July 29, 2024 • 43 mins
This episode features Greg Kotzbauer, co-founder of the About Me Institute, who shares his path from healthcare tech to championing value-based care at Dartmouth Institute for Health Policy and Clinical Practice. Discover how his efforts are steering organizations away from fee-for-service models towards systems that prioritize patient well-being and high-value care.
In this enlightening episode, John Hauber and Greg unpack the concept of value-based care, where outcomes take precedence over costs. Learn how proactive screenings and preventive measures, inspired by Sweden’s patient-centered approach, can transform healthcare. We also spotlight initiatives in North Carolina aimed at fostering meaningful provider-patient conversations, centering care around individual goals and preferences. Dive into stories and strategies that place the patient's voice at the forefront of healthcare.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:07):
We also knew that change comes through stories.
Right, you know, I wouldfrequently present to the board
and physician board as well asadministrative board of the
health system, and it wouldstart with patient stories.
It would start with physicianstories.
How is this making a differenceto the lives?
Not just care, but you knowwhat people experience.
(00:27):
People who were, for example, apatient early on, who was, you
know, a single father of adaughter who was just not
managing his diabetes, keptshowing up at the hospital.
I mean, I think it was 18 timeswithin the first few months
that we started work with themand we just engaged them in this
human conversation.
What's going on?
Part of it was a matter of notlack of motivation, it was a
lack of understanding of theircare plan, why they needed to do
(00:49):
this, and we just built arelationship and partnership and
a little bit of coaching and wedidn't see them in the hospital
anymore.
Speaker 2 (01:04):
Welcome to the Senior Housing Investors Podcast.
If you are an owner operator,investor, developer or buyer of
senior housing, you've come tothe right place.
The best way to stay connectedwith us is to sign up for our
weekly newsletter athavenseniorinvestmentscom.
This podcast doesn't existwithout you, our community.
(01:26):
Thank you for listening andreach out to us anytime.
Speaker 1 (01:36):
Welcome back everyone .
Speaker 3 (01:37):
Today, john Haber is having an insightful
conversation with Greg Kotzbauer, co-founder of the About Me
Institute.
Join them as they discusshuman-centered care for the
aging population.
John Greg, it's great to haveyou on our show.
Thank you so much for beingwilling to participate and share
(01:58):
your knowledge with ouraudience.
Tell us a little bit aboutyourself and your background.
Speaker 1 (02:08):
Yeah, thank you for having me.
I'm excited to join you and theteam in sharing ideas of what
we can do to create newpossibilities for the aging
population.
I've been working in healthcarereally since the early 2000s,
primarily on the technology side, but it was about 2010 or so
where I was director of productmanagement for this healthcare
analytics company and I'dalready started and sold a
(02:29):
healthcare technology companyfocused on wellness for the
employee population.
And I just said to myself I'mjust not smart enough.
I'm just sort of tired of beinga hack at this.
I want to be as thoughtful as Ican and create solutions that
lead to, you know, help peoplelive their best life.
And so I decided to get my goto get my master's and I was
(02:49):
lucky enough to get accepted toan institute under Dartmouth
Medical School and called theDartmouth Institute for Health
Policy and Clinical Practice.
And so I went there and I gotmy master's, but then I was
asked to do to work for theinstitute while I was getting my
master's, part time, and itjust changed my life, and so the
enthusiasm that the researchersand the staff all had around
(03:12):
their commitment to identifyingnew ways to create a better
health care system.
It just sunk into me me and I'dnever really been part of a
team that was so committed andso passionate to just fighting
for a new way of working and youknow, especially the healthcare
and in the healthcare space.
(03:32):
And so from them I just tookthat on and it was in.
It just was embodied in me eversince.
And so now I'm doing everythingI can to find new ways to
create care solutions that helppeople lead to their best life.
And so while I was at Dartmouthand working, I was leading
several national collaborativeson how do we make the health
(03:55):
care system better by creating ahigh value care system, not
just a fee for service.
Do more, you know.
Do more tests, go to thehospital more.
Do more you know, do more tests, go to the hospital more,
really try to help people livetheir best life and do whatever
we can to help organizationssucceed under that new way of
working and clinicians succeedunder that new way of working.
And so I was doing that.
(04:16):
And then I from that spun out acompany from Dartmouth that was
a change leadership solution fororganizations, trying to move
from fee-for-service tovalue-based payment models and
work with seven or soorganizations where they use my
product to create a strategicplan, as we used to say, a GPS
(04:38):
to success under value-basedcare.
So it was really ingrained inwith executive leaders, boards,
clinician leaders, patientadvocates.
How do we make this work?
And clearly, for those of youwho and John, maybe you know as
well there's been some ups anddowns on our country's ability
(04:59):
to succeed under this concept ofvalue-based care, and so
hopefully we'll continue to keepworking at it and create care
systems that can care for people, not just disease, and not just
reactively care for people, butproactively create a care
system that helps people livetheir best life before they get
sick and help them thrive aswhether they're aging or not.
(05:21):
But of course, our conversationtoday is about aging.
So what?
Speaker 3 (05:25):
is value-based care.
So to our audience, who is usedto the current system, what do
you mean by values-based care?
Speaker 1 (05:32):
It's outcomes over cost.
So today, when we say afee-for-service model, that
means that a provider that couldbe a hospital, it could be a
primary care physician, it couldbe a specialty provider like a
cardiologist, they simply, undera fee-for-service model, get
paid for anything they do.
So I do something to a person,I'm paid a certain amount for
(05:55):
the work that I do Undervalue-based care.
The idea is that you want toincentivize healthcare providers
again healthcare providersagain physicians or hospitals to
produce value.
That matters.
So when we say outcomes overcost, it means are we delivering
care that with high quality?
High quality could be?
(06:16):
Are we doing proactivescreenings?
Things that we know from anevidence point of view are
helping us identify, proactive,identify medical issues among
our patient population, wherethen we can care for them and
prevent, say, a disease, whetherit be cancer or so on, or
dementia, and then so we havethese measures that we evaluate.
(06:36):
We evaluate quality, but it'snot just about quality.
We value this quality over costequation as the cost part two.
We want to do as good a job aswe can to also manage the cost
of care.
So right now, cost justcontinues to go up.
It's more than a fifth of oureconomy and what we're trying to
do is to say well, let's notjust deliver high quality care,
(06:58):
let's also do our best to managecost.
So, if you can, what avalue-based care is?
It's a payment model structureto where, whether it be Medicare
, private payers like United orAetna are also setting up these
agreements.
They sign agreements withproviders and say here is your
attributed population, here'sthe benchmarks that we're
(07:21):
setting.
And if you achieve thosebenchmarks and there's a lot of
variations on this, so I'mspeaking very generically.
There's a lot of differentmodels out there, but just
generically if you can beatthose benchmarks, meaning hit
these quality measures, savemoney you'll receive a portion
of those savings and perhaps abonus for delivering high value
(07:43):
care.
For those of you who do knowwhat I'm talking about, you know
well that there are a lot ofvariations on that.
I'm not getting into somedetails, but that's generally,
john, how it works.
We're trying to incentivizecare providers to deliver
high-quality care at a cost thatwell, I won't say we can't
afford.
But that is also minimizing thecost of care moving forward.
Speaker 3 (08:04):
Does that help?
That does very much so, and Iappreciate that description of
variation of the model andhopefully we have a healthcare
system and a pharmaceuticalsystem that will buy into that
and I appreciate you being aleader in that movement.
(08:24):
And I appreciate you being aleader in that movement.
And so tell us some of the youknow number one, what you've
done in terms of leading thiseffort, not only here in the
United States butinternationally.
Speaker 1 (08:39):
Yeah, thanks for that was a bit of frustration where
the payment models were oftenleading in us trying to design
what's the specifics of thispayment model and what's the
benchmark and who's theattributed population.
All these things, all thosematter and are important for
designing the way that care isstructured in the future.
But for me, it became reallyimportant personally to focus on
(09:02):
.
Well, let's not forget how dowe make sure that the person is
at the center of all the care.
You know the vision that we'retalking about in high value care
and I was lucky enough atDartmouth to get involved in
some international projects thatwas really looking to insert
the voice of the patient intothe center of care.
And so those projects where wewere saying look a patient's
(09:27):
voice, their preferences, theirgoals and making sure that
they're viewed as more than thedisease that you know, more than
diabetes, more than you know aperson with dementia and so on,
that they are, that theconversations they have with
their providers are reallycentered around them as a whole
(09:47):
person.
Being lucky enough to beinvolved in some of those
conversations, we're learningfrom people from around the
world, particularly some thoughtleaders from Sweden, and how
they were doing this.
We're trying to bring theirthought leadership back to the
US and I'm just taking thoseideas, their thought leadership,
back to the US and I'm justtaking those ideas.
