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WELCOME TO THE CLINICAL
CENTER GRAND ROUNDS,

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A WEEKLY SERIES OF EDUCATIONAL
LECTURES FOR PHYSICIANS AND

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HEALTH CARE PROFESSIONALS
BROADCAST FROM THE CLINICAL

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CENTER AT THE NATIONAL
INSTITUTES OF HEALTH IN

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BETHESDA, MD.

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THE NIH CLINICAL CENTER IS THE
WORLD'S LARGEST HOSPITAL TOTALLY

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DEDICATED TO INVESTIGATIONAL
RESEARCH AND LEADS THE GLOBAL

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EFFORT IN TRAINING TODAY'S
INVESTIGATORS AND DISCOVERING

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TOMORROW'S CURES.

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LEARN MORE BY VISITING US ONLINE
AT HTTP://CLINICALCENTER.NIH.GOV

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GOOD AFTERNOON AND WELCOME TO

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TODAY'S CLINICAL CENTER NURSING

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GRAND ROUNDS. 

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I'M DR. COURTNEY ACTING DIRECTOR

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OF THE NURSING INSTITUTE OF

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RESEARCH.

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BEFORE WE BEGENERATED I HAVE A

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FEW HOUSEKEEPING ITEMS TO

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ADDRESS, THE HOPKINS CME

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ACTIVITY CODE FOR TODAY'S GRAND

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ROWPPEDS IS CME CODE 57904.

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PLEASE TEXT THIS CODE TO THE

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JOHNS HOPKINS CME PHONE NUMBEROT

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SLIDE TO RECEIVE CME CREDIT FOR

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THIS LECTURE.

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WE KINDLY INVITE TO YOU PROVIDE

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FEEDBACK ON TODAY'S LECTURE BY

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KAN--KANAING THE QR CODEOT CME

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SLIDE.

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FOR THOSE APPLYING FOR CME, YOU

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WILL RECEIVE THE LINK VIA

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E-MAIL.

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THE SURVEY WILL BE USED TO

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PROVIDE US WITH IMPORTANT

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FEEDBACK ABOUT THIS PRESENTATION

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AND ALLOWS TO YOU MAKE ANY

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SUGGESTIONS FOR FUTURE GRAND

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ROUNDS TOPICS.

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YOU CAN SUBMIT YOUR COMMENTS

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TODAY BY CONTROLLING DOWN AND

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CLICKING ON THE SEND LIVE

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FEEDBACK BUTTON ON THE WEBSITE.

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TIME WILL BE ANSWERED AS TIME

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PERMITS AND AT THE CONCLUSION OF

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THIS PRESENTATION EMPLOY NOW

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SWITCHING OVER TO THE REASON

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WE'RE ALL TUNE NOTHING TODAY.

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I AM DEEPLY HONORED TO INTRODUCE

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DR. ANDRIEA WALLACE, A TRUE

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VISIONARY IN THE LEADER AND

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INTEGRATING THE CONDITIONS OF

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WHERE WE WORK, PLAY AND LIVE

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WITH CLINICAL CARE.

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DR. WALLACE IS A ASSOCIATE DEAN

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OF PROFESSOR AND WERE AT THE

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UTAH COLLEGE -- RESEARCH AT THE

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UTAH COLLEGE OF NURSING.

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DR. WALLACE IS ALLY RESPECTED

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RESEARCHER WHOSE CAREER FOCUSED

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ON DESIGNING AND IMPLEMENTING

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HIGH QUALITY INTERVENTIONS TO

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IMPROVE OUTCOMES FOR PATIENT

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POPULATIONS ISSUES SHE'S NOT

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JUST OBSERVING THE GAPS AND

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CARE, BUT SHE'S ALSO ACTIVELY

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CREATING TESTING AND SOLUTIONS

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THAT CAN BE FEASIBLY INTEGRATED

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INTO ROUTINE PRACTICE.

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ALL MINDFUL OF THE RESOURCE

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CONSTRAINTS.

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HER EARLY WORK ON HEALTH ACCESS

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AND CHILDREN LAID THE FOUNDATION

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FOR A CAREER DEDICATED TO

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INNOVATIVE SYSTEM LEVEL CHANGE.

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DR. WALLACE'S RESEARCH HAS BEEN

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CONTINUE LOWSLY SUPPORTED BY NIH

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AND HRQ UNDERSCORING THE

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RIGOROUS IMPACT OF HER WORK.

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MOST RECENTLY SHE'S FOCUSED ON

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IMPROVEMENT OF PATIENT CARE IN

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ED SETTINGS BY SCREENING SOCIAL

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DETERMINANTS OF HEALTH AND

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APPLYING RISK MODELING

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TECHNIQUES.

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THIS WORK IS INCREDIBLY

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IMPORTANT AS NURSING SCIENCE

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PLAYS A VITAL ROLE IN BRIDGING

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THE GAP BETWEEN RESEARCH AND

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PRACTICE, DEVELOPING SOLUTIONS

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THAT ARE BOTH EVIDENCE BASED AND

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PATIENT-CENTERED.

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NURSING SCIENCE IS UNIQUELY

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POSITIONED TO IMPROVE PATIENT

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OUTCOMES IN A WHOLISTIC PATIENT

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SYSTEMS BASED WAY.

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THE NATIONAL INTUITY OF NURSING

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RESEARCH IS AT THE FOREFRONT OF

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SUPPORTING THIS ESSENTIAL WORK,

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NINR'S COMMITMENT TO FUNDING

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NURSE LAB RESEARCH LIKE

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DR. WALLACE'S IS A HEALTHIER

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INVESTMENT TO THE FUTURE FOR

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ALL.

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WE BELIEVE IN THE SYSTEMS AND

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MODELS ARE CARE AND DISCOVERIES

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AND BREAKTHROUGHS IN DISEASE AND

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EMPOWERS PEOPLE AND COMMUNITIES

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TO OPTIMIZE THEIR OWN HEALTH.

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TODAY DR. WALLACE WILL SHARE HER

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EXPERTISE ON INTEGRATING SOCIAL

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AND CLINICAL CARE, BUILDING BEST

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PRACTICES FOR ADDRESSING HEALTH

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RELATED SOCIAL NEEDS AND I KNOW

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WE ARE ALL VERY EAGER TO HEAR

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HER PERSPECTIVES ON THIS TIMELY

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AND CRITICAL TOPIC.

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SO PLEASE I DIDN'T EVEN ME IN

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EXTENDING A WARM WELCOME TO

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DR. ANDREA WALLACE.

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>> THANK YOU SO MUCH FOR
THE

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OPPORTUNITY TO BE HERE.

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LET'S GET STARTED.

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I TRUST THAT EVERYONE CAN HEAR

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THIS OKAY?

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>> YES. 

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>> OKAY.

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GREAT.

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SO I HAVE NO FINANCIAL OR

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RECOLLECT CONFLICTS OF INTEREST

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RELATED TO THE CONTENT OF THIS

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PRESENTATION TODAY.

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SO, YOU KNOW I KNOW YOU ALL AT

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THE CLINICAL CENTER AND I WANTED

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TO SAY WE'RE PRACTICE DISCIPLINE

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IN NURSING AND YOU KNOW YOU

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UNDERSTAND THAT EACH OF US HAS A

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WHY BEHIND THE RESEARCH WE

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PURSUE, AS THE DOCTOR MENTIONED

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MY OWN WHY BEGAN EARLY IN MY

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NURSING CAREER WORKING WITH

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CHILDREN WITH ASTHMA IN DENVER.

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I SAW THAT MEDICATIONS AND

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APPOINTMENTS WERE NOT ENOUGH,

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WHAT REALLY SHAPED OUTCOMES WERE

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THE SOCIAL REALITIES FAMILY

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FACED WHILE COPING WITH A CHILD

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A ASTHMA, SUCH AS SUPPORTING,

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SCHOOL, AND OTHERS.

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THAT LED ME TO DO A STUDY ON HOW

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SOCIAL INFLUENCES SOCIAL

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ACSETION TO PATTERNS THROUGH

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ILLNESS.

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LATER THROUGH AN T32, WE FOCUSED

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ON FINDING PATIENTS WHERE ARE

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THAT I, ACCOUNTING FOR LITERACY,

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SUPPORT SYSTEMS, LONG DISTANCE

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PS TO CARE.

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AS A SHIFT TO ADULT WITH

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CONDITIONS, LIKE DIABETES, PAIN

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AND COAGULATION DISORDERS ISSUES

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THE PATTERN HELPED, WHAT

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MATTERED IS WHAT EXISTED OUTSIDE

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OF THE CLINIC AND YET WHAT WE

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MOST OFTEN RELY ON IN IS THIS,

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WHEN PATIENTS STEP INTO OUR

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CLINICAL SETTINGS, A DEMOGRAPHIC

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SNAPSHOT IN THE EHR THAT TELLS

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US VERY LITTLE ABOUT THE

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PATIENT'S LIFE AND WHAT'S KEY TO

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MANAGING THEIR CONDITION, SO MY

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WHY WHICH HAS EVOLVED INTO A

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CORE QUESTION:  HOW CAN WE ALIGN

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MODELS THAT WORK WITH THEIR

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LIVES WHERE THEY LIVE, WORK AND

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CARE FOR OTHERS THAT, WOS IN

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FAST PACED CLINICAL SETTINGS,

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THAT'S BEEN MY PURPOSE AND

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PASSION FOR NEARLY 2 DECADES

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NOW.

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SO WITH THAT, TODAY, WE WILL

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EXPLORE OW SOCIAL CARE

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INTEGRATION CAN HAPPEN ACROSS

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SETTINGS, HOW CLINICIANS AND

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PATIENTS ENGAGE WITH IT, HOW WE

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APPLY IMPLEMENTATION FRAMEWORKS

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AND WHAT KINDS OF DIGITAL AND

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TEAM BASED INTERVENTIONS MAKE

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THIS ALL POSSIBLE.

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SO LET'S FIRST START BY DEFINING

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THE LANDSCAPE TO EXPLORE WHY

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THESE NEEDS MATTER AND WHAT

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MAKES SOCIAL CARE DISTINCT FROM

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BROADER PUBLIC HEALTH EFFORTS

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AND THROUGHOUT THIS TALK TODAY,

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YOU WILL SEE WHAT WE SEE IN OUR

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SOCIAL LAND SCAPE HERE AT THE

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UNIVERSITY OF UTAH.

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NOW THIS SLIDE IS KEY, IT

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DISTINGUISHES BETWEEN FACTORS OF

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THE POPULATION LEVEL AND MORE

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ACTIONABLE INDIVIDUAL LEVEL

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NEEDS.

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WHAT WE CAN IDENTIFY AND

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INTERVENE ON IN HEALTHCARE

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SETTINGS.

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ONE THING TO RECOGNIZE IS THAT

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EVERYONE LISTENING TODAY IS

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SUBJECT TO SOCIAL DETERMINANTS

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OR DRIVERS OF HEALTH.

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THESE ARE SIMPLY SOCIAL FACTORS

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ASSOCIATED POSITIVELY OR

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NEGATIVELY WITH HEALTH OUTCOMES.

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AS WE MOVE TO SHOACIAL RISK,

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THESE NEGATIVELY AFFECT HEALTH

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BUT AT THIS LEVEL IT'S NOT

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NECESSARILY YET ACTIONABLE.

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WHEN WE MOVE TO SOCIAL NEEDS WE

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BECOME MORE ACTIONABLE,

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ASSESSING FOR THE CONCRETE

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TANGIBLE MORE AND IMMEDIATE

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NEEDS THAT ARE CRITICAL FOR WELL

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BEING SUCH AS HOUSING AND FOOD

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AND RELATED FACTOR AND 1 THEY

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WILL DISCUSS AS PART OF

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INPATIENT CARE IS SOCIAL SUPPORT

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THAT IS INSTRUMENTAL.

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HAVING HELP WITH HEALTH RELATED

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TASKS SUCH AS WOUND CARE,

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COOKING AND ERRANDS DURING

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HOSPITALIZATION ARE PART OF THE

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ONGOING MANAGEMENT OF A CHRONIC

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DISEASE.

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AND I JUST LOST MY SLIDES.

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SO I APOLOGIZE FOR THAT.

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IRB APOLOGIZE, I WILL HAVE TO

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SHARE AGAIN.

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IT WAS EVERYONE SEE THIS. 

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>> NOT YET.

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>> THE BEST LAID PLANS,
YOU ALL.

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I HAVE TO DO THIS FAST.

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ALL RIGHT, DO YOU SEE MY SLIDES

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NOW?

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>> WE DO.

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>> SO NOW OF COURSE THESE

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PERCENTAGES CHANGE DEPENDING ON

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HOW AND WHERE THEY'RE EXAMINED

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AND YOU DO A WEB SEARCH, I'M

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SORRY, YOU WILL FIND MANY

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COLORFUL SECOND QUARTERLES THAT

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LOOK LIKE THIS BUT WITH

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DIFFERENT PERCENTAGES, BUT THIS

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IS TO ILLUSTRATE THAT, JUST AS I

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EXPERIENCED AS A CLINICAL NURSE,

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RECENT EVIDENCE SHOWS THAT MOST

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OF OUR HEALTH AT THE POPULATION

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LEVEL IS DETERMINED BY SOCIAL

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VERSUS BIOLOGICAL REALITIES AND

258
00:08:33,663 --> 00:08:34,964
THE CRUX OF WHY THIS MATTER

259
00:08:34,964 --> 00:08:37,033
SYSTEM THAT PEOPLE DON'T LIVE IN

260
00:08:37,033 --> 00:08:38,401
CLINICAL SETTINGS, YET MUCH OF

261
00:08:38,401 --> 00:08:41,471
OUR CARE STILL OPERATES AS IF

262
00:08:41,471 --> 00:08:42,038
THEY DO.

263
00:08:42,038 --> 00:08:44,474
AND 1 OF OUR TEAMS CHALLENGES

264
00:08:44,474 --> 00:08:45,441
HAS BEEN TO COMMUNICATE THE

265
00:08:45,441 --> 00:08:47,176
EFFECTS OF THE SOCIAL FACTORS AT

266
00:08:47,176 --> 00:08:48,478
POPULATION LEVEL TO SYSTEMS

267
00:08:48,478 --> 00:08:50,013
FOCUSED ON INDIVIDUAL OUTCOMES,

268
00:08:50,013 --> 00:08:51,414
LOCAL DATA HELPS ILLUSTRATE

269
00:08:51,414 --> 00:08:53,082
THIS, HERE'S A VISUAL OF WHY WE

270
00:08:53,082 --> 00:08:54,784
CARE ABOUT SOCIAL CONTEXT, THIS

271
00:08:54,784 --> 00:08:56,753
IS URBAN SALT LAKE CITY, WHERE I

272
00:08:56,753 --> 00:08:58,788
LIVE AND WHERE THE UNIVERSITY OF

273
00:08:58,788 --> 00:09:01,257
UTAH HEALTH AND MAIN CAMPUS ARE

274
00:09:01,257 --> 00:09:02,558
LOCATED, THERE ARE MANY MAPS

275
00:09:02,558 --> 00:09:07,096
LIKE THIS DEMON TRAITING HEALTH

276
00:09:07,096 --> 00:09:11,000
OUTCOMES 

277
00:09:11,000 --> 00:09:11,467
OUTCOME.

278
00:09:11,467 --> 00:09:14,470
BUT THIS IS PERSONAL FOR ME,

279
00:09:14,470 --> 00:09:16,205
THESE ARE NUMBERS FROM THE AREA

280
00:09:16,205 --> 00:09:18,341
WHERE I BUY MY COFFEE IN DOWN

281
00:09:18,341 --> 00:09:19,075
DOWN SALT LAKE.

282
00:09:19,075 --> 00:09:21,911
BUT SCRINNING FOR NEEDS IS

283
00:09:21,911 --> 00:09:22,145
NASCENT.

284
00:09:22,145 --> 00:09:24,514
IN THIS 2022 REPORT COLLEAGUES

285
00:09:24,514 --> 00:09:25,715
AT UCSF REPORT THAD WHILE

286
00:09:25,715 --> 00:09:29,252
PATIENTS ARE GENERAL LYE OPEN TO

287
00:09:29,252 --> 00:09:32,121
HAVING QUESTIONS ASKED OF THEM,

288
00:09:32,121 --> 00:09:34,090
PROVIDERS ARE RESTRAINED IN HOW

289
00:09:34,090 --> 00:09:35,725
THEY ARE ASKED, COLLECTED ARE,

290
00:09:35,725 --> 00:09:37,460
SHARED AND USE THE.

291
00:09:37,460 --> 00:09:39,796
BUT SINCE THE 2022 REPORT WE ARE

292
00:09:39,796 --> 00:09:41,764
SEEING RAPID TOP DOWN MOVEMENT

293
00:09:41,764 --> 00:09:43,266
AS SYSTEMS WIDELY RECOGNIZE THE

294
00:09:43,266 --> 00:09:45,335
SOCIAL FACTORS IN HEALTH.

295
00:09:45,335 --> 00:09:46,903
CMS IS 1 MAJOR DRIVE WHERE WE

296
00:09:46,903 --> 00:09:49,639
HAD REGULATIONS IN PLACE SCREEN

297
00:09:49,639 --> 00:09:51,040
AS PART OF PATIENT ADMISSIONS

298
00:09:51,040 --> 00:09:55,912
BUT WITH THAT COMES COMPLEX

299
00:09:55,912 --> 00:09:57,180
GORCHANCE, INTERROPERABILITY AND

300
00:09:57,180 --> 00:09:58,715
CONSENT, AND UNCOVERED HERE IN

301
00:09:58,715 --> 00:09:59,949
ACADEMIC HEALTH SYSTEMS.  THIS

302
00:09:59,949 --> 00:10:01,617
IS BECAUSE WE'RE NOT ONLY

303
00:10:01,617 --> 00:10:02,752
SCREENING FOR NEEDS BUT WE'RE

304
00:10:02,752 --> 00:10:04,487
ALSO TRYING TO CONNECT PATIENTS

305
00:10:04,487 --> 00:10:06,122
TO SERVICES BEYOND THOSE CLINIC

306
00:10:06,122 --> 00:10:10,760
WALLS, OUT IN OUR COMMUNITY

307
00:10:10,760 --> 00:10:11,594
SETTINGS.

