thank you. And so I was trying to be cute and find a picture that was, I'm sorry, and thank you. And I put these words in. And on the World Wide Web, I found this Hawaiian practice of combining love, forgiveness, repentance, and gratitude called ho'oponopono. And it's these four steps that really translates to English as kind of a correction that you can start using it as personal strength, kind of through a self-love, repeat these components back to yourself and start to let stuff go, recognize where you are, recognize that you're thankful for that situation and that you love yourself. But what I'm proposing is we also externally propel those things forward in the world and say, I'm sorry, please forgive me, thank you, and I love you. And the practice is saying those words over and over again until you believe those words, until you feel those words and truly believe that you are there. So just an idea, you know, as you go into the world and continue to do the great work that you're doing, I thought I'd share that too. Slide. So I propose that home-based medicine is really the solution, right? And, you know, it's vocationally rewarding work because it's challenging. This is why you went to medical school. This is why you went to nursing school. This is why you became a nurse practitioner, a PA, and, you know, a social worker. It is exciting, exciting work. It's complex. It requires a lot of high communication. You know, the reimbursement might not be there all the time, but it's moving forward and people are excited. You feel part of the system, part of the solution, and it allows for personal flexibility in your own lives as you can kind of dictate and start and stop and structure your work day a little bit different than maybe a strict eight to five clinic day. Now, that doesn't mean that you won't feel these things in this, but if you keep focusing, and all the things we've talked about how great home-based medicine is, you start to feel these things back. So I'll do a slide. So some strategies on operational, some operational strategies. You know, if we think about burnout again and these stressors at the systemic level, then really we need to talk about the external and not just the self-care part. So how do we structurally get rid of red tape? Because we talked about that as a barrier. So joint visits to manage tension. Can I bring someone else with me on a visit? Can I separate and get the family members on the same page, right? How do I start to work within the family dynamic that exists except the reality that's occurring and draw those boundaries appropriately? You know, how do I recognize all the time it takes to do paperwork? And I build in time for that. And what does that mean? Does that mean sacrificing one patient visit? So I build that in, but how many of you are sitting at home at night at 10 o'clock documenting all your charts? Maybe once one night a week, but are you doing it five nights a week, right? And so build in that time for you to get those things done, build in it for others to get those things done. The lower overhead overall can usually be more flexibility to see more patients, which is good. We can kind of keep talking about the financial model and value-based care tomorrow. You know, a team approach to educating everyone and being present to focus on the care plan. That doesn't have to mean that you do all that work. You know, are there top of licensure work where you can reorganize and find efficiencies? So again, operational strategies to reduce the burnout feel. Administrative support to manage scheduling and routing. How many of you are plotting out your map every night? You know, what are the supports there? And hopefully we've given you some good ideas today. Slide. So how do we start to think, and this is a shift of mind, right? How do we start to think instead of reactive, I have proactive steps in place. Here are some questions. You could fill out 50 questions here. What are your top stressors? And you start to tackle them. How do you handle patient noncompliance? It's easy, you know, it's easy to see when a patient hasn't followed instructions in their home. You said, take this pill. The pill jar is completely full. They didn't take the pill, right? So how do you handle patient noncompliance? How do you, they're not, you know, they're not returning your calls. They're not doing any of your medication changes. They're not getting up and stretching. What does that look like for you in your practice? How do you handle patient no-shows? How many times will you say it's, you know, we're no longer gonna follow you? Is it one, two, three, four? Is it two in a row, three in a year, two in a month? What does that look like? It's a lot of energy for you to show up and not have anybody be there on the other side. How often do you meet with your colleagues and your team? You know, there's not one right answer, but it really helps to feel supported by your colleagues. Probably in the time of COVID, you're meeting more often. How do you take your learnings from what we're doing here and attach those to the future world after COVID to be more efficient? So think of your role as you move forward as seeing into the future about what are the future pitfalls. You can certainly do this clinically. Now you gotta think about what barriers might be coming up operationally that are driving me nuts. Next slide. So then you start to build and create a culture of support and addressing stress and burnout. And if it's just you, it may be easier in some ways from a stress and burnout standpoint to start addressing those things because you don't have to then control others, which are harder. But if you're part of a larger organization, how do you have individuals all feel as though they're part of the solution? They're problem solvers. They can be part of the group that's removing red tape. As you think about building an HR department or even with your colleagues, think about policies that support these