(10:08):
And I said you know what I wantto focus less on the payment
models themselves and designingthem and helping lead success
around the organizational levelto success under payment models
and get down into thegranularity of creating care
conversations between a providerand a patient that will make
the provider feel connectedagain as a care practitioner, as
someone who is not just rushingthrough the practice of care
(10:31):
and the business of healthcarebut that can slow down a
conversation and say let's talkabout you, you the patient as a
whole person, and be ready toserve you around your whole
person needs, not just how'syour diabetes today and we're
going to give you some drugs andgo on and okay, great, and I'll
see you in six months orwhatever a year and really
trying to change the way thatair conversation and the care
(10:53):
system was centered not justaround disease and payments, but
the person that we're caringfor.
And so that led me to John.
I was lucky enough to be askedto lead a strategy project for a
health system in North Carolina, to engage a community in what
(11:14):
mattered to them.
And so I did that.
We had some amazing outcomes.
The community was reallystarting to lead the way in
their own health and as part ofthat, I took advantage of that
relationship with that healthsystem and said you know what?
You will also not?
Just maybe you're not engagingyour communities as much as you
can and release reallythoughtful conversations and
(11:34):
supporting them, not just, again, reactively, but proactively,
and helping them create acommunity of health, but you're
also not regularly engagingpatients in conversations that
matter to them, about whatmatters most to them.
And so I created, I took a staband I said you know what,
(11:54):
without even being asked, I'mgoing to, you know, take all
these lessons I learned aroundpatient-centered care and
building patient-centeredinstruments and questionnaire
surveys, that type of thing.
And I created this card,literally on an index card, john
, and called it the About MeCare Card.
And the idea was to createsomething super simple to where
(12:16):
there was going to be minimalbarrier for providers to adopt
it, minimal barriers forpatients to answer, you know,
instead of answering a bunch oflong-winded questions, just make
it super simple for providersand patients.
And it was this index card,john, that Simply asked and this
was in a primary care setting,a specialty care setting.
They even were doing thehospital.
They asked the patient in theprimary care setting example
(12:38):
I'll give you is what are yourgoals for the visit today?
So that's at the forefront.
And the patients would answerthis card either in the office
before the visit or, most of thetime, in the office right
before the visit.
And then we would say what havebeen your primary concerns over
the past 12 months and wewouldn't ask about, we'd ask if
(12:59):
they had concerns about thedisease or, to say, your health,
and we'd also ask things aroundsocial determinants of health,
which I'm sure you've probablyheard of, john, and that is
things like my dieting or accessto food or my safety or my
housing, my electricity goingout, things like that.
And we would ask patientswhat's your level of confidence
to address these issues?
(13:20):
Another question we ask is doyou think that any of these
concerns are going to lead yougoing to the hospital or ED the
next 30 days?
Again, asking their perspectiveon not just their worries about
health, not just related todisease, about their whole
person concerns, but also reallyasking them do these concerns?
Do you see any possibility ofdecline or again not being able
(13:44):
to help yourself find a pathwayon your own to address these
problems.
And the idea, john, was that wewanted the patient to inform the
care team what they think theirbroader, whole person concerns
are.
And there's a ton of researchthat shows this concept of
social determinants or thingsthat and some people don't like
(14:06):
to call them determinants, butindicators of life that we know,
like dieting, like exercise,like safety, like not having
electricity in your home areindicators of future health
decline.
And so we wanted the primarycare and other care providers in
the system to recognize thoseso that we could, as a broader
(14:28):
health system, use thatinformation to have people not
the primary care providers, buthave other care team members
reach out to them and talk tothem about those concerns or
work with the local countygovernment, you know, make sure
if we recognize that a personhad a housing issue, electricity
issue, we built relationshipswith the local human health and
(14:49):
services department too, wherethey would reach out to that
patient to help them addresstheir housing issues.
So by asking the patient thesequestions, they not only
established this deeperrelationship with the provider,
but the provider knew that well.
They didn't have to do anythingabout these other concerns.
We built the care systemoutside of the medical system
(15:09):
that could address theseconcerns of those patients and
help them deal with and manageas best they could the other
non-medical issues that wereimpacting their health and their
well-being, like housing, lackof access to food, etc.
And so we built this throughthis car to initiate this whole,
this revision, this change intoa care system not just a
(15:32):
medical system but a wholeperson care system that really
could, just by gatheringinformation in the primary care
setting, we could use that tofacilitate a new way of caring
for people and addressing theirwhole person needs.
Speaker 3 (15:46):
Wow, why hasn't this ever been done before?
Meaning that the individualproviders actually care for who
they're caring for?
Yeah, you know, it'sdisheartening that the providers
many of them and there arereally good ones out there also
don't put that at the forefrontof their minds of truly
(16:07):
understanding the feelings andthe fears and the concerns of
that individual patient and, bynot doing so, not being able to
uncover those things that thepatient may be hiding from them
able to uncover those thingsthat the patient may be hiding
from them.
Speaker 1 (16:21):
Yeah Well, and I think, john, to your point.
So this is something reallyimportant for the leaders on the
call.
So the work I did at Dartmouthand I mentioned this change
leadership model that I built,and so I was really from that
well-prepared to have theseconversations about talking to
clinicians about this idea ofthe About Me card, and so some
of the initial responses werepatients are never going to fill
(16:44):
it out.
I haven't run into a physicianout of the whatever hundred or
maybe more than a thousand thatI've talked to but who has said
they don't understand that thesenon-medical issues they all
understand that matter, but whatthey said is but I can't do
anything about them, so I'm notgoing to ask, and which is fully
understandable, right?
Because one of the thingsclinicians don't want to do is
(17:05):
they don't want to.
They have so little time tohave a conversation with a
patient.
Support, particularly whenyou're under fee for service.
It doesn't support paying forthese non-medical needs or
having long conversations aboutthat can go on for a while if
(17:28):
you're talking about housing orwhatever, and so they've avoided
it because this system didn'tsupport them, whether it be
payment and or they didn't havea team to support them.
And so what I did immediatelywith that and I think this is
the key lesson for us is whenyou're establishing an
innovation and have this visionfor change, where we have to
understand the system barrierstoo right.
(17:49):
Like you can always, often,often, always, convince one or
two or three or four or fivepeople, but if you want to see
systemic change, the systemitself, you need a system right,
and so early on, we identifiedsome providers who were saying
those things.
But we knew them, we had somerelationship with them already
and we're like let's give it ashot.
(18:10):
If you decide not to do it,fine, that's great.
Well, can you give it a shot?
One we saw patients were veryinterested in completing this
card and because it was simplethese were checkboxes we were
asking again a lot of times yousee these surveys and it'll go
on 20 words.
You're going to read this wholequestion.
We were keeping it super simpleDoes this concern you, yes or
(18:31):
no?
Like that's it right.
So it's really easy, and it waseasy for providers to review.
But then what we do is we saidto providers look, all we're
asking you to do is review thecard of the patient, you might
take 30 seconds.
Say you recognize it right, sayI see this, but here's what's
going to happen I'm here as yourmedical provider to address
(18:55):
your diabetes, and so on.
These other things are perhapsreasons.
You know one or two reasons, ora reason or part of the reason.
Maybe you have diabetes, youcan't exercise, you don't have
the right food right, you don'thave a refrigerator in your home
to maintain your risk, orwhatever.
But what we're going to do withthat is we have a care team
who's going to follow up withyou and talk to you about that,
(19:17):
and that is all they had to do.
John is just say okay, I'mgoing to refer you.
And it gave them this abilityto do what they want to do, that
is, address, you know, makesure the people they care for
are healthy, not just givingthem prescriptions and drugs and
so on.
And so it gave them thisability then to just do a
(19:38):
referral.
So this team that I'm talkingabout we called it the Center
for Health and Social Care andthe providers some providers end
up calling the care suite.
Some providers called them theteam, the care bears, because it
was this team that was givingthem and the patients a sense of
care around you know, sort ofthe busyness of their daily life
(20:01):
and the interaction busynessand interaction they have with
providers, and so that's whatled to the success.
You know, it wasn't just theinnovation of this card, it was
the fact that we implemented thecard.
Yes, and that was creative.
It was brief, it was short, itwas fun.
We even did like color-codedcards to you just to again to do
any sort of art and forwardthing.
(20:22):
We could and but we create thiscare system and, like I said,
these Care Bears, the Care Suite.
They knew that their job was tofacilitate partnerships with
those in the community.
To then they weren't going tobe able to solve all the
problems.
They needed partners.
So we also built theserelationships and partnerships
with, like I mentioned, likeHealth and Human Services or an
(20:43):
aging group or so on there aremany others to really address
these issues and be facilitatorsof people getting addressed in
their whole health needs.
That was the success of thatand it's what's really amazing.
You know, we started off withthree physicians you know one or
two of those three physicians.
They adopted it, they gave us abit of a test run and they gave
(21:06):
us enough then for us to go tofive.