308
00:10:11,594 --> 00:10:13,029
SO WHEN WE EMBARKED ON THIS

309
00:10:13,029 --> 00:10:14,564
WORK, WE DECIDED TO BREAK THIS

310
00:10:14,564 --> 00:10:16,165
ISSUE IN 3ICISMEM PIECES

311
00:10:16,165 --> 00:10:18,001
CRITICAL TO DRIVING CRITICAL

312
00:10:18,001 --> 00:10:18,935
INTEGRATION OF SOCIAL

313
00:10:18,935 --> 00:10:19,869
INFORMATION BY CLINICIANS AND

314
00:10:19,869 --> 00:10:20,303
HEALTH SYSTEMS.

315
00:10:20,303 --> 00:10:22,739
WHAT WE SHOW HERE IS THAT FOR

316
00:10:22,739 --> 00:10:24,140
SOCIAL INFORMATION TO ACTUALLY

317
00:10:24,140 --> 00:10:25,908
IMPROVE CLINICAL CARE AND HEALTH

318
00:10:25,908 --> 00:10:27,977
OUTCOMES, WE NEED METHODS FOR

319
00:10:27,977 --> 00:10:28,778
UNDERSTANDING PATIENTS SOCIAL

320
00:10:28,778 --> 00:10:30,980
CONTEXT THAT ARE CONSISTENT AND

321
00:10:30,980 --> 00:10:31,247
EFFECTIVE.

322
00:10:31,247 --> 00:10:32,849
WE NEED THE INFORMATION TO BE

323
00:10:32,849 --> 00:10:34,117
COMMUNICATED TO CLINICAL TEAMS

324
00:10:34,117 --> 00:10:35,385
AND USED TO GUIDE CLINICAL

325
00:10:35,385 --> 00:10:37,520
DECISION MAKING AND IT HAS TO DO

326
00:10:37,520 --> 00:10:41,324
SOMETHING AND NOT BE INFORMATION

327
00:10:41,324 --> 00:10:41,858
FOR INFORMATION'S SAKE.

328
00:10:41,858 --> 00:10:43,026
AND WITH THE UNDERSTANDING THAT

329
00:10:43,026 --> 00:10:45,128
THIS IS ABOUT PATIENT'S SOCIAL

330
00:10:45,128 --> 00:10:46,896
CONTEXT, WE NEED TO INVOLVE

331
00:10:46,896 --> 00:10:48,364
PATIENT'S PERSONAL RESOURCES AND

332
00:10:48,364 --> 00:10:49,232
WHEN APPROPRIATE COMMUNITY BASED

333
00:10:49,232 --> 00:10:53,169
SERVICES TO WHICH THEY HAVE

334
00:10:53,169 --> 00:10:53,403
ACCESS.

335
00:10:53,403 --> 00:10:55,471
SO NOW I WILL SHARE FINDINGS

336
00:10:55,471 --> 00:10:57,740
FROM STUDIES WE'VE LED ACROSS

337
00:10:57,740 --> 00:11:01,577
OUTPATIENT AND IN PATIENT

338
00:11:01,577 --> 00:11:04,547
SETTING STARTING FIRST WITH

339
00:11:04,547 --> 00:11:04,847
OUTPATIENT.

340
00:11:04,847 --> 00:11:06,182
OUR PURPOSE WAS START INDEED

341
00:11:06,182 --> 00:11:07,850
2017 HAS BEEN DEVELOPING A MEANS

342
00:11:07,850 --> 00:11:09,852
OF ETHICALLY AND EFFECTIVELY

343
00:11:09,852 --> 00:11:10,520
IDENTIFYING SHOACIAL NEEDS THAT

344
00:11:10,520 --> 00:11:13,089
CAN BE USE INDEED RETEEN CARE

345
00:11:13,089 --> 00:11:14,824
WHEN THE WORK ISN'T NECESSARILY

346
00:11:14,824 --> 00:11:17,760
SUPPORTED BY RESEARCH STAFF TO

347
00:11:17,760 --> 00:11:18,861
FACILITATE ACCESS TO COMMUNITY

348
00:11:18,861 --> 00:11:21,030
BASED RESOURCES AND THEN TO

349
00:11:21,030 --> 00:11:22,098
INTEGRATE COMMUNITY BASED DATA.

350
00:11:22,098 --> 00:11:25,535
TO DATE WE COMPLETED OVER 70,000

351
00:11:25,535 --> 00:11:28,204
SCREENINGS FUNDED BY HRQQ AND

352
00:11:28,204 --> 00:11:30,773
NINR, AND OUR WORK IS GRANTED IN

353
00:11:30,773 --> 00:11:32,308
A PARTNERSHIP WITH UTAH 2 AND 1,

354
00:11:32,308 --> 00:11:35,812
WHICH IS PART OF A REFERRAL

355
00:11:35,812 --> 00:11:36,946
CENTER OFFERING CONNECTIONS TO

356
00:11:36,946 --> 00:11:39,916
FREE AND LOW COST COMMUNITY

357
00:11:39,916 --> 00:11:42,218
BASED PROGRAMS LIKE FOOD AND

358
00:11:42,218 --> 00:11:44,787
HOUSING TO ALL THOSE WHO DIAL

359
00:11:44,787 --> 00:11:45,354
2-1-1.

360
00:11:45,354 --> 00:11:47,056
AND THROUGH THE YEARS THIS HAS

361
00:11:47,056 --> 00:11:48,491
TAKEN A LOT OF WORK BUT THE

362
00:11:48,491 --> 00:11:50,226
OVERVIEW OF HOW THIS IS DONE IS

363
00:11:50,226 --> 00:11:52,095
QUITE SIMPLE.

364
00:11:52,095 --> 00:11:53,396
PATIENTS EITHER SELF-COMPLETE OR

365
00:11:53,396 --> 00:11:57,133
ADMINISTER THE NOW VALIDATED 10

366
00:11:57,133 --> 00:11:58,201
ITEMS SINCERE SCREENER, IT'S

367
00:11:58,201 --> 00:11:59,969
ADAPTABLE WHICH IS KEY IN

368
00:11:59,969 --> 00:12:01,204
CLINICAL SETTINGS, WE'VE

369
00:12:01,204 --> 00:12:02,805
SCREENED IN PERSON WITH VARIOUS

370
00:12:02,805 --> 00:12:04,807
LEVELS OF STAFF OR PATIENTS CAN

371
00:12:04,807 --> 00:12:06,642
SELF-COMPLETE DURING OR BEFORE A

372
00:12:06,642 --> 00:12:09,278
VISIT USING A PORTAL SUCH AS

373
00:12:09,278 --> 00:12:11,314
ETHICS OR MY CHART, USING A

374
00:12:11,314 --> 00:12:13,916
HIPAA LINK TO THE 211 DATA

375
00:12:13,916 --> 00:12:15,518
SYSTEM, WE REFER THEM TO A

376
00:12:15,518 --> 00:12:18,354
COMMUNITY SERVICE NAVIGATOR WHO

377
00:12:18,354 --> 00:12:20,790
AIMS PARENTS TO TEXT, OR E-MAIL

378
00:12:20,790 --> 00:12:22,959
WITHIN 48 HOURS OF SCREENING AND

379
00:12:22,959 --> 00:12:24,260
WE COMPILE DATA FROM INSIDE AND

380
00:12:24,260 --> 00:12:26,129
OUTSIDE THE HELT NEEDS AND THE

381
00:12:26,129 --> 00:12:28,397
COMMUNITY OUTREACH PROCESS, OUR

382
00:12:28,397 --> 00:12:30,066
PARTNERSHIP WITH THE 211 HAS A

383
00:12:30,066 --> 00:12:32,435
ROBUST ENCOUNTER AND RESOURCE

384
00:12:32,435 --> 00:12:35,371
DATABASE HAS ALLOWED US TO DO

385
00:12:35,371 --> 00:12:36,272
THIS.

386
00:12:36,272 --> 00:12:39,108
AND OF COURSE, THIS IS DISPLAYED

387
00:12:39,108 --> 00:12:40,176
DIFFERENTLY AND TOUCH PADS ON

388
00:12:40,176 --> 00:12:41,911
THE EHR BUT THIS IS A CLEAR

389
00:12:41,911 --> 00:12:44,013
VISUAL OF WHAT IS ADMINISTERED

390
00:12:44,013 --> 00:12:45,781
ON THE LEFT ARE QUESTIONS FROM

391
00:12:45,781 --> 00:12:47,383
THE 10 ITEMS SINCERE SCREENER

392
00:12:47,383 --> 00:12:48,417
WHICH TAKE A MINUTE TO COMPLETE

393
00:12:48,417 --> 00:12:50,086
AND ON THE RIGHT IS INFORMATION

394
00:12:50,086 --> 00:12:50,920
GATHER FRIDAY THOSE WHO WOULD

395
00:12:50,920 --> 00:12:57,493
LIKE TO BE CONTACTED BY 211 FOR

396
00:12:57,493 --> 00:12:58,394
SERVICE CONNECTIONS.

397
00:12:58,394 --> 00:12:59,762
AND THIS SNAPSHOT COMES FROM

398
00:12:59,762 --> 00:13:01,430
WHEN WE FIRST IMPLEMENTED THE

399
00:13:01,430 --> 00:13:03,966
SOCIAL NEED SCREENER AS PART OF

400
00:13:03,966 --> 00:13:05,001
ROUTINE EMERGENCY DEPARTMENT

401
00:13:05,001 --> 00:13:07,170
CARE, WHILE THESE ARE FROM 8000

402
00:13:07,170 --> 00:13:09,238
PATIENTS AND AGAIN NOW WE

403
00:13:09,238 --> 00:13:10,540
CONNECTED KREENINGS OF OVER

404
00:13:10,540 --> 00:13:11,841
70,000 PATIENTS ACROSS SITES,

405
00:13:11,841 --> 00:13:13,809
WHAT IS REMARKABLE ABOUT IT IS

406
00:13:13,809 --> 00:13:15,811
THIS, IS HOW CONSISTENT THESE

407
00:13:15,811 --> 00:13:16,979
HAVE REMAINED OVER TIME, NEARLY

408
00:13:16,979 --> 00:13:18,414
HALF OF THOSE WHO COMPLETE

409
00:13:18,414 --> 00:13:20,082
SCREENING REPORT AT LEAST 1

410
00:13:20,082 --> 00:13:23,152
UNMET NEED IN ED, THE MOST

411
00:13:23,152 --> 00:13:24,620
REPORTEDNY NEEDS ARE FOR

412
00:13:24,620 --> 00:13:25,922
UTILITIES RENT OR MORTGAGE, AND

413
00:13:25,922 --> 00:13:27,390
COLLECT EVALUATION PROCESS LIE

414
00:13:27,390 --> 00:13:29,358
ARE ALMOST PREDICTIVE OF WANTING

415
00:13:29,358 --> 00:13:29,759
OUTREACH.

416
00:13:29,759 --> 00:13:32,795
BUT EITHER WHEN THESE ARE

417
00:13:32,795 --> 00:13:34,197
IDENTIFIED ONLY 44% MADE CONTACT

418
00:13:34,197 --> 00:13:36,465
WITH THE RESOURCE NAVIGATOR AND

419
00:13:36,465 --> 00:13:37,700
FEWER THAN ONE-THIRD ULTIMATELY

420
00:13:37,700 --> 00:13:38,768
CONNECKED WITH THE COMMUNITY

421
00:13:38,768 --> 00:13:39,969
SERVICE SHOWING JUST HOW MUCH

422
00:13:39,969 --> 00:13:41,904
CAN BE LOST BETWEEN SCREENING

423
00:13:41,904 --> 00:13:42,405
AND SUPPORT.

424
00:13:42,405 --> 00:13:44,941
THE RIGHT SIDE OF THE SLIDE MAY

425
00:13:44,941 --> 00:13:46,676
ALSO SHOWS WHY SOME MAY COMPLETE

426
00:13:46,676 --> 00:13:48,144
THE SCREENER.

427
00:13:48,144 --> 00:13:51,747
THIS IS MOSTLY FOR REFUSALS OR

428
00:13:51,747 --> 00:13:53,816
CLINICAL REASONS LIKE TRAUMA OR

429
00:13:53,816 --> 00:13:55,251
COGNITIVE IMPAIRMENT, BUT ON THE

430
00:13:55,251 --> 00:13:56,886
OTHER SIDE ARE STAFF AND WORK

431
00:13:56,886 --> 00:13:57,954
FLOW RELATED BARRIERS AND

432
00:13:57,954 --> 00:13:59,021
IMPORTANTLY WE FOUND PATIENTS

433
00:13:59,021 --> 00:14:00,423
WITH MULTIPLE LEADS WERE FAR

434
00:14:00,423 --> 00:14:01,824
MORE LIKELY TO ACCEPT HEALTH AND

435
00:14:01,824 --> 00:14:03,559
A KREENING TOOL AND BOTH VALID

436
00:14:03,559 --> 00:14:14,036
AND  RERIEBL. RE-- RELIABLE.

437
00:14:15,137 --> 00:14:17,106
APPROXIMATE AND BEYOND THE

438
00:14:17,106 --> 00:14:18,040
SCREENING AND CONNECTION RESULTS

439
00:14:18,040 --> 00:14:19,508
WE'VE BEEN ABLE TO BEGIN INSIGHT

440
00:14:19,508 --> 00:14:21,444
INTO THE MULTILEVEL NATURE OF

441
00:14:21,444 --> 00:14:23,412
THESE NEEDS AND THESE LIKE FOOD

442
00:14:23,412 --> 00:14:24,714
AND SECURITY CORRELATE WITH

443
00:14:24,714 --> 00:14:25,381
COMMUNITY RESOURCE AVAILABILITY,

444
00:14:25,381 --> 00:14:28,417
A LACK OF DIGITAL ACCESS IS A

445
00:14:28,417 --> 00:14:29,585
KEY BARRIER IN DELIVERING FOLLOW

446
00:14:29,585 --> 00:14:31,754
UP SUPPORT AND THESE NEEDS ALL

447
00:14:31,754 --> 00:14:32,822
LAYER UPON 1 ANOTHER ESPECIALLY

448
00:14:32,822 --> 00:14:35,825
WITH THE NEED FOR HOUSING, RENT,

449
00:14:35,825 --> 00:14:39,562
MORTGAGE AND ACROSS URBAN AND

450
00:14:39,562 --> 00:14:40,129
FRONTIER GEOGRAPHY.

451
00:14:40,129 --> 00:14:43,099
BUT THIS IS WHY COMMUNITY

452
00:14:43,099 --> 00:14:44,233
SERVICE NAVIGATION LOOKS LIKE,

453
00:14:44,233 --> 00:14:47,036
IN HER INITIAL CALL, A 211

454
00:14:47,036 --> 00:14:48,437
NAVIGATOR SPOKE WITH THE

455
00:14:48,437 --> 00:14:49,705
PATIENT'S DAUGHTER WHO SHARED

456
00:14:49,705 --> 00:14:51,474
THAT SHE NEEDED HELP WITH MEALS

457
00:14:51,474 --> 00:14:52,742
AND TRANSPORTATION TO MEDICAL

458
00:14:52,742 --> 00:14:54,477
APPOINTMENTS ISSUES THE

459
00:14:54,477 --> 00:14:55,778
NAVIGATOR GAVE THE DAUGHTER A

460
00:14:55,778 --> 00:15:01,083
LIST OF RESOURCES AND SCHEDULED

461
00:15:01,083 --> 00:15:02,918
A CALL, AND AT 2 WEEKS, SHE

462
00:15:02,918 --> 00:15:06,289
FOUND OUT THE PATIENT HAD O WAS

463
00:15:06,289 --> 00:15:09,025
83, HAD MS AND HEART CONDITIONS

464
00:15:09,025 --> 00:15:11,694
AND THEIR HUSES IS ON OXYGEN,

465
00:15:11,694 --> 00:15:12,928
THEIR DAUGHTER IS OVERWHELMED

466
00:15:12,928 --> 00:15:14,263
WITH WORK AND SCHOOL AND UNABLE

467
00:15:14,263 --> 00:15:16,365
TO CONNECT WITH RESOURCES, THE

468
00:15:16,365 --> 00:15:17,300
NAVIGATOR CONNECTED THE PATIENT

469
00:15:17,300 --> 00:15:19,568
TO AGING AND ADULT SERVICES AND

470
00:15:19,568 --> 00:15:20,603
HELPED COMPLETE APPLICATIONS FOR

471
00:15:20,603 --> 00:15:22,371
MEALS ON WHEELS AND RISE FOR

472
00:15:22,371 --> 00:15:23,506
WELLNESS, AS A RESULT THE

473
00:15:23,506 --> 00:15:25,808
PATIENT AND HER HUSBAND BEGAN

474
00:15:25,808 --> 00:15:27,310
RECEIVING MUCH NEEDED MEAL

475
00:15:27,310 --> 00:15:28,744
DELIVERIES AND TRANSPORTATION TO

476
00:15:28,744 --> 00:15:30,146
FUTURE MEDICAL APPOINTMENTS THE

477
00:15:30,146 --> 00:15:31,447
FOLLOWING WEEK AND THIS IS

478
00:15:31,447 --> 00:15:32,581
REALLY THESE STORIES ARE WHAT

479
00:15:32,581 --> 00:15:37,987
KEEP US GOING IN THIS WORK.

