Senior Housing Investors
Patient Voices Leading the Way in Healthcare
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.
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.
We also knew that change comes through stories. Right, you know, I would frequently present to the board and physician board as well as administrative board of the health system, and it would start with patient stories. It would start with physician stories. How is this making a difference to the lives? Not just care, but you know what people experience. People who were, for example, a patient early on, who was, you know, a single father of a daughter who was just not managing his diabetes, kept showing up at the hospital. I mean, I think it was 18 times within the first few months that we started work with them and we just engaged them in this human conversation. What's going on? Part of it was a matter of not lack of motivation, it was a lack of understanding of their care plan, why they needed to do this, and we just built a relationship and partnership and a little bit of coaching and we didn't see them in the hospital anymore.
Speaker 2:Welcome to the Senior Housing Investors Podcast. If you are an owner operator, investor, developer or buyer of senior housing, you've come to the right place. The best way to stay connected with us is to sign up for our weekly newsletter at havenseniorinvestmentscom. This podcast doesn't exist without you, our community. Thank you for listening and reach out to us anytime.
Speaker 1:Welcome back everyone.
Speaker 3:Today, john Haber is having an insightful conversation with Greg Kotzbauer, co-founder of the About Me Institute. Join them as they discuss human-centered care for the aging population. John Greg, it's great to have you on our show. Thank you so much for being willing to participate and share your knowledge with our audience. Tell us a little bit about yourself and your background.
Speaker 1:Yeah, thank you for having me. I'm excited to join you and the team in sharing ideas of what we can do to create new possibilities for the aging population. I've been working in healthcare really since the early 2000s, primarily on the technology side, but it was about 2010 or so where I was director of product management for this healthcare analytics company and I'd already started and sold a healthcare technology company focused on wellness for the employee population. And I just said to myself I'm just not smart enough. I'm just sort of tired of being a hack at this. I want to be as thoughtful as I can and create solutions that lead to, you know, help people live their best life. And so I decided to get my go to get my master's and I was lucky enough to get accepted to an institute under Dartmouth Medical School and called the Dartmouth Institute for Health Policy and Clinical Practice. And so I went there and I got my master's, but then I was asked to do to work for the institute while I was getting my master's, part time, and it just changed my life, and so the enthusiasm that the researchers and the staff all had around their commitment to identifying new ways to create a better health care system. It just sunk into me me and I'd never really been part of a team that was so committed and so passionate to just fighting for a new way of working and you know, especially the healthcare and in the healthcare space. And so from them I just took that on and it was in. It just was embodied in me ever since. And so now I'm doing everything I can to find new ways to create care solutions that help people lead to their best life.
Speaker 1:And so while I was at Dartmouth and working, I was leading several national collaboratives on how do we make the health care system better by creating a high value care system, not just a fee for service. Do more, you know. Do more tests, go to the hospital more. Do more you know, do more tests, go to the hospital more, really try to help people live their best life and do whatever we can to help organizations succeed under that new way of working and clinicians succeed under that new way of working. And so I was doing that.
Speaker 1:And then I from that spun out a company from Dartmouth that was a change leadership solution for organizations, trying to move from fee-for-service to value-based payment models and work with seven or so organizations where they use my product to create a strategic plan, as we used to say, a GPS to success under value-based care. So it was really ingrained in with executive leaders, boards, clinician leaders, patient advocates. How do we make this work? And clearly, for those of you who and John, maybe you know as well there's been some ups and downs on our country's ability to succeed under this concept of value-based care, and so hopefully we'll continue to keep working at it and create care systems that can care for people, not just disease, and not just reactively care for people, but proactively create a care system that helps people live their best life before they get sick and help them thrive as whether they're aging or not. But of course, our conversation today is about aging. So what?
Speaker 3:is value-based care. So to our audience, who is used to the current system, what do you mean by values-based care?