You know another two physicians, another eight, and you know it
took a few years to get full 21clinics in the practice.
And it just shows sort of theone, the persistence that you
need.
And how do we do that?
John, I think a key thing forthe leaders to recognize is that
(21:27):
we also knew that change comesthrough stories.
Right, I would frequentlypresent to the board and
physician board as well asadministrative board of the
health system, and it wouldstart with patient stories, it
would start with physicianstories.
How is this making a differenceto the lives, not just hair,
(21:48):
but what people experience.
People who were, for example, apatient early on, who was a
single father of a daughter, whowas just not managing his
diabetes, kept showing up at thehospital.
I mean, I think it was 18 timeswithin the first few months
that we started to work with himand we just engaged them in
this human conversation.
What's going on and it was partof it was a matter of not lack
(22:10):
of motivation, it was a lack ofunderstanding of their care plan
, why they needed to do this,and we just built a relationship
and partnership and a littlebit of coaching and we didn't
see them in the hospital anymore.
And so those types of storiesare providers saying how much
they call them the care bearsright, like they see the value
in having this partnership andit took that and stories.
(22:33):
And then we also use data toshow the pre and post impact of
patients.
What type of utilization werethey?
You know what was theutilization before we engaged
these patients, what was itafter?
And there were a lot of nuances, for you know from an
epidemiological point of viewand how you need to look at
these, and sometimes there'sregression of the mean.
(22:54):
You know where patients arejust simply by talking to them.
For example, they might usehealthcare less, but generally
we use evidence-based methods.
We saw a tremendous value in areduction in utilization among
these patients the Care Bears,the Care Suite team, those
patients that they engage.
We saw reductions inutilization, we saw improved
(23:15):
quality of life and we use thosestories.
And now we have probably as ofthis month or so, we have more
than 100,000 of these cards thathave supported conversations
and we've even deployed a secondcard that is specific to the
age of population and is asked.
So now we have one card that'sasked of any patient.
(23:38):
This is in Epic, by the way,which is an EMR.
All this is deployed in Epic.
Now we have the original cardthat I just described, the
social determinants of health.
One is asked of anyone belowthe age of 55.
And anyone 55 and above is askedthis aging card, which has
social determinants but it'smore specific to aging, and that
(23:59):
came about by an internationalproject that I led to convert
that original care card intothis aging card and we work with
teams in Sweden and Spain andKorea and across the US and
assisted living and neurologistsin the hospitals and
neuropsychologists to developthis aging card.
That asked the aging populationmore specifically, things like
(24:23):
what matters most to you in yourlife, and we asked the answer.
Options were bullet optionslike maintaining my friendship,
maintaining my hobbies, thingsthat we know are often stop or
slow down as we age.
And we ask patients well, whatare the biggest concerns around
(24:44):
you?
Not being able to live thatbest life that you just
described?
And we talk about things likefinances and losing my finances,
losing my independence, notbeing able to do the things I
used to do, my anxiety, myhearing, my vision, and so it
was more specific to issues thatwe have as we age, and so
(25:06):
deploying that card was a snap,john, because we built all this
will over the prior years whenwe approached a primary care
group about adopting this agingcard and splitting the card
between the below 55 and above55, they're like no problem.
We did it in a basic, we put inan epic, perhaps it was two
months and you know in duration.
(25:27):
The effort was small but ittook minimal convincing and the
team is working it.
Now we have thousands of theseaging cards as well going in
parallel to the original card,because we developed this
culture of what patients tell usmatter and we want to make sure
that they feel heard around,where they are in their life and
what matters to them and how wecan help them live their best
(25:49):
life, really no matter wherethey are in their life's journey
.
Speaker 3 (25:53):
So tell us a little bit about how you integrated
this aging card into independentliving, assisted living and
memory care, and what theoutcomes of that were in your
study.
Speaker 1 (26:07):
Yeah, for example, on assisted living, we partnered
with a primary care clinicianfocused on the senior population
.
I met her because I did somestrategy work for a palliative
care and hospice organizationand she used to be the medical
director there.
So she's also well work for apalliative care and hospice
organization and she used to bethe medical director there.
So she's also well-trained andpalliative.
And when we did this projectshe was focused on caring for
(26:27):
the senior population assistedliving.
So how she did it is she had anurse that worked with her and
that would deploy the card tothe patients before she saw them
.
You know, do a brief interviewwith the residents in assisted
living, talk to them about thecard and ask them questions that
we have on the card againaround what is your best life,
(26:49):
what are the concerns that youhave about, you know, being able
to live your best life?
And then she would hand thatcard to the clinician prior to
the visit.
She would review the card andhave a conversation with the
patient again about theirmedical needs as well, but also
about the card.
And what was amazing about thisis this you know, I'm giving
you one example, but it'sthoughtful is that this
(27:10):
clinician is, you know, just asuper wonderful human and so
caring, and I can imagine heralways having these human
centered conversations.
But what she told is she goes.
I learned things that I didn'tknow about patients that I had
been talking, you know, that Ihad a relationship with for a
few years, you know, and whetherit be about you know some of
(27:31):
their hobbies or whether it betheir concerns about their
daughter or so on, and how itsort of led to this rejuvenation
of creating a human-centeredrelationship with their patients
.
We found this in.
We also worked with a few PACEprograms.
It was the same thing with theprimary care providers who were
engaging patients through PACEand really opening up and they
(27:56):
were already doing thesebooklets and things.
But how it just led to a pausein the typically medically
focused conversation into wow,oh, tell me more about your
daughter, what does that mean toyou?
Or tell me more about thishobby.
Or tell me you're afraid aboutlosing this hobby.
Let's talk about what we canmaybe do to make sure you don't,
(28:18):
etc.
Things like that that just openup the window for these
human-centered and personalizedconversations was really really
powerful.
The other thing that was reallypowerful about this work John
is.
We also tested it in a family.
We had a family that we engagedwhose father was towards the
(28:40):
end of not the end of life, buthe had a dementia that was
progressing pretty rapidly, andthey used this to have a
conversation with him.
And what they did is theyactually left the card, because
we created this one as a trifoldas opposed to an index card.
They left the card on the tableso that it served as a reminder
(29:04):
of things that mattered to himand they actually would engage
him in those conversationsaround the card every so often
and would update it.
So it wasn't just a staticartifact for them, it was a way
to make sure that they werealways centered and reminded to
document and ask some of thesequestions on a somewhat regular
(29:25):
basis and every family would bedifferent about how frequent
that is, but again, to make surethat there was this artifact of
what they talked about, whatmattered.
If anyone else, say, anothercare provider came into the
house for a visit that they alsohad, they could review this too
to see the history of theconversation.
It wasn't just a verbalconversation of did the
(29:52):
transition between pastconversations and communicating
with these past conversations,other care providers could read
and see what mattered to thisgentleman.
And so the power of that.
We've been really lucky thisgentleman, and so the power of
that.
We've been really lucky again.
We have this adopted so quicklywithin primary care in North
Carolina.
This health system just to putin Epic now it's being used
every day and just to see thepower of that is very meaningful
(30:12):
.
Speaker 3 (30:14):
Well, greg, I wish our family would have had that.
My father passed fromcomplications, from dementia, or
he had dementia but he passedfrom other means, but he tended
to not be as open about what hisneeds were, what his fears were
, and to have that card wouldhave been really powerful for
(30:34):
all of us to know what he reallycared about, and so I commend
you for putting that together.
And you said over 100,000 ofthese cards have been filled out
.
What are the top three checkmarks that you get on these
cards that?
I'm sure you're gathering allthis data?
(30:54):
You know all this data.
What's coming out of thesecards that tell you about those
100,000 patients?
Speaker 1 (31:02):
That's a great question and I haven't looked at
the data recently but it'spretty dispersed.
On the aging card itself youknow that's a little bit newer
right we have a few thousand ofthose.
The combination of the agingand the original is over 100,000
now of the Asian and theoriginals over 100,000 now.
(31:23):
So it's pretty dispersed aroundthe primary concerns because it
often depends on where theylive and the circumstances of
where they live.
But what's really interestingin the data, what we saw is that
we could tie.
For example, when someone saidthat they were I mentioned that
there was this question thereabout their level of confidence
(31:44):
to address their concerns andthat question was a question
that I learned about from acolleague at Dartmouth, the
primary care clinician atDartmouth and he's been using it
for thousands of patients,thousands of conversations as
well.
So this also reflects hisresearch.
But when we saw patients saythey were not very confident to
address really whatever issueand this relationship increased
(32:09):
if they reported more than oneissue but we would see that they
had a higher likelihood ofgoing to the ED or going to the
hospital.
You know this concept ofconfidence is a real.
It's an amazing indicator forsuch a simple question.
You know what is your level ofconfidence and your ability to
address your concerns.
(32:29):
We also asked this otherquestion that I mentioned, john.
That was a really importantindicator in that and we took
this.