480
00:15:37,987 --> 00:15:39,855
AND THIS SLIDE SUMMARIZES

481
00:15:39,855 --> 00:15:43,459
COMBINED FINDINGS OF OVER 65 IN

482
00:15:43,459 --> 00:15:45,061
DEPTH PATIENT INTERVIEWS

483
00:15:45,061 --> 00:15:45,928
ADDITIONAL FOCUS GROUPS WITH

484
00:15:45,928 --> 00:15:47,163
FRONT LINE STAFF.

485
00:15:47,163 --> 00:15:49,799
THIS WAS A SUBSTANTIAL QUAL

486
00:15:49,799 --> 00:15:51,200
FIGHTIVE EFFORT CONDUCTED AS

487
00:15:51,200 --> 00:15:54,370
PART OF OUR NINR STAFF.

488
00:15:54,370 --> 00:15:56,439
WE HEAR FROM STAFF, THEY ARE

489
00:15:56,439 --> 00:15:57,707
STRONG TO SUPPORT WITH RESOURCES

490
00:15:57,707 --> 00:16:00,242
ARE AVAILABLE BUT THEY ALSO

491
00:16:00,242 --> 00:16:03,479
DISCOVERED ASKING SENSITIVE

492
00:16:03,479 --> 00:16:05,881
QUESTIONS ESPECIALLY WHEN

493
00:16:05,881 --> 00:16:06,682
ANSWERS ARE UNCOMFORTABLE.

494
00:16:06,682 --> 00:16:08,217
PATIENTS ON THE OTHER HAND

495
00:16:08,217 --> 00:16:10,052
LARGELY VALUED UNIVERSAL AND

496
00:16:10,052 --> 00:16:11,687
SINCERE SCREENING, BUT THEY FACE

497
00:16:11,687 --> 00:16:12,988
SIGNIFICANT BARRIERS IN THIS, A

498
00:16:12,988 --> 00:16:16,726
LACK OF AWARENESS ABOUT WHAT

499
00:16:16,726 --> 00:16:18,828
RESOURCES EXIST, STIGMA BELIEFS

500
00:16:18,828 --> 00:16:23,499
ABOUT WHO REALLY DESERVES HELP

501
00:16:23,499 --> 00:16:24,934
HELP SEEKING AND NAVIGATING

502
00:16:24,934 --> 00:16:26,168
SYSTEMS FOR ELIGIBILITY

503
00:16:26,168 --> 00:16:26,502
REQUIREMENTS.

504
00:16:26,502 --> 00:16:30,506
ONE THEME WAS THE DIGIT DIVIDE.

505
00:16:30,506 --> 00:16:31,674
PATIENTS FREQUENTLY LACKED

506
00:16:31,674 --> 00:16:35,111
INTERNET ACCESS OR STRUGGLED

507
00:16:35,111 --> 00:16:37,613
WITH DIGITAL LITERACY, MANY

508
00:16:37,613 --> 00:16:40,649
STRUGGLES REMAIN AND PATIENTS

509
00:16:40,649 --> 00:16:41,083
STILL NEED SUPPORT.

510
00:16:41,083 --> 00:16:42,852
SO THIS WORK HIGHLIGHTS WHERE

511
00:16:42,852 --> 00:16:44,053
SYSTEMS FALL SHORT AND WHERE WE

512
00:16:44,053 --> 00:16:46,522
NEED TO FOCUS TO TRULY ENABLE

513
00:16:46,522 --> 00:16:47,623
CONNECTION AND FALTHROUGH.

514
00:16:47,623 --> 00:16:50,926
THIS IS PART OF THE REASON WHY

515
00:16:50,926 --> 00:16:54,463
WITH STRONG CROSS SECTOR

516
00:16:54,463 --> 00:16:55,865
PARTNERSHIPS, DIGITAL ACCESS

517
00:16:55,865 --> 00:16:57,666
BARRIERS TO HEALTH AND SOCIAL

518
00:16:57,666 --> 00:17:01,570
CARE IS A FOCUS OF OUR MOST

519
00:17:01,570 --> 00:17:03,672
RECENTLY FUNDED NINR STUDY.

520
00:17:03,672 --> 00:17:05,641
SO TECHNICALLY SPEAKING, THIS

521
00:17:05,641 --> 00:17:07,009
APPROACH OF SCREENING AND

522
00:17:07,009 --> 00:17:08,411
REFERRAL WORKS.

523
00:17:08,411 --> 00:17:10,880
INCLUDED HERE ARE 2 OF OUR

524
00:17:10,880 --> 00:17:12,148
MARXAISEING 211 NAVIGATORS LEX

525
00:17:12,148 --> 00:17:13,249
AND PATTY WHO WORKED WITH US

526
00:17:13,249 --> 00:17:15,117
OVER THE YEARS BUT THE REAL

527
00:17:15,117 --> 00:17:16,485
CHALLENGE IS ENGAGEMENT, MAKING

528
00:17:16,485 --> 00:17:17,853
PEOPLE FEEL SAFE SHARING

529
00:17:17,853 --> 00:17:20,890
INFORMATION AND TRUSTING PEOPLE

530
00:17:20,890 --> 00:17:22,158
LIKE LEX AND PATTY WHEN THEY

531
00:17:22,158 --> 00:17:32,601
REACH OUT TO OFFER HELP. 

532
00:17:35,137 --> 00:17:38,607
SO NOW LET'S CHECK OUT THIS.

533
00:17:38,607 --> 00:17:40,109
USING THE SUMMARY, DEVELOPING

534
00:17:40,109 --> 00:17:41,043
SOCIAL SUPPORT QUESTIONS DEVELOP

535
00:17:41,043 --> 00:17:43,779
INDEED OUR PRIOR WORK,

536
00:17:43,779 --> 00:17:45,614
SUGGESTING ERRANDOMIZED TRIALS

537
00:17:45,614 --> 00:17:47,349
MEDICATION AND BILLING, OUR ARK

538
00:17:47,349 --> 00:17:49,018
STUDY AIMED TO SYSTEMATICALLY

539
00:17:49,018 --> 00:17:50,486
AND UNIVERSALLY OOH DENTIFY

540
00:17:50,486 --> 00:17:51,921
SOCIAL NEEDS AND SUPPORT DURING

541
00:17:51,921 --> 00:17:53,189
HOSPITALIZATION, THE GOAL WAS TO

542
00:17:53,189 --> 00:17:54,356
UNDERSTAND WHETHER AND HOW THIS

543
00:17:54,356 --> 00:17:56,959
INFORMATION CAN INFORM AND

544
00:17:56,959 --> 00:17:57,693
IMPROVE HOSPITAL DISCHARGE

545
00:17:57,693 --> 00:18:00,196
PLANNING, WE CONDUCTED A

546
00:18:00,196 --> 00:18:02,264
PRAGMATIC TRIAL INVOLVING OVER

547
00:18:02,264 --> 00:18:04,166
4000 DISCHARGES EXAMINING OW

548
00:18:04,166 --> 00:18:05,201
SCREENING INFLUENCED BOTH

549
00:18:05,201 --> 00:18:06,402
DISCHARGE PLANNING PROCESSES AND

550
00:18:06,402 --> 00:18:07,636
OUTCOMES.

551
00:18:07,636 --> 00:18:10,473
WE USED AN INTENT TO TREAT

552
00:18:10,473 --> 00:18:14,243
APPROACH AND SEGMENT ANALYSIS TO

553
00:18:14,243 --> 00:18:15,344
AFFECT LOOK AT CHANGES IN

554
00:18:15,344 --> 00:18:16,278
PRACTICE OVER TIME.

555
00:18:16,278 --> 00:18:17,513
THIS WAS CONDUCTED IN THE

556
00:18:17,513 --> 00:18:19,315
CONTEXT OF REAL WORLD CLINICAL

557
00:18:19,315 --> 00:18:20,916
CARE, SO RANDOMIZATION AT THE

558
00:18:20,916 --> 00:18:23,452
UNIT LEVEL WASN'T FEASIBLE WE

559
00:18:23,452 --> 00:18:24,854
USE A PRE-AND POST DESIGN WITH

560
00:18:24,854 --> 00:18:26,722
THE WASH OUT PERIOD BETWEEN

561
00:18:26,722 --> 00:18:26,956
PHASES.

562
00:18:26,956 --> 00:18:29,158
OUR HYPOTHESIS WAS THAT

563
00:18:29,158 --> 00:18:31,060
IDENTIFYING AND COMMUNICATING

564
00:18:31,060 --> 00:18:32,661
PATIENT NEEDS AND AVAILABLE

565
00:18:32,661 --> 00:18:33,295
SUPPORT DURING HOSPITALIZATION

566
00:18:33,295 --> 00:18:35,831
WOULD LEAD TO BETTER OUTCOMES BY

567
00:18:35,831 --> 00:18:36,365
STRENGTHENING INFORMATION

568
00:18:36,365 --> 00:18:38,033
BETWEEN CARE TEAMS AND IMPROVING

569
00:18:38,033 --> 00:18:41,537
QUALITY OF DISCHARGE PLANNING.

570
00:18:41,537 --> 00:18:43,506
AND THIS GRAPHIC ILLUSTRATES THE

571
00:18:43,506 --> 00:18:45,708
COMPONENTS OF THE INTERVENTION

572
00:18:45,708 --> 00:18:47,443
ITSELF, AT ADMISSION, UNIT BASE

573
00:18:47,443 --> 00:18:48,711
CASED MANAGERS COMPLETED SOCIAL

574
00:18:48,711 --> 00:18:49,545
NEEDS AND SOCIAL SUPPORT

575
00:18:49,545 --> 00:18:51,347
QUESTIONS AS PART OF THEIR

576
00:18:51,347 --> 00:18:52,781
INITIAL ASSESS AM, THE STUDY

577
00:18:52,781 --> 00:18:54,083
TEAM TRACKED PATIENTS WITH

578
00:18:54,083 --> 00:18:55,818
RESPONSES NOTED IN THE

579
00:18:55,818 --> 00:18:57,620
IDENTIFIED NEEDS AND THE IF,A

580
00:18:57,620 --> 00:18:58,621
CYSTANCE WAS REQUESTED.

581
00:18:58,621 --> 00:19:00,489
FOR PATIENT WITH IDENTIFIED

582
00:19:00,489 --> 00:19:02,892
NEEDS WE SENT ALERTS TO

583
00:19:02,892 --> 00:19:04,493
TEAPPEDDING PHYSICIANS FLAGGING

584
00:19:04,493 --> 00:19:05,561
THE RELEVANT INFORMATION, AND

585
00:19:05,561 --> 00:19:07,162
THEN OTHER TEAM MEMBERS COULD

586
00:19:07,162 --> 00:19:11,100
REVIEW THIS IN A DEDICATED

587
00:19:11,100 --> 00:19:12,601
SUMMARY DISCHARGE TAB, USE THE

588
00:19:12,601 --> 00:19:14,770
SUMMARY TO ADJUST PLANS AND

589
00:19:14,770 --> 00:19:18,607
ASHES JUST AS NEEDED.

590
00:19:18,607 --> 00:19:20,376
WE ALSO GATHERED ADDITIONAL

591
00:19:20,376 --> 00:19:22,211
OUTCOME DATA INCLUDING CAREGIVER

592
00:19:22,211 --> 00:19:23,646
AND NURSE REPORTED READINESS

593
00:19:23,646 --> 00:19:25,781
BOTH OF WHICH ALONG WITH PATIENT

594
00:19:25,781 --> 00:19:27,716
READINESS FOR ASSOCIATE WIDE

595
00:19:27,716 --> 00:19:29,218
READMISSION RISK AND OF COURSE

596
00:19:29,218 --> 00:19:32,655
WE FOLLOWED UP ON HEALTH SERVICE

597
00:19:32,655 --> 00:19:33,556
USE, MOST NOTABLY, 30 DAY

598
00:19:33,556 --> 00:19:35,190
ADMISSION TO THE HOSPITAL, AS

599
00:19:35,190 --> 00:19:38,827
WELL AS E. D.

600
00:19:38,827 --> 00:19:42,131
AND THESE TABLES HAVE HIGHLIGHTS

601
00:19:42,131 --> 00:19:43,899
DISCHARGE PROCESSES WITH A FOCUS

602
00:19:43,899 --> 00:19:45,200
ON OUTCOMES, FIRST WHETHER

603
00:19:45,200 --> 00:19:46,135
FAMILY INTERACTION WAS

604
00:19:46,135 --> 00:19:47,102
DOCUMENTED IN THE DISCHARGE PLAN

605
00:19:47,102 --> 00:19:48,837
AND SECOND, WHETHER THE

606
00:19:48,837 --> 00:19:50,472
DISCHARGE OCCURRED AFTER

607
00:19:50,472 --> 00:19:52,408
2:00 P.M., WHICH CAN DELAY CARE

608
00:19:52,408 --> 00:19:54,376
COORDINATION FOLLOW UP, FOR

609
00:19:54,376 --> 00:19:55,210
DOCUMENTED FAMILY INTERACTION,

610
00:19:55,210 --> 00:19:56,946
AND WE SAW MODEST BUT

611
00:19:56,946 --> 00:19:58,213
SIGNIFICANT EFFECT OVER TIME,

612
00:19:58,213 --> 00:20:00,049
SPECIFICALLY THE TIME AND TIME

613
00:20:00,049 --> 00:20:01,717
AFTER VARIABLE SHOWING OVERALL

614
00:20:01,717 --> 00:20:02,518
INCREASE IN DOCUMENTATION,

615
00:20:02,518 --> 00:20:09,358
INDEPENDENT OF THE

616
00:20:09,358 --> 00:20:10,960
INTERVENTIONAL TIME, BUT IN

617
00:20:10,960 --> 00:20:13,429
CONTRAST, THOSE OCCURS AFTER

618
00:20:13,429 --> 00:20:14,296
2:00 P.M. WERE MORE DIRECTLY

619
00:20:14,296 --> 00:20:15,598
ASSOCIATED WITH THE

620
00:20:15,598 --> 00:20:15,931
INTERVENTION.

621
00:20:15,931 --> 00:20:17,299
AFTER IMPLEMENTATION, PATIENTS

622
00:20:17,299 --> 00:20:20,636
IN THE INTERVENTION GROUP WERE

623
00:20:20,636 --> 00:20:22,404
SIGNIFICANTLY LESS LIKELY TO BE

624
00:20:22,404 --> 00:20:23,973
CHARGED AFTER 2 P.M.  THIS WAS

625
00:20:23,973 --> 00:20:26,909
NOT SUSTAINED BY OVER TIME, IT'S

626
00:20:26,909 --> 00:20:28,877
SHOWN BY TIME AFTER RESULT, SO

627
00:20:28,877 --> 00:20:30,946
TO SUM UP, WE SAW DISCHARGE

628
00:20:30,946 --> 00:20:32,381
TIMING AND COMMUNICATION

629
00:20:32,381 --> 00:20:33,983
PROCESSES, ESPECIALLY

630
00:20:33,983 --> 00:20:34,583
IMMEDIATELY FOLLOWING

631
00:20:34,583 --> 00:20:35,384
IMPLEMENTATION, BUT SUSTAINING

632
00:20:35,384 --> 00:20:44,994
THAT CHANGE WILL LIKELY REQUIRE

633
00:20:44,994 --> 00:20:45,728
ONGOING REINFORCEMENT.

634
00:20:45,728 --> 00:20:47,529
THIS IS TOLD TO ASSESS THE

635
00:20:47,529 --> 00:20:49,064
QUALITY OF DISCHARGE SUPPORT PER

636
00:20:49,064 --> 00:20:52,701
PATIENTS AND ASSOCIATED WITH THE

637
00:20:52,701 --> 00:20:54,670
READMISSIONS.

638
00:20:54,670 --> 00:20:56,438
AND UNFORTUNATELY THERE WAS NO

639
00:20:56,438 --> 00:20:58,107
NOTABLE CHANGE IN THE OPERATIONS

640
00:20:58,107 --> 00:21:02,611
AND EMERGENCY DEPARTMENT VISITS.

641
00:21:02,611 --> 00:21:05,147
BUT ARE THOSE THE ONLY QUESTIONS

642
00:21:05,147 --> 00:21:05,781
AND OUTCOMES?

643
00:21:05,781 --> 00:21:07,182
THANKFULLY BECAUSE WE CONDUCTED

644
00:21:07,182 --> 00:21:09,385
A MIXED METHOD STUDY THAT ALSO

645
00:21:09,385 --> 00:21:10,052
TRACKED IMPLEMENTATION OUTCOMES

646
00:21:10,052 --> 00:21:11,286
WE ARE ABLE TO SEE THERE WAS

647
00:21:11,286 --> 00:21:16,225
MUCH MORE TO THE STORY.

648
00:21:16,225 --> 00:21:18,861
IN THIS STUDY, 29% OF PATIENTS,

649
00:21:18,861 --> 00:21:21,063
ALMOST ONE-THIRD OF THOSE

650
00:21:21,063 --> 00:21:23,132
ASSESSED BY CASE MANAGERS WERE

651
00:21:23,132 --> 00:21:25,668
IDENTIFIED AS HAVING LESS THAN

652
00:21:25,668 --> 00:21:26,568
ADEQUATE HOME RESOURCES, WHAT'S

653
00:21:26,568 --> 00:21:29,405
IMPORTANT IS THAT RN ASSESSMENTS

654
00:21:29,405 --> 00:21:30,673
ALIGN WITH READINESS DISCHARGE

655
00:21:30,673 --> 00:21:32,941
REINFORCING THE VALUE OF NURSING

656
00:21:32,941 --> 00:21:34,576
INPUT IN SAFE DISCHARGE

657
00:21:34,576 --> 00:21:35,811
PLANNING, AND THIS HIGHLIGHTS

658
00:21:35,811 --> 00:21:37,279
HOW THE RNs USE THE UNIQUE

659
00:21:37,279 --> 00:21:38,280
SOCIAL INFORMATION WE COLLECTED

660
00:21:38,280 --> 00:21:40,449
AS PART OF THE STUDY, NOT JUST

661
00:21:40,449 --> 00:21:42,151
CLINICAL DADA TO MAKE THESE

662
00:21:42,151 --> 00:21:45,087
DETERMINATIONS AND TOP

663
00:21:45,087 --> 00:21:45,888
PREDICTERS OF INADEQUATE

664
00:21:45,888 --> 00:21:46,955
SUPPORT, IS HIGH CLINICAL RISK

665
00:21:46,955 --> 00:21:49,158
BUT ISN'T THAT SURPRISING, BUT

666
00:21:49,158 --> 00:21:50,459
LIMITED FAMILY OR SOCIAL SUPPORT

667
00:21:50,459 --> 00:21:52,728
AND FINANCIAL AND INSURANCE

668
00:21:52,728 --> 00:21:53,195
BARRIERS.

