are spearheading the quality improvement movement in home-based primary care. So, let's go ahead with the video. All of us want to do right by our patients. We want to give them the best care possible. And we think we're doing that. You know, we get good training, we try to do continuous learning, and so we think we're doing a good job, but we actually, we don't know unless we measure what we're doing. What quality and quality measurement gives us the opportunity to do is to think about how to take that thing that we really want to have happen for our patients and make it so. And in the words of William Edwards Deming, who's considered the father of quality, it's really about love. It's about making sure that we're doing the most caring thing for our patients by not only getting the training, making sure we have the learning, but taking that into practice and measuring it, capturing the data, looking at the variations, seeing where there are gaps, and then doing something about that. And Deming talked about sort of three different components of quality, the structural components, like do we have the right structure in terms of like maybe electronic medical record or the right team? And then do we have the right processes? Are we doing things in a standardized way that's based on what the research tells us? And then finally, what about outcomes? Are patients doing better? Are caregivers less distressed? Are patients feeling like they're truly being cared for in the most competent way? Those are sort of the different components of quality. And we can look at each pieces of those, but it does require us to think about each of those pieces, to measure our structures and what's actually going on in our practice, to measure those processes. And then finally, to measure the outcomes, to hear from our patients and their caregivers about how they're doing. And when we do that, amazing things happen. We learn about where there are challenges and we learn about how to improve those challenges. And we do small tests of change to see, well, if we do this, would this actually improve the outcome? Oh no, well, maybe let's do this. And by making those small changes, we can actually lead to very big changes in terms of outcome. And that's really exciting. You know, when you think about quality of care and quality improvement in home-based medical care, and I'll use that term to think about both home-based primary care and home-based palliative care, you know, the setting of care becomes important because I think it has a profound impact on our patients. And also our patients themselves have some unique characteristics. So patients who are receiving home-based medical care are people usually with a lot of trauma, are people usually with multiple chronic conditions, functional impairment, you know, they're usually home limited and they often have limited social capitals. They tend to have lower rates of educational attainment. They tend to live less commonly with a partner, tend to live alone a bit more, more likely to have symptoms of depression, more likely to have dementia, less likely to be able to walk, for instance, half a block and much more likely to end up in the hospital over the course of a year. So these people are not like you and I, and they're really not like typical medical patients who can access primary care services in an office setting or in an ambulatory practice. Because of that, they need, I think, a unique approach to assessing quality and thinking about quality of care and quality improvement. And that's part of the reason, as you know, that we started on our journey about six years ago to think about quality of care in the context of home-based medical care. We were concerned that the current crop of quality measures if applied to vulnerable population who are homebound might actually result in bad care. So the need to develop a quality of care framework and quality indicators that were specifically suited both to the setting and to the patient was critically important. So over the last few years, we put together a national stakeholder network, and this was a network of people from exemplar home-based medical care practices, people from professional societies like the American Geriatric Society, the American Academy of Home Care Medicine, the American Academy of Hospice and Palliative Medicine, and several patient and advocacy organizations such as AARP and the Kaiser Family Foundation. And we got together and we did qualitative research to understand what is the quality of care framework that should be applied to people who are homebound? What did you learn? So we learned that there are, in fact, unique quality of care areas. You know, large buckets of care, we called those domains and then subdomains that really were not well represented in the current crop of quality measures. We realized that we would need to develop unique quality indicators for this population and this setting, and we set to do that. We then developed a set of quality measures. We put those quality measures into an initial version of a quality of care registry and tested that out in San Francisco and in Baltimore. And then more recently, we were able to take our quality measures and put them into a Center for Medicare and Medicaid Services approved qualified clinical data registry, which may not sound like much, but it was actually a pretty heavy lift and it's a really big deal because if practices use that registry to record their quality data, those data, that information can be reported to the Center for Medicare and Medicaid Services and those practices can actually qualify for performance payment under the Merit Incentive Payment System Program, which is basically a way to get performance payment. And again, using that registry, we've also been involved in creating a learning collaborative of an initial group of five practices that are part of the US Medical Management Practice, which is one of the larger home-based medical care practices around the country. And we've been engaged with those practices to use the registry for the purposes, as you were saying before, of quality improvement, to understand where they are in terms of certain quality metrics compared to other practices, and then help them engage in small tests of change, small plan, do, study, act cycles so that they could actually raise their game. And it's been gratifying to see how interested they've been in not only their own performance, but how their performance compares with their peers, trying to learn from their peers