Some of you who have someexperience with palliative care.
We adapted this from Mayo'spalliative question.
Mayo palliative team asked aquestion, the clinicians.
They asked themselves thisquestion would you be surprised
(32:49):
if this patient died within thenext 18 months?
We took that and said that's anamazing question, it's super
thoughtful.
But what if we asked thepatient version of that?
Right, because we don't do thatenough and we ask the patient
would you be surprised if youwent to the ED or the hospital
in the next 30 days, addresstheir concerns and sort of feel
(33:22):
into where they are in theirwhether it be their disease
trajectory or the issues thatare bothering them relating to
their housing, their safety, etcetera.
And so, really, beyond, what wefound was it's less about what
the check marks are.
It's about their relationshipbetween those questions and
whether or not you know they'retelling us.
You know it's this riskindicator, right, this predictor
(33:43):
of where this patient is goingto be, and we actually use those
.
And we also asked them thisother question they had
mentioned, john, about, are anyof your needs urgent?
And we broke that out.
We see.
If they would say yes, we wouldsay is it a social need, is it
a medical need?
We see.
If they would say yes, we wouldsay is it a social need, is it
a medical need?
That question, the confidencequestion and the surprise
question I talked about, thoseare the ones that actually drove
(34:14):
the Care Bears, the Care Suite,who they talked to first, and
so what we did with thatinformation is the Care Bears.
Every morning we had a teamhuddle and we would look at the
patient that said do I have anurgent need?
Yes, okay, well, those are theones.
The first we looked at theirlevel of confidence.
Okay, not very confident.
We've seen the data.
Those patients are going tolikely decline.
We're going to talk to themnext and then we would use, you
know, their concerns that theyreported, john, whether it be
(34:37):
diet, whether it be safety.
We would use the urgent and theconfidence and the surprises as
our ranking.
But then we would have aconversation with that patient
specific to their card, right,okay, you said you have this
urgent need.
You said you're not veryconfident and you've listed
these things as your primaryconcern.
Let's talk about that.
What is the number one thing?
If you listed three things?
(34:57):
Well, we need to make sure weaddress the highest priority for
you and what you think thebiggest concern is, or where you
lack the most confidence, andwe're going to address that
first and over time, we'll doour best to address the next.
But we use that data to everyday in a team huddle to
prioritize the patients that weare going to talk to through
(35:18):
those other questions the urgent, the confidence and the
surprise question and then wereference the other concerns to
help us facilitate a real, youknow, human whole person care
conversation.
Speaker 3 (35:31):
Are you doing this by phone caregivers or are you
doing it face-to-face?
Are you doing it viatelemedicine?
Speaker 1 (35:38):
It depends.
So a lot of times the patients,the follow-up with them, will
be by phone, or if we hadactually an office in one of the
hospitals in this town.
They have a poor hospitalsystem and if we could schedule
some of the patient grades,maybe they had to go see them
(35:59):
when they were coming in for thenext visit, which obviously
could be delayed.
So that's not ideal.
Sometimes we might actuallyhave to just text a patient.
Whatever we needed to do, wewould do our best to engage with
that person, establish a trustrelationship, and a lot of times
it was by phone, just becausethat was a primary means and the
(36:19):
only tool that we had out ofthe gate.
Speaker 3 (36:22):
So here's the last question for you, greg, okay,
and that is, as you know, mostof our listeners are interested
in the senior housing spaceCalled me up and we had
pre-conversation about what yourinterest was in that space.
So tell our audience how yourcare card or age card could
(36:43):
benefit these senior housingoperators within their own EMRs,
because each one of them has anEMR within their system.
How do you see that benefitingthe residents not patients,
residents and their caretakersand operators?
Speaker 1 (37:01):
Yeah, that's a wonderful question and I'm sure
some people are doing someversion or something around this
.
I think for me, when I envisionthis one is if you anchor and
I'll say all conversations andmaybe it's not literally all,
but we'll just focus on doing,you know, striving for the best
(37:22):
is all conversations on what arethe self-reported goals,
preferences and values of everyindividual, and then around that
are perhaps the medical needsand addressing the medical needs
through that land, and so youmight, as a resident, come for
any resident that's existing,but let's just say there's a new
resident.
We'll follow that use case.
(37:43):
We start the conversation withbeing really clear on what is
the about me card or about meresponse, is that this
individual giving them thechance to self-report and to
answer that card and to makesure that they're seen, they're
heard, make sure that they'reseen, they're heard.
That card itself, if it's aphysical artifact, could be
(38:04):
posted on the wall, so everyperson that interacts with that
individual sees what they'rewe've used this phrase sometimes
the value compass Again, whatare their goals, what are their
concerns, what are theirconversations?
Like to have Having that as avisible artifact for all the
care team members to see as theyinteract with that individual
and to your point about the EMR,every so often, whether it be
(38:27):
again if they're a new patient,and then on some interval three
months, six months that beingasked and updated in the EHR.
So there is an understanding ofthe potential relationship
between, for that resident,their medical condition and
where they are from apreferences and goals point of
view, and be able to track thenover time.
(38:47):
How are we?
Is the care plan that we'reimplementing?
Does it support what they'veexpressed as a concern and are
we able to address thoseconcerns and their medical
concerns over time by building arelationship with them,
providing the support they needto address those concerns and
their medical concerns over time?
By building a relationship withthem, providing the support
they need to address theirconcern about whatever their
concern around decline is orwhatever their concern is of not
(39:09):
being able to live their bestlife is.
Are we addressing that and wecan track that in the EMR?
That would allow some reportinganalytics to say, yes, we're
providing the best care, thebest lived experience, the best
quality of life to thisindividual, not just from the
care team's perspective but fromthe self-reported resident
perspective, and we can measurethat over time using the EMR.
Speaker 3 (39:33):
Yeah, that would be fantastic.
I have not seen it within thesenior housing environment yet,
but I know it's coming withinthe senior housing environment
yet, but I know it's coming.
I know that patient-centeredcare or resident-centered care
is extremely important, but whatwe do have is we have a higher
turnover of caregivers withinthe senior housing space and so
(39:55):
you know when you have thatturnover, then having that new
caretaker come in either in thehome setting or in the community
setting, that new caretakerwould then see that card or
those answers to those questions.
It would be brought up to datereally quickly on what Betty
(40:16):
loves about life, what herconcerns are and such Betty
loves about life, what herconcerns are and such.
Now, the way I see it is if it'sdone within the community
setting, at the skilled nursingor assisted living or memory
care, and that information isthen passed on to the providers,
to that resident, that's evenmore powerful, right?
Because now everyone's talkingamongst each other in regards to
(40:40):
Betty and what Betty needs andwhat Betty's fears are, what
Betty's, this and that are.
So kudos to you, greg.
Thank you so much for allyou've done so far and what
you're doing as it relates toaging and really digging deep
into the needs and concerns ofthe individual patient and
(41:03):
resident, because they're both.
They could be both a patientand a resident.
So thank you so much.
Speaker 1 (41:10):
Well, john, I will say one thing Thank you for that
, John, it's really nice.
I, like you, really share acommitment to this work.
And to your last point.
What's interesting is thisabout me model that I talked
about, you know, won an awardfrom the North Carolina Hospital
Association, and the reason isbecause we're able to use data
to show the impact.
(41:30):
So I think to your point around.
The MR part is you know whetheryou're using it for business
development or whether youdecide, you know, at some point
to become part of a value-basedpayment model or whatever.
You just want to make sure thepatient can see the value that
they're getting on an individuallevel.
It really does allow you, if youcapture that data over time and
(41:54):
tie it and be able to show thequality of life and, based off
the patient report not thefacility owners, the
administrators, not the careproviders, but the patient
report it can really lead to,again, a viable, sustainable and
growing business, because youcan prove that.
One thing I would mention aswell is that in this population
(42:16):
we know how important it is forindividuals, for example, who
have cognitive dementia, to alsoask questions of the family or
loved ones right to have theirperspective and that's another
way that we can think about thistoo is not just asking the
resident, but making sure thatthe resident might have some
input into the self-report ofhow this patient is doing, what
(42:39):
their concerns are, what theysee in the patient as well, and
so just never forget that ourresidents have family members
that can also give key insightsthat we might want to think
about as we craft a whole personcare partnership with each
individual, each resident.
Speaker 3 (42:55):
Well, thank you very much, Frig.
And how do individuals get intouch with you?
How can they get that amazingpresentation you sent?
If that's okay with you, I'mgoing to attach it to this
podcast, and that is thepresentation on the About Me
Care Card morphstudioio.
Speaker 1 (43:23):
So m-o-r-p-h-studioio , just greg at morphstudioio and
you're welcome to share that.
Anybody can reach out and justask questions and get insights
and be happy to help do whatever.
Speaker 3 (43:29):
I can Well appreciate your time, Greg.