669
00:21:53,195 --> 00:21:54,329
A SOCIAL SUPPORT STANCE STOOD

670
00:21:54,329 --> 00:22:00,302
OUT AS A KEY FACTOR INFLUENCING

671
00:22:00,302 --> 00:22:00,769
RN JUDGMENT.

672
00:22:00,769 --> 00:22:03,005
AND THIS SLIDE SHOWS WHY RN

673
00:22:03,005 --> 00:22:04,206
SOCIAL ASSESSMENT MATTERED TO

674
00:22:04,206 --> 00:22:04,473
OUTCOMES.

675
00:22:04,473 --> 00:22:06,308
WE FOUND THAT PATIENTS WITHOUT

676
00:22:06,308 --> 00:22:08,277
SOCIAL SUPPORT HAD A GREATER

677
00:22:08,277 --> 00:22:10,512
LIKELIHOOD OF RETURNING TO E. D.

678
00:22:10,512 --> 00:22:12,247
WITHIN 30 DAYS AND IMPORTANTLY

679
00:22:12,247 --> 00:22:14,216
WHEN SOCIAL RISK INFORMATION WAS

680
00:22:14,216 --> 00:22:16,151
AVAILABLE IT DIRECTLY INFLUENCED

681
00:22:16,151 --> 00:22:17,786
DISCHARGE PLANNING.

682
00:22:17,786 --> 00:22:19,188
PATIENTS IDENTIFIED AS HAVING

683
00:22:19,188 --> 00:22:21,256
FEWER RESOURCES OR MORE LIKELY

684
00:22:21,256 --> 00:22:23,358
TO BE DISCHARGED TO HOME HEALTH

685
00:22:23,358 --> 00:22:25,360
OR SKILLED NURSING FACILITIES TO

686
00:22:25,360 --> 00:22:27,129
INSURE THEY ARE LINKED TO

687
00:22:27,129 --> 00:22:28,063
IMPORTANT SERVICES AND IT'S

688
00:22:28,063 --> 00:22:29,231
IMPORTANT TO NOTE THAT THESE

689
00:22:29,231 --> 00:22:32,334
CAME IN FROM FACILITYS, THEY

690
00:22:32,334 --> 00:22:33,135
CAME FROM HOME.

691
00:22:33,135 --> 00:22:36,171
SO THIS IS CLEAR, INDGREATING IN

692
00:22:36,171 --> 00:22:39,441
SOCIAL SCREENING CAN HELP PLAY

693
00:22:39,441 --> 00:22:43,679
AN IMPORTANT ROLE IN PREDICTING

694
00:22:43,679 --> 00:22:44,346
PATIENT DISCHARGE OUTCOMES.

695
00:22:44,346 --> 00:22:46,215
SO NOW LET'S FRAME THE

696
00:22:46,215 --> 00:22:47,249
IMPLEMENTATION DATA TO SEE WHERE

697
00:22:47,249 --> 00:22:51,887
THAT LEADS US NEXT.

698
00:22:51,887 --> 00:22:53,055
FROM THE DATA DISCHARGE THAT I

699
00:22:53,055 --> 00:22:54,656
JUST GAVE, WE HAVE A GOOD DEAL

700
00:22:54,656 --> 00:22:55,624
OF EVIDENCE OF HOW SOCIAL

701
00:22:55,624 --> 00:22:58,427
INFORMATION IS KEY TO THE

702
00:22:58,427 --> 00:23:00,729
CLINICAL DECISION MAKING BUT,

703
00:23:00,729 --> 00:23:02,931
DESPITE THAT, ONLY HALF OF

704
00:23:02,931 --> 00:23:03,766
PATIENTS ACTUALLY RECEIVE

705
00:23:03,766 --> 00:23:04,733
SCREENING AFTER IT WAS

706
00:23:04,733 --> 00:23:06,235
IMPLEMENTED IN THE UNIT AND

707
00:23:06,235 --> 00:23:10,873
ENGAGEMENT DROPPED OVER TIME,

708
00:23:10,873 --> 00:23:11,874
WHY IS THIS?

709
00:23:11,874 --> 00:23:13,575
THE CASE MANAGERS TOLD US THIS,

710
00:23:13,575 --> 00:23:15,677
THEY SEE SOCIAL SCREENING AS

711
00:23:15,677 --> 00:23:16,879
REDUNDANT WITH CURRENT

712
00:23:16,879 --> 00:23:17,479
ASSESSMENTS COMPLETED BY

713
00:23:17,479 --> 00:23:18,747
THEMSELVES AND OTHERS ON THE

714
00:23:18,747 --> 00:23:19,081
TEAM.

715
00:23:19,081 --> 00:23:20,816
THEY SEE IT AS OUTSIDE THEIR

716
00:23:20,816 --> 00:23:22,518
SCOPE OF PRACTICE AND THEY DON'T

717
00:23:22,518 --> 00:23:23,385
THINK SCREEN SUGGEST NECESSARY

718
00:23:23,385 --> 00:23:24,286
FOR EVERY PATIENT.

719
00:23:24,286 --> 00:23:25,454
THEY ARE SIMPLY OVERWHELMED BY

720
00:23:25,454 --> 00:23:26,755
THE IDEA OF KNOWING EVERY

721
00:23:26,755 --> 00:23:28,290
PATIENT IN THIS LEVEL OF DETAIL,

722
00:23:28,290 --> 00:23:29,558
THEY BELIEVE THEY COULD TELL WHO

723
00:23:29,558 --> 00:23:35,230
SHOULD BE ASKED THE QUESTIONS.

724
00:23:35,230 --> 00:23:36,498
THEY WERE ALSO HEAVILY

725
00:23:36,498 --> 00:23:37,766
INFLUENCED BY THE IDEA THAT THE

726
00:23:37,766 --> 00:23:38,967
INFORMATION WOULD GO UNUSED BY

727
00:23:38,967 --> 00:23:41,236
THE TEAM AND THAT THEY DIDN'T

728
00:23:41,236 --> 00:23:42,538
THINK THEY COULD OFFER SOLUTIONS

729
00:23:42,538 --> 00:23:43,939
FOR THE PATIENTS WITH NEEDS,

730
00:23:43,939 --> 00:23:46,108
THEY FELT THEY AND OTHERS

731
00:23:46,108 --> 00:23:47,042
COULDN'T DO ANYTHING WITH THE

732
00:23:47,042 --> 00:23:48,110
INFORMATION AND I WANT TO POINT

733
00:23:48,110 --> 00:23:49,845
OUT THAT THESE CONCERNS ARE NOT

734
00:23:49,845 --> 00:23:51,146
UNIQUE TO THESE NURSE CASE

735
00:23:51,146 --> 00:23:53,615
MANAGERS, THESE ARE VERY SIMILAR

736
00:23:53,615 --> 00:23:54,783
CONCERNED AS THOSE RAISED BY

737
00:23:54,783 --> 00:23:57,553
STAFF IN THE EARLY DAYS OF OUR

738
00:23:57,553 --> 00:24:02,157
SOCIAL NEEDS SCREENING IN THE E.

739
00:24:02,157 --> 00:24:02,624
D.

740
00:24:02,624 --> 00:24:03,559
WHEN ATTENDING PHYSICIANS WERE

741
00:24:03,559 --> 00:24:05,294
ASKED TO REFLECT ON INTEGRATING

742
00:24:05,294 --> 00:24:06,295
SOCIAL SCREENING AND DISCHARGE

743
00:24:06,295 --> 00:24:08,630
PLANNING, THERE WAS A STRONG

744
00:24:08,630 --> 00:24:09,698
SENSE OF SHARED RESPONSIBILITY

745
00:24:09,698 --> 00:24:11,233
AS 1 SURGEON PUT IT, I NEED TO

746
00:24:11,233 --> 00:24:13,068
MAKE SURE THAT THE CARE

747
00:24:13,068 --> 00:24:15,370
CONTINUES AFTER THE HOSPITAL.

748
00:24:15,370 --> 00:24:17,206
THIS SUGGESTS PHYSICIANS SEE

749
00:24:17,206 --> 00:24:18,473
CONTINUITY OF CARE AS PART OF

750
00:24:18,473 --> 00:24:21,076
THEIR ROLE EVEN WHEN IT EXTENDS

751
00:24:21,076 --> 00:24:23,478
BEYOND CLINICAL BOUNDARIES.

752
00:24:23,478 --> 00:24:24,446
PHYSICIANS RELIED ON INFORMAL

753
00:24:24,446 --> 00:24:26,048
COMMUNICATION NORMS TO ADDRESS

754
00:24:26,048 --> 00:24:27,416
SOCIAL NEEDS INITIATING

755
00:24:27,416 --> 00:24:28,250
CONVERSATIONS DIRECTLY WITH

756
00:24:28,250 --> 00:24:29,418
PATIENTS AND CASE MANAGERS

757
00:24:29,418 --> 00:24:31,620
WITHOUT A FORMAL PROCESS, FOR

758
00:24:31,620 --> 00:24:33,021
EXAMPLE, IF I SENSE A PATIENT

759
00:24:33,021 --> 00:24:34,656
HAS A MAJOR POST DISCHARGE NEED,

760
00:24:34,656 --> 00:24:37,226
I CAN THEM DIRECTLY AND LOOP IN

761
00:24:37,226 --> 00:24:38,393
CASE MANAGEMENT INFORMALLY.

762
00:24:38,393 --> 00:24:40,229
THIS KIND OF DISCRETIONARY ON

763
00:24:40,229 --> 00:24:41,763
THE FLY COORDINATION THOUGH,

764
00:24:41,763 --> 00:24:43,265
SHOWS INITIATIVE BUT IT ALSO

765
00:24:43,265 --> 00:24:44,566
POINTS TO VARIABILITY IN HOW

766
00:24:44,566 --> 00:24:47,102
NEEDS ARE ACTUALLY ADDRESSED.

767
00:24:47,102 --> 00:24:48,837
AND FINALLY, THERE'S TENSION

768
00:24:48,837 --> 00:24:52,107
BETWEEN LIMITED CONTROL AND HIGH

769
00:24:52,107 --> 00:24:53,208
ACCOUNTABILITY, 1 PHYSICIAN

770
00:24:53,208 --> 00:24:54,142
SHARED, I COORDINATED WITH

771
00:24:54,142 --> 00:24:56,211
SOCIAL WORKERS AND FAMILIES BUT

772
00:24:56,211 --> 00:24:57,880
I FEEL VASTLY LIMITED IN WHAT I

773
00:24:57,880 --> 00:25:00,148
CAN DO TO SUPPORT FAMILIES

774
00:25:00,148 --> 00:25:02,684
WITHOUT HOUSING OR INSURANCE,

775
00:25:02,684 --> 00:25:03,852
THE CAPTURES FRUSTRATION MANY

776
00:25:03,852 --> 00:25:05,787
CLINICIANS FEEL WHEN STRUCTURAL

777
00:25:05,787 --> 00:25:07,022
OR SYSTEMIC BARRIERS LIMIT THEIR

778
00:25:07,022 --> 00:25:08,790
ABILITY TO ACT EVEN WHEN THE

779
00:25:08,790 --> 00:25:11,226
NEED IS CLEAR.

780
00:25:11,226 --> 00:25:12,494
THESE INSIDES POINT TO

781
00:25:12,494 --> 00:25:14,329
OPPORTUNITIES FROM TEAM PATHWAY

782
00:25:14,329 --> 00:25:15,731
BASED SUPPORT AND POLICY LEVEL

783
00:25:15,731 --> 00:25:17,099
SOLUTIONS THAT,A LIEN

784
00:25:17,099 --> 00:25:21,904
RESPONSIBILITY WITH ACTUAL

785
00:25:21,904 --> 00:25:22,170
CAPACITY.

786
00:25:22,170 --> 00:25:25,574
SO THIS SLIDE TURNS US TO THE

787
00:25:25,574 --> 00:25:26,508
IMPLEMENTATION RESEARCH LODGEEC

788
00:25:26,508 --> 00:25:28,210
BE, TO MAP OUT OUR STUDY DESIGN

789
00:25:28,210 --> 00:25:31,013
AND LEARNING PROCESS, WE BEGAN

790
00:25:31,013 --> 00:25:32,447
BY IDENTIFYING THE DETERMINANTS,

791
00:25:32,447 --> 00:25:34,883
THE CONDITIONS WE KNOW COULD

792
00:25:34,883 --> 00:25:36,418
INFLUENCE IMPLEMENTATION.

793
00:25:36,418 --> 00:25:37,586
THESE INCLUDED STRONG EVIDENT

794
00:25:37,586 --> 00:25:39,988
QUALITY WITH PRIOR TRIALS AND

795
00:25:39,988 --> 00:25:41,723
EHR INTEGRATION ALREADY IN

796
00:25:41,723 --> 00:25:42,190
PLACE.

797
00:25:42,190 --> 00:25:43,492
CHALLENGES IN THE INTERSETTING

798
00:25:43,492 --> 00:25:46,962
LIKE BURN OUT, LOW PERCEIVED

799
00:25:46,962 --> 00:25:49,031
PRIORITY AND EXTERNAL

800
00:25:49,031 --> 00:25:49,865
LEADERSHIP, EXTERNAL DRIVES SUCH

801
00:25:49,865 --> 00:25:52,501
AS POLICIES AND REGULATIONS,

802
00:25:52,501 --> 00:25:54,803
INDIVIDUAL LEVELS LIKE STAFF,

803
00:25:54,803 --> 00:25:56,672
PATIENT ROLES, STIGMA AND MORAL

804
00:25:56,672 --> 00:25:59,074
DISTRESS, BASED ON THOSE WE LAID

805
00:25:59,074 --> 00:26:00,108
OUT OUR IMPLEMENTATION STRATEGIC

806
00:26:00,108 --> 00:26:03,312
PLAN EDGE IS, ADAPTING THE

807
00:26:03,312 --> 00:26:05,681
ORIGINAL PROTOCOL TO ENGAGE WORK

808
00:26:05,681 --> 00:26:07,382
FLOWS, ENGAGING STAFF EARLY AND

809
00:26:07,382 --> 00:26:08,684
BUILDING VISUAL INTEGRATION INTO

810
00:26:08,684 --> 00:26:09,651
THE EHR, HIRING STAFF

811
00:26:09,651 --> 00:26:11,486
SPECIFICALLY TO,A CYST WITH

812
00:26:11,486 --> 00:26:14,923
SCREENING AND EMBEDDING

813
00:26:14,923 --> 00:26:16,158
STRUCTURED FEEDBACK LOOPS.

814
00:26:16,158 --> 00:26:17,426
THESE STRATEGIES WERE MEANT TO

815
00:26:17,426 --> 00:26:19,428
ADDRESS REAL BARRIER BUT HERE'S

816
00:26:19,428 --> 00:26:22,030
THE KEY POINT, WE WEREN'T

817
00:26:22,030 --> 00:26:24,366
ENTIRELY SURE WHICH MECHANISMS

818
00:26:24,366 --> 00:26:26,401
WE WERE ACTIVATING, WOULD

819
00:26:26,401 --> 00:26:28,036
CONFIDENCE IMPROVE, WOULD

820
00:26:28,036 --> 00:26:29,204
COMMUNICATION GET BETTER, WOULD

821
00:26:29,204 --> 00:26:30,639
TEAM TRUST SHIFT, THAT'S WHAT WE

822
00:26:30,639 --> 00:26:35,544
NEED TO OTHER THAN, NOT JUST HOW

823
00:26:35,544 --> 00:26:36,979
THEY IMPROVED BUT WHAT HAPPENED.

824
00:26:36,979 --> 00:26:40,248
AND ON THE OUTCOME SLIDE, WE

825
00:26:40,248 --> 00:26:42,184
TRACKED STANDARD IMPLEMENTATION

826
00:26:42,184 --> 00:26:44,453
MEASURES LIKE MAINTENANCE AND

827
00:26:44,453 --> 00:26:45,854
ALSO PROCESSED COMMUNICATION AND

828
00:26:45,854 --> 00:26:47,456
DISCHARGE QUALITY AND 30 DAY

829
00:26:47,456 --> 00:26:48,190
RETURN VISITS.

830
00:26:48,190 --> 00:26:50,826
SO THIS MODEL GUIDED OUR

831
00:26:50,826 --> 00:26:53,228
APPROACH BUT IT SHOWED US WHERE

832
00:26:53,228 --> 00:26:56,098
MORE APPROACH WAS NEEDED

833
00:26:56,098 --> 00:26:57,399
ESPECIALLY IN CONNECTING

834
00:26:57,399 --> 00:26:58,834
STRATEGY TO IMPACT.

835
00:26:58,834 --> 00:27:00,135
SO WE DUG INTO THIS MORE

836
00:27:00,135 --> 00:27:02,304
RECENTLY TO SEE WHAT WE CAN

837
00:27:02,304 --> 00:27:03,638
REALLY IDENTIFY AS REASON STAFF

838
00:27:03,638 --> 00:27:06,041
ADOPTED THIS AS A PRACTICE.