how to do better. And that's been terrific. And now we're looking forward to engaging in a national learning collaborative. You know, the nice thing about using the registry in addition to being part of a learning community and a learning collaborative is that, again, those practices could use the registry to get performance payment. Another thing we've built into the registry is that if they use the registry for quality improvement purposes, diplomats of the American Board of Internal Medicine can actually use that to get credit for their maintenance of certification activities, which is basically a twofer, which is always nice. So, unique population, unique quality of care needs. And, you know, over the last bunch of years, we've set up mechanisms for practices to be able to engage in quality improvement and in performance payment. So where do you see this quality initiative going in the future? So that's a great question. You know, right now the registry is a quality-focused registry. And I think the real vision for the future is to really blow that up and start to get other data streams into the registry to really enhance the field. So imagine a registry that had contained information on the characteristics of practices, characteristics of patients, the quality data, and then also Medicare claims data. If you had all of those streams of data coming into one place in a linked way, you'd really start to be able to answer some really profound questions about medical care and medical practice for people who are homebound. So you could start to understand how do practices that do or do not have, for instance, a social worker, how does that influence outcomes, say, related to hospitalization or patient satisfaction with care? How do practices that engage in certain quality-focused activities vary in their outcomes? So the ability to have all of those streams would really be able to help us do some pretty incredible kinds of discovery and really help raise the whole field. So that's what we're really looking forward to. And we have wonderful collaborators at the Home-Centered Care Institute, at the West Health Institute, the John A. Hartford Foundation, who have really been just spectacular about sponsoring this work as well. So the ability to leverage those multiple lanes of data over time would really, I think, create an amazing resource for the field that could inform payment policy, that could inform procedural policies, that could inform quality measurement. And that's really the exciting frontier that we're gonna be marching towards. And really shining a light on what's historically been an invisible population. Right, so this is a population that sort of hides in plain sight at times. And it's always been astonishing to me that in geriatrics, I think in general, older people hide in plain sight. And then this population in particular, which is really among the highest need, highest cost patients, also hides in plain sight. It's not a sexy population. It's not the population that policy and executives and C-suites tend to focus on. They tend to look elsewhere to their own detriment. Until recently, now that value-based payment has become more of a reality, and we're realizing that these folks really need right-sized care so that they're not so costly and so that they actually are experiencing true benefit from healthcare. Exactly. Yeah. When you are a part of a community, you think about things you wouldn't otherwise think about. You have the opportunity to understand what's going on outside of your own practice framework. And you can identify potentially best practices that are important to your practice that you learn from another practice. So what learning health systems and learning communities do is they give you a chance to compare notes, to identify what things are working, not working, and for you to share some of your best practices with another practice and another organization. It's also a way to feel less alone because many practices, they're out there doing really hard work. And for them to see that another practice in another part of the country is struggling with the very same thing, durable medical equipment, for example, it makes them feel less alone. And then together they can think about how they can address some of these thorny and challenging issues around quality and around best practice. The other thing is it brings a community that many practices don't have. We all enjoy going to the annual meeting of the American Academy of Home Care Medicine. We enjoy the opportunities that we have through the Home Center Care Institute. In between those times, how do we maintain a sense of community? And this can offer that opportunity because you're working with these other practices together to figure out how to do a better job in caring for patients. So another thing that's important about being part of a learning community is, maybe quality improvement isn't your thing. You haven't had an opportunity to learn about it. It gives you a chance to learn about it in a kind of less painful environment because you're learning about it with other people. You're thinking about quality from the standpoint of how do we all get better? How do we do better for our patients? And then incrementally using what you learn so that you can do it even outside of that learning community. I mean, people have to be willing to have a certain openness about things, right? Absolutely. It's a great way to learn quality improvement. Most of us did not learn quality improvement in our training programs. And so to have that opportunity to come alongside others and say, oh, so this is how you actually think about measurement. Oh, and so this is how you might actually do a small test of change. Oh, so this is how we could think about iterating on this particular issue. That's much more fun to do with others than to just do it on your own. So there's a number of different reasons why being a part of a learning health system can be both enriching and good for practice. Imagine a world where you have data on the characteristics of practices, the characteristics of patients, data on quality metrics, as well as Medicare claims data, all in the same place. The ability then to really answer questions, both for the practice of home-based medical care and for research and discovery in home-based medical care really become astonishingly fascinating and wide. All right, well, thank you. So just in the interest of time, I'm going to go over some upcoming slides because there was a lot of information