things. Think about paid time off and actually encourage it and promote a balance there. I am not suggesting that you don't text your colleague at seven o'clock at night if you need something. I am suggesting though that if they always took the one trip to wherever, the cabin every year, that you continue to support that even though they may feel stressed out. That time for everyone to kind of, you know, regenerate what they want in their energy is a good time. Talk about employee assistance programs. I have had, I've been at this company eight years. I've been CEO for three years. I have seen numerous divorces. I have seen numerous now, unfortunately, children die of our employees. I've seen this year alone, we've had 12 family members of our employees die, close family members, parents, brothers, brother-in-laws. We've had two sons die. You know, we don't know what's gonna come up in other people's lives. So build a structure around there where they can have an outlet that's not you to help, you know, a relatively free outlet to help talk about these things. Compensate within the work level. So, you know, I do encourage, you know, you can include bonuses and stuff like that, but build a program that's gonna compensate appropriately. And again, be proactive and always show team appreciation. How do you say thank you? And how, and I always think the more you say it out, the more you get it back. So here's some resources that I pulled for burnout. They'll be in your slide deck. But, you know, as you, can we go to the next slide? As you think about stress and burnout and self-care and grief and loss, as you move forward, you know, I do always encourage people, if you have a C, you know, a CEU, certainly take a CEU, whether it's through HCCI or other organizations that do talk about this topic, maybe at least once a year, just to not lose sight of the work that's happening today and not lose sight of the problems. So you continue to be part of the solution. Because there are a lot of stressors that you face in this environment. But I think just being here and being so engaged as you are in home-based medicine, that you're inherently part of the solution and you want to continue to be part of that innovative solution on the edge of transformational healthcare at all times, that leading edge. And then, you know, really we can put up a lot of slides around operational administrative strategies. And in some ways, the entire two days is about strategies to make you more efficient and to help your practice and make you feel more confident in the field and connect all of us together. So as you think about, you know, returning to work on Monday, you start to say, where's my biggest headache? I sometimes call it the spouse test. I do this for employees. If something bothers an employee and they go home and, you know, they go home and they still think about it on Monday. Oh, they still think about it on Tuesday. And by Wednesday, they're thinking about it and they've mentioned it to their spouse by the third day, then it's a big issue. And we need to talk about it. And so I call it the spouse test. And if you do the spouse test, you know, my staff know you've got to come talk to me about it because it's really eating at you. You've held onto it for a few days and you mentioned it over dinner. So it's time to bring it forward. And you all have those ways and things to think about to bring those things to light. I was unable to kind of keep up with the chat. I felt like lots of good things were happening. You know, we're going to go right now into, again, that happy hour time and structure. So I know I have a couple of slides on that too, but we keep talking. As they're pulling up those slides, any thoughts for me? Anything I missed? Amanda, well, you missed a lot of our learners sharing and encouraging each other, you know, some of their challenges and feelings of grief during COVID especially. And so this has really been a wonderful way to share in a community. Yes, yes, yes, man. All right, all right. That's fantastic. I will go back and certainly read those and come a hundred percent prepared because I open the day tomorrow and add any additional comments that I will, you know, that might be helpful. As we think about, you know, the first day, I thought this was so cool. The HCCI staff put together a word cloud of, and so the bigger words are the ones that were mentioned more often in the chat. I mean, it's no surprise that home pops out at us, but like home, better health, outcomes, mental health, family, others, understanding, base care, time management. I mean, look at these words that are popping out at us, right? We're going to spend a lot of time tomorrow and I'm really excited about the procedures. And it's really fun in person, but we've done an exceptional job. The HCCI has done an exceptional job getting the videos ready and stuff. So we'll talk about some of the clinical things, but I think what people sometimes are maybe most surprised about, I'm going out on a limb, after they come here is one, you're not alone. You know, two, you may be probably know more than you thought. And three, like we're not spending a ton, a ton of time saying this is exactly how you do medicine. You know how to do medicine. It's tying all these external things together. And I think that's what you see come out of this word cloud. So I think that is so cool. Tomorrow, as we think about tomorrow, Brianna and I are not clinical. And so when we do the procedure component, we're going to break up into the sections and you're going to each be able to see different procedures by our clinical faculty. And it's going to be really neat. For those who don't want to see a specific procedure, maybe you already know it. Those who are not clinical at all, or those who just want to spend a little more time with us, Brianna and I will be in a separate session, just talking about any questions you want to bring. Really, I mean, business or administrative