839
00:27:06,041 --> 00:27:06,675
DESPITE STRONG MOTIVATION AND

840
00:27:06,675 --> 00:27:09,811
BELIEF IN THE VALUE OF

841
00:27:09,811 --> 00:27:11,646
SCREENING, FRONT LINE STAFF FACE

842
00:27:11,646 --> 00:27:13,382
TENSIONS THAT ARE HARD TO

843
00:27:13,382 --> 00:27:15,017
NEFFIGATE ALONE AND THAT LEEDS

844
00:27:15,017 --> 00:27:16,985
US TO A DEEPER TRUTH, INDIVIDUAL

845
00:27:16,985 --> 00:27:18,587
COMMITMENT IS NOT ENOUGH IF THE

846
00:27:18,587 --> 00:27:19,788
SYSTEM AROUND THEM ISN'T SAFE

847
00:27:19,788 --> 00:27:21,023
AND SUPPORTIVE.

848
00:27:21,023 --> 00:27:22,090
THIS FRAMEWORK HIGHLIGHTS

849
00:27:22,090 --> 00:27:22,958
LAYERED EXPERIENCE OF CLINICAL

850
00:27:22,958 --> 00:27:24,693
STAFF ON 1 HAND THEY FEEL A DEEP

851
00:27:24,693 --> 00:27:26,428
MORAL DRIVE TO RESPOND TO

852
00:27:26,428 --> 00:27:27,596
PATIENTS SOCIAL NEEDS, THEY

853
00:27:27,596 --> 00:27:28,897
RECOGNIZE THE CONNECTION BETWEEN

854
00:27:28,897 --> 00:27:30,732
THOSE NEEDS AND HELT OUTCOMES,

855
00:27:30,732 --> 00:27:33,468
BUT THEY ALSO EXPERIENCE

856
00:27:33,468 --> 00:27:36,338
UNCERTAINTY AROUND RURAL

857
00:27:36,338 --> 00:27:37,739
BOUNDARIES, DISCOMFORT

858
00:27:37,739 --> 00:27:38,840
NAVIGATING EMOTIONALLY COMPLEX

859
00:27:38,840 --> 00:27:39,808
CONVERSATIONS AND FRUSTRATION

860
00:27:39,808 --> 00:27:42,277
WHEN THERE'S NOWHERE TO REFER

861
00:27:42,277 --> 00:27:42,878
PATIENTS.

862
00:27:42,878 --> 00:27:44,579
SO ADOPTION DOESN'T DEPEND ON

863
00:27:44,579 --> 00:27:48,016
TRAINING AND KNOWLEDGE, IT

864
00:27:48,016 --> 00:27:49,151
CLARIFIES EXPECTATIONS, PROTECTS

865
00:27:49,151 --> 00:27:51,119
EMOTIONAL LABOR AND INSURES THAT

866
00:27:51,119 --> 00:27:55,123
WORK FLOWS AND TOOLS ALIGN WITH

867
00:27:55,123 --> 00:27:55,390
REALITIES.

868
00:27:55,390 --> 00:27:56,558
WHAT WE'RE SEEING HERE IS THAT

869
00:27:56,558 --> 00:27:57,726
THE DECISION TO SCREEN IS NOT

870
00:27:57,726 --> 00:27:59,261
JUST CAN I DO THIS, BUT ALSO

871
00:27:59,261 --> 00:28:02,731
LIKE WILL THIS BE SUPPORTED WHEN

872
00:28:02,731 --> 00:28:02,998
I DO?

873
00:28:02,998 --> 00:28:09,004
THAT DISTINCTION IS CRITICAL FOR

874
00:28:09,004 --> 00:28:09,971
IMPLEMENTATION SUCCESS.

875
00:28:09,971 --> 00:28:12,274
AND OUR DATA SUGGESTS THAT 1 OF

876
00:28:12,274 --> 00:28:14,342
THE MOST IMPORTANT AND OFFENSE

877
00:28:14,342 --> 00:28:15,977
OVERLOOKED FACTORS IN SUCCESSFUL

878
00:28:15,977 --> 00:28:17,579
SOCIAL NEEDS SCREENING AND

879
00:28:17,579 --> 00:28:18,447
PSYCHOLOGICAL SAFETY, NOT JUST

880
00:28:18,447 --> 00:28:20,382
FOR PATIENTS BUT ALSO FOR STAFF.

881
00:28:20,382 --> 00:28:22,417
SCREENING FOR SOCIAL NEED SYSTEM

882
00:28:22,417 --> 00:28:24,653
A RELATIONAL TASK, IT'S NOT JUST

883
00:28:24,653 --> 00:28:27,222
CHECKING BOXES, THESE QUESTIONS

884
00:28:27,222 --> 00:28:28,990
CAN SERVE AS HARD SHIFT, TRAUMA

885
00:28:28,990 --> 00:28:30,492
AND FEAR OF THE JUDGMENT, FOR

886
00:28:30,492 --> 00:28:32,527
PATIENTS IT MAY FEEL RISK TOW

887
00:28:32,527 --> 00:28:34,496
DISCLOSE BUT FOR STAFF IT CAN

888
00:28:34,496 --> 00:28:36,264
FEEL JUST AS VULNERABLE TO ASK

889
00:28:36,264 --> 00:28:37,232
ESPECIALLY WHEN THEY INSURE HOW

890
00:28:37,232 --> 00:28:38,600
THE INFORMATION WILL BE USED AND

891
00:28:38,600 --> 00:28:40,769
WHETHER THEY CAN TRULY HELP.

892
00:28:40,769 --> 00:28:42,838
FROM SYSTEM SCIENCE, WE KNOW

893
00:28:42,838 --> 00:28:44,940
THAT FAILURES ARE OFTEN SYSTEMIC

894
00:28:44,940 --> 00:28:46,975
AND NOT INDIVIDUAL AND THAT

895
00:28:46,975 --> 00:28:48,610
WORKPLACE CULTURE CAN SUPPRESS

896
00:28:48,610 --> 00:28:51,213
FEEDBACK AND REINFORCE SILENCE.

897
00:28:51,213 --> 00:28:54,216
IF STAFF DON'T FEEL SAFE RAISING

898
00:28:54,216 --> 00:28:54,783
CONCERNS OR DEVIATE FREE

899
00:28:54,783 --> 00:28:57,719
RADICALS GENERATED TASKS LISTS

900
00:28:57,719 --> 00:29:00,021
THESE MOMENTS OFTEN GET SKIPPED.

901
00:29:00,021 --> 00:29:02,724
BUT WHEN PSYCHOLOGICAL SAFETY IS

902
00:29:02,724 --> 00:29:03,758
PRESENT WE SEE DIFFERENT

903
00:29:03,758 --> 00:29:04,793
BEHAVIORS.

904
00:29:04,793 --> 00:29:07,662
IN OUR STUDY, A NURSE DOING

905
00:29:07,662 --> 00:29:09,030
DISCHARGE TO CLARIFY SOCIAL

906
00:29:09,030 --> 00:29:09,264
NEED.

907
00:29:09,264 --> 00:29:11,032
A CASE MANAGER SUGGESTING

908
00:29:11,032 --> 00:29:14,369
IMPROVEMENT AMS TO THE SCREENER

909
00:29:14,369 --> 00:29:15,637
ITSELF TEAMS INCLUDING ROUND

910
00:29:15,637 --> 00:29:16,938
DEBRIEFS NOT JUST IN CLINICAL

911
00:29:16,938 --> 00:29:18,707
METRICS AND WHAT THIS TELLS US

912
00:29:18,707 --> 00:29:20,442
IS THIS, IF WE WANT SOCIAL NEEDS

913
00:29:20,442 --> 00:29:21,710
SCREENING TO WORK AND NOT JUST

914
00:29:21,710 --> 00:29:23,378
BE A CHECK BOX, WE MEDE TO

915
00:29:23,378 --> 00:29:26,047
DESIGN SYSTEMS THAT FOSTER

916
00:29:26,047 --> 00:29:27,482
RELATIONAL TRUST AND

917
00:29:27,482 --> 00:29:29,184
PSYCHOLOGICAL SAFETY, BECAUSE

918
00:29:29,184 --> 00:29:31,253
ULTIMATELY THIS WORK ASKS

919
00:29:31,253 --> 00:29:33,255
EVERYONE, PATIENTS AND STAFF, TO

920
00:29:33,255 --> 00:29:35,157
BE JUST A LITTLE VULNERABLE, AND

921
00:29:35,157 --> 00:29:36,658
THAT ONLY WORKS AT THE

922
00:29:36,658 --> 00:29:42,797
ENVIRONMENT ITSELF IS SAFE.

923
00:29:42,797 --> 00:29:45,400
SO NOW LET'S TURN TO THIS

924
00:29:45,400 --> 00:29:47,702
VERSION THAT BUILDS ON AN

925
00:29:47,702 --> 00:29:50,472
EARLIER MODEL BY SOMETHING WE

926
00:29:50,472 --> 00:29:51,840
HADN'T ACTUALLY ARTICULATED.

927
00:29:51,840 --> 00:29:54,009
THE MECHANISMS WE BELIEVE ARE

928
00:29:54,009 --> 00:29:57,045
PLAGUED AND WHERE WE MIGHT GO

929
00:29:57,045 --> 00:29:57,879
NEXT.

930
00:29:57,879 --> 00:29:59,414
HERE ARE QUALITATIVE AND

931
00:29:59,414 --> 00:30:00,582
IMPLEMENTATION WORK, WE SAW

932
00:30:00,582 --> 00:30:01,750
SUCCESS WASN'T JUST ABOUT THE

933
00:30:01,750 --> 00:30:03,385
SCREENER IS BUILT INTO THE WORK

934
00:30:03,385 --> 00:30:05,153
FLOW OR INTEGRATED INTO THE EHR,

935
00:30:05,153 --> 00:30:12,060
IT CAME DOWN TO HOW  HOW CLINICS

936
00:30:12,060 --> 00:30:14,963
SUPPORTED THE TASK AND CARRIED

937
00:30:14,963 --> 00:30:18,066
IT OUT CLEARLY.

938
00:30:18,066 --> 00:30:19,768
THAT'S WHERE WE NEED A POWERFUL

939
00:30:19,768 --> 00:30:21,236
LENS, IT SUGJEFULTS PEOPLE ARE

940
00:30:21,236 --> 00:30:24,306
ABLE TO ENGAGE IN AND SUSTAIN

941
00:30:24,306 --> 00:30:26,141
MEANINGFUL ACTIONS WHEN 3 CORE

942
00:30:26,141 --> 00:30:28,043
NEEDS ARE MET, COMPETENCE, CAN I

943
00:30:28,043 --> 00:30:29,277
DO THIS WELL?

944
00:30:29,277 --> 00:30:30,445
RELATEDNESS DOES THIS MATTER TO

945
00:30:30,445 --> 00:30:33,982
THE PEOPLE I SERVE OR WORK WITH?

946
00:30:33,982 --> 00:30:35,617
AUTONOMY, DO I HAVE CONTROL HOW

947
00:30:35,617 --> 00:30:37,118
THIS FITS IN MY ROLE?

948
00:30:37,118 --> 00:30:38,887
WE SEE THESE REFLECTED IN THE

949
00:30:38,887 --> 00:30:39,154
DATA.

950
00:30:39,154 --> 00:30:40,522
CLINICIANS WERE ASKING, CAN I

951
00:30:40,522 --> 00:30:42,824
RESPOND IF A PATIENT SHARING

952
00:30:42,824 --> 00:30:43,592
SOMETHING SERIOUS?

953
00:30:43,592 --> 00:30:44,859
DOES IT REALLY HELP THE PATIENT

954
00:30:44,859 --> 00:30:46,361
OR IS IT JUST ANOTHER CHECK BOX

955
00:30:46,361 --> 00:30:48,730
IN DO I HAVE A SAY IN HOW THIS

956
00:30:48,730 --> 00:30:49,297
IS IMPLEMENTED?

957
00:30:49,297 --> 00:30:51,166
THESE ARE THE MECHANISMS WE

958
00:30:51,166 --> 00:30:53,702
BELIEVE SHAPE SUCCESS, AND BY

959
00:30:53,702 --> 00:30:55,203
IDENTIFYING THEM, WE NOW HAVE A

960
00:30:55,203 --> 00:30:59,007
PATH FORWARD, WE START DESIGNING

961
00:30:59,007 --> 00:31:00,075
IMPLEMENTATION STRATEGIES THAT

962
00:31:00,075 --> 00:31:01,710
SUPPORT CONFIDENCE, A SENSE OF

963
00:31:01,710 --> 00:31:04,012
RELATIONAL MEETING AND

964
00:31:04,012 --> 00:31:04,846
PROFESSIONAL AUTONOMY, INSTEAD

965
00:31:04,846 --> 00:31:07,415
OF ASSUMING THE WORK FLOW ALONE

966
00:31:07,415 --> 00:31:08,049
ISN'T ENOUGH.

967
00:31:08,049 --> 00:31:10,885
IN OTHER WORDS THIS THEORY SEES

968
00:31:10,885 --> 00:31:12,087
THAT SOCIAL NEEDS SCREENING IS

969
00:31:12,087 --> 00:31:13,321
AS MUCH ABOUT MOTIVATION AND

970
00:31:13,321 --> 00:31:15,257
MEANING AS IT IS ABOUT TOOLS AND

971
00:31:15,257 --> 00:31:15,557
TRAINING.

972
00:31:15,557 --> 00:31:16,958
AND THAT'S THE SHIFT

973
00:31:16,958 --> 00:31:23,131
IMPLEMENTATION SCIENCE HAS

974
00:31:23,131 --> 00:31:23,832
HELPED US MAKE.

975
00:31:23,832 --> 00:31:25,100
FRONT LINE INSIGHTS AREN'T GOING

976
00:31:25,100 --> 00:31:26,735
TO BE ENOUGH, WE NEED STRUCTURED

977
00:31:26,735 --> 00:31:28,236
WAYS TO UNDERSTAND WHAT WORKS,

978
00:31:28,236 --> 00:31:30,472
WHERE IT FAILS AND HOW TO ADAPT

979
00:31:30,472 --> 00:31:35,410
IT TO CONTINUE MOVING US

980
00:31:35,410 --> 00:31:35,777
FORWARD.

981
00:31:35,777 --> 00:31:38,613
THIS BRINGS US TO WHY HYBRID

982
00:31:38,613 --> 00:31:42,183
DESIGNS ARE SO, ESSENTIAL TO

983
00:31:42,183 --> 00:31:43,051
THIS WORK.

984
00:31:43,051 --> 00:31:45,487
AS WE JUST SAW ON THE ILM,

985
00:31:45,487 --> 00:31:46,187
UNDERSTANDING SOMETHING WORKS

986
00:31:46,187 --> 00:31:47,589
ISN'T ENOUGH, WE NEED TO

987
00:31:47,589 --> 00:31:48,657
UNDERSTAND HOW, WHY AND UNDER

988
00:31:48,657 --> 00:31:52,861
WHAT CONDITIONS IT CAN BE

989
00:31:52,861 --> 00:31:55,697
IMPLEMENTED SUSTAINABLY AND

990
00:31:55,697 --> 00:31:56,197
EQUITABLY.

991
00:31:56,197 --> 00:31:58,300
THIS IS WHERE HIGH SCALING

992
00:31:58,300 --> 00:31:59,801
SOLUTIONS MY A HIGH CLINICAL

993
00:31:59,801 --> 00:32:00,302
ROLE.

994
00:32:00,302 --> 00:32:02,270
THEY ALLOW US TO LOOK AT PROESES

995
00:32:02,270 --> 00:32:03,438
ISS SIMULTANEOUSLY WHICH IS

996
00:32:03,438 --> 00:32:04,739
ESSENTIAL WHEN YOU ARE TRYING TO

997
00:32:04,739 --> 00:32:06,241
RELATE TO SOMETHING ESSENTIAL

998
00:32:06,241 --> 00:32:08,543
AND COMPLEX AS SOCIAL SCREENING.

999
00:32:08,543 --> 00:32:10,645
EQUALLY IMPORTANT WASSURE MIXED

1000
00:32:10,645 --> 00:32:11,379
USE METHODS, QUANTITATIVE DATA

1001
00:32:11,379 --> 00:32:13,915
TOLD US WHAT WAS HAPPENING BUT

1002
00:32:13,915 --> 00:32:14,883
QUALITATIVE INSIGHTS TOLD US

1003
00:32:14,883 --> 00:32:19,321
WHY, THAT'S HOW WE WERE ABLE TO

1004
00:32:19,321 --> 00:32:21,456
UNCOVER COMECHANISMS LIKE

1005
00:32:21,456 --> 00:32:22,524
PSYCHOLOGICAL SAFETY AND TEAM

1006
00:32:22,524 --> 00:32:22,757
CLARITY.

1007
00:32:22,757 --> 00:32:24,492
AND AS WE THINK ABOUT MOVING

1008
00:32:24,492 --> 00:32:26,361
THIS FORWARD TOWARDS WIDE SPREAD

1009
00:32:26,361 --> 00:32:28,697
ADOPTION IMPACT, IT'S HYBRID

1010
00:32:28,697 --> 00:32:30,899
MIXED METHOD SCIENCE THAT GIVES

1011
00:32:30,899 --> 00:32:32,734
US THE CLEAREST PATH NOT JUST TO

1012
00:32:32,734 --> 00:32:33,601
BUILD EVERYDAYS BUT DESIGN

1013
00:32:33,601 --> 00:32:36,438
SYSTEMS WHERE THE EVIDENCE COMES

1014
00:32:36,438 --> 00:32:36,905
TO LIFE.

