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October 21, 2020: Today’s focus is on caring for the vulnerable. CommonSpirit and Docent Health’s program to help underserved communities will have you at hello. Are we talking client-facing technology? Are we putting something on a phone? Are we talking about technology that's connecting housing, transportation and education needs? Dr. Alisahah Cole from CommonSpirit and Royal Tuthill from Docent Health join us to explain their “air traffic control” virtual care program which helps vulnerable patients navigate the best opportunities to receive the finest care possible. In the words of Dignity Health’s hello humankindness campaign “Aim for nothing less than to inspire change in health care that leads to more empathy, listening, and respect.” 

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Welcome to this week in Health It, where we amplify great thinking to Propel Healthcare forward. My name is Bill Russell, former healthcare CIO coach, consultant, and creator of this week in health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders.

Speaking of developing the next generation of healthcare leaders, uh, we want to thank Sirius for supporting our mission and the mission of our show. Their weekly support of the show this year has allowed us to expand and develop our services to the community. I. Alright, today we are e excited to have Dr.

Alicia Cole with Common Spirit, uh, VP of Population Health, innovation and Policy in Royal Tuthill with Docent Health. He's the, uh, co-founder and president of the organization. Uh, join us. Uh, welcome, welcome to the show, the two of you. Thank you. We're excited to be here. Thanks to that, that's pretty, pretty smooth for me, huh?

Welcome. The two of you. But Dr. Alicia Cole, you, you're recently married. That's probably the most exciting thing you have going on, . Yes. Just this weekend. Congratulations. That's really exciting. But that's not what we're gonna talk about, although I'm sure it would make a a great, a great story. We're gonna talk about.

The expansion of a program that you guys are doing in, in these communities. So let's just jump right into it. 'cause I think this is a really exciting announcement. So Alicia, before we go there, give us a little background on Common Spirit for those people who aren't familiar. Yes, thank you, bill. So I definitely would love to just give a little bit of background around Common Spirit as a lot of people still don't know us as Common Spirit.

So this was a. Uh, health system that came together in February of 2019 through the alignment of Catholic Health Initiatives and Dignity Health. So with those two organizations and strategically, uh, we actually became one of the largest healthcare systems in the country. Uh, as far as a nonprofit healthcare system, we have over 150,000 employees.

We employ over 25,000 physicians in advanced practice care providers. We have over 137 hospitals, and we are in 21 states. Uh, so serving almost half the country and, and again, with a focus on caring for the vulnerable. So this is such an amazing organization, and thank you for giving me an opportunity to just share a little bit about it.

Yeah, and this is such a great program. Why, why don't you just move straight into the program that you guys are expanding and the, I'm very familiar with Common Spirit, with and with Dignity, having been in the, uh, California market and, uh, worked with some health systems in in Colorado as well. Uh, but you guys literally are across the country, but you are strategically located in some, some communities that are really underserved, and these are, are people that have challenges in terms of keeping up with their care programs and identifying the best.

I really matching the . The best opportunities to receive the best care. So talk a little bit about the partnership with Docent and what you guys are doing. Yes, and I'll definitely hand it over to Royal as well to talk a little bit more about the great work that docent, um, has been doing in the program that they've put together.

So I joined Common. Spirit a few months ago as the new, uh, assistant Vice President for population health, innovation and policy in that role had the amazing opportunity to, uh, learn more about docent and initially become the, uh, medical director, uh, for that program in our, uh, partnership with them. Uh, so I'm a practicing family medicine doctor.

I come from the academic side, so I'm one of those old holdouts that was still doing inpatient medicine as well as outpatient medicine and still providing maternity care and . Again, when I heard about this amazing program and what they were doing, particularly in the space of maternity care, I was extremely excited.

So our partnership with Docent really focuses on helping our patients navigate through certain episodes of care. And so again, specifically looking at the maternity care journey as well as the orthopedic journey and what we found, uh, in, in our initial pilot, . , uh, was that we saw some significant health outcomes that was a maybe a little bit surprising to to some, but not, not all, and some of those health outcomes given the population that we serve.

As you mentioned, we serve a very large Medicare and Medicaid population, one of the largest providers of Medicaid in the country, actually, and what we saw was still these significant outcomes even in . The Medicaid and Medicare population, which often are a little bit more challenging to, to help you know them, navigate through their care.

So we saw about a 37% reduction in preterm births in that population. We saw a pretty significant reduction, about 70% in readmissions. And we also saw pretty significant reduction in length of stay for both our maternity care patients and our orthopedic patients, uh, whi, which meant that we were able to get patients home sooner, rehabbing and healing in their environment, which oftentimes is, is better than being in a hospital setting.

Some pretty significant. Outcomes, uh, that we saw in clinical outcomes. And, and because of that, one of the things I have said about healthcare is there are times when we have evidence-based practices. We know there are things that work. I. But for some reason we don't standardize that across our systems.

And so here was a program that we saw pretty significant outcomes. And so we said, wait a minute. Why shouldn't every patient that we serve in this space have the ability to access this amazing program? And so that's what we launched into now, this second wave, if you will, to really expand this amazing program across, across all of our facilities.