questions, non-clinical questions. And so if you want to start thinking either tonight or in the morning throughout the day, before that session about any questions, just jot them down and we will just answer anything you guys want to talk about. And we'll come with a couple of things if people have ideas, but every time we do this, we always fill the time. In fact, we probably could go, you know, another half day just chit-chatting about everything. So I think that'll be really fun. So stick around for some informal networking as we spend time together. And like I said, if you imbibe, you know, certainly grab your glass and we'll just, we'll be here, I think another half hour. Is that right, Melissa? Sorry. Yes. Yeah, till five o'clock. All right. Yeah. Thanks guys. I'm not saying like, thank you, like I'm leaving. Thank you everyone for attending today's workshop. We hope many of you choose to stay in network. For those of you who need to leave on behalf of Home Centered Care Institute and our presenters, thank you for sharing your time with us today. Please log in tomorrow at 9 a.m. central time to check your connection and audio. For everyone else, we will be moving into the gallery view. Please unmute and turn your camera on. This is also a great time, you know, with our faculty here, that if you had a burning question too, that, you know, didn't get addressed today and you want to make sure you get that answered, you know, you can feel free to ask the question. I think before the question, I'd just like to say really thank you. It was so well done. And I was so tempted to just, you know, all I kept thinking is during the last part and the self-care and the burnout. To me, this was self-care, right? This was educational. It wasn't a COVID webinar one after the other and reading the new studies. And, you know, it was really, it was very professionally fulfilling. It was, and of course we're all living through the same, you know, healthcare nightmare right now. But to me, this was self-care, you know, to take the day off from extra work and to take the day off from work and to take the day off from actual physical clinical work. And so thank you very much, you know, before the general question set. Thank you. This was very well done. First time I did something with the HCCI and I found it really great. Thank you. That's great to hear. Thank you so much for sharing that. Yeah, and the reason why we did this was just because you guys were so great about, you know, all the chatting that this was not planned. It was because, boy, you know, in Orlando, we'd be, you know, as Amanda said, we'd be going to happy hour with, you know, those who desired it to kind of get to know each other. And so, you know, we just thought we would just offer this to you guys, but obviously if you need to go, you know, fine. But any questions or just any comments? That was great. Thanks for the first one. I just want to follow up at the beginning. I do think it would be great to know who is participating and, you know, the locations. I think there's probably a lot of us who kind of do the same thing, but maybe a little bit differently that you could get ideas of each other. There were so many great resources. So are we going to be able to have access to that information? Yes. In fact, we've pulled together that. And tell me, do you want to have the, you want to have a person's name and where they practice? Well, if they agree to that, I don't know if that's like privacy. I wasn't sure. I wasn't sure. So we can absolutely, actually, I can share that very shortly. I mean, if other, you know, if the other participants would agree to that, I think it would be great to kind of see how are you guys doing it over here, especially if you're in the same region, you know, just like you said, the difference between suburban urban settings is I think kind of crucial with how you structure your practices. I think getting resources from people working in similar, you know, settings would be great. It would be great if we have that, but what I have been doing since we started is to private message, private message to the individual and ask them, you know, if it's okay if we connect. So I leave it up to them. If it's okay, then we can connect. But if we are able to get that information, that would be good too. I can show you a list of just the practices and the cities and states that are represented. So that would be a start, but I would encourage you, yeah, to do that, the private room chat or the, you know, in the chat to message somebody and see if you can connect. If there's one thing that I've learned about home-based providers and professionals is they're always caring and always willing to help. So I think you'll find many friends from doing that. I would go as far as say the people that you meet here or you network with, it could be part of your team too, right, informally, but just having someone that lives and breathes what you do or might've tried something and done it a little differently. I mean, I love when we're able to kind of create that sense of community with the practices HCCI tries to, you know, stay engaged with and just share from each other, not even us, just what you guys are doing. Because most significant others don't get it. What was that? Most significant others just don't get it, or they don't care. Yeah. Peer-to-peer venting. I hear you, Barbara. And, you know, can I just say, so as a physician, you know, as an MD, I just have to give a shout out to all, you know, NPs, PAs, physician extenders, right? And I see that a lot of, you know, NP presence is here today. I personally, you know, I love working with my NPs, actually a lot more than with, you know, some of my colleagues. So I'm currently hiring for a provider and I'm clearly going for an NP. And it's just a different, I love that. So it's great to see that, you know, that's a field where NPs, I feel, really can also thrive and really, you know, practice up to the scope of their