1015
00:32:36,905 --> 00:32:39,374
AND THIS SLIDE HELPS ILLUSTRATE

1016
00:32:39,374 --> 00:32:40,709
WHERE WE CAN'T AFFORD TO STAY

1017
00:32:40,709 --> 00:32:42,744
LOCKED IN THE TRADITIONAL

1018
00:32:42,744 --> 00:32:45,080
RESEARCH PIPELINE, WHEN WE

1019
00:32:45,080 --> 00:32:46,348
SEPARATE EFFICACY, EFFECTIVENESS

1020
00:32:46,348 --> 00:32:49,551
AND IN A RIGID SEQUENTIAL FACES

1021
00:32:49,551 --> 00:32:51,486
WHAT HAPPEN SYSTEM WE GENERATE

1022
00:32:51,486 --> 00:32:53,788
PROMISING INTERVENTIONS BUT THEY

1023
00:32:53,788 --> 00:32:55,323
REMAIN STUCK INITEOLATED PILOTS,

1024
00:32:55,323 --> 00:32:56,825
THEY DON'T SCALE AND THEY DON'T

1025
00:32:56,825 --> 00:32:59,894
SUSTAIN AND THEY RARELY MAKE IT

1026
00:32:59,894 --> 00:33:01,262
TO THE ROUTINE CARE IN A

1027
00:33:01,262 --> 00:33:01,930
MEANINGFUL WAY.

1028
00:33:01,930 --> 00:33:03,998
YOU CAN SEE HERE ALL PIPELINES

1029
00:33:03,998 --> 00:33:06,234
STOPPING SHORT OF REAL WORLD

1030
00:33:06,234 --> 00:33:07,869
IMPACT, THIS FRAGMENTATION MEANS

1031
00:33:07,869 --> 00:33:09,537
EACH TEAM REINVEBTS THE WHEEL

1032
00:33:09,537 --> 00:33:11,306
AND STRONG EVIDENCE MAY NOT

1033
00:33:11,306 --> 00:33:12,674
TRANSLATE INTO PRACTICE.

1034
00:33:12,674 --> 00:33:13,942
THIS IS ESPECIALLY PROBLEMATIC

1035
00:33:13,942 --> 00:33:16,010
FOR SOCIAL NEEDS SCREENING WHERE

1036
00:33:16,010 --> 00:33:17,312
CONTEXT SEEMS TO MATTER SO MUCH.

1037
00:33:17,312 --> 00:33:20,081
SCREENING IN THE E. D. ISN'T THE

1038
00:33:20,081 --> 00:33:22,283
SAME AS SCREENING IN OB OR

1039
00:33:22,283 --> 00:33:24,686
PRIMARY CARE OR OVERALL HEALTH

1040
00:33:24,686 --> 00:33:27,255
SYSTEM, TO AVOID THESE

1041
00:33:27,255 --> 00:33:29,190
DISCONNECTIVE PILOTS WE NEED TO

1042
00:33:29,190 --> 00:33:29,924
DESIGN FOR SPREAD AND

1043
00:33:29,924 --> 00:33:31,059
SUSTAINABILITY FROM THE START

1044
00:33:31,059 --> 00:33:33,261
AND THAT'S WHAT HYBRID SCIENCE

1045
00:33:33,261 --> 00:33:34,028
AND IMPLEMENTATION SCIENCE ALLOW

1046
00:33:34,028 --> 00:33:34,896
US TO DO.

1047
00:33:34,896 --> 00:33:37,565
THEY HELP US ASK NOT JUST WHAT

1048
00:33:37,565 --> 00:33:39,734
WORKS BUT WHAT WORKS WHERE, FOR

1049
00:33:39,734 --> 00:33:41,436
WHOM AND UNDER WHAT CONDITIONS

1050
00:33:41,436 --> 00:33:43,138
AND THAT'S WHAT MOVES US FROM

1051
00:33:43,138 --> 00:33:46,741
INNOVATION TO REAL HEALTH SYSTEM

1052
00:33:46,741 --> 00:33:47,108
TRANSFORMATION.

1053
00:33:47,108 --> 00:33:48,376
TO AVOID THE FRAGMENTATION WE

1054
00:33:48,376 --> 00:33:51,446
JUST SAW AND MOVE TOWARDS

1055
00:33:51,446 --> 00:33:52,480
SCALABLE SUSTAINABLE SYSTEM

1056
00:33:52,480 --> 00:33:54,182
CHANGE REALLY TO UNDERSTANDING

1057
00:33:54,182 --> 00:33:56,384
AND ACTING UPON SOCIAL NEEDS, WE

1058
00:33:56,384 --> 00:33:58,753
NEED MORE THAN JUST GOOD

1059
00:33:58,753 --> 00:34:00,188
EVIDENCE, WE NEED

1060
00:34:00,188 --> 00:34:01,823
INFRASTRUCTURE, HERE WE HAVE 5

1061
00:34:01,823 --> 00:34:02,857
ESSENTIAL BUILDING BLOCKS THAT

1062
00:34:02,857 --> 00:34:04,058
SUPPORT THE TRANSITION FROM

1063
00:34:04,058 --> 00:34:06,127
PROMISING SOCIAL NEEDS PILOT TO

1064
00:34:06,127 --> 00:34:07,629
REAL WORLD PRACTICE ACROSS

1065
00:34:07,629 --> 00:34:09,831
SYSTEMS, BUT FIRST WE NEED TO

1066
00:34:09,831 --> 00:34:10,999
ALIEVEN FUNDING, SHARED

1067
00:34:10,999 --> 00:34:11,699
INVESTMENTS AND LONG-TERM

1068
00:34:11,699 --> 00:34:12,534
INFRANCIS COLLINS STRNTHURE LIKE

1069
00:34:12,534 --> 00:34:14,903
DID SHE BOARDS OR WORKFORCE ONLY

1070
00:34:14,903 --> 00:34:16,137
HAPPENS WHEN FUNDERS AND

1071
00:34:16,137 --> 00:34:17,405
IMPLEMENTERS ARE WORKING FROM

1072
00:34:17,405 --> 00:34:19,274
THE SAME BLUEPRINT.

1073
00:34:19,274 --> 00:34:21,609
WE ALSO NEED TO STRENGTHEN

1074
00:34:21,609 --> 00:34:22,444
LEADERSHIP COMMITMENT.

1075
00:34:22,444 --> 00:34:24,112
WITHOUT IT, METRICS AND

1076
00:34:24,112 --> 00:34:32,787
PRIORITIES DRIFT AND WITH IT WE

1077
00:34:32,787 --> 00:34:35,423
GET CONSISTENT APPLICATION OF

1078
00:34:35,423 --> 00:34:36,591
METRICS AND PRIORITIES ACROSS

1079
00:34:36,591 --> 00:34:39,794
SITES, WE NEED TO MIC SURE IT

1080
00:34:39,794 --> 00:34:41,763
ENSURES METRICS, AND SUPPORTS

1081
00:34:41,763 --> 00:34:43,164
INTEROPERABILITY ASK CONSIST EPT

1082
00:34:43,164 --> 00:34:44,799
MEASURE:  WE NEED SYSTEMS THAT

1083
00:34:44,799 --> 00:34:45,533
SUPPORT INTEROPERABILITY AND

1084
00:34:45,533 --> 00:34:47,001
MAKE IT EASY TO MEASURE WHAT

1085
00:34:47,001 --> 00:34:49,604
MATTERS IN CONSISTENT WAYS AND

1086
00:34:49,604 --> 00:34:50,238
FINALLY, STANDARDIZED METRICS,

1087
00:34:50,238 --> 00:34:52,740
SO THAT THE DATA FROM 1 SITE

1088
00:34:52,740 --> 00:34:54,442
MEANS SOMETHING TO ANOTHER,

1089
00:34:54,442 --> 00:34:55,610
WITHOUT THIS WE CAN'T SCALE OR

1090
00:34:55,610 --> 00:34:59,047
COMPARE AND THIS IS A GROWING

1091
00:34:59,047 --> 00:34:59,881
PRIORITY THAT'S HIGHLIGHTED IN

1092
00:34:59,881 --> 00:35:01,149
RECENT WORK.

1093
00:35:01,149 --> 00:35:02,417
AND TOGETHER THESE BUILDING

1094
00:35:02,417 --> 00:35:05,887
BLOCKS HELP US SHAPE ISOLATED

1095
00:35:05,887 --> 00:35:11,259
INNOVATION TO COORDINATED SYSTEM

1096
00:35:11,259 --> 00:35:12,794
LEVEL IMPACT.

1097
00:35:12,794 --> 00:35:13,862
AND TO TRULY SUPPORT SYSTEM

1098
00:35:13,862 --> 00:35:15,630
CHANGE WE NEED TO BUILD EVIDENCE

1099
00:35:15,630 --> 00:35:17,432
BASED AROUND WHAT IT TAKES TO

1100
00:35:17,432 --> 00:35:19,033
INTEGRATE SOCIAL AND HEGHT CARE.

1101
00:35:19,033 --> 00:35:20,902
THIS SLIDE SHOWS KEY FOCUS AREAS

1102
00:35:20,902 --> 00:35:22,437
WE'RE STUDYING IN OUR CURRENT

1103
00:35:22,437 --> 00:35:23,872
PROGECS EACH OF WHICH CONNECTS

1104
00:35:23,872 --> 00:35:25,773
DIRECTLY TO THE CHALLENGES I

1105
00:35:25,773 --> 00:35:28,142
DISCUSSED TODAY.

1106
00:35:28,142 --> 00:35:29,978
SCREENING AND REFERRAL WE'RE

1107
00:35:29,978 --> 00:35:31,579
COMPARING APPROACHES ACROSS

1108
00:35:31,579 --> 00:35:32,547
POPULATIONS AND PLATFORMS,

1109
00:35:32,547 --> 00:35:34,182
WHETHER THE EHR OR USING

1110
00:35:34,182 --> 00:35:35,350
EXTERNAL SYSTEMS LIKE SALES

1111
00:35:35,350 --> 00:35:36,651
FORCE TO UNDERSTAND WHAT WORKS

1112
00:35:36,651 --> 00:35:38,319
BEST AND WHERE, WE ARE ALSO

1113
00:35:38,319 --> 00:35:41,456
INVESTING IN PATIENT ENGAGEMENT,

1114
00:35:41,456 --> 00:35:44,559
TESTING STRATEGIES LIKE LAB

1115
00:35:44,559 --> 00:35:46,160
COLLABORATIVE GOAL SETTING, SO

1116
00:35:46,160 --> 00:35:48,329
PATIENTS AREN'T JUST SCREENED,

1117
00:35:48,329 --> 00:35:49,063
THEY'RE SUPPORTED.

1118
00:35:49,063 --> 00:35:50,732
AND WE'RE LOOKING BEYOND METRICS

1119
00:35:50,732 --> 00:35:52,333
TO PATIENT REPORTED OUTCOMES AND

1120
00:35:52,333 --> 00:35:53,034
REAL WORLD SERVICE

1121
00:35:53,034 --> 00:35:54,068
CONNECTIONINGS OUT IN THE

1122
00:35:54,068 --> 00:35:54,469
COMMUNITY.

1123
00:35:54,469 --> 00:35:57,705
WE'RE STUDYING STAFF ENGAGEMENT.

1124
00:35:57,705 --> 00:35:59,474
HOW CONFIDENCE AND ROLE

1125
00:35:59,474 --> 00:36:02,710
INFLUENCES SUCCESS AND THIS IS

1126
00:36:02,710 --> 00:36:04,245
CRITICAL FOR SUSTAINABILITY AND

1127
00:36:04,245 --> 00:36:04,579
SCALING.

1128
00:36:04,579 --> 00:36:07,015
AND SPREEKING OF SUSTAINABILITY,

1129
00:36:07,015 --> 00:36:08,283
WE'RE EXAMINING THESE TESTING

1130
00:36:08,283 --> 00:36:10,785
DIGITAL TOOLS THAT CAN EXTEND

1131
00:36:10,785 --> 00:36:12,120
NAVIGATION SUPPORT WITHOUT

1132
00:36:12,120 --> 00:36:12,754
OVERBURDENING CLINICAL TEAMS

1133
00:36:12,754 --> 00:36:14,656
WITH THE MOST RECENT NINR FUNDED

1134
00:36:14,656 --> 00:36:16,090
STUDY AND EACH OF THESE REFLECTS

1135
00:36:16,090 --> 00:36:18,126
A PART OF THE SYSTEM THAT MUST

1136
00:36:18,126 --> 00:36:19,928
BE ONLINE AND WE'RE LEARNING IN

1137
00:36:19,928 --> 00:36:21,095
REALTIME THROUGH ONGOING STUDIES

1138
00:36:21,095 --> 00:36:22,730
WHAT IT MAKES TO MAKE THE

1139
00:36:22,730 --> 00:36:29,737
INTEGRATION EFFECTIVE AND

1140
00:36:29,737 --> 00:36:30,071
SUSTAINABLE.

1141
00:36:30,071 --> 00:36:31,706
LET'S EPPED BY ZOOMING OUT FROM

1142
00:36:31,706 --> 00:36:33,708
WHERE WE BEGAN BY WHAT WE SEE IN

1143
00:36:33,708 --> 00:36:34,776
THE EHR.

1144
00:36:34,776 --> 00:36:36,511
A TYPICAL SCREENING RESULT MIGHT

1145
00:36:36,511 --> 00:36:38,346
LOOK LIKE AICISMEM CHECK BOX OR

1146
00:36:38,346 --> 00:36:48,756
FLAGGED RISK, A HOUSING

1147
00:36:50,124 --> 00:36:51,092
INSECURITY, AND FOOD, AND WHAT

1148
00:36:51,092 --> 00:36:53,628
WE SEE FROM THIS SHEET IS A

1149
00:36:53,628 --> 00:36:55,396
SNAPSHOT CAPTURE INDEED DATA AND

1150
00:36:55,396 --> 00:36:55,597
TIME.

1151
00:36:55,597 --> 00:36:57,532
BEHIND IT IS A REAL PERSON, WITH

1152
00:36:57,532 --> 00:36:59,801
A FAMILY, STORY, HOME, LIFE AND

1153
00:36:59,801 --> 00:37:04,872
STRUGGLING WITH A CHRONIC

1154
00:37:04,872 --> 00:37:05,640
CONDITION.

1155
00:37:05,640 --> 00:37:06,941
THESE PHOTOS REMIND US AGAIN,

1156
00:37:06,941 --> 00:37:08,343
THIS WORK MATTERS FOR EVERY

1157
00:37:08,343 --> 00:37:10,311
PATIENT, WHETHER IT'S THE PARENT

1158
00:37:10,311 --> 00:37:12,380
CHOOSING BETWEEN MEDICATION, THE

1159
00:37:12,380 --> 00:37:14,048
OLDER ADULT NAVIGATING MOBILITY

1160
00:37:14,048 --> 00:37:15,416
ANDITEOLATION OR THE COUPLE

1161
00:37:15,416 --> 00:37:18,586
TRYING TO SIMPLY LIVE WELL AND

1162
00:37:18,586 --> 00:37:20,221
LIVE WITH DIGNITY, THIS IS WHO

1163
00:37:20,221 --> 00:37:21,022
WE DESIGN THANKSGIVING FOR.

1164
00:37:21,022 --> 00:37:22,223
WHEN WE TALK ABOUT SOCIAL NEEDS

1165
00:37:22,223 --> 00:37:23,825
AND CARE, IT'S NOT JUST ABOUT

1166
00:37:23,825 --> 00:37:25,026
BUILDING A BETTER WORK FLOW,

1167
00:37:25,026 --> 00:37:26,094
IT'S ABOUT MAKING SURE

1168
00:37:26,094 --> 00:37:26,828
HEALTHCARE MEETS PEOPLE WHERE

1169
00:37:26,828 --> 00:37:28,496
THEY ARE AND REFLECTS WHAT THEY

1170
00:37:28,496 --> 00:37:30,431
ACTUALLY NEED TO LIVE WELL.

1171
00:37:30,431 --> 00:37:31,966
SO AS WE BUILD THESE SYSTEMS,

1172
00:37:31,966 --> 00:37:34,002
LET'S REMEMBER FROM THE

1173
00:37:34,002 --> 00:37:37,872
INDIVIDUAL TO THE SYSTEM, THIS

1174
00:37:37,872 --> 00:37:38,773
SCIENCE, THIS NEARING SCIENCE

1175
00:37:38,773 --> 00:37:41,709
AND ABOUT EVERY PATIENT WE

1176
00:37:41,709 --> 00:37:41,943
SERVE.

1177
00:37:41,943 --> 00:37:43,344
AND WHAT WE'VE DONE IN THE PAST

1178
00:37:43,344 --> 00:37:44,879
AND WHAT WE'RE DOING NOW IS

1179
00:37:44,879 --> 00:37:46,247
GREAT, BUT NOW LET'S TALK ABOUT

1180
00:37:46,247 --> 00:37:51,085
YOU HOY WOO WILL CHARGE FORWARD.