there. And we're talking about quality metrics and this is kind of a little bit vague terminology. So let's start with the first slide. So we're talking about quality metrics. And this is kind of a little bit vague terminology. So let's, over the next few slides, I'm going to go over some specifics. So the, oh, and there's a comment, the QCDR measures begin on page 49. So some metrics that are usable are hospitalizations, 90 days before death, ICU stays 30 days before death, hospitalization rate per 100 beneficiary months, number of deaths at home versus SNF or home versus hospital, percentage of patients who died in the practice who died at home, percentage of patients who died on hospice. It's things, percentage of patients who have advanced care planning discussions. These are all really important metrics and they'll be important. Some will carry more weight for some practices than others. So let's go to the next slide. So for instance, IAH stands for independence at home. Some of you might know this program. It's a CMS demonstration project. And it looked, and I'll be very brief because it's a really, I can go into the description for a long time for this, but it's basically a CMS demonstration project to show if this alternate delivery of care with home-based care, if that can reduce costs, but also maintain quality. And the quality metrics are what you see on the right-hand side. I won't read them out loud, but those are six quality metrics that practices who are chosen were graded on and also cost of care. And lo and behold, home-based primary care saved CMS $81 million in the first five years. So CMS is looking hard at this. And if we can go to the next slide. And CMS just relatively recently launched another demonstration project, Primary Care First. And SIP stands for Seriously Ill Population. So these are really ill patients who have, I'll just go into this HCC scores, 1.5 to greater than, sorry, 1.5 and higher. And the quality metrics are going to be measured there and it's going to be looked at for cost of care and like a different risk. It's like a shared risk, shared savings model. So let me go into the next slide. So there are a lot of takeaways from the video. And I think the main thing is that the value of quality measurement in home-based primary care as a field and also for your practices, it can't be overestimated. What the goal is for a comprehensive research data warehouse that goal will help identify best practices in the field and can lead to consistent practice across the field and also improvement in patient outcomes. The quality effort by Drs. Leff and Ritchie, it's going to provide support to the argument that home-based primary care is not a good fit that home-based primary care is a model of care that should be recognized. And that's kind of evident in the information from independence at home and in other programs across the country. This field is demonstrating that it's a model of care that isn't just quote unquote nice to have but should be supported by hospital systems and payers. So I want to encourage you all to think about a scorecard for your practice that includes quality and practice management measures that will tell the story of your practice. And put that in your HCCI learning plan, next slide, as one of the topics, please put in the learning plan any information that you would like to learn more about. And just as an aside, the learning network, the learning collaborative, I in my practice participate in that and it's a fantastic network. And if anyone is interested, please private message me and I'll be more than happy to continue the conversation. So thank you. Okay, thank you. So we're gonna move on to self-care, Amanda. Yep, hi, can you hear me? Yep. Okay, great. I'm gonna put people in gallery mode and as I kind of do that too, I'm gonna encourage you to pull out the video. We're in the homestretch guys and this is very interactive. So let's turn them on. I don't drink caffeine. I got three kids, five-year-old, eight-month-old, two-week-old, we're gonna take this thing home. We're swinging right into happy hour, okay guys? So good, good, good. Let's start from self-care. First of all, raise a hands, just do your hand on here. You don't have to say anything. Raise a hands of if since COVID you as a leader have had to prepare a speech about self-care, loss, resiliency, burnout, stress, you have attended a seminar at your employer, you have attended a paid or unpaid seminar. Anybody who has talked about this in the last 10 months, right? Yes, yes, okay. Then you know it all, you could do the same thing I'm gonna do. Hopefully I put some spins on it that are meaningful to you. So we're gonna kind of go through, you can see the goals here. We're gonna go through it, slide. All right, let's watch a two-minute video on empathy and come back together and really think about empathy and sympathy. And we're gonna come back. So what is empathy? And why is it very different than sympathy? Empathy fuels connection. Sympathy drives disconnection. Empathy, it's very interesting. Teresa Wiseman is a nursing scholar who studied professions, very diverse professions, and she found that empathy is a very important part of empathy. Empathy is a very important part of empathy. She studied professions, very diverse professions where empathy is relevant and came up with four qualities of empathy. Perspective taking, the ability to take the perspective of another person or recognize their perspective as their truth. Staying out of judgment, not easy when you enjoy it as much as most of us do. Recognizing emotion in other people and then communicating that. Empathy is feeling with people. And to me, I always think of empathy as this kind of sacred space when someone's kind of in a deep hole and they shout out from the bottom and they say, I'm stuck, it's dark, I'm overwhelmed. And then we look and we say, hey, can you climb down? I know what it's like down here. And you're not alone. Sympathy is, ooh, it's bad, uh-huh. No, you want a sandwich? Empathy is a choice and it's a vulnerable choice because in order to connect with you, I have to connect with something in myself that knows that feeling. Rarely, if ever, does an empathic response begin with at least. I had a, yeah. And we do it all the time because you know what? Someone just shared something with us that's incredibly painful and we're trying to silver lining it. I don't think that's a verb, but I'm using it as one. We're trying to put the silver lining around it. So I had a miscarriage. At least