license and can teach us a lot, right, about communication and things like that. So I love seeing this group and the comments from, you know, the NP kind of side. So thank you also. And Odessa, this is Amanda. I think it's certainly not against physicians or any other practice, but I think it's inherent to those who are attracted to nursing and the team-based structure in nursing. And then to continue that through to nurse practitioners, you know, we don't have PAs, but certainly I'd extend the same function to PAs too. But I've done a lot of hiring in the last couple of years. And I would say it is, I think it is just inherent in their DNA and how they're trained to be that highly collaborative and highly integrated into the team and just a partner side-by-side through and through. So I think you're doing the right thing on your hiring strategy right there. One of my favorite stories, and this is over 20 years ago now, is after seeing a patient, the daughter, as I was, and I remember being in the driveway, she walked me out to my car and she goes, you know, who's gonna come back next? And I knew it was gonna be Ansi. I'd already had, you know, written it in the chart, but, you know, wanted to be supportive of my NP. And so I said, but, you know, it really doesn't matter who comes out because we work together and stuff like that. And Ansi is just so great. And she goes, oh, no, no, no, that's not what I meant. When Ansi comes, she sits down and she is so relaxed. And you just kind of work so fast, it makes mom a little nervous. So we were hoping Ansi would come next. And so that was a good kind of humility, you know, kind of thing. But it really is just how wonderful how this team-based care is just so wonderful for the patient. So I tried to slow down a little bit. I don't think it ever worked, but. Considering we told people to wear their running shoes if they went out on ride-alongs with you, I'm not sure we got there yet, Tom. Lovingly though. Shout out to NPs too. You know, hopefully everyone on this call, NPs and physicians assistants who can now independently order and certify patients for home health at the federal level. I've heard a couple, actually, I just got an email from someone in Maryland. I guess Maryland's having to try and pass it as a state policy barrier. But majority, if you're, you know, working with your home health agencies and educating them, you know, they should have that flexibility now a lot more broadly. It is finalized from CMS federal policy standpoint. Oh, wow. Now we have to work on hospice. Yeah, hospice not yet, unfortunately, but I've heard that's next, but home health, at least it's a start. Yeah, that was a struggle. That was a struggle earlier in the whole pandemic. It looks like it was approved federally, but in the state, it was a challenge. A lot of the home health wouldn't let me sign. I still needed to get a physician to co-sign. But now it looks like it's starting to, they're starting to open up. I have, that barrier is less now. But I just have to say that HCCI has been truly my resource. It looks like I'm the only home-based primary care here in Alaska at the moment. Aside from the VA system, there's nothing else up here. So it's, I just kind of threw myself out there and said, I'm going to do it. And COVID threw another wrench at that. It made it a little bit harder. But this has been a really great resource. And I've also managed to connect with a few of you guys from the last class we had in November. So that was really good. I'm going to pop on real quick. I apologize for interrupting. This is a wonderful conversation. I just want to make sure if everybody could, once you finish today, just verify that you have the Zoom link for tomorrow. I had a couple of individuals that said it had ended up in spam or there was an issue with the link. If you haven't received it, please send an email to education at hccinstitute.org. And I will resend it this evening. I just want to make sure that there's no issues for anybody because this is such a dynamic group. Thank you. While you're talking business, how do we submit our learning plan back? Do we need to? You can do the same thing. The learning plans were sent in an email to everybody. And if you save them to your computer, you can attach it to an email as well to education at hccinstitute.org. And those will be collected. So is the Zoom link we got for today different than the one tomorrow? Is that what you're saying? I believe they're the same link. So you should be able to do both, but I am of the mindset that I send it one for each day just to clarify. But I want to make sure that everybody is good to go because I did get a couple of emails where individuals had said it had gone to spam or a different link or something. Yes. So I want to make sure that nobody is struggling tomorrow and we get everybody in. Absolutely. And I'll type in the email address in the chat box too for everyone. So, I'm having the hardest time. I'm trying to get this document so I can share with everybody. It would be great to know where everyone's from or what areas they cover. I'm in Florida, but I get calls for parts of Florida that I don't cover, and I would love to have a resource for them other than to tell them to go look on Google. I don't like not having an answer, so if I know where people are, then I can at least give them a name and a phone number or a name and a website so that they have somewhere definite to go to instead of just trying to continue to search. Yeah, so I think I mentioned one of the things that we're going to try to do. Did everybody find and get into their HCCI Learning Hub? Okay, and that's where you would find the workbook for this workshop. And so, we can set up a discussion board in there for this group, and that's a way to continue to do some networking and, you know, that online community. But anyway, so I'm showing, you should be able to see on your screen just a list of the practices that are represented and where