Speaker 1:It's outcomes over cost. So today, when we say a fee-for-service model, that means that a provider that could be a hospital, it could be a primary care physician, it could be a specialty provider like a cardiologist, they simply, under a fee-for-service model, get paid for anything they do. So I do something to a person, I'm paid a certain amount for the work that I do Under value-based care. The idea is that you want to incentivize healthcare providers again healthcare providers again physicians or hospitals to produce value. That matters. So when we say outcomes over cost, it means are we delivering care that with high quality? High quality could be? Are we doing proactive screenings? Things that we know from an evidence point of view are helping us identify, proactive, identify medical issues among our patient population, where then we can care for them and prevent, say, a disease, whether it be cancer or so on, or dementia, and then so we have these measures that we evaluate. We evaluate quality, but it's not just about quality. We value this quality over cost equation as the cost part two. We want to do as good a job as we can to also manage the cost of care. So right now, cost just continues to go up. It's more than a fifth of our economy and what we're trying to do is to say well, let's not just deliver high quality care, let's also do our best to manage cost.
Speaker 1:So, if you can, what a value-based care is? It's a payment model structure to where, whether it be Medicare, private payers like United or Aetna are also setting up these agreements. They sign agreements with providers and say here is your attributed population, here's the benchmarks that we're setting. And if you achieve those benchmarks and there's a lot of variations on this, so I'm speaking very generically. There's a lot of different models out there, but just generically if you can beat those benchmarks, meaning hit these quality measures, save money you'll receive a portion of those savings and perhaps a bonus for delivering high value care. For those of you who do know what I'm talking about, you know well that there are a lot of variations on that. I'm not getting into some details, but that's generally, john, how it works. We're trying to incentivize care providers to deliver high-quality care at a cost that well, I won't say we can't afford. But that is also minimizing the cost of care moving forward.
Speaker 3:Does that help? That does very much so, and I appreciate that description of variation of the model and hopefully we have a healthcare system and a pharmaceutical system that will buy into that and I appreciate you being a leader in that movement. And I appreciate you being a leader in that movement. And so tell us some of the you know number one, what you've done in terms of leading this effort, not only here in the United States but internationally.
Speaker 1:Yeah, thanks for that was a bit of frustration where the payment models were often leading in us trying to design what's the specifics of this payment model and what's the benchmark and who's the attributed population. All these things, all those matter and are important for designing the way that care is structured in the future. But for me, it became really important personally to focus on. Well, let's not forget how do we make sure that the person is at the center of all the care. You know the vision that we're talking about in high value care and I was lucky enough at Dartmouth to get involved in some international projects that was really looking to insert the voice of the patient into the center of care. And so those projects where we were saying look a patient's voice, their preferences, their goals and making sure that they're viewed as more than the disease that you know, more than diabetes, more than you know a person with dementia and so on, that they are, that the conversations they have with their providers are really centered around them as a whole person. Being lucky enough to be involved in some of those conversations, we're learning from people from around the world, particularly some thought leaders from Sweden, and how they were doing this. We're trying to bring their thought leadership back to the US and I'm just taking those ideas, their thought leadership, back to the US and I'm just taking those ideas. And I said you know what I want to focus less on the payment models themselves and designing them and helping lead success around the organizational level to success under payment models and get down into the granularity of creating care conversations between a provider and a patient that will make the provider feel connected again as a care practitioner, as someone who is not just rushing through the practice of care and the business of healthcare but that can slow down a conversation and say let's talk about you, you the patient as a whole person, and be ready to serve you around your whole person needs, not just how's your diabetes today and we're going to give you some drugs and go on and okay, great, and I'll see you in six months or whatever a year and really trying to change the way that air conversation and the care system was centered not just around disease and payments, but the person that we're caring for. And so that led me to John.
Speaker 1:I was lucky enough to be asked to lead a strategy project for a health system in North Carolina, to engage a community in what mattered to them. And so I did that. We had some amazing outcomes. The community was really starting to lead the way in their own health and as part of that, I took advantage of that relationship with that health system and said you know what? You will also not? Just maybe you're not engaging your communities as much as you can and release really thoughtful conversations and supporting them, not just, again, reactively, but proactively, and helping them create a community of health, but you're also not regularly engaging patients in conversations that matter to them, about what matters most to them.
Speaker 1:And so I created, I took a stab and I said you know what, without even being asked, I'm going to, you know, take all these lessons I learned around patient-centered care and building patient-centered instruments and questionnaire surveys, that type of thing. And I created this card, literally on an index card, john, and called it the About Me Care Card. And the idea was to create something super simple to where there was going to be minimal barrier for providers to adopt it, minimal barriers for patients to answer, you know, instead of answering a bunch of long-winded questions, just make it super simple for providers and 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 the hospital. They asked the patient in the primary care setting example I'll give you is what are your goals for the visit today? So that's at the forefront. And the patients would answer this card either in the office before the visit or, most of the time, in the office right before the visit.