1181
00:37:51,085 --> 00:37:53,755
OUR TEAM IS CURRENTLY WORKING ON

1182
00:37:53,755 --> 00:37:56,524
AN RCT OF AN EHR INTEGRATED

1183
00:37:56,524 --> 00:37:58,860
KREENING AND REFERRAL SYSTEM FOR

1184
00:37:58,860 --> 00:38:00,028
COMMUNITY BASED ORGANIZATIONS,

1185
00:38:00,028 --> 00:38:01,496
SOME OF WHICH I TALK ABOUT

1186
00:38:01,496 --> 00:38:03,931
TODAY, BUT WE HAVE SO MUCH MORE

1187
00:38:03,931 --> 00:38:05,967
ON THE HORIZON BUT THE REALITY

1188
00:38:05,967 --> 00:38:07,935
IS THAT A LOT OF WHAT IS

1189
00:38:07,935 --> 00:38:10,004
IMPLEMENTED IN OUR CARE SYSTEMS

1190
00:38:10,004 --> 00:38:12,407
IS WITHOUT RIGOROUS STUDY, MANY

1191
00:38:12,407 --> 00:38:14,942
SUCH AS THOSE LISTED HERE ARE

1192
00:38:14,942 --> 00:38:18,012
EXCITING INNOVATIONS BUT REAL

1193
00:38:18,012 --> 00:38:19,881
WORLD EVALUATIONS OF

1194
00:38:19,881 --> 00:38:21,883
EFFECTIVENESS, SUSTAINABILITY OR

1195
00:38:21,883 --> 00:38:22,550
SCALABILITY, IMPLEMENTATION

1196
00:38:22,550 --> 00:38:23,618
OUTPACES OUR UNDERSTANDING OF

1197
00:38:23,618 --> 00:38:25,586
WHAT WORKING FOR WHOM AND IN

1198
00:38:25,586 --> 00:38:27,088
WHAT CONTEXT AND OFTEN PATIENT'S

1199
00:38:27,088 --> 00:38:31,426
VOICE IS ABSENT IN PROWR

1200
00:38:31,426 --> 00:38:36,564
OUTCOMES EVALUATION AND MUST BE

1201
00:38:36,564 --> 00:38:36,831
INCLUDED.

1202
00:38:36,831 --> 00:38:39,233
SO AS WE THINK ABOUT SOCIAL

1203
00:38:39,233 --> 00:38:41,069
INTERVENTIONS, WE NEED TO BE

1204
00:38:41,069 --> 00:38:43,371
CLEAR, THIS MUST INVOLVE NURSING

1205
00:38:43,371 --> 00:38:43,838
SCIENCE.

1206
00:38:43,838 --> 00:38:45,673
NURSES ARE UNIQUELY POSITIONS TO

1207
00:38:45,673 --> 00:38:46,841
BRIDGE EVERY LAYER OF CARE FROM

1208
00:38:46,841 --> 00:38:47,809
THE PATIENT AND FAMILY AT THE

1209
00:38:47,809 --> 00:38:50,578
CENTER TO THE BROADER NETWORK OF

1210
00:38:50,578 --> 00:38:51,012
COMMUNITY PARTNERS.

1211
00:38:51,012 --> 00:38:53,214
WE'RE PART OF THE DIRECT CARE

1212
00:38:53,214 --> 00:38:53,581
TEAM.

1213
00:38:53,581 --> 00:38:54,949
WE LEAD CARE COORDINATION.

1214
00:38:54,949 --> 00:38:57,118
AND WE SERVE AS THE CONNECTATIVE

1215
00:38:57,118 --> 00:38:59,620
TISSUE ACROSS DISCIPLINES AND

1216
00:38:59,620 --> 00:38:59,954
SETTINGS.

1217
00:38:59,954 --> 00:39:03,057
THIS BIG RED ARROW REPRESENTS

1218
00:39:03,057 --> 00:39:05,093
THE VERTICAL REACH OF NURSES,

1219
00:39:05,093 --> 00:39:07,695
THEY OPERATE ACROSS ALL LEVELS

1220
00:39:07,695 --> 00:39:08,996
OFTEN SIMULTANEOUSLY, THAT GIVES

1221
00:39:08,996 --> 00:39:10,331
THEM CRITICAL INSIGHT INTO

1222
00:39:10,331 --> 00:39:11,899
WHAT'S WORKING AND WHERE SYSTEMS

1223
00:39:11,899 --> 00:39:12,500
ARE BREAKING DOWN.

1224
00:39:12,500 --> 00:39:14,368
BUT IT ALSO MEANS THAT NURSING

1225
00:39:14,368 --> 00:39:16,070
SCIENCE BRINGS THE LENS WE NEED

1226
00:39:16,070 --> 00:39:18,239
TO MOVE BEYOND PILOTS AND INTO

1227
00:39:18,239 --> 00:39:20,541
SUSTAINABLE SYSTEMS THAT IMPROVE

1228
00:39:20,541 --> 00:39:21,008
HEALTHCARE.

1229
00:39:21,008 --> 00:39:22,410
WHETHER IT'S UNDERSTANDING

1230
00:39:22,410 --> 00:39:23,111
PATIENT CONTEXT, DESIGNING WORK

1231
00:39:23,111 --> 00:39:24,746
FLOWS THAT WORK IN REAL WORLD

1232
00:39:24,746 --> 00:39:26,247
CARE ENVIRONMENTS OR BUILDING

1233
00:39:26,247 --> 00:39:27,849
TRUST WITHIN TEAMSES ARE NURSING

1234
00:39:27,849 --> 00:39:32,587
SCIENCE ISN'T JUST HELPFUL HERE,

1235
00:39:32,587 --> 00:39:33,154
IT'S ESSENTIAL.

1236
00:39:33,154 --> 00:39:35,123
AND THIS IS WHERE NURSE

1237
00:39:35,123 --> 00:39:36,290
SCIENTISTS BRING ENORMOUS VALUE,

1238
00:39:36,290 --> 00:39:38,359
AND WHERE WE MUST CONTINUE

1239
00:39:38,359 --> 00:39:38,893
INVESTING.

1240
00:39:38,893 --> 00:39:40,895
WE NEED TO PLACE GREATER

1241
00:39:40,895 --> 00:39:42,830
EMPHASIS AND TRAINING ON SKILLS

1242
00:39:42,830 --> 00:39:44,699
THAT ARE ALREADY PROVING

1243
00:39:44,699 --> 00:39:46,000
ESSENTIAL FOR IMPACT, COMMUNITY

1244
00:39:46,000 --> 00:39:47,735
ENGAGEMENT WHICH BUILDS TRUST

1245
00:39:47,735 --> 00:39:53,241
AND INSURING INTERVENTIONS ARE

1246
00:39:53,241 --> 00:39:55,309
RELEVANT, DEVELOPING FLU

1247
00:39:55,309 --> 00:39:56,911
ENSELLING IN MULTILEVEL CROSS

1248
00:39:56,911 --> 00:39:59,814
SECTOR DATA ASK ANALYTICS, A

1249
00:39:59,814 --> 00:40:01,149
MUST FOR EVALUATING COMPLEX

1250
00:40:01,149 --> 00:40:03,451
INTERVENTIONS ACROSS HEALTH AND

1251
00:40:03,451 --> 00:40:04,385
SOCIAL SYSTEMS.

1252
00:40:04,385 --> 00:40:12,894
STRENGTH EVENING THESE

1253
00:40:12,894 --> 00:40:14,729
CAPABILITIES HELPS NURSES TO

1254
00:40:14,729 --> 00:40:16,798
EVALUATION REAL WORLD ACCESS AND

1255
00:40:16,798 --> 00:40:18,065
SUSTAINABILITY OF COMMUNITY

1256
00:40:18,065 --> 00:40:18,499
BASED ORGANIZATIONS.

1257
00:40:18,499 --> 00:40:21,235
THIS KIND OF WORK GENERATES

1258
00:40:21,235 --> 00:40:22,737
EVIDENCE THAT DRIVES SYSTEM

1259
00:40:22,737 --> 00:40:25,873
LEVEL CHANGE IMPROVING OUTCOMES,

1260
00:40:25,873 --> 00:40:27,108
REDUCING AVOIDABLE UTILIZATION,

1261
00:40:27,108 --> 00:40:28,409
ADDRESSING DISPARITIES AND

1262
00:40:28,409 --> 00:40:29,777
BUILDING MODELS THAT ARE

1263
00:40:29,777 --> 00:40:30,311
SCALABLE AND SUSTAINABLE.

1264
00:40:30,311 --> 00:40:32,814
SO AS WE LOOK AHEAD TRAINING THE

1265
00:40:32,814 --> 00:40:33,748
NEXT GENERATION OF NURSE

1266
00:40:33,748 --> 00:40:34,916
SCIENTISTS AND CORE AREAS WILL

1267
00:40:34,916 --> 00:40:40,054
BE KEY TO ADVANCING HEALTH AND

1268
00:40:40,054 --> 00:40:40,354
HEALTHCARE.

1269
00:40:40,354 --> 00:40:41,689
SO AS WE CLOSE, I WANT TO

1270
00:40:41,689 --> 00:40:43,658
REFLECT ON WHERE WE ARE IN THIS

1271
00:40:43,658 --> 00:40:46,060
MOMENT AND WHY THIS WORK MATTERS

1272
00:40:46,060 --> 00:40:46,627
MORE THAN EVER.

1273
00:40:46,627 --> 00:40:48,296
THIS YEAR MARKS THE 40 RGT

1274
00:40:48,296 --> 00:40:49,797
ANNIVERSARY OF THE NATIONAL

1275
00:40:49,797 --> 00:40:53,568
INSTITUTE OF NURSING RESEARCH, 4

1276
00:40:53,568 --> 00:40:54,735
DECADES OF ADVANCING SCIENCE

1277
00:40:54,735 --> 00:40:56,938
THAT NOT ONLY IMPROVES CARE BUT

1278
00:40:56,938 --> 00:40:58,472
REDEFINES WHAT CARE WITH BE.

1279
00:40:58,472 --> 00:41:00,408
THIS IMAGE, THIS LANDSCAPE

1280
00:41:00,408 --> 00:41:02,243
REMINDS US, JOURNEY OF NURSING

1281
00:41:02,243 --> 00:41:05,146
SCIENCES HAS ALWAYS BEEN 1 OF

1282
00:41:05,146 --> 00:41:06,414
DEPTH, PERSISTENCE AND

1283
00:41:06,414 --> 00:41:07,348
TRANSFORMATION, IS ABOUT

1284
00:41:07,348 --> 00:41:08,716
NOTICING WHAT OTHERS MISS,

1285
00:41:08,716 --> 00:41:10,785
ASKING DIFFERENT QUESTIONS AND

1286
00:41:10,785 --> 00:41:12,720
DESIGNING SOLUTIONS THAT REFLECT

1287
00:41:12,720 --> 00:41:14,589
THE FULL COMPLEXITY OF PEOPLE'S

1288
00:41:14,589 --> 00:41:16,390
LIVES NOT JUST THEIR CONDITIONS

1289
00:41:16,390 --> 00:41:17,725
BUT THEIR COMMUNITIES, STRUGGLES

1290
00:41:17,725 --> 00:41:19,126
AND STRENGTHS.

1291
00:41:19,126 --> 00:41:20,194
IN THIS PRESENTATION, WE'VE

1292
00:41:20,194 --> 00:41:21,829
EXPLORED HOW WE CAN INTEGRATE

1293
00:41:21,829 --> 00:41:23,831
SOCIAL NEEDS IN THE CARE IN A

1294
00:41:23,831 --> 00:41:26,234
WAY THAT'S MEANINGFUL AND SO

1295
00:41:26,234 --> 00:41:26,701
THAT IT'S SCALABLE.

1296
00:41:26,701 --> 00:41:28,769
WE LOOK AT HOW WE MOVE FROM

1297
00:41:28,769 --> 00:41:30,404
FRAGMENTED PILOTS TO SUSTAINED

1298
00:41:30,404 --> 00:41:31,706
PRACTICE, AND WE'VE SEEN THAT

1299
00:41:31,706 --> 00:41:32,640
DOING BETTER MEANS BUILDING

1300
00:41:32,640 --> 00:41:33,608
SYSTEMS THAT SUPPORT THE PEOPLE

1301
00:41:33,608 --> 00:41:36,777
DOING THE WORK AND THAT NURSES

1302
00:41:36,777 --> 00:41:38,546
ARE UNIQUELY POSITIONED TO LEAD

1303
00:41:38,546 --> 00:41:39,480
THIS TRANSFORMATION, THE SCIENCE

1304
00:41:39,480 --> 00:41:41,449
WE SHAPE TODAY, THE QUESTIONS WE

1305
00:41:41,449 --> 00:41:44,085
ASK, THE METHODS WE REFINE, THE

1306
00:41:44,085 --> 00:41:45,419
PARTNERSHIPS WE BUILD WILL

1307
00:41:45,419 --> 00:41:46,821
DETERMINE THE NEXT 40 YEARS OF

1308
00:41:46,821 --> 00:41:48,522
NURSING SCIENCE, SO LET'S KEEP

1309
00:41:48,522 --> 00:41:50,391
GOING, LET'S CONTINUE THIS

1310
00:41:50,391 --> 00:41:52,193
JOURNEY, NOT JUST FOR DOING

1311
00:41:52,193 --> 00:41:53,361
BETTER SCIENCE BUT TOWARD

1312
00:41:53,361 --> 00:41:54,662
CREATING A BETTER HEALTH SYSTEM

1313
00:41:54,662 --> 00:42:01,002
FOR EVERYONE WE SERVE.

1314
00:42:01,002 --> 00:42:02,637
AND BEFORE CLOSING I WANT TO

1315
00:42:02,637 --> 00:42:04,038
TAKE A MOMENT TO ACKNOWLEDGE THE

1316
00:42:04,038 --> 00:42:06,474
MANY PEOPLE AND PARTNERS WHO

1317
00:42:06,474 --> 00:42:08,509
MAKE THIS POSSIBLE, SO NOT

1318
00:42:08,509 --> 00:42:09,577
UNLIKE THIS COLORADO RIVER

1319
00:42:09,577 --> 00:42:11,746
RAFTERS THIS JOURNEY IS A HUGE

1320
00:42:11,746 --> 00:42:11,979
TEAM.

1321
00:42:11,979 --> 00:42:14,849
OUR PROGRESS HAS BEEN SUPPORTED

1322
00:42:14,849 --> 00:42:18,319
BY FUNDING FROM AHRQ AND NINR

1323
00:42:18,319 --> 00:42:22,223
INCLUDING THE  SINCERE NEEDS

1324
00:42:22,223 --> 00:42:24,792
STUDY AND HEALTH IT, WE ARE

1325
00:42:24,792 --> 00:42:25,927
ESPECIALLY PROUD TO HIGHLIGHT

1326
00:42:25,927 --> 00:42:30,598
THIS IN THE NINR'S 40 YEARS OF

1327
00:42:30,598 --> 00:42:32,099
SCIENCE TO IMPROVE CARE, THIS

1328
00:42:32,099 --> 00:42:35,002
WORK HAS BEEN SHAPED BY A TRULY

1329
00:42:35,002 --> 00:42:37,171
INTERDISCIPLINARY TEAM INCLUDING

1330
00:42:37,171 --> 00:42:38,572
FACLETY, RESEARCH STAFF AND

1331
00:42:38,572 --> 00:42:41,175
STUDENTS AS WELL AS VITAL

1332
00:42:41,175 --> 00:42:42,944
COLLABORATIONS AND CARE TEAMS

1333
00:42:42,944 --> 00:42:45,379
ACROSS NURSING MEDICINE, THERAPY

1334
00:42:45,379 --> 00:42:45,846
AND IT.

1335
00:42:45,846 --> 00:42:47,448
TOGETHER, THEY'VE HELPED US NOT

1336
00:42:47,448 --> 00:42:49,216
ONLY STUDY THE INTEGRATION OF

1337
00:42:49,216 --> 00:42:50,484
SOCIAL ASSESSMENTS AND CARE

1338
00:42:50,484 --> 00:42:52,553
DELIVERY, BUT ALSO LIVE OUT THE

1339
00:42:52,553 --> 00:42:55,189
COMPLEXITY AND TEAM WORK ALL OF

1340
00:42:55,189 --> 00:42:57,892
THIS REQUIRES, I'M INCREDIBLY

1341
00:42:57,892 --> 00:43:01,762
GRATEFUL, AND COMMITMENT TO

1342
00:43:01,762 --> 00:43:04,999
DOING BETTER FOR PATIENTS.

1343
00:43:04,999 --> 00:43:06,300
SO I'M ALWAYS HAPPY TO CONTINUE

1344
00:43:06,300 --> 00:43:08,035
THE CONVERSATION WHETHER WORKING

1345
00:43:08,035 --> 00:43:09,904
ON SIMILAR CHALLENGES, THINKING

1346
00:43:09,904 --> 00:43:11,639
ABOUT IMPLEMENTATION IN YOUR OWN

1347
00:43:11,639 --> 00:43:12,940
SETTINGS OR HOW TO INTEGRATE

1348
00:43:12,940 --> 00:43:14,008
BETTER CARE AND SCIENCE, THANK

1349
00:43:14,008 --> 00:43:15,443
YOU AGAIN FOR YOUR TIME, YOUR

1350
00:43:15,443 --> 00:43:17,211
ATTENTION AND YOUR SHARED

1351
00:43:17,211 --> 00:43:18,579
COMMITMENT TO IMPROVING CARE AT

1352
00:43:18,579 --> 00:43:26,721
NIH, I LOOK FORWARD TO WHAT WE

1353
00:43:26,721 --> 00:43:27,388
CAN BUILD TOGETHER.

1354
00:43:27,388 --> 00:43:28,856
>> WOW THANK YOU SO MUCH

1355
00:43:28,856 --> 00:43:29,623
DR. WALLACE FOR SHARING YOUR

1356
00:43:29,623 --> 00:43:31,158
WORK WITH US AND SHOWING

1357
00:43:31,158 --> 00:43:32,159
DIRECTLY HOW THE RESEARCH IS

1358
00:43:32,159 --> 00:43:34,395
LOOKING AT SOCIAL NEEDS AND

1359
00:43:34,395 --> 00:43:35,196
EPITHELIALIGRATION AND

1360
00:43:35,196 --> 00:43:36,397
ENHANCEMENT OF SYSTEMS CAN

1361
00:43:36,397 --> 00:43:37,465
DIRECTLY IMPACT THE CARE OF

1362
00:43:37,465 --> 00:43:38,499
CLINICAL PATIENTS AND YOU

1363
00:43:38,499 --> 00:43:39,834
COULDN'T HAVE SAID IT BETTER IN

1364
00:43:39,834 --> 00:43:41,369
TERMS OF ALSO SHARING WHERE WE

1365
00:43:41,369 --> 00:43:44,572
ARE WITH OUR 40th ANNIVERSARY,

1366
00:43:44,572 --> 00:43:45,172
WE'RE INCREDIBLY EXCITED TO

1367
00:43:45,172 --> 00:43:46,474
SHARE WITH ALM OF YOU WHERE WE

1368
00:43:46,474 --> 00:43:47,775
ARE AND HOW WE MOVE FORWARD AND

1369
00:43:47,775 --> 00:43:50,077
WHERE WE'RE MOVING TO NEXT AND I

1370
00:43:50,077 --> 00:43:51,812
THANK YOU FOR HIGHLIGHTING THE

1371
00:43:51,812 --> 00:43:53,147
WORK YOU'VE DONE AS PART OF THAT

1372
00:43:53,147 --> 00:43:53,981
CELEBRATION AS WELL, THERE WILL

1373
00:43:53,981 --> 00:43:58,919
BE MORE TO COME.