they are. And if anyone needs to make it bigger, if you drag, use your arrow to take the screen with the videos and make it smaller, it'll get a little bigger for you guys. Also, I'm not sure who that was I just mentioned in Florida, but, you know, part of HCCI's research, Katie, was that you? Okay, the Florida House Call Project, you should meet some champion friends. But also, another resource, the American Academy of Home Care Medicine, if you haven't ever been to their website, they have a provider locator that any of their members that ask to be located on there, you can just click on your state and it'll list at least usually five or so practices in every state. It depends on the area, but people that have asked for their information that are usually members of the academy, that's one resource I used to use when checking around because to your point, you know, it's hard to say no to patients and then, you know, I'm the type of person where you have to give them something, right? Can I at least connect them with an area on aging or do I know a couple other house call practices with other service areas that I can refer them to? Exactly. And I'm actually on the- Katie, are you in Fort Ritchie? I'm sorry. Are you in Fort Ritchie? That's where our home office is, yes. And I am actually on the Florida project. I just, I would much rather have a face with the name. So I like to, you know, I do go to the websites, but it's still, I don't know who they are from the next person. So, you know, it's great making contacts here because then I can at least, you know, say I've met the person and spoken with them. So. Okay. I go up to Newport Ritchie about every other week or so. I live in Tampa area. Okay. I actually personally live in Pinellas County, but our office is in Newport Ritchie and we cover Gainesville South for the most part of Florida. Okay. All right. So we can definitely connect. Wonderful. I will share my information to you privately in the chat. Likewise. You are part of our, the Florida house call project, which is described on the HCCI website. And we've invited those selected champions to be part of our training this fall. So that's why we have such a big contingent from Florida. And then as part of that grant funded project, the group is going to convene during the first quarter next year as really just all of you. So you're going to have lots of time together. I promise. Melissa on the, you know, because of all these questions on the, can we have people opt in or opt out? It might be better to have op-in to have their tomorrow and that way. I'm going to put together something. We'll probably have to email it to get their consent, but yeah, if we get people opt in, then I can share more information. Right. and obviously the expectation is that you know it'll just be used for you know personal you know kind of stuff uh would be uh would be great so well super great anybody else have anything they want to share or a question to ask or so is bergen geriatric care on the line or have they gone to dinner bergen geriatric what that's me uh i went i grew up in wycoff oh yeah where are you i'm so i'm in oradelle that's where you know the i call it our mission control but we're completely outreach based you know only al's homes and subacute mission control is in so bergen county you know up right up here okay yeah that was in the 60s so it was a while ago i'm originally from germany and i've always you know moved here so i've always lived here in the states for 17 years now straight out of um medical school started as a traditional family physician and then just you know i think a lot of people i always say when if someone would have asked me if i saw myself doing exclusively geriatrics as a family physician i didn't know that i looked for it but i feel like it's found me right and i think one of the experiences i think that a lot of people had is finding real satisfaction what we're doing despite the you know obstacles of the pandemic is really being fulfilled with what we're doing and i have the all hands on deck mentality so it's really really uh you know enjoying the field it's definitely a challenge you know just to pull it all together and you know brianna i think we actually spoke right before i was gonna say i actually remember believe it or not i pretty much remember everyone i talked to and i was really excited uh when i saw your name because i was like i remember talking to virginia virgin geriatric like a year ago and then covet happened and we were like ready to start helping each other and you know so i was so happy to see that you're here i didn't want to put you on the spot but now i definitely remember our conversations and i'm so happy it worked out for you to join us the practice and we're gonna you know just get this all and now i feel there's so much restructuring going on you know so i figured this would be a good forum to kind of get new ideas and i don't know if other people find that too it's just it's not just the stress and the cutie it's the whole we start redefining the the way we operate this world is so different right it's this fluid situation is really a challenge in itself i wanted to ask amanda to teach us the pronunciation again of the hawaiian word because i want to i wanted to share that with my family tonight how much is sure how much have you before you give us the uh i'm teaching sir i have done none of that okay but uh i will in eight minutes no i'm just kidding i have three children i will not be doing that so um it's it's just it's you just kind of like it looks ho pono pono so hl and then it's oh so ho a pono pono oh pono pono yeah and i it's really it's really neat i mean i i think it i want to say it started with like um like criminals or something to kind of like as a rehabilitation thing so i like i didn't mention that to the company or here but i because i but i mean i think it could be it's highly applicable to anybody who's you know again for this kind of interior