Speaker 1:And then we would say what have been your primary concerns over the past 12 months and we wouldn't ask about, we'd ask if they had concerns about the disease or, to say, your health, and we'd also ask things around social determinants of health, which I'm sure you've probably heard of, john, and that is things like my dieting or access to food or my safety or my housing, my electricity going out, things like that. And we would ask patients what's your level of confidence to address these issues? Another question we ask is do you think that any of these concerns are going to lead you going to the hospital or ED the next 30 days? Again, asking their perspective on not just their worries about health, not just related to disease, about their whole person concerns, but also really asking them do these concerns? Do you see any possibility of decline or again not being able to help yourself find a pathway on your own to address these problems.
Speaker 1:And the idea, john, was that we wanted the patient to inform the care team what they think their broader, whole person concerns are.
Speaker 1:And there's a ton of research that shows this concept of social determinants or things that and some people don't like to call them determinants, but indicators of life that we know, like dieting, like exercise, like safety, like not having electricity in your home are indicators of future health decline.
Speaker 1:And so we wanted the primary care and other care providers in the system to recognize those so that we could, as a broader health system, use that information to have people not the primary care providers, but have other care team members reach out to them and talk to them about those concerns or work with the local county government, you know, make sure if we recognize that a person had a housing issue, electricity issue, we built relationships with the local human health and services department too, where they would reach out to that patient to help them address their housing issues.
Speaker 1:So by asking the patient these questions, they not only established this deeper relationship with the provider, but the provider knew that well. They didn't have to do anything about these other concerns. We built the care system outside of the medical system that could address these concerns of those patients and help them deal with and manage as best they could the other non-medical issues that were impacting their health and their well-being, like housing, lack of access to food, etc. And so we built this through this car to initiate this whole, this revision, this change into a care system not just a medical system but a whole person care system that really could, just by gathering information in the primary care setting, we could use that to facilitate a new way of caring for people and addressing their whole person needs.
Speaker 3:Wow, why hasn't this ever been done before? Meaning that the individual providers actually care for who they're caring for? Yeah, you know, it's disheartening that the providers many of them and there are really good ones out there also don't put that at the forefront of their minds of truly understanding the feelings and the fears and the concerns of that individual patient and, by not doing so, not being able to uncover those things that the patient may be hiding from them able to uncover those things that the patient may be hiding from them.
Speaker 1:Yeah Well, and I think, john, to your point. So this is something really important for the leaders on the call. So the work I did at Dartmouth and I mentioned this change leadership model that I built, and so I was really from that well-prepared to have these conversations about talking to clinicians about this idea of the About Me card, and so some of the initial responses were patients are never going to fill it out. I haven't run into a physician out of the whatever hundred or maybe more than a thousand that I've talked to but who has said they don't understand that these non-medical issues they all understand that matter, but what they said is but I can't do anything about them, so I'm not going to ask, and which is fully understandable, right? Because one of the things clinicians don't want to do is they don't want to. They have so little time to have a conversation with a patient. Support, particularly when you're under fee for service. It doesn't support paying for these non-medical needs or having long conversations about that can go on for a while if you're talking about housing or whatever, and so they've avoided it because this system didn't support them, whether it be payment and or they didn't have a team to support them.
Speaker 1:And so what I did immediately with that and I think this is the key lesson for us is when you're establishing an innovation and have this vision for change, where we have to understand the system barriers too right. Like you can always, often, often, always, convince one or two or three or four or five people, but if you want to see systemic change, the system itself, you need a system right, and so early on, we identified some providers who were saying those things. But we knew them, we had some relationship with them already and we're like let's give it a shot. If you decide not to do it, fine, that's great. Well, can you give it a shot? One we saw patients were very interested in completing this card and because it was simple these were checkboxes we were asking again a lot of times you see these surveys and it'll go on 20 words. You're going to read this whole question. We were keeping it super simple Does this concern you, yes or no? Like that's it right. So it's really easy, and it was easy for providers to review. But then what we do is we said to providers look, all we're asking you to do is review the card of the patient, you might take 30 seconds. Say you recognize it right, say I see this, but here's what's going to happen I'm here as your medical provider to address your diabetes, and so on.