So Royal, you wanna talk a little bit more in detail about docent, but I did wanna just acknowledge that we saw those significant patient outcomes and utilization outcomes and, and made it really easy for us to say this is something that we need to expand across our system. Fantastic. Uh, Royal, give us an idea of the program.

That you guys are scaling up now and that you're expanding, but give us an idea of what's the challenge that you're, you're solving and what you guys have been able to do. Yeah, so probably two, two aspects of it. One is. What we built in the past and then what we're working on expanding off of from there.

And it's been an amazing journey to work with Common Spirit, originally dignity and now Common Spirit. And obviously great leaders like Dr. Cole who are very committed to this work and, and we're dosing started. We've been around since. Uh, 2016 and been working closely with Dignity as one of our anchor partners as we started engaging communities.

And a lot of the communities, to, to your point, uh, that we were working with at Dignity Health originally had high Medicaid populations. We had really bit hard to engage communities. Uh, a number of areas we were working in had . Documented workers. We had English, high English as a second language. We had a large indigenous community.

And so pretty quickly we realized if we were going to be able to have an impact, we needed to be able to connect to the communities in a, in a more culturally appropriate way. And so the core part of the docent program is technology that helps scale. Community-based navigators. And so we hire navigators from the community, but we enable these programs with technology that, um, we can go more into.

But those a really key part to making sure that we could connect to the patients, we could get them engaged in their healthcare. We could provide that longitudinal support both in the community and as they get ready to go into the hospital and, and back home. It's really a key driver for the program is making sure that we had.

Communities that were supported by people in the community and working really closely with the healthcare system and partners like Dignity and Common Spirit to help ensure that they were on the best track. To good healthcare and, and good outcomes. So that's a core tenet of docent from the beginning.

And, and that was a key driver in a lot of the results that Dr. Cole just highlighted. And as we've been expanding out this program and looking forward to the future, uh, a big focus for us is, you know, how do we continue to replicate the results at scale? How do we standardize some of the best practices?

And then also a big focus for us over the course of the spring and the, the movement around social justice and more attention to, uh, social. Determinants of health and racial disparities has been, how can we make sure that no communities are getting left behind as we deploy these programs and, and really being thoughtful about this model that we've started to build, how do we ensure that we can replicate that in other communities?

And, uh, a very specific focus on African American mothers and infant and child, uh, and maternal mortality is a, a key focus within those programs. And so we're really privileged to be able to work with. Uh, providers in the country on that. So, so let me change this up a little bit. I'm a former CIO for a large health system, and we had similar populations.

To the population that you're talking about. So I'm gonna change this out up as okay. You, you had me at, hello. I'm interested, but now I need to understand it further. So are we talking about client facing technology? Are we putting something on a phone or are we talking about technology that we're putting in front of care navigators that's connecting the housing, transportation, education needs and those kinds of things?

What, what are we talking about? Yeah, let me explain the technology a little bit on the patient facing side. There's no apps to download, there's no portals, there's no websites or logins to remember. It's text Me. It's primarily a text messaging based program, uh, and phone. And we have some web surveys as well, but it's primarily a text-based program, and we do automated push campaigns.

Bidirectional AI communications, and then two communications as well for navigators and for care teams. So on the patient facing side, and this has been hugely important to the the hard to engage communities, that it's leveraging the tools that they have in their pocket today. It works for. At risk and vulnerable populations.

It also works really well for commercial insured, uh, patients, and that's been a key part of the program to getting really high engagement rates so that we can connect with patients early, we can get more frequent data points, uh, we can build connectivity, we can understand who they are. And then we also have the navigators.

And so some of our partners. We'll work with outsource navigators from docent. Some of our partners just licensed the technology to scale their teams, their care managers, social workers, community health workers. Um, but the technology platform then is really designed. To integrate data sources from the EMR, from the practice management system, hcaps billing, to get a holistic profile of who that patient is as a person.

And then workflow tools that we queue off of. That'll then surface activities up into a care management platform for the navigators to use, or then triggers messages directly out to the patient. And so there's a really coordinated. Program that's built to longitudinally guide a patient through that journey, and we're surfacing up the right information at the right time to keep them engaged and on track and as we learn more about them as we capture social determinants of health, as we capture personal preferences.

We can then, uh, we have a mapping of what the resources are. Um, and that could be community resources or hospital resources or clinical resources or digital apps to download. We can make the connections between the patient attributes and the attributes of those programs to know where the, the next best steps or what are the next best resources to get those individuals connected to.

Yeah. You know what I love about it? As a technologist, we have people on the show. They're constantly talking about ai. They're constantly talking about really cool smartphone apps and navigation that, but one of the principles you drop there, which I think is so important, is, uh, technology. The best technology is the technology that people can use.

And you looked at the communities that you serve and you're like, you know what? Texting. Is a way that they, that you, you can really get to a majority of that population and interact with them pretty easily. Is is that the principle that really you, you looked at and, and designed around? Yeah, absolutely.