Thank you very much for beingpart of my life and letting us
know about you and your efforts,and the outcomes that are being
created by you, which you'veinvented.
Thank you so much.
We also knew that change comes through stories.
Right, you know, I wouldfrequently present to the board
and physician board as well asadministrative board of the
health system, and it wouldstart with patient stories.
It would start with physicianstories.
How is this making a differenceto the lives?
Not just care, but you knowwhat people experience.
(00:27):
People who were, for example, apatient early on, who was, you
know, a single father of adaughter who was just not
managing his diabetes, keptshowing up at the hospital.
I mean, I think it was 18 timeswithin the first few months
that we started work with themand we just engaged them in this
human conversation.
What's going on?
Part of it was a matter of notlack of motivation, it was a
lack of understanding of theircare plan, why they needed to do
(00:49):
this, and we just built arelationship and partnership and
a little bit of coaching and wedidn't see them in the hospital
anymore.
Speaker 2 (01:04):
Welcome to the Senior Housing Investors Podcast.
If you are an owner operator,investor, developer or buyer of
senior housing, you've come tothe right place.
The best way to stay connectedwith us is to sign up for our
weekly newsletter athavenseniorinvestmentscom.
This podcast doesn't existwithout you, our community.
(01:26):
Thank you for listening andreach out to us anytime.
Speaker 1 (01:36):
Welcome back everyone .
Speaker 3 (01:37):
Today, john Haber is having an insightful
conversation with Greg Kotzbauer, co-founder of the About Me
Institute.
Join them as they discusshuman-centered care for the
aging population.
John Greg, it's great to haveyou on our show.
Thank you so much for beingwilling to participate and share
(01:58):
your knowledge with ouraudience.
Tell us a little bit aboutyourself and your background.
Speaker 1 (02:08):
Yeah, thank you for having me.
I'm excited to join you and theteam in sharing ideas of what
we can do to create newpossibilities for the aging
population.
I've been working in healthcarereally since the early 2000s,
primarily on the technology side, but it was about 2010 or so
where I was director of productmanagement for this healthcare
analytics company and I'dalready started and sold a
(02:29):
healthcare technology companyfocused on wellness for the
employee population.
And I just said to myself I'mjust not smart enough.
I'm just sort of tired of beinga hack at this.
I want to be as thoughtful as Ican and create solutions that
lead to, you know, help peoplelive their best life.
And so I decided to get my goto get my master's and I was
(02:49):
lucky enough to get accepted toan institute under Dartmouth
Medical School and called theDartmouth Institute for Health
Policy and Clinical Practice.
And so I went there and I gotmy master's, but then I was
asked to do to work for theinstitute while I was getting my
master's, part time, and itjust changed my life, and so the
enthusiasm that the researchersand the staff all had around
(03:12):
their commitment to identifyingnew ways to create a better
health care system.
It just sunk into me me and I'dnever really been part of a
team that was so committed andso passionate to just fighting
for a new way of working and youknow, especially the healthcare
and in the healthcare space.
(03:32):
And so from them I just tookthat on and it was in.
It just was embodied in me eversince.
And so now I'm doing everythingI can to find new ways to
create care solutions that helppeople lead to their best life.
And so while I was at Dartmouthand working, I was leading
several national collaborativeson how do we make the health
(03:55):
care system better by creating ahigh value care system, not
just a fee for service.
Do more, you know.
Do more tests, go to thehospital more.
Do more you know, do more tests, go to the hospital more,
really try to help people livetheir best life and do whatever
we can to help organizationssucceed under that new way of
working and clinicians succeedunder that new way of working.
And so I was doing that.
(04:16):
And then I from that spun out acompany from Dartmouth that was
a change leadership solution fororganizations, trying to move
from fee-for-service tovalue-based payment models and
work with seven or soorganizations where they use my
product to create a strategicplan, as we used to say, a GPS
(04:38):
to success under value-basedcare.
So it was really ingrained inwith executive leaders, boards,
clinician leaders, patientadvocates.
How do we make this work?
And clearly, for those of youwho and John, maybe you know as
well there's been some ups anddowns on our country's ability
(04:59):
to succeed under this concept ofvalue-based care, and so
hopefully we'll continue to keepworking at it and create care
systems that can care for people, not just disease, and not just
reactively care for people, butproactively create a care
system that helps people livetheir best life before they get
sick and help them thrive aswhether they're aging or not.
(05:21):
But of course, our conversationtoday is about aging.
So what?
Speaker 3 (05:25):
is value-based care.
So to our audience, who is usedto the current system, what do
you mean by values-based care?
Speaker 1 (05:32):
It's outcomes over cost.
So today, when we say afee-for-service model, that
means that a provider that couldbe a hospital, it could be a
primary care physician, it couldbe a specialty provider like a
cardiologist, they simply, undera fee-for-service model, get
paid for anything they do.
So I do something to a person,I'm paid a certain amount for
(05:55):
the work that I do Undervalue-based care.
The idea is that you want toincentivize healthcare providers
again healthcare providersagain physicians or hospitals to
produce value.
That matters.
So when we say outcomes overcost, it means are we delivering
care that with high quality?
High quality could be?
(06:16):
Are we doing proactivescreenings?
Things that we know from anevidence point of view are
helping us identify, proactive,identify medical issues among
our patient population, wherethen we can care for them and
prevent, say, a disease, whetherit be cancer or so on, or
dementia, and then so we havethese measures that we evaluate.
(06:36):
We evaluate quality, but it'snot just about quality.
We value this quality over costequation as the cost part two.
We want to do as good a job aswe can to also manage the cost
of care.
So right now, cost justcontinues to go up.
It's more than a fifth of oureconomy and what we're trying to
do is to say well, let's notjust deliver high quality care,
(06:58):
let's also do our best to managecost.
So, if you can, what avalue-based care is?
It's a payment model structureto where, whether it be Medicare
, private payers like United orAetna are also setting up these
agreements.
They sign agreements withproviders and say here is your
attributed population, here'sthe benchmarks that we're
(07:21):
setting.
And if you achieve thosebenchmarks and there's a lot of
variations on this, so I'mspeaking very generically.
There's a lot of differentmodels out there, but just
generically if you can beatthose benchmarks, meaning hit
these quality measures, savemoney you'll receive a portion
of those savings and perhaps abonus for delivering high value
(07:43):
care.
For those of you who do knowwhat I'm talking about, you know
well that there are a lot ofvariations on that.
I'm not getting into somedetails, but that's generally,
john, how it works.
We're trying to incentivizecare providers to deliver
high-quality care at a cost thatwell, I won't say we can't
afford.
But that is also minimizing thecost of care moving forward.
Speaker 3 (08:04):
Does that help?
That does very much so, and Iappreciate that description of
variation of the model andhopefully we have a healthcare
system and a pharmaceuticalsystem that will buy into that
and I appreciate you being aleader in that movement.
(08:24):
And I appreciate you being aleader in that movement.
And so tell us some of the youknow number one, what you've
done in terms of leading thiseffort, not only here in the
United States butinternationally.
Speaker 1 (08:39):
Yeah, thanks for that was a bit of frustration where
the payment models were oftenleading in us trying to design
what's the specifics of thispayment model and what's the
benchmark and who's theattributed population.
All these things, all thosematter and are important for
designing the way that care isstructured in the future.
But for me, it became reallyimportant personally to focus on
(09:02):
.
Well, let's not forget how dowe make sure that the person is
at the center of all the care.
You know the vision that we'retalking about in high value care
and I was lucky enough atDartmouth to get involved in
some international projects thatwas really looking to insert
the voice of the patient intothe center of care.
And so those projects where wewere saying look a patient's
(09:27):
voice, their preferences, theirgoals and making sure that
they're viewed as more than thedisease that you know, more than
diabetes, more than you know aperson with dementia and so on,
that they are, that theconversations they have with
their providers are reallycentered around them as a whole
(09:47):
person.
Being lucky enough to beinvolved in some of those
conversations, we're learningfrom people from around the
world, particularly some thoughtleaders from Sweden, and how
they were doing this.
We're trying to bring theirthought leadership back to the
US and I'm just taking thoseideas, their thought leadership,
back to the US and I'm justtaking those ideas.
(10:08):
And I said you know what I wantto focus less on the payment
models themselves and designingthem and helping lead success
around the organizational levelto success under payment models
and get down into thegranularity of creating care
conversations between a providerand a patient that will make
the provider feel connectedagain as a care practitioner, as
someone who is not just rushingthrough the practice of care
(10:31):
and the business of healthcarebut that can slow down a
conversation and say let's talkabout you, you the patient as a
whole person, and be ready toserve you around your whole
person needs, not just how'syour diabetes today and we're
going to give you some drugs andgo on and okay, great, and I'll
see you in six months orwhatever a year and really
trying to change the way thatair conversation and the care
(10:53):
system was centered not justaround disease and payments, but
the person that we're caringfor.