Speaker 1:These other things are perhaps reasons. You know one or two reasons, or a reason or part of the reason. Maybe you have diabetes, you can't exercise, you don't have the right food right, you don't have a refrigerator in your home to maintain your risk, or whatever. But what we're going to do with that is we have a care team who's going to follow up with you and talk to you about that, and that is all they had to do. John is just say okay, I'm going to refer you. And it gave them this ability to do what they want to do, that is, address, you know, make sure the people they care for are healthy, not just giving them prescriptions and drugs and so on. And so it gave them this ability then to just do a referral.
Speaker 1:So this team that I'm talking about we called it the Center for Health and Social Care and the providers some providers end up calling the care suite. Some providers called them the team, the care bears, because it was this team that was giving them and the patients a sense of care around you know, sort of the busyness of their daily life and the interaction busyness and interaction they have with providers, and so that's what led to the success. You know, it wasn't just the innovation of this card, it was the fact that we implemented the card. Yes, and that was creative. It was brief, it was short, it was fun. We even did like color-coded cards to you just to again to do any sort of art and forward thing.
Speaker 1:We could and but we create this care system and, like I said, these Care Bears, the Care Suite. They knew that their job was to facilitate partnerships with those in the community. To then they weren't going to be able to solve all the problems. They needed partners. So we also built these relationships and partnerships with, like I mentioned, like Health and Human Services or an aging group or so on there are many others to really address these issues and be facilitators of people getting addressed in their whole health needs. That was the success of that and it's what's really amazing. You know, we started off with three physicians you know one or two of those three physicians. They adopted it, they gave us a bit of a test run and they gave us enough then for us to go to five. You know another two physicians, another eight, and you know it took a few years to get full 21 clinics in the practice. And it just shows sort of the one, the persistence that you need. And how do we do that?
Speaker 1:John, I think a key thing for the leaders to recognize is that we also knew that change comes through stories. Right, I would frequently present to the board and physician board as well as administrative board of the health system, and it would start with patient stories, it would start with physician stories. How is this making a difference to the lives, not just hair, but what people experience. People who were, for example, a patient early on, who was a single father of a daughter, who was just not managing his diabetes, kept showing up at the hospital. I mean, I think it was 18 times within the first few months that we started to work with him and we just engaged them in this human conversation. What's going on and it was part of it was a matter of not lack of motivation, it was a lack of understanding of their care plan, why they needed to do this, and we just built a relationship and partnership and a little bit of coaching and we didn't see them in the hospital anymore. And so those types of stories are providers saying how much they call them the care bears right, like they see the value in having this partnership and it took that and stories.
Speaker 1:And then we also use data to show the pre and post impact of patients. What type of utilization were they? You know what was the utilization before we engaged these patients, what was it after? And there were a lot of nuances, for you know from an epidemiological point of view and how you need to look at these, and sometimes there's regression of the mean. You know where patients are just simply by talking to them. For example, they might use healthcare less, but generally we use evidence-based methods. We saw a tremendous value in a reduction in utilization among these patients the Care Bears, the Care Suite team, those patients that they engage. We saw reductions in utilization, we saw improved quality of life and we use those stories.
Speaker 1:And now we have probably as of this month or so, we have more than 100,000 of these cards that have supported conversations and we've even deployed a second card that is specific to the age of population and is asked. So now we have one card that's asked of any patient. This is in Epic, by the way, which is an EMR. All this is deployed in Epic. Now we have the original card that I just described, the social determinants of health. One is asked of anyone below the age of 55.
Speaker 1:And anyone 55 and above is asked this aging card, which has social determinants but it's more specific to aging, and that came about by an international project that I led to convert that original care card into this aging card and we work with teams in Sweden and Spain and Korea and across the US and assisted living and neurologists in the hospitals and neuropsychologists to develop this aging card. That asked the aging population more specifically, things like what matters most to you in your life, and we asked the answer. Options were bullet options like maintaining my friendship, maintaining my hobbies, things that we know are often stop or slow down as we age. And we ask patients well, what are the biggest concerns around you? Not being able to live that best life that you just described?