you know you can get pregnant. I think my marriage is falling apart. At least you have a marriage. John's getting kicked out of school. At least Sarah is an A student. But one of the things we do sometimes in the face of very difficult conversations is we try to make things better. If I share something with you that's very difficult, I'd rather you say, I don't even know what to say right now. I'm just so glad you told me. Because the truth is, rarely can a response make something better. What makes something better is connection. Okay, great. Is there a backslide? Is there another slide where we can just hang out on that one for a minute? Okay. So after thinking about this, let's talk about empathy and sympathy. And Brene Brown does a good job of kind of outlining her definitions. Does anybody have any other definitions they want to throw out there? Any other examples? And as it relates to your practice that we want to talk about? I don't have one that relates to my practice, but I will say I just recently had to put my very senior Labradoodle down. I know, it was very difficult. My daughter was there. We were putting my dog down in the vectionary. And as my dog was taking their last breath, her last breath, said to us, I have a Labradoodle. I have a Labradoodle. And she reminds me a lot of my Labradoodle. And then she started going on about her dog. And it absolutely, it rubbed me so wrong. I could never imagine doing that to one of my patients. It was just so, and that's the one thing that stands out to me, putting my dog down a couple of months ago. It was really sad. Yeah, that's a great example. I mean, Brene Brown kind of gives an example of the silver lining, right? And how we kind of, and what I find often, I also do some talks around negotiation, contract negotiation, is we get a little nervous when there's quiet time and we try to fill the space. And we try to say what we think the other person wants to hear, what we think will be helpful. And especially being in healthcare, is I think about, you really can't have a self-care conversation without overlapping the reality of COVID right now on top of it. And so as I think about the last 10 months and trying to talk to our group around a lot of the things we're talking about, empathy, sympathy, stress, pressure, resiliency, and you start to kind of layer those things on top of each other. What it really comes down to is we're all in a profession of fixing, right? And even as we heard earlier in the conversation today from my colleagues and clinicians, right, is we overestimate the prognosis. We overestimate the likelihood the drugs will work. And we're doing those things to try to solve a problem for people. And it, and that's not, it's not necessarily bad. It's what we can do from a self-care standpoint is we can start to take a step back and say, when do I tap into my empathy? When am I recognizing my sympathies coming out and I'm really not really meeting someone where they are? How do I pause and take that minute as fixers? You know, how do we do that? You know, when we look at patients like Ralph and Betty, we feel this intense pressure to solve their problems and to go through everything. How do we talk about polypharmacy? How do we talk about all the psychosocial things, right? You all know working in this field, and this is what we have to do with our providers onboarding who have never done home-based medicine before, is we have to really sit down and say, you are starting a relationship that is not gonna be fixed in the first five minutes. It's so complicated. It's gonna take months, years, and you're gonna form these meaningful relationships and it's gonna be very hard on you. And so as you get that engaged and you pull that empathy from your personal lives into that situation, it starts to feel very heavy. And that's why we talk about self-care because you are leaders and you're leading others to do this work. And so then you have to say, well, how do I coach other people through this and how do I get myself through it? Next slide. So I just kinda wanna talk a little bit about burnout and stress. And this goes into, I do another course in the advance. So if you're gonna see this, you may see this slide again. I created this for a talk in January for HCCI just to talk about the difference between kind of stress and burnout, right? We understand situational pressure. We understand stress is now this buildup within us of this physical body change of strain and tension. But that stress over time is what we call burnout. And those things as burnout, it really starts to get into physical manifestations. And we're going to kind of talk about this. But I really was unable to find an agreed-upon definition for this work. It's long-term stress. It's this constellation of symptoms over time where you just can't balance out that negative energy. And it's a public health crisis. And again, I'd overlay COVID on top of it. COVID won't be here forever. But we're going into the winter months where we're going to have to continue to talk about what this means and the overwhelming sense of our healthcare system. I'm sure you and our providers are saying the same things. I've never felt as stressed as I am under the current situation. I can't get PPE. I can't get information. I can't get the testing when I want it. I just saw Mrs. Smith yesterday and she died this morning. She was fine. And so even as we talk about the patterns of functional decline earlier in the day, we talk about sudden death, cancer death, organ failure death, dementia and frailty death. How many of us are starting to see a condensed timeline because of COVID in our frail older patients? They were fine. Now they're not. They had dementia. Now all of a sudden they have organ failure. Oh, they're getting better. No, they're not. So there's a lot. There's kind of a lot to unpack there. But as you really start to take these things in, just think about, again, stress is what we're under. Burnout is the prolonged experience of that. Next slide. So this is from Medscape in 2019. And it just highlights here, and I highlight, I know there's a other variety of specialties here, but internal medicine and family medicine, around 50% are burned out. And I would just qualify, the Medscape, I quote it again, the Medscape is a physician burnout, but I would apply that to health care administrators, to social workers, to RNs, to NPs, to PAs, you name it in the health care system. And again, especially in today's environment, we're seeing a growing trend of stress and