And so that led me to John.
I was lucky enough to be askedto lead a strategy project for a
health system in North Carolina, to engage a community in what
(11:14):
mattered to them.
And so I did that.
We had some amazing outcomes.
The community was reallystarting to lead the way in
their own health and as part ofthat, I took advantage of that
relationship with that healthsystem and said you know what?
You will also not?
Just maybe you're not engagingyour communities as much as you
can and release reallythoughtful conversations and
(11:34):
supporting them, not just, again, reactively, but proactively,
and helping them create acommunity of health, but you're
also not regularly engagingpatients in conversations that
matter to them, about whatmatters most to them.
And so I created, I took a staband I said you know what,
(11:54):
without even being asked, I'mgoing to, you know, take all
these lessons I learned aroundpatient-centered care and
building patient-centeredinstruments and questionnaire
surveys, that type of thing.
And I created this card,literally on an index card, john
, and called it the About MeCare Card.
And the idea was to createsomething super simple to where
(12:16):
there was going to be minimalbarrier for providers to adopt
it, minimal barriers forpatients to answer, you know,
instead of answering a bunch oflong-winded questions, just make
it super simple for providersand patients.
And it was this index card,john, that Simply asked and this
was in a primary care setting,a specialty care setting.
They even were doing thehospital.
They asked the patient in theprimary care setting example
(12:38):
I'll give you is what are yourgoals for the visit today?
So that's at the forefront.
And the patients would answerthis card either in the office
before the visit or, most of thetime, in the office right
before the visit.
And then we would say what havebeen your primary concerns over
the past 12 months and wewouldn't ask about, we'd ask if
(12:59):
they had concerns about thedisease or, to say, your health,
and we'd also ask things aroundsocial determinants of health,
which I'm sure you've probablyheard of, john, and that is
things like my dieting or accessto food or my safety or my
housing, my electricity goingout, things like that.
And we would ask patientswhat's your level of confidence
to address these issues?
(13:20):
Another question we ask is doyou think that any of these
concerns are going to lead yougoing to the hospital or ED the
next 30 days?
Again, asking their perspectiveon not just their worries about
health, not just related todisease, about their whole
person concerns, but also reallyasking them do these concerns?
Do you see any possibility ofdecline or again not being able
(13:44):
to help yourself find a pathwayon your own to address these
problems.
And the idea, john, was that wewanted the patient to inform the
care team what they think theirbroader, whole person concerns
are.
And there's a ton of researchthat shows this concept of
social determinants or thingsthat and some people don't like
(14:06):
to call them determinants, butindicators of life that we know,
like dieting, like exercise,like safety, like not having
electricity in your home areindicators of future health
decline.
And so we wanted the primarycare and other care providers in
the system to recognize thoseso that we could, as a broader
(14:28):
health system, use thatinformation to have people not
the primary care providers, buthave other care team members
reach out to them and talk tothem about those concerns or
work with the local countygovernment, you know, make sure
if we recognize that a personhad a housing issue, electricity
issue, we built relationshipswith the local human health and
(14:49):
services department too, wherethey would reach out to that
patient to help them addresstheir housing issues.
So by asking the patient thesequestions, they not only
established this deeperrelationship with the provider,
but the provider knew that well.
They didn't have to do anythingabout these other concerns.
We built the care systemoutside of the medical system
(15:09):
that could address theseconcerns of those patients and
help them deal with and manageas best they could the other
non-medical issues that wereimpacting their health and their
well-being, like housing, lackof access to food, etc.
And so we built this throughthis car to initiate this whole,
this revision, this change intoa care system not just a
(15:32):
medical system but a wholeperson care system that really
could, just by gatheringinformation in the primary care
setting, we could use that tofacilitate a new way of caring
for people and addressing theirwhole person needs.
Speaker 3 (15:46):
Wow, why hasn't this ever been done before?
Meaning that the individualproviders actually care for who
they're caring for?
Yeah, you know, it'sdisheartening that the providers
many of them and there arereally good ones out there also
don't put that at the forefrontof their minds of truly
(16:07):
understanding the feelings andthe fears and the concerns of
that individual patient and, bynot doing so, not being able to
uncover those things that thepatient may be hiding from them
able to uncover those thingsthat the patient may be hiding
from them.
Speaker 1 (16:21):
Yeah Well, and I think, john, to your point.
So this is something reallyimportant for the leaders on the
call.
So the work I did at Dartmouthand I mentioned this change
leadership model that I built,and so I was really from that
well-prepared to have theseconversations about talking to
clinicians about this idea ofthe About Me card, and so some
of the initial responses werepatients are never going to fill
(16:44):
it out.
I haven't run into a physicianout of the whatever hundred or
maybe more than a thousand thatI've talked to but who has said
they don't understand that thesenon-medical issues they all
understand that matter, but whatthey said is but I can't do
anything about them, so I'm notgoing to ask, and which is fully
understandable, right?
Because one of the thingsclinicians don't want to do is
(17:05):
they don't want to.
They have so little time tohave a conversation with a
patient.
Support, particularly whenyou're under fee for service.
It doesn't support paying forthese non-medical needs or
having long conversations aboutthat can go on for a while if
(17:28):
you're talking about housing orwhatever, and so they've avoided
it because this system didn'tsupport them, whether it be
payment and or they didn't havea team to support them.
And so what I did immediatelywith that and I think this is
the key lesson for us is whenyou're establishing an
innovation and have this visionfor change, where we have to
understand the system barrierstoo right.
(17:49):
Like you can always, often,often, always, convince one or
two or three or four or fivepeople, but if you want to see
systemic change, the systemitself, you need a system right,
and so early on, we identifiedsome providers who were saying
those things.
But we knew them, we had somerelationship with them already
and we're like let's give it ashot.
(18:10):
If you decide not to do it,fine, that's great.
Well, can you give it a shot?
One we saw patients were veryinterested in completing this
card and because it was simplethese were checkboxes we were
asking again a lot of times yousee these surveys and it'll go
on 20 words.
You're going to read this wholequestion.
We were keeping it super simpleDoes this concern you, yes or
(18:31):
no?
Like that's it right.
So it's really easy, and it waseasy for providers to review.
But then what we do is we saidto providers look, all we're
asking you to do is review thecard of the patient, you might
take 30 seconds.
Say you recognize it right, sayI see this, but here's what's
going to happen I'm here as yourmedical provider to address
(18:55):
your diabetes, and so on.
These other things are perhapsreasons.
You know one or two reasons, ora reason or part of the reason.
Maybe you have diabetes, youcan't exercise, you don't have
the right food right, you don'thave a refrigerator in your home
to maintain your risk, orwhatever.
But what we're going to do withthat is we have a care team
who's going to follow up withyou and talk to you about that,
(19:17):
and that is all they had to do.
John is just say okay, I'mgoing to refer you.
And it gave them this abilityto do what they want to do, that
is, address, you know, makesure the people they care for
are healthy, not just givingthem prescriptions and drugs and
so on.
And so it gave them thisability then to just do a
(19:38):
referral.
So this team that I'm talkingabout we called it the Center
for Health and Social Care andthe providers some providers end
up calling the care suite.
Some providers called them theteam, the care bears, because it
was this team that was givingthem and the patients a sense of
care around you know, sort ofthe busyness of their daily life
(20:01):
and the interaction busynessand interaction they have with
providers, and so that's whatled to the success.
You know, it wasn't just theinnovation of this card, it was
the fact that we implemented thecard.
Yes, and that was creative.
It was brief, it was short, itwas fun.
We even did like color-codedcards to you just to again to do
any sort of art and forwardthing.
(20:22):
We could and but we create thiscare system and, like I said,
these Care Bears, the Care Suite.
They knew that their job was tofacilitate partnerships with
those in the community.
To then they weren't going tobe able to solve all the
problems.
They needed partners.
So we also built theserelationships and partnerships
with, like I mentioned, likeHealth and Human Services or an
(20:43):
aging group or so on there aremany others to really address
these issues and be facilitatorsof people getting addressed in
their whole health needs.
That was the success of thatand it's what's really amazing.
You know, we started off withthree physicians you know one or
two of those three physicians.
They adopted it, they gave us abit of a test run and they gave
(21:06):
us enough then for us to go tofive.
You know another two physicians, another eight, and you know it
took a few years to get full 21clinics in the practice.
And it just shows sort of theone, the persistence that you
need.
And how do we do that?
John, I think a key thing forthe leaders to recognize is that
(21:27):
we also knew that change comesthrough stories.
Right, I would frequentlypresent to the board and
physician board as well asadministrative board of the
health system, and it wouldstart with patient stories, it
would start with physicianstories.
How is this making a differenceto the lives, not just hair,
(21:48):
but what people experience.
People who were, for example, apatient early on, who was a
single father of a daughter, whowas just not managing his
diabetes, kept showing up at thehospital.