Speaker 1:And we talk about things like finances and losing my finances, losing my independence, not being able to do the things I used to do, my anxiety, my hearing, my vision, and so it was more specific to issues that we have as we age, and so deploying that card was a snap, john, because we built all this will over the prior years when we approached a primary care group about adopting this aging card and splitting the card between the below 55 and above 55, they're like no problem. We did it in a basic, we put in an epic, perhaps it was two months and you know in duration. The effort was small but it took minimal convincing and the team is working it. Now we have thousands of these aging cards as well going in parallel to the original card, because we developed this culture of what patients tell us matter and we want to make sure that they feel heard around, where they are in their life and what matters to them and how we can help them live their best life, really no matter where they are in their life's journey.
Speaker 3:So tell us a little bit about how you integrated this aging card into independent living, assisted living and memory care, and what the outcomes of that were in your study.
Speaker 1:Yeah, for example, on assisted living, we partnered with a primary care clinician focused on the senior population. I met her because I did some strategy work for a palliative care and hospice organization and she used to be the medical director there. So she's also well work for a palliative care and hospice organization and she used to be the medical director there. So she's also well-trained and palliative. And when we did this project she was focused on caring for the senior population assisted living. So how she did it is she had a nurse that worked with her and that would deploy the card to the patients before she saw them. You know, do a brief interview with the residents in assisted living, talk to them about the card and ask them questions that we have on the card again around what is your best life, what are the concerns that you have about, you know, being able to live your best life? And then she would hand that card to the clinician prior to the visit. She would review the card and have a conversation with the patient again about their medical needs as well, but also about the card. And what was amazing about this is this you know, I'm giving you one example, but it's thoughtful is that this clinician is, you know, just a super wonderful human and so caring, and I can imagine her always having these human centered conversations. But what she told is she goes. I learned things that I didn't know about patients that I had been talking, you know, that I had a relationship with for a few years, you know, and whether it be about you know some of their hobbies or whether it be their concerns about their daughter or so on, and how it sort of led to this rejuvenation of creating a human-centered relationship with their patients. We found this in. We also worked with a few PACE programs. It was the same thing with the primary care providers who were engaging patients through PACE and really opening up and they were already doing these booklets and things. But how it just led to a pause in the typically medically focused conversation into wow, oh, tell me more about your daughter, what does that mean to you? Or tell me more about this hobby. Or tell me you're afraid about losing this hobby. Let's talk about what we can maybe do to make sure you don't, etc. Things like that that just open up the window for these human-centered and personalized conversations was really really powerful. The other thing that was really powerful about this work John is.
Speaker 1:We also tested it in a family. We had a family that we engaged whose father was towards the end of not the end of life, but he had a dementia that was progressing pretty rapidly, and they used this to have a conversation with him. And what they did is they actually left the card, because we created this one as a trifold as opposed to an index card. They left the card on the table so that it served as a reminder of things that mattered to him and they actually would engage him in those conversations around the card every so often and would update it. So it wasn't just a static artifact for them, it was a way to make sure that they were always centered and reminded to document and ask some of these questions on a somewhat regular basis and every family would be different about how frequent that is, but again, to make sure that there was this artifact of what they talked about, what mattered.
Speaker 1:If anyone else, say, another care provider came into the house for a visit that they also had, they could review this too to see the history of the conversation. It wasn't just a verbal conversation of did the transition between past conversations and communicating with these past conversations, other care providers could read and see what mattered to this gentleman. And so the power of that. We've been really lucky this gentleman, and so the power of that. We've been really lucky again. We have this adopted so quickly within primary care in North Carolina. This health system just to put in Epic now it's being used every day and just to see the power of that is very meaningful.
Speaker 3:Well, greg, I wish our family would have had that. My father passed from complications, from dementia, or he had dementia but he passed from other means, but he tended to not be as open about what his needs were, what his fears were, and to have that card would have been really powerful for all of us to know what he really cared about, and so I commend you for putting that together. And you said over 100,000 of these cards have been filled out. What are the top three check marks that you get on these cards that? I'm sure you're gathering all this data? You know all this data. What's coming out of these cards that tell you about those 100,000 patients?