burnout. Next slide. So what are the top stressors? And this is, as I kind of go through them, I want you guys to think about it and put in the chat, the top stressors that you also think, what are we missing? What else are you seeing here? Let me make, there we go. Okay. Mediation, patient, family conflicts, right? We have a, we have something within the family dynamic that is very hard to reconcile. And it's, it's becoming very challenging and it's stressing out the system. It's stressing out the person who takes a call every other day. It's stressing me out and I have to coordinate all of the other people involved in their lives, right? Electronic health record and paperwork complexity. You know, there was the old saying, aging isn't for sissies. Healthcare isn't for sissies. My goodness, we have created the most convoluted infrastructure to provide care that one could really ever think of. Financial pressure. As we were talking at the beginning and you were all telling your stories, I counted 13 different states represented here and grant funded independent practices, new practices, established practices, hospital-based, multiple disciplines here. And really the core of what you were asking, I think, is, you know, you're here, you know the why. You're here to find out a little bit more about the how, a little bit more about the what, a little bit more about the where and the when and how we do some of these things. And a lot of these things, and as we go into tomorrow and I kind of set us up for tomorrow, is really about, you know, the business case, sustainability. Those financial pressures become really difficult. You know you can do the good care, but it's hard to connect all the dots to get paid for it. Patient adherence. You do all the best work and sure enough, you come into a pillbox set up where you don't know if it's weekly, daily, and you don't even know how many are in there or what colors they are. Scheduling and logistics of getting to people's homes. You know, how big is your geographical area? We'll talk more about that tomorrow too. How do you get to everybody? How do you get to there with weather? How do you get there safely? Providers feeling unsupported. How, especially if you're a sole provider, how do you manage all of that? Okay, let's see. We have a couple chat notes here. I'm trying, someone start me where it was. It's okay to show you, yeah. Yeah, when Rita said when patients expect a miracle with no effort on their part. Yeah, I was, I almost said something super cynical like, ah the American way, but I won't. Yeah, right. Totally. Yeah. We don't, we can't connect the outcomes. You know, we can't connect that the, you know, what is it? The, is it the, the, oh, there's a foundation where they do the impacts of healthcare or the impacts of aging. I'll have to find, I think it's a Robert Wood Foundation and they say, you know, 20% of it is genetics. You know, 30% of it is eating. 20, 10% is your actual medical care. Like so much of it is not within your control and yet other people don't take that personal responsibility. Totally. Okay. What else? Caroline said prioritizing to get it all done. Yeah, absolutely. Too many demands on your time. And who has felt super overwhelmed by COVID? What's the new information? Where am I supposed to look? What's supposed to be happening? I mean, HCCI is here to help in those scenarios too, but it is so much to keep up with. When we started with COVID, we had an entire practice of people. We have 180 employees. We have an entire practice of people meeting an hour a day to try to keep up on all of the changing information. Right. And then you layer that on top of what you're already doing in the stress out system. Jennifer Wainer says patients who do not communicate consistently, they wait all week and then call on the weekend with a crisis. Totally. The Friday at 5 p.m. call. What? You know? Absolutely. Yeah. I just got around to, no, you should have prioritized this at 10, you know, on Tuesday when this was the issue. Absolutely. Yeah. Yeah. Sometimes understanding how patients are going to kind of get in their own way for their success. Yeah. Jennifer Aery, balancing a clinical role with administrative demands. Absolutely. Oh, absolutely. You know, especially sole providers, independent practices, you know, you're trying to figure out how in this day and age, how do I keep the lights on? How do I make sure I'm doing everything I want to do and keep track of all of the clinical pieces? I don't have the exact answer for all this. We're certainly going to talk about, you know, some of the ways to support that. But, yeah, that's very stressful. Okay. Good. Next slide. So before we get to kind of outcomes, or before we get to kind of coping mechanisms, just a couple of things if we let these things fester around stress, burnout, these pressures that we're feeling. Individual outcomes are really depression, exhaustion. You can read them here. The things to kind of note is higher rate of addiction, sense of failure, job or career change, and suicide rates. You can notice burnout in someone else when someone who had such passion starts to pull back that passion and is going through the motions. That's the visual. That's the conversational. And you may recognize it inside of healthcare, and you may recognize it inside of your loved ones and families and all sorts of scenarios. But as they start that pullback, that's burnout. Medscape, the same Medscape article I referred to a few slides ago, asked specifically around the suicide rates. 80% of people said they had, of the physicians, said they had never thought of suicide. 