We made a strategic decision not to build an app, uh, a number of years ago. And I think especially now during the pandemic and c Ovid 19, we've seen a lot of our partners look to us and really lean into using text messaging because it's so much easier to drive engagement. And there's certain things that you can't communicate over SMS that wouldn't be clinically appropriate, but you can use that as a channel for engagement to then connect them to other services.

And so it's been a really important part of that arsenal to drive connectivity and engagement and more frequent points of connection over time. But just 'cause it's text-based doesn't mean it's not high tech. You're talking about artificial intelligence to get a whole person profile and then map the right services to those individuals.

I. So you, you're using a, a, a lot of data, bringing that data together and, and really making decisions around what's the best nudge to help people to make the right choices. Is that Yeah. Yeah. So there's a, a big part of this is getting the data together to understand what's going on and. Having this air traffic control system for patients.

So you can see where they are as they navigate the system. And then a rules engine off of that. So we can then trigger what are the right messages to the patients at the right time. And then AI capabilities to help scale some of those communications. Understanding when it's appropriate for a human to actually intervene and, and drive engagement, uh, when appropriate.

What are the right resources to be connecting and pushing through that channel? So there's a lot of sophisticated tech to your point underneath. Text messaging, uh, is funny. It feels like the new killer app these days, but in order to make it effective, it does require a lot of sophistication underneath.

Absolutely. Yeah. And one of the things I would add is that this, uh, not only is it messaging to the patients, but also to the care team. And sending those triggers to the care team, not only, uh, allowing or encouraging the patient to advocate for themselves, but for the care team to also, uh, advocate for the patient.

I think if you look at some of the reasons that these disparities exist, particularly in the African American, uh, mom and, and baby disparities from a mortality and morbidity standpoint. Oftentimes it's a navigation, um, issue. How do patients get to the right care at the right time? How do they know which resources to access and, and how are they supported in in getting to those resources?

And so that's one of the great things, um, about docent that . We loved is that it also not only, again, encouraged the patient to advocate for themselves, but in, in a sense provided advocates through the docents and through the rest of the care team to advocate for the patient and their family. Yeah, and just to add, add on to that, it's been great having a clinician as a partner and Dr.

Cole and us really thinking through how do we make sure the great information that we capture about a patient. Fears and concerns, social needs, barriers to care. Um, how do we make sure that doesn't get isolated with the navigators, but we can share that with the care teams as well. And so we're giving them more scale.

They have that information as they go to engage the patients as opposed to, you know, spending time to try to collect that information. So I think that's a key part of the, the partnership going forward is how can we democratize some of that information that we're, we're capturing from the patients. Yeah, and really add as a tool to the, the frontline care providers.

I think that's one of the things I often hear from my colleagues, my physician colleagues. Okay. Are you asking me to do one more thing? I don't even like the EMR and now you wanna bring another technology to me and so this really does not add any additional work. . On the providers, the way the technology is set up, but gives them more information that, again, they can choose to use in order to take better care of their patients.

But that was one of the key things that we did wanna make sure as even we were gathering the data, how do we make sure we don't put any additional burden on our frontline clinical staff? You, you read my mind. That is the question I was gonna ask . And you went there before I got there. So, Dr. Cole, I'll give you the last word on this because I wanna, let's fast forward two years from now and we're having this meeting, what would be really phenomenal outcomes?

What, what, what do you hope to accomplish in the next couple of years with this program? Yeah, that's a great question, bill. Thank you. I think, of course, we would want to continue to see some of the significant outcomes that we've seen already in regards to decreasing the length of stay for our patients, decreasing the readmission rates.

I. For our patients, expanding this beyond, uh, just the maternity care episode or the orthopedic episode, but do we see benefits in a congestive heart failure episode or in A-C-O-P-D episode? Sepsis, there are so many different potential opportunities for this program, and of course, I, I think what . I'm excited about, as we have now started to really focus intentionally on these, uh, healthcare disparities in the maternal child space, uh, again, specifically to African American women.

My goal would be we eliminate those disparities in our system. There is, I feel no reason that we can't do that if we're being very strategic about this work, if we're being very intentional about this work. And quite frankly, if we're checking and monitoring the data, uh, and . So that I, I think ultimately we at Common Spirit and the docent team would like to be able to say that we eliminated that, that infant maternal mortality and morbidity disparity that exists in African American women and children, big, huge statement that I know might scare some people, but someone has to make it and someone has to commit to doing it.

Yeah. And I, I love the work that Common Spirit's doing. I love your, every time I get a.

I love the campaign. I think it's still your campaign. The Hello, human Kindness. Is that still your campaign? Yes. It's, it's, uh, that was really powerful when they rolled that out in Southern California. People were talking about it. It's, yeah. I love the work that you guys are doing. And Royal, thanks. Thanks for the, you know, text.

Text is the new killer app. Is that what I heard you say? That's right, that's right. It's, it's great to use the technology in a way that people can interact with it and it can have an outcome. So I really appreciate this announcement and I appreciate you guys coming on the show. Thank you, bill. That's all for this week.

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