I mean, I think it was 18 timeswithin the first few months
that we started to work with himand we just engaged them in
this human conversation.
What's going on and it was partof it was a matter of not lack
(22:10):
of motivation, it was a lack ofunderstanding of their care plan
, why they needed to do this,and we just built a relationship
and partnership and a littlebit of coaching and we didn't
see them in the hospital anymore.
And so those types of storiesare providers saying how much
they call them the care bearsright, like they see the value
in having this partnership andit took that and stories.
(22:33):
And then we also use data toshow the pre and post impact of
patients.
What type of utilization werethey?
You know what was theutilization before we engaged
these patients, what was itafter?
And there were a lot of nuances, for you know from an
epidemiological point of viewand how you need to look at
these, and sometimes there'sregression of the mean.
(22:54):
You know where patients arejust simply by talking to them.
For example, they might usehealthcare less, but generally
we use evidence-based methods.
We saw a tremendous value in areduction in utilization among
these patients the Care Bears,the Care Suite team, those
patients that they engage.
We saw reductions inutilization, we saw improved
(23:15):
quality of life and we use thosestories.
And now we have probably as ofthis month or so, we have more
than 100,000 of these cards thathave supported conversations
and we've even deployed a secondcard that is specific to the
age of population and is asked.
So now we have one card that'sasked of any patient.
(23:38):
This is in Epic, by the way,which is an EMR.
All this is deployed in Epic.
Now we have the original cardthat I just described, the
social determinants of health.
One is asked of anyone belowthe age of 55.
And anyone 55 and above is askedthis aging card, which has
social determinants but it'smore specific to aging, and that
(23:59):
came about by an internationalproject that I led to convert
that original care card intothis aging card and we work with
teams in Sweden and Spain andKorea and across the US and
assisted living and neurologistsin the hospitals and
neuropsychologists to developthis aging card.
That asked the aging populationmore specifically, things like
(24:23):
what matters most to you in yourlife, and we asked the answer.
Options were bullet optionslike maintaining my friendship,
maintaining my hobbies, thingsthat we know are often stop or
slow down as we age.
And we ask patients well, whatare the biggest concerns around
(24:44):
you?
Not being able to live thatbest life that you just
described?
And we talk about things likefinances and losing my finances,
losing my independence, notbeing able to do the things I
used to do, my anxiety, myhearing, my vision, and so it
was more specific to issues thatwe have as we age, and so
(25:06):
deploying that card was a snap,john, because we built all this
will over the prior years whenwe approached a primary care
group about adopting this agingcard and splitting the card
between the below 55 and above55, they're like no problem.
We did it in a basic, we put inan epic, perhaps it was two
months and you know in duration.
(25:27):
The effort was small but ittook minimal convincing and the
team is working it.
Now we have thousands of theseaging cards as well going in
parallel to the original card,because we developed this
culture of what patients tell usmatter and we want to make sure
that they feel heard around,where they are in their life and
what matters to them and how wecan help them live their best
(25:49):
life, really no matter wherethey are in their life's journey
.
Speaker 3 (25:53):
So tell us a little bit about how you integrated
this aging card into independentliving, assisted living and
memory care, and what theoutcomes of that were in your
study.
Speaker 1 (26:07):
Yeah, for example, on assisted living, we partnered
with a primary care clinicianfocused on the senior population
.
I met her because I did somestrategy work for a palliative
care and hospice organizationand she used to be the medical
director there.
So she's also well work for apalliative care and hospice
organization and she used to bethe medical director there.
So she's also well-trained andpalliative.
And when we did this projectshe was focused on caring for
(26:27):
the senior population assistedliving.
So how she did it is she had anurse that worked with her and
that would deploy the card tothe patients before she saw them
.
You know, do a brief interviewwith the residents in assisted
living, talk to them about thecard and ask them questions that
we have on the card againaround what is your best life,
(26:49):
what are the concerns that youhave about, you know, being able
to live your best life?
And then she would hand thatcard to the clinician prior to
the visit.
She would review the card andhave a conversation with the
patient again about theirmedical needs as well, but also
about the card.
And what was amazing about thisis this you know, I'm giving
you one example, but it'sthoughtful is that this
(27:10):
clinician is, you know, just asuper wonderful human and so
caring, and I can imagine heralways having these human
centered conversations.
But what she told is she goes.
I learned things that I didn'tknow about patients that I had
been talking, you know, that Ihad a relationship with for a
few years, you know, and whetherit be about you know some of
(27:31):
their hobbies or whether it betheir concerns about their
daughter or so on, and how itsort of led to this rejuvenation
of creating a human-centeredrelationship with their patients
.
We found this in.
We also worked with a few PACEprograms.
It was the same thing with theprimary care providers who were
engaging patients through PACEand really opening up and they
(27:56):
were already doing thesebooklets and things.
But how it just led to a pausein the typically medically
focused conversation into wow,oh, tell me more about your
daughter, what does that mean toyou?
Or tell me more about thishobby.
Or tell me you're afraid aboutlosing this hobby.
Let's talk about what we canmaybe do to make sure you don't,
(28:18):
etc.
Things like that that just openup the window for these
human-centered and personalizedconversations was really really
powerful.
The other thing that was reallypowerful about this work John
is.
We also tested it in a family.
We had a family that we engagedwhose father was towards the
(28:40):
end of not the end of life, buthe had a dementia that was
progressing pretty rapidly, andthey used this to have a
conversation with him.
And what they did is theyactually left the card, because
we created this one as a trifoldas opposed to an index card.
They left the card on the tableso that it served as a reminder
(29:04):
of things that mattered to himand they actually would engage
him in those conversationsaround the card every so often
and would update it.
So it wasn't just a staticartifact for them, it was a way
to make sure that they werealways centered and reminded to
document and ask some of thesequestions on a somewhat regular
(29:25):
basis and every family would bedifferent about how frequent
that is, but again, to make surethat there was this artifact of
what they talked about, whatmattered.
If anyone else, say, anothercare provider came into the
house for a visit that they alsohad, they could review this too
to see the history of theconversation.
It wasn't just a verbalconversation of did the
(29:52):
transition between pastconversations and communicating
with these past conversations,other care providers could read
and see what mattered to thisgentleman.
And so the power of that.
We've been really lucky thisgentleman, and so the power of
that.
We've been really lucky again.
We have this adopted so quicklywithin primary care in North
Carolina.
This health system just to putin Epic now it's being used
every day and just to see thepower of that is very meaningful
(30:12):
.
Speaker 3 (30:14):
Well, greg, I wish our family would have had that.
My father passed fromcomplications, from dementia, or
he had dementia but he passedfrom other means, but he tended
to not be as open about what hisneeds were, what his fears were
, and to have that card wouldhave been really powerful for
(30:34):
all of us to know what he reallycared about, and so I commend
you for putting that together.
And you said over 100,000 ofthese cards have been filled out
.
What are the top three checkmarks that you get on these
cards that?
I'm sure you're gathering allthis data?
(30:54):
You know all this data.
What's coming out of thesecards that tell you about those
100,000 patients?
Speaker 1 (31:02):
That's a great question and I haven't looked at
the data recently but it'spretty dispersed.
On the aging card itself youknow that's a little bit newer
right we have a few thousand ofthose.
The combination of the agingand the original is over 100,000
now of the Asian and theoriginals over 100,000 now.
(31:23):
So it's pretty dispersed aroundthe primary concerns because it
often depends on where theylive and the circumstances of
where they live.
But what's really interestingin the data, what we saw is that
we could tie.
For example, when someone saidthat they were I mentioned that
there was this question thereabout their level of confidence
(31:44):
to address their concerns andthat question was a question
that I learned about from acolleague at Dartmouth, the
primary care clinician atDartmouth and he's been using it
for thousands of patients,thousands of conversations as
well.
So this also reflects hisresearch.
But when we saw patients saythey were not very confident to
address really whatever issueand this relationship increased
(32:09):
if they reported more than oneissue but we would see that they
had a higher likelihood ofgoing to the ED or going to the
hospital.
You know this concept ofconfidence is a real.
It's an amazing indicator forsuch a simple question.
You know what is your level ofconfidence and your ability to
address your concerns.
(32:29):
We also asked this otherquestion that I mentioned, john.
That was a really importantindicator in that and we took
this.
Some of you who have someexperience with palliative care.
We adapted this from Mayo'spalliative question.
Mayo palliative team asked aquestion, the clinicians.
They asked themselves thisquestion would you be surprised
(32:49):
if this patient died within thenext 18 months?
We took that and said that's anamazing question, it's super
thoughtful.
But what if we asked thepatient version of that?
Right, because we don't do thatenough and we ask the patient
would you be surprised if youwent to the ED or the hospital
in the next 30 days, addresstheir concerns and sort of feel
(33:22):
into where they are in theirwhether it be their disease
trajectory or the issues thatare bothering them relating to
their housing, their safety, etcetera.