14% had thought of it. 1% have tried it. And 6% refused to answer. So we have one in five where we really don't know if suicide, it either is on their mind or it's likely on their mind or they're trying. And so that is a public health crisis. Because that's individual health outcomes, patient outcomes. Now we start to spread out what happens to the feeling, right? Lower patient satisfaction, lower quality of care, and higher risk of malpractice claims. I think you can kind of feel those as you have your excitement and passion about work, taking those calls as you start to see other people experience stress and burnout. And then really at a system level, the system never gets better. We never raise the red flag and ask for help. Students are unprepared and untrained for the real world. And at the end of the day, innovation is stalled. And I think, you know, what I love about HCCI and I love about home-based medicine is, in many ways, I think this begins to be the solution for people who are feeling burnt out in a traditional system, right? How do I know why I went to med school? I know why I went to nursing school, why I became an APP. I know these things and they were to help people. And if I can get through the administrative burdens that are put on me, then I can do the real work, right? And we'll keep talking about that. So that's exciting. So some other coping strategies, slide. So operationally, right? Joint visits to manage the separate discussions with family members, you know, trying to coordinate some of this. Documentation, recognizing all of the time involved, you know, allowing time within your schedule for completion of work hours. You know, as we will talk more about some financial models tomorrow and the economic wheels that kind of We'll talk more about some financial models tomorrow and the economic wheels that kind of make this thing turn. I want to say probably everybody will be just glued to their screen for coding and billing. Briana does such an exceptional job. We always go over on that one, right? So the financial model, as we can understand fee for service, we can understand maximizing revenue for the work you're already doing. We can understand how we get into value contracts, right? That financial model can allow that flexibility. So you don't feel that stress of I have to see 10 patients today. The team approach, you know, can I find other people to continue to educate patients, families and reinforce that care plan and administrative support? Are there things that we can do? And we talked about this in operations and safety and technology tomorrow to manage scheduling and routing. Now, all this is a great list and we were working on absolutely all of them and then COVID hit, right? And how many of these coping strategies went out the window? It's like, oh, I have the best laid plans and now it takes me an hour to don and doff PPE to go anywhere, right? Trying to see faces either nodding or not nodding, right? What? Ah, I know, totally. So I can tell you my current predicament. I'm a very animated speaker. I'm currently, I would take as much advice as I can get from you guys. I have been asked next week to give a talk to our providers. We have one of our medical directors coming in to talk about grief and loss and how to manage this strategy. And I am coming in to talk about kind of the fixing solution, meaningfulness and finding meaning in all of this. And I'm at a loss because then I've told our team, like there is no way around it. There's only through it. And that feels horrible for a fixer, but there are silver linings in 2020. And there are these things, as you look at your life and your patient's lives and your practice, we are still learning and growing. How many people have gotten more efficient in some ways? How, you know, telemedicine is a great example. The HIPAA restrictions are lifted and we get and we learn more. We try stuff. We try to innovate on our note. We have so many different virtual connections now that while it seems really stressful now, we will take these learnings and we will apply them to subsequent years, which will benefit us all in the future. So has anybody heard of the quadruple aim? You put yes or no in the chat. Yes. You can raise your hand. Yeah. Yeah. Okay. Great. I think so it was the triple aim. We all know the triple aim, enhancing patient experience, improving patient population health and reducing costs. This is the general structure. I think around 2014, the IHI comes back and says, we're going to add a quadruple aim. We're going to add a fourth one here. And it's really improving the work life of healthcare providers, including clinicians and staff. And so now we have another avenue and another space in which we really need to continue to explore what does that look like. At the end of the day, all of us individual humans, and then the mob mentality of all of us trying to work with inside of the healthcare system, really the things that will make us feel better are not motivational speeches. They are fixing our problems to make us more efficient. And again, I think as we look back on 2020, and you can see a list here in a normal year, and then you can apply all those things and you can think about 2020. And again, I think you find some of these wins of how we've been more nimble and innovative and how we have to touch patients in new ways, even though sometimes it's very frustrating that will make us successful, I believe in the future. Any questions on any of those things so far? Okay. All right. Dream team. We're going to keep going. Resiliency. Okay. Anybody been to a talk on resiliency lately? Yeah. A couple nods. Okay. All right. Good. Okay. I pulled up a definition here. Let me find a team. The capacity to recover quickly from difficulties and toughness. For those who have children, isn't that the one thing you always say? It's like the kind of the parent line of like, you know, and you're like, I hope I'm teaching them that. And then, you know, they cry in the playground. You're like, well, clearly that didn't work. Not doing that very well. So what are people doing out there as you are thinking about yourselves and you're thinking about your loved ones, you're thinking about your community members, maybe going through COVID, maybe not, you're thinking about your family, you're thinking about your friends, you're thinking about your community members, maybe going through COVID, maybe not. Your patients as they are experiencing their family members or your colleagues. What are really cool things of resiliency and examples that you guys are seeing out in the field? I'm from Texas. I'm not really from the Midwest. So I don't have the ability built in to feel comfortable with silence. No, I just, it feels great. Nobody? I'll offer a comment just to maybe spur some other conversation. I've heard a lot of really creative ways on how people are utilizing their team. And for roles that, you know, they may not have been meant for or trained for, especially during COVID. So they don't have to do staffing cuts. Even using, you know, medical students, someone mentioned earlier for like phone calls, social isolation visits. You know, I know a lot of providers that have partnered with their local institutions to utilize interns and students in creative ways, whether they're face-to-face or not face-to-face and just getting you that help that, and not a high cost because they can use credit hours and things like