Speaker 1:That's a great question and I haven't looked at the data recently but it's pretty dispersed. On the aging card itself you know that's a little bit newer right we have a few thousand of those. The combination of the aging and the original is over 100,000 now of the Asian and the originals over 100,000 now. So it's pretty dispersed around the primary concerns because it often depends on where they live and the circumstances of where they live. But what's really interesting in the data, what we saw is that we could tie. For example, when someone said that they were I mentioned that there was this question there about their level of confidence to address their concerns and that question was a question that I learned about from a colleague at Dartmouth, the primary care clinician at Dartmouth and he's been using it for thousands of patients, thousands of conversations as well. So this also reflects his research. But when we saw patients say they were not very confident to address really whatever issue and this relationship increased if they reported more than one issue but we would see that they had a higher likelihood of going to the ED or going to the hospital. You know this concept of confidence is a real. It's an amazing indicator for such a simple question. You know what is your level of confidence and your ability to address your concerns.
Speaker 1:We also asked this other question that I mentioned, john. That was a really important indicator in that and we took this. Some of you who have some experience with palliative care. We adapted this from Mayo's palliative question. Mayo palliative team asked a question, the clinicians. They asked themselves this question would you be surprised if this patient died within the next 18 months? We took that and said that's an amazing question, it's super thoughtful. But what if we asked the patient version of that? Right, because we don't do that enough and we ask the patient would you be surprised if you went to the ED or the hospital in the next 30 days, address their concerns and sort of feel into where they are in their whether it be their disease trajectory or the issues that are bothering them relating to their housing, their safety, et cetera. And so, really, beyond, what we found was it's less about what the check marks are. It's about their relationship between those questions and whether or not you know they're telling us. You know it's this risk indicator, right, this predictor of where this patient is going to be, and we actually use those.
Speaker 1:And we also asked them this other question they had mentioned, john, about, are any of your needs urgent? And we broke that out. We see. If they would say yes, we would say is it a social need, is it a medical need? We see. If they would say yes, we would say is it a social need, is it a medical need? That question, the confidence question and the surprise question I talked about, those are the ones that actually drove the Care Bears, the Care Suite, who they talked to first, and so what we did with that information is the Care Bears. Every morning we had a team huddle and we would look at the patient that said do I have an urgent need? Yes, okay, well, those are the ones.
Speaker 1:The first we looked at their level of confidence. Okay, not very confident. We've seen the data. Those patients are going to likely decline. We're going to talk to them next and then we would use, you know, their concerns that they reported, john, whether it be diet, whether it be safety.
Speaker 1:We would use the urgent and the confidence and the surprises as our ranking. But then we would have a conversation with that patient specific to their card, right, okay, you said you have this urgent need. You said you're not very confident and you've listed these things as your primary concern. Let's talk about that. What is the number one thing? If you listed three things? Well, we need to make sure we address the highest priority for you and what you think the biggest concern is, or where you lack the most confidence, and we're going to address that first and over time, we'll do our best to address the next. But we use that data to every day in a team huddle to prioritize the patients that we are going to talk to through those other questions the urgent, the confidence and the surprise question and then we reference the other concerns to help us facilitate a real, you know, human whole person care conversation.
Speaker 3:Are you doing this by phone caregivers or are you doing it face-to-face? Are you doing it via telemedicine?
Speaker 1:It depends. So a lot of times the patients, the follow-up with them, will be by phone, or if we had actually an office in one of the hospitals in this town. They have a poor hospital system and if we could schedule some of the patient grades, maybe they had to go see them when they were coming in for the next visit, which obviously could be delayed. So that's not ideal. Sometimes we might actually have to just text a patient. Whatever we needed to do, we would do our best to engage with that person, establish a trust relationship, and a lot of times it was by phone, just because that was a primary means and the only tool that we had out of the gate.
Speaker 3:So here's the last question for you, greg, okay, and that is, as you know, most of our listeners are interested in the senior housing space Called me up and we had pre-conversation about what your interest was in that space. So tell our audience how your care card or age card could benefit these senior housing operators within their own EMRs, because each one of them has an EMR within their system. How do you see that benefiting the residents not patients, residents and their caretakers and operators?