look of um kind of correcting correcting a path i think is what's its original intent and you know and for therapists it seems to be something that is not not used so i thought you know and then i and then i maybe extrapolated a little bit to try to use it to you know a group of people as we jointly experience grief but um you know i can't remember in a time you know like so so often in health care we all are on our own waves of experiencing grief and covet is like while it's not all the exact same at the exact time it's it's pretty similar like we ride these waves together and so as as a leader i've been being like well how do i what do i do to keep removing red tape or whatever it is and like i got on the horn yesterday with everyone and i said we're not doing anything new in december we're canceling meetings we're not doing anything like no new initiatives we have all these things planned so we're just gonna focus on us we're you know patients family self those are the things we're focused on in december and we'll start over in 2021 you guys so that's anyway that was my theory who knows people probably think i'm just wildly insane that's okay you're probably all clinically diagnosing me right now no i actually heard that hello pono that one from our palliative care social worker she used to in hospice and and with folks at the end of the at the end of life individually but yeah and i don't think you're crazy Paul i was almost going to put you on the spot during amanda's self-care if she needed questions to talk about your your jars and how you show team appreciation just even like little gestures like that i always enjoy hearing you talk about that you know yeah covid has been so tough and and amanda you talked about finding little things to rejoice in and celebrate and um and that and and i have such an amazing team of apms i am i have i've been so blessed um they're incredibly hard-working there's such team players um so finding joy in leading the team and and working with them uh it's just been incredible and and and i should not leave off my front of back office because uh you know um we talked about efficiency i need everybody to work as as efficient as possible from you know from intake to scheduling to having scripting to do all the screening now for covid and ili symptoms right so that us providers will know you know what gear to bring and to the back office doing refills calling back with labs and all that kind of stuff i just have an amazing team um so um i try to uh give them an opportunity um to share and the three jars that um that brianna is talking about is you know i have the three jar one is the thankful jar it is so easy for us to to complain and gripe and there are just so many things that are wrong in this world uh if we go down that path it gets dark um and and and it doesn't help us so i have a thankful jar and i'll we can put in whatever you're thankful for i'm thankful for my staff i'm thankful for my family my health you know you fill in the blank uh they encourage us one another um to reflect and and to think about the good that we have uh the other is a jedi skill i'm a star wars fan big mandalorian you know yeah i know that i love it um and um uh we all have jedi skills uh we all have um special abilities that we can share uh with one another whether it's uh getting a talk at a patient off the phone or you know dealing with i have an angry patient literally just you know uh demanding to to talk to me and hanging up on the staff so i mean how do you cope with that uh so jedi skills that can be shared or ehr jedi skills uh so that we can cut down on pajama time you know we don't i don't want my staff uh you know work is work i don't want them working at 10 o'clock at night in their pajamas that's just no that's just no so there's the thankful jar the jedi skills and then there's the wish list uh not the b word uh it's the wish list um it's it's about things that they wish that they could have um that i can bring up my chain of command and say hey you know my my staff is really uh uh concerned about this or you know my you know we're working on some uh laptop issues today and and broadband card so i'm going to bring that up to uh to administration and say hey you know what can you help me with in terms of some of the wish lists that's uh that's uh uh that my staff is bringing up so those are the three jars uh we also have a caught in the act um that we can write something if somebody did uh something that's just we thought it was just it could be minor uh like shoveling snow for one of our patients so that they're they have a path uh that's clear for them and that's a caught in the act and it's just just kindness that my staff uh are doing for my patients or cleaning a diaper or whatnot um and then we give them a little starbucks card or something like that um as as um as a way to to show appreciation for the all the hard work that we're doing i just took my palliative care boards and uh one of the things um and you guys may have there's this dr ira by byoc b y o c k and he writes about the five things to communicate at the end of life and it's interesting how it's very similar to what um amanda said and it said uh to communicate you know for this the closure i love you thank you i forgive you forgive me and i'll be okay and so that's uh very similar and um something i highlighted so well this has been great um thank you all very much um we look forward to seeing you tomorrow um we will start with our uh check-in um with audio and make sure everything's working all right although you are all rock stars uh we'll start at nine o'clock central time with that and um and and then soon after that with our first talk so thank you all so much and have a wonderful evening

finding meaning in grief

trauma

grief and loss

death of a loved one

loss of normalcy

coping with grief

expressing gratitude

community support

ho'oponopono practice

home-based medicine

burnout in healthcare

stress management