that. So I think really just rather than sitting there, you know, be creative and it never hurts to ask, explore what resources or what other kind of supports you might have in your community, or even on your own team. You know, people doing roles that they may have not normally been doing to help you such as telehealth workflows, right? Peppering the visit and kind of rooming the patient, doing a mock visit with the patient before you hand that to your provider. Yeah, it's a good example. You know, so I have two thoughts around how we've tried to build some resiliency at a corporate level. One really, I think, kind of spurs or spawns right off of that or splits off of that. And, you know, so when we first got this, I'm getting a little feedback, sorry. When we first got, when we first, especially with COVID and we started going here, what we did is we opened up the space of dialogue. And two things came out of that. One, it has turned into a space around how we express, you know, express frustrations and grief and anger. And so that, you know, and I think that's been really great. We have also allowed open dialogue where you can call into the medical director and just share about your experiences. And people are really learning. We then take that to other locations and other people's experiences. And then some weeks people just can't do it. It's just too much or some weeks people are fine. And the flip side of that, when we allow this open dialogue, then we started and realized that people had different ways internally that they wanted to cope with this. We had one physician and she wanted to dig into the data. She doesn't want to lead. She wants, she's public health epidemiology all the way. And she has coped with and felt resilient by having more data around here. So she is in charge of all of collecting all the data and disseminating the data. Okay. We had another group who said, you know, I really want to start a prayer group. And we have, we have an affinity group, prayer group. It meets once a week and every week we have members talk about how that's impacting you. For the, you know, and, and for the record, you guys are probably all in the same boat. We have seen 1200 COVID positive patients. We have a 31% mortality rate. We represent 10% of the Minnesota mortality rate. We have one provider so far who has lost 75 patients in the last 10 months. And so as we, again, you know, we, and, and he's an interesting one. He is not that interested in talking about his feelings. So we have not, we've nothing's mandatory. We're back off of him. Right. So as we think about resiliency, I think it's individual and at a corporate level, as you're trying to apply it to you and your peers, really think about how someone needs to respond and how, as we, as administrators, you in your own practice, how do you express to people? This is what I need. And then do that for yourself. So a couple of thoughts there. So I know we're wrapping up soon. My last slide is a debrief slide. So race, recovery, rest, repeat. The four R's that we got to think about, you know, how does our culture typically view the idea of rest and recovery? Not, not a rhetorical question. Jump in. What kind of weakness? Well, okay. Let's throw this out there. I mean, we don't, you know, like we don't even have, you know, paid paternal or maternal leave in this country. So, I mean, let's, let's go with, oh, okay. So repeat the question. How does a culture typically view the idea of rest and recovery? I'm going to go with not great. Americans double down, more on work. Let's do more and more and more and see how fast you can get someone, you know, over the line. See. I heard somebody say that it's a sign of weakness, which I thought was really astute. Sure. Absolutely. It's a sign of weakness. I'll make a comment. I think that a lot of times we don't get to rest in order to be able to recover. I mean, and isn't it funny how, especially how many providers, it's got to be at least 90% providers on this would recommend to your patients to rest and sleep and how important sleep is to kind of get through your day until make sure that the medications and the disease or whatever is going on in your body gets a little bit of time to acclimate to your body and refocus. I've had five hours sleep. Well, and, and the stress of COVID too, right? Like how many, how many have worked even, you know, I mean, I'm not going to maybe even harder than you've ever worked because you feel like if you don't, you're letting someone down. If I don't make it, if I'm not there, someone could die. I could miss something. I didn't talk to the right person. I didn't connect the dots, right? That intense pressure. You know, as a fixer, I would at least say it's universal. And so then once we know everyone has it, then we have to start carving out time for ourselves of what that looks like and what that means for us. I don't think Amanda, I, sorry, I just wanted to make a comment. I think that there's a real cultural difference around in comparing Americans against the rest of the world, really in how we don't really not only value and uphold how important it is to rest, recover, and race repeat, you know, like taking that time out. I was recently somewhere where I said, I said, wow, you look, they, somebody shared their age. And I was just like, oh my gosh, you look great. And they're like, that's because I think it's really important to take that time. And I kept, I kept thinking about that. They, they said that culturally, they, they assign a lot of value to it, but couple that with healthcare and the complexity and the, this sort of race car that we've been in for the last 10 months. And we're all in it together. I think that adds sort of this not peer pressure, but kind of, of all being all in at one time, you know, so just to know. Yeah. No, great. Thank you. I was just going to say, I think sleep is it's not even stressed in medical school and everything else. And I would say only in the past five years, even for me that I've had kind of a breakthrough, like, oh my God, sleep affects so much, right? Because you go through med school and then residency. And that when I did it, it was like starting the 30 hour shifts which was reduced, right. And 80, 80 work weeks and then young kids. So it was only when I got past that point, you know, when the kids were maybe like five or so, and then they were kind of sleeping through the night and like my whole, everything changed. And I was, and I really kind of understood the importance of sleep. And I think