Speaker 1:Yeah, that's a wonderful question and I'm sure some people are doing some version or something around this. I think for me, when I envision this one is if you anchor and I'll say all conversations and maybe it's not literally all, but we'll just focus on doing, you know, striving for the best is all conversations on what are the self-reported goals, preferences and values of every individual, and then around that are perhaps the medical needs and addressing the medical needs through that land, and so you might, 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. We start the conversation with being really clear on what is the about me card or about me response, is that this individual giving them the chance to self-report and to answer that card and to make sure that they're seen, they're heard, make sure that they're seen, they're heard. That card itself, if it's a physical artifact, could be posted on the wall, so every person that interacts with that individual sees what they're we've used this phrase sometimes the value compass Again, what are their goals, what are their concerns, what are their conversations?
Speaker 1:Like to have Having that as a visible artifact for all the care team members to see as they interact with that individual and to your point about the EMR, every so often, whether it be again if they're a new patient, and then on some interval three months, six months that being asked and updated in the EHR.
Speaker 1:So there is an understanding of the potential relationship between, for that resident, their medical condition and where they are from a preferences and goals point of view, and be able to track then over time. How are we? Is the care plan that we're implementing? Does it support what they've expressed as a concern and are we able to address those concerns and their medical concerns over time by building a relationship with them, providing the support they need to address those concerns and their medical concerns over time? By building a relationship with them, providing the support they need to address their concern about whatever their concern around decline is or whatever their concern is of not being able to live their best life is. Are we addressing that and we can track that in the EMR? That would allow some reporting analytics to say, yes, we're providing the best care, the best lived experience, the best quality of life to this individual, not just from the care team's perspective but from the self-reported resident perspective, and we can measure that over time using the EMR.
Speaker 3:Yeah, that would be fantastic. I have not seen it within the senior housing environment yet, but I know it's coming within the senior housing environment yet, but I know it's coming. I know that patient-centered care or resident-centered care is extremely important, but what we do have is we have a higher turnover of caregivers within the senior housing space and so you know when you have that turnover, then having that new caretaker come in either in the home setting or in the community setting, that new caretaker would then see that card or those answers to those questions. It would be brought up to date really quickly on what Betty loves about life, what her concerns are and such Betty loves about life, what her concerns are and such.
Speaker 3:Now, the way I see it is if it's done within the community setting, at the skilled nursing or assisted living or memory care, and that information is then passed on to the providers, to that resident, that's even more powerful, right? Because now everyone's talking amongst each other in regards to Betty and what Betty needs and what Betty's fears are, what Betty's, this and that are. So kudos to you, greg. Thank you so much for all you've done so far and what you're doing as it relates to aging and really digging deep into the needs and concerns of the individual patient and resident, because they're both. They could be both a patient and a resident. So thank you so much.
Speaker 1:Well, john, I will say one thing Thank you for that, John, it's really nice. I, like you, really share a commitment to this work. And to your last point. What's interesting is this about me model that I talked about, you know, won an award from the North Carolina Hospital Association, and the reason is because we're able to use data to show the impact. So I think to your point around.
Speaker 1:The MR part is you know whether you're using it for business development or whether you decide, you know, at some point to become part of a value-based payment model or whatever.
Speaker 1:You just want to make sure the patient can see the value that they're getting on an individual level.
Speaker 1:It really does allow you, if you capture that data over time and tie it and be able to show the quality of life and, based off the patient report not the facility owners, the administrators, not the care providers, but the patient report it can really lead to, again, a viable, sustainable and growing business, because you can prove that. One thing I would mention as well is that in this population we know how important it is for individuals, for example, who have cognitive dementia, to also ask questions of the family or loved ones right to have their perspective and that's another way that we can think about this too is not just asking the resident, but making sure that the resident might have some input into the self-report of how this patient is doing, what their concerns are, what they see in the patient as well, and so just never forget that our residents have family members that can also give key insights that we might want to think about as we craft a whole person care partnership with each individual, each resident.
Speaker 3:Well, thank you very much, Frig. And how do individuals get in touch with you? How can they get that amazing presentation you sent? If that's okay with you, I'm going to attach it to this podcast, and that is the presentation on the About Me Care Card morphstudioio.
Speaker 1:So m-o-r-p-h-studioio, just greg at morphstudioio and you're welcome to share that. Anybody can reach out and just ask questions and get insights and be happy to help do whatever.
Speaker 3:I can Well appreciate your time, Greg. Thank you very much for being part of my life and letting us know about you and your efforts, and the outcomes that are being created by you, which you've invented. Thank you so much.