And so, really, beyond, what wefound was it's less about what
the check marks are.
It's about their relationshipbetween those questions and
whether or not you know they'retelling us.
You know it's this riskindicator, right, this predictor
(33:43):
of where this patient is goingto be, and we actually use those
.
And we also asked them thisother question they had
mentioned, john, about, are anyof your needs urgent?
And we broke that out.
We see.
If they would say yes, we wouldsay is it a social need, is it
a medical need?
We see.
If they would say yes, we wouldsay is it a social need, is it
a medical need?
That question, the confidencequestion and the surprise
question I talked about, thoseare the ones that actually drove
(34:14):
the Care Bears, the Care Suite,who they talked to first, and
so what we did with thatinformation is the Care Bears.
Every morning we had a teamhuddle and we would look at the
patient that said do I have anurgent need?
Yes, okay, well, those are theones.
The first we looked at theirlevel of confidence.
Okay, not very confident.
We've seen the data.
Those patients are going tolikely decline.
We're going to talk to themnext and then we would use, you
know, their concerns that theyreported, john, whether it be
(34:37):
diet, whether it be safety.
We would use the urgent and theconfidence and the surprises as
our ranking.
But then we would have aconversation with that patient
specific to their card, right,okay, you said you have this
urgent need.
You said you're not veryconfident and you've listed
these things as your primaryconcern.
Let's talk about that.
What is the number one thing?
If you listed three things?
(34:57):
Well, we need to make sure weaddress the highest priority for
you and what you think thebiggest concern is, or where you
lack the most confidence, andwe're going to address that
first and over time, we'll doour best to address the next.
But we use that data to everyday in a team huddle to
prioritize the patients that weare going to talk to through
(35:18):
those other questions the urgent, the confidence and the
surprise question and then wereference the other concerns to
help us facilitate a real, youknow, human whole person care
conversation.
Speaker 3 (35:31):
Are you doing this by phone caregivers or are you
doing it face-to-face?
Are you doing it viatelemedicine?
Speaker 1 (35:38):
It depends.
So a lot of times the patients,the follow-up with them, will
be by phone, or if we hadactually an office in one of the
hospitals in this town.
They have a poor hospitalsystem and if we could schedule
some of the patient grades,maybe they had to go see them
(35:59):
when they were coming in for thenext visit, which obviously
could be delayed.
So that's not ideal.
Sometimes we might actuallyhave to just text a patient.
Whatever we needed to do, wewould do our best to engage with
that person, establish a trustrelationship, and a lot of times
it was by phone, just becausethat was a primary means and the
(36:19):
only tool that we had out ofthe gate.
Speaker 3 (36:22):
So here's the last question for you, greg, okay,
and that is, as you know, mostof our listeners are interested
in the senior housing spaceCalled me up and we had
pre-conversation about what yourinterest was in that space.
So tell our audience how yourcare card or age card could
(36:43):
benefit these senior housingoperators within their own EMRs,
because each one of them has anEMR within their system.
How do you see that benefitingthe residents not patients,
residents and their caretakersand operators?
Speaker 1 (37:01):
Yeah, that's a wonderful question and I'm sure
some people are doing someversion or something around this
.
I think for me, when I envisionthis one is if you anchor and
I'll say all conversations andmaybe it's not literally all,
but we'll just focus on doing,you know, striving for the best
(37:22):
is all conversations on what arethe self-reported goals,
preferences and values of everyindividual, and then around that
are perhaps the medical needsand addressing the medical needs
through that land, and so youmight, as a resident, come for
any resident that's existing,but let's just say there's a new
resident.
We'll follow that use case.
(37:43):
We start the conversation withbeing really clear on what is
the about me card or about meresponse, is that this
individual giving them thechance to self-report and to
answer that card and to makesure that they're seen, they're
heard, make sure that they'reseen, they're heard.
That card itself, if it's aphysical artifact, could be
(38:04):
posted on the wall, so everyperson that interacts with that
individual sees what they'rewe've used this phrase sometimes
the value compass Again, whatare their goals, what are their
concerns, what are theirconversations?
Like to have Having that as avisible artifact for all the
care team members to see as theyinteract with that individual
and to your point about the EMR,every so often, whether it be
(38:27):
again if they're a new patient,and then on some interval three
months, six months that beingasked and updated in the EHR.
So there is an understanding ofthe potential relationship
between, for that resident,their medical condition and
where they are from apreferences and goals point of
view, and be able to track thenover time.
(38:47):
How are we?
Is the care plan that we'reimplementing?
Does it support what they'veexpressed as a concern and are
we able to address thoseconcerns and their medical
concerns over time by building arelationship with them,
providing the support they needto address those concerns and
their medical concerns over time?
By building a relationship withthem, providing the support
they need to address theirconcern about whatever their
concern around decline is orwhatever their concern is of not
(39:09):
being able to live their bestlife is.
Are we addressing that and wecan track that in the EMR?
That would allow some reportinganalytics to say, yes, we're
providing the best care, thebest lived experience, the best
quality of life to thisindividual, not just from the
care team's perspective but fromthe self-reported resident
perspective, and we can measurethat over time using the EMR.
Speaker 3 (39:33):
Yeah, that would be fantastic.
I have not seen it within thesenior housing environment yet,
but I know it's coming withinthe senior housing environment
yet, but I know it's coming.
I know that patient-centeredcare or resident-centered care
is extremely important, but whatwe do have is we have a higher
turnover of caregivers withinthe senior housing space and so
(39:55):
you know when you have thatturnover, then having that new
caretaker come in either in thehome setting or in the community
setting, that new caretakerwould then see that card or
those answers to those questions.
It would be brought up to datereally quickly on what Betty
(40:16):
loves about life, what herconcerns are and such Betty
loves about life, what herconcerns are and such.
Now, the way I see it is if it'sdone within the community
setting, at the skilled nursingor assisted living or memory
care, and that information isthen passed on to the providers,
to that resident, that's evenmore powerful, right?
Because now everyone's talkingamongst each other in regards to
(40:40):
Betty and what Betty needs andwhat Betty's fears are, what
Betty's, this and that are.
So kudos to you, greg.
Thank you so much for allyou've done so far and what
you're doing as it relates toaging and really digging deep
into the needs and concerns ofthe individual patient and
(41:03):
resident, because they're both.
They could be both a patientand a resident.
So thank you so much.
Speaker 1 (41:10):
Well, john, I will say one thing Thank you for that
, John, it's really nice.
I, like you, really share acommitment to this work.
And to your last point.
What's interesting is thisabout me model that I talked
about, you know, won an awardfrom the North Carolina Hospital
Association, and the reason isbecause we're able to use data
to show the impact.
(41:30):
So I think to your point around.
The MR part is you know whetheryou're using it for business
development or whether youdecide, you know, at some point
to become part of a value-basedpayment model or whatever.
You just want to make sure thepatient can see the value that
they're getting on an individuallevel.
It really does allow you, if youcapture that data over time and
(41:54):
tie it and be able to show thequality of life and, based off
the patient report not thefacility owners, the
administrators, not the careproviders, but the patient
report it can really lead to,again, a viable, sustainable and
growing business, because youcan prove that.
One thing I would mention aswell is that in this population
(42:16):
we know how important it is forindividuals, for example, who
have cognitive dementia, to alsoask questions of the family or
loved ones right to have theirperspective and that's another
way that we can think about thistoo is not just asking the
resident, but making sure thatthe resident might have some
input into the self-report ofhow this patient is doing, what
(42:39):
their concerns are, what theysee in the patient as well, and
so just never forget that ourresidents have family members
that can also give key insightsthat we might want to think
about as we craft a whole personcare partnership with each
individual, each resident.
Speaker 3 (42:55):
Well, thank you very much, Frig.
And how do individuals get intouch with you?
How can they get that amazingpresentation you sent?
If that's okay with you, I'mgoing to attach it to this
podcast, and that is thepresentation on the About Me
Care Card morphstudioio.
Speaker 1 (43:23):
So m-o-r-p-h-studioio , just greg at morphstudioio and
you're welcome to share that.
Anybody can reach out and justask questions and get insights
and be happy to help do whatever.
Speaker 3 (43:29):
I can Well appreciate your time, Greg.
Thank you very much for beingpart of my life and letting us
know about you and your efforts,and the outcomes that are being
created by you, which you'veinvented.
Thank you so much.
Popular Podcasts
Bookmarked by Reese's Book Club
Welcome to Bookmarked by Reese’s Book Club — the podcast where great stories, bold women, and irresistible conversations collide! Hosted by award-winning journalist Danielle Robay, each week new episodes balance thoughtful literary insight with the fervor of buzzy book trends, pop culture and more. Bookmarked brings together celebrities, tastemakers, influencers and authors from Reese's Book Club and beyond to share stories that transcend the page. Pull up a chair. You’re not just listening — you’re part of the conversation.
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com