that we're not like in college, I remember saying that like, oh, sleep is for the weak, you know, because that's what you're kind of led to believe. Right. So, oh, absolutely. It's really important. Jennifer, you had your hand raised. Oh, sorry. No, I was just going to say, you know, it can pertain to a lot of different things with rest and recovery. And, you know, even if it's just a physical thing that we need to rest from, you know, oftentimes we'll medicate and we think we feel better. So we're ready to go, but really we haven't fully recovered. And then we end up finding ourselves taking 10 steps backwards. Yeah. Well, you know, and, you know, there's some of, so just I'll tie, I'll tie some of these things together potentially in a story. I'm not on social media. I am the only one I'm on is LinkedIn. And recently I was, you know, you know, how some of the really popular ones populate and you may not know that many people involved. And so this gentleman posts on there, you know, what are, you know, now that everything is virtual and we have all these meetings online you know, what are your biggest pet peeves? And he said, my biggest pet peeve is when there's a bed in the background and you're, we're in your guest room. And he's like, I'm here for work, not for pillow talk. And so he starts to get this, these feedbacks, right. And, and a CEO of a major organization in Minnesota responds and says, you know, that's a really privileged position to stand from. You know, she goes, you know, I don't, she goes, I, you know, I have an office. The office was the place that my father recently came home to die in. And I don't want to be in that room. So right now I'm in the guest room and I don't want to, I don't want to be in that room. Like you kind of don't know my life. And I've read a couple more things like you know, millennials are more likely to eat on a call, you know, one of these. And I've had colleagues who have at other organizations who have said, you know, I got, I got in trouble for eating or people are like, I don't, you know, the kids show up in the background or they feel super embarrassed or whatever that is. And, you know, and I, I, as someone who yesterday was on a meeting and I have two babies and one of them was crying and I needed to hold one, I could still listen. I, my video was on and I apologized, but I also, it was a reality of the situation. And we're in, we're in this space where we, we have the choice, I believe to, to judge each other or to stay silent or to really say, Hey, the, the change within the culture for what we need starts at an individual level. And it starts with me by expressing what I need and how to get through it. And so as you kind of go through these things, you know, my talk used to be slightly different, but I've learned a lot in the last 10 months of COVID. I've really learned how individual people need to come up with their solutions to get through. Once you identify again, that stress, that burnout to get through the situation, how you take your self-care and then how you are to articulate it to the people around you and the people who love you to make sure you get those things to be the best you. And then you have all the outcomes that we talked about, those individual, those patient and the system outcomes. Now that door opens up when you're fully authentically you and you're ready to work into a whole new opportunity. Now we get innovative systems, that top best patient care, we get your best work, your best thinking. So it, you know, I think there, and, and your best happiness, your, your best happy place. So we have an assignment that Dr. Smith's going to talk to us through, and I encourage you to watch another Brene Brown video tonight and we'll continue the conversation. So I hope I did okay on time. Yeah, you did great. Thank you very much. And, and thank you all for hanging in there with us through overtime. Dr. Smith, do you just want to have some closing, closing remarks? Sure. I do want everyone to try to get to watch the Brene Brown video on setting boundaries and the, you should have the link there. And it's only about five minutes long. It's pretty quick. It's entertaining. I, I totally identified with it. We can talk about it tomorrow a little bit. And then also don't forget to fill out your learning plans. And maybe on your learning plans, you could include one thing that you were especially glad you learned today. And you could put that in the chat if you'd like, or you can put it on your learning plan. Maybe we can take a few minutes tomorrow morning as people are getting settled and chat about that. And then if you have any questions, please feel free to ask, probably in the chat is best at this point is where we are running over time. And then I guess we started nine o'clock central time, Melissa. Is that right? Yeah. Just given that we've packed in an extra 12 minutes today, you know, do go ahead and try and sign in right at nine o'clock central. And, and we will start early if it looks like we've got most people here. And just a couple of notes, the YouTube link for the Brene Brown, that's in your workbook. And the learning plan, if you, if you fill that out online or, you know, like electronically, there's some buttons at the bottom where you can automatically print that. And then also submit it to us via email. Please put your name on that. That's a great way for us to continue to work with you even after the workshop is over to help you achieve the goals on your learning plan. So please do turn that in and we're going to give you a fresh copy tomorrow. Question, a quick question. I downloaded the learning plan, fill it out, and try to submit it from my computer, but the submission button does not work. What should I do? Scan it in the, in the scanner and send it? Or I print it out already, it's fill out in the computer, I download it, but the submission button doesn't work. Okay, I'm sorry about that. If it doesn't work, just email it to education at hccinstitute.org. Okay. Okay. All right. All right. Any other final comments from our faculty? And I know that the questions that you all have been submitting, the faculty have been answering in the chat, but we're also transcribing them all to make sure that if we haven't answered it, we will address those tomorrow. Thank you all so much for your time today, your extra time, and we will see you at nine o'clock central tomorrow. Bye everyone. Thank you so much. Bye. Thank you. Thank you. Thank you.

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