1374
00:43:58,919 --> 00:44:00,021
WE DO HAVE TIME NOW TO TAKE

1375
00:44:00,021 --> 00:44:02,323
QUESTIONS AND I WILL LOOK AT THE

1376
00:44:02,323 --> 00:44:03,758
VIDEOCAST CHAT TO MAKE SURE

1377
00:44:03,758 --> 00:44:04,492
THERE ARE QUESTIONS.

1378
00:44:04,492 --> 00:44:05,359
PLEASE MAKE SURE TO BRING THEM

1379
00:44:05,359 --> 00:44:06,961
FORWARD BUT I WILL TAKE LIBERTY

1380
00:44:06,961 --> 00:44:09,597
AS I WAIT FOR A FEW OF THOSE TO

1381
00:44:09,597 --> 00:44:10,798
COME THROUGH TO ASK YOU 1 IN

1382
00:44:10,798 --> 00:44:12,600
PARTICULAR TO START WITH AND I

1383
00:44:12,600 --> 00:44:16,704
WANTED TO TALK ABOUT THE UTAH

1384
00:44:16,704 --> 00:44:17,538
211 PROGRAM, THE SCREENING AND

1385
00:44:17,538 --> 00:44:19,407
IF YOU COULD SHARE WITH US

1386
00:44:19,407 --> 00:44:21,042
SPECIFIC STRATEGIES YOU FOUND

1387
00:44:21,042 --> 00:44:21,842
MOST EFFECTIVE IN INSURING THAT

1388
00:44:21,842 --> 00:44:23,277
PATIENT WHO IS ARE REFERRED TO

1389
00:44:23,277 --> 00:44:25,679
THIS COMMUNITY BASED RESOURCES

1390
00:44:25,679 --> 00:44:27,815
ACTUALLY CONNECT WITH AND ARE

1391
00:44:27,815 --> 00:44:28,616
UTILIZING THE SERVICES.

1392
00:44:28,616 --> 00:44:29,884
SO COULD YOU TALK ABOUT THAT.

1393
00:44:29,884 --> 00:44:31,052
>> THAT'S BEEN A HUGE
EMPHASIS

1394
00:44:31,052 --> 00:44:32,353
OF OUR CURRENT WORK.

1395
00:44:32,353 --> 00:44:35,656
SO THE CURRENT TRIAL WHICH WAS

1396
00:44:35,656 --> 00:44:37,291
ENROLLMENT LAST MONTH SO WE'RE

1397
00:44:37,291 --> 00:44:39,026
THRILLED TO LOOK AT THOSE DATA.

1398
00:44:39,026 --> 00:44:40,594
WE'RE WAITING FOR THE FOLLOW UP

1399
00:44:40,594 --> 00:44:42,797
SURVEYS TO GET COMPLETED, THE 6

1400
00:44:42,797 --> 00:44:45,966
MONTH FOLLOW UP BUT WE'VE TESTED

1401
00:44:45,966 --> 00:44:47,468
STRATEGIES FOR ENGAGING PATIENTS

1402
00:44:47,468 --> 00:44:51,972
IN REALLY USING -- APPLYING

1403
00:44:51,972 --> 00:44:52,973
HEALTH BEHAVIOR STRATEGIES

1404
00:44:52,973 --> 00:44:53,808
AROUND GOAL SETTING AND FOLLOW

1405
00:44:53,808 --> 00:44:56,343
UP SUPPORT SO WE'RE TESTING

1406
00:44:56,343 --> 00:44:57,978
INCREMENTAL GOAL SETTING, ACTION

1407
00:44:57,978 --> 00:44:58,746
PLANNING AND ESSENTIALLY SMART

1408
00:44:58,746 --> 00:45:00,014
GOALS WITH THE PATIENTS AS PART

1409
00:45:00,014 --> 00:45:01,982
OF OUR PROCESS AND THEN WE'RE

1410
00:45:01,982 --> 00:45:03,484
COMPARING WITH THE TENSION,

1411
00:45:03,484 --> 00:45:04,418
CONTROL AND STANDARD PRACTICE

1412
00:45:04,418 --> 00:45:06,787
WHICH IS OFTEN GIVING PATIENTS,

1413
00:45:06,787 --> 00:45:09,390
YOU KNOW 4 OR 5 REFERRALS WHICH

1414
00:45:09,390 --> 00:45:10,691
WE APPRECIATE FROM THE SERVICE

1415
00:45:10,691 --> 00:45:12,526
NAVIGATORS THAT THEY WANT TO

1416
00:45:12,526 --> 00:45:13,928
GIVE PEOPLE AS MUCH INFORMATION

1417
00:45:13,928 --> 00:45:16,097
AS POSSIBLE DURING A CONTACT BUT

1418
00:45:16,097 --> 00:45:17,631
WE ALSO FIND THAT THAT WAS

1419
00:45:17,631 --> 00:45:19,467
REALLY OVERWHELPING THE

1420
00:45:19,467 --> 00:45:23,037
PATIENTS, SO WE'RE TESTING

1421
00:45:23,037 --> 00:45:23,771
DIFFERENT ENGAGEMENT STRATEGIES.

1422
00:45:23,771 --> 00:45:25,940
AND PART OF THE NEW STUDY THAT

1423
00:45:25,940 --> 00:45:29,710
WE FOUND THAT AGAIN, DIGITAL

1424
00:45:29,710 --> 00:45:30,878
CONNECTIONS WERE REALLY KEY.

1425
00:45:30,878 --> 00:45:32,646
IT'S A LIMITATION FOR MANY OF

1426
00:45:32,646 --> 00:45:34,915
OUR PATIENTS IN TERNALS OF

1427
00:45:34,915 --> 00:45:37,585
HEALTH LITERACY -- IN TERMS OF

1428
00:45:37,585 --> 00:45:38,886
HEALTHITYERACY AND ACCESS TO THE

1429
00:45:38,886 --> 00:45:39,787
INTERNET PARTICULARLY IN THE

1430
00:45:39,787 --> 00:45:49,897
RURAL AND FRONT  -- FRONTIER

1431
00:45:49,897 --> 00:45:51,432
AREAS AND WE'RE WORKING ON

1432
00:45:51,432 --> 00:45:53,167
GETTING PHONES IN PATIENTS HANDS

1433
00:45:53,167 --> 00:45:55,369
AND TESTING THE BENEFIT OF THAT.

1434
00:45:55,369 --> 00:45:58,973
AND THEN THERE'S A HOST OF OTHER

1435
00:45:58,973 --> 00:46:00,307
STRATEGIES, SHARING PICTURE,

1436
00:46:00,307 --> 00:46:05,946
STORIES OF  PATIENTS, LOOKING AT

1437
00:46:05,946 --> 00:46:07,214
TRUST, EXPLAINING TO THE

1438
00:46:07,214 --> 00:46:08,415
PATIENTS WHY WE ARE DOING THE

1439
00:46:08,415 --> 00:46:10,117
SCREENING BEFORE WE ENGAGE IN

1440
00:46:10,117 --> 00:46:10,951
THE QUESTIONS.

1441
00:46:10,951 --> 00:46:13,154
>> SO THAT'S ACTUALLY A
PERFECT

1442
00:46:13,154 --> 00:46:14,555
SEGUE TO A QUESTION THAT CAME TO

1443
00:46:14,555 --> 00:46:16,557
MY ATTENTION WHICH IS RELATED TO

1444
00:46:16,557 --> 00:46:17,358
THE SINCERE SCREENER AND HOW

1445
00:46:17,358 --> 00:46:19,560
IMPORTANT IT IS TO BE ABLE TO

1446
00:46:19,560 --> 00:46:21,095
INCLUDE SCREENERS WHEN WE DO

1447
00:46:21,095 --> 00:46:21,795
CLINICAL INTERVENTION AND JUST

1448
00:46:21,795 --> 00:46:24,798
TO THE POINT WE WERE SAYING

1449
00:46:24,798 --> 00:46:26,066
CONSIDERING THE DIGITAL DIVIDE,

1450
00:46:26,066 --> 00:46:28,369
DIDN'T COMPLETE THE SCREENER,

1451
00:46:28,369 --> 00:46:30,171
VIA SELF-COMPLETION OR VERBALLY

1452
00:46:30,171 --> 00:46:31,472
WITH STAFF, WHAT CAN WE DO

1453
00:46:31,472 --> 00:46:32,873
BETTER TO REACH THIS INDIVIDUAL

1454
00:46:32,873 --> 00:46:34,275
TO INSURE EVERYONE HAS ACCESS TO

1455
00:46:34,275 --> 00:46:35,943
THE SOCIAL NEEDS SCREENING.

1456
00:46:35,943 --> 00:46:38,679
>> WELL, WE ACTUALLY --
SO, JUST

1457
00:46:38,679 --> 00:46:41,182
WITHIN THE PAST YEAR, IT IS

1458
00:46:41,182 --> 00:46:42,750
FULLY INTEGRATED INTO OUR EHR,

1459
00:46:42,750 --> 00:46:44,718
SO THAT'S BEEN VERY HELPFUL, AND

1460
00:46:44,718 --> 00:46:47,922
WE'VE BEEN  CONNECTING A LOT OF

1461
00:46:47,922 --> 00:46:49,723
TRAINING WITH THE NEW STAFF WITH

1462
00:46:49,723 --> 00:46:53,160
THE HEALTH AND GIVING THEM

1463
00:46:53,160 --> 00:46:59,066
CAREFUL SUPPORT AROUND

1464
00:46:59,066 --> 00:47:00,301
 ENGAGING

1465
00:47:00,301 --> 00:47:02,002
PATIENTS IN THESE CONDITIONS.

1466
00:47:02,002 --> 00:47:04,638
SO OUR SCREENING RATES AND RATES

1467
00:47:04,638 --> 00:47:05,673
HAVE GONE DOWN CONSIDERABLY

1468
00:47:05,673 --> 00:47:06,774
SINCE THAT ALL HAPPENED.

1469
00:47:06,774 --> 00:47:11,612
YOU KNOW THOSE EARLY REPORTS

1470
00:47:11,612 --> 00:47:13,147
WERE -- REALLY REFLECTED THE

1471
00:47:13,147 --> 00:47:14,682
RELUCTANCE OF THE E. D. STAFF IN

1472
00:47:14,682 --> 00:47:15,849
APPROACHING THE PATIENTS AND

1473
00:47:15,849 --> 00:47:17,451
THIS IS WHERE REALLY WE

1474
00:47:17,451 --> 00:47:20,287
ENCOVERRED SO MUCH WORK ABOUT

1475
00:47:20,287 --> 00:47:22,489
VULNERABILITY, AND ABOUT WE HOW

1476
00:47:22,489 --> 00:47:23,557
AS CLIN GZS WE PREDETERMINE WHO

1477
00:47:23,557 --> 00:47:26,660
SHOULD BE SCREENED AND WHO

1478
00:47:26,660 --> 00:47:27,995
SHOULDN'T BE AND SO WE'VE REALLY

1479
00:47:27,995 --> 00:47:29,363
WORKED ON THAT WITH THE STAFF

1480
00:47:29,363 --> 00:47:30,764
AND CONTINUE TO DO SO.

1481
00:47:30,764 --> 00:47:34,068
BUT THIS IS AN AREA THAT REALLY

1482
00:47:34,068 --> 00:47:35,369
CLINICIANS STRUGGLE WITH ON A

1483
00:47:35,369 --> 00:47:37,805
REGULAR BASIS, YOU KNOW, WHY AM

1484
00:47:37,805 --> 00:47:39,006
I ASKING THESE QUESTIONS IF I

1485
00:47:39,006 --> 00:47:40,941
DON'T HAVE SERVICES BUT WE'RE

1486
00:47:40,941 --> 00:47:42,810
VERY FORTUNATE IN THAT

1487
00:47:42,810 --> 00:47:43,877
PARTNERSHIP WITH UTAH 2 AND 1,

1488
00:47:43,877 --> 00:47:45,980
WE DO HAVE A METHOD FOR

1489
00:47:45,980 --> 00:47:47,248
REFERRING PATIENTS AT LEAST TO

1490
00:47:47,248 --> 00:47:49,583
SERVICES, EACH IF THEY DON'T

1491
00:47:49,583 --> 00:47:50,184
ULTIMATELY RECEIVE ASSISTANCE,

1492
00:47:50,184 --> 00:47:54,388
THEY AT LEAST HAVE SOMEONE TO

1493
00:47:54,388 --> 00:47:54,622
CONTACT.

1494
00:47:54,622 --> 00:47:55,789
>> THANK YOU FOR THAT.

1495
00:47:55,789 --> 00:47:56,757
SO WE'RE GETTING ANOTHER

1496
00:47:56,757 --> 00:47:57,925
MESSAGE, SOMEONE IS SAYING THANK

1497
00:47:57,925 --> 00:48:00,628
YOU SO MUCH FOR YOUR TALK WITH

1498
00:48:00,628 --> 00:48:01,262
AN EXCLAMATION POINT.

1499
00:48:01,262 --> 00:48:02,997
I WOULD LO TO HEAR MORE ABOUT

1500
00:48:02,997 --> 00:48:07,801
HOW I ENVEGZ SUPPORTING THE

1501
00:48:07,801 --> 00:48:09,903
TYPICALLY TIGHT KNIT CBOs, AND

1502
00:48:09,903 --> 00:48:11,038
PATHWAY GIVES MANAGING CASE

1503
00:48:11,038 --> 00:48:14,074
LOOEDS BEYOND JUST FUNDING AND

1504
00:48:14,074 --> 00:48:14,908
FOR THESE ORGANIZATIONS.

1505
00:48:14,908 --> 00:48:17,011
>> YES, SO WE'VE BEEN
WORKING

1506
00:48:17,011 --> 00:48:17,978
WITH IT, WE'RE VERY FORTUNATE

1507
00:48:17,978 --> 00:48:20,281
THAT WE HAVE A RELATIVELY TIGHT

1508
00:48:20,281 --> 00:48:22,149
KNIT COMMUNITY OF CBOs WHO

1509
00:48:22,149 --> 00:48:24,451
HAVE BEEN REALLY ENGAGED IN THIS

1510
00:48:24,451 --> 00:48:27,021
WORK AND ARE -- WELL THEY HAVE

1511
00:48:27,021 --> 00:48:28,522
LIMITED RESOURCES THEY ARE ALSO

1512
00:48:28,522 --> 00:48:30,391
VERY SUPPORTIVE OF INCREASING

1513
00:48:30,391 --> 00:48:31,992
THE CONSISTENCY AND OUTREACH

1514
00:48:31,992 --> 00:48:34,828
THAT THEY DO RECEIVE.

1515
00:48:34,828 --> 00:48:37,398
IN TERMS, WE ACTUALLY DO HAVE A

1516
00:48:37,398 --> 00:48:40,768
SYMPOSIUM COMING UP TO EXPLORE

1517
00:48:40,768 --> 00:48:42,970
SHARED RETURN ON INVESTMENT WITH

1518
00:48:42,970 --> 00:48:45,639
THE CBOs, WE'RE ENGAGING THE

1519
00:48:45,639 --> 00:48:48,042
CBOs HERE AT THE UNIVERSITY OF

1520
00:48:48,042 --> 00:48:50,244
UTAH WITH HEALTH ECONOMISTS AS

1521
00:48:50,244 --> 00:48:51,545
WELL AS OTHER SOCIAL SCIENTISTS

1522
00:48:51,545 --> 00:48:53,314
AS WELL AS CLINICIANS TO TALK

1523
00:48:53,314 --> 00:48:56,050
ABOUT HOW WE CAN DEVELOP A WAY

1524
00:48:56,050 --> 00:48:57,584
WHERE WE SHARE IN THE BENEFIT

1525
00:48:57,584 --> 00:48:59,219
BECAUSE SO OFTEN TIMES WE BUILD

1526
00:48:59,219 --> 00:49:01,622
THESE SYSTEMS AROUND THE

1527
00:49:01,622 --> 00:49:02,489
CLINICAL INFRASTRUCTURE AND WE

1528
00:49:02,489 --> 00:49:05,359
REALLY NEED TO BE BUILDING IT

1529
00:49:05,359 --> 00:49:06,827
AROUND THE CBOs AND THEIR

1530
00:49:06,827 --> 00:49:07,127
CAPABILITY.

1531
00:49:07,127 --> 00:49:08,729
SOME OF THE BEST ADVICE I GOT

1532
00:49:08,729 --> 00:49:09,897
WHEN I FIRST EMBARKED ON THIS

1533
00:49:09,897 --> 00:49:14,134
WORK IT WAS FROM SOMEONE IN OUR

1534
00:49:14,134 --> 00:49:17,971
DIGITAL INNOVATIONS LAB WHO SAID

1535
00:49:17,971 --> 00:49:19,773
THE BUILDER THE INFRASTRUCTURE

1536
00:49:19,773 --> 00:49:21,809
AROUND 211, NOT TO EXPECT THEM

1537
00:49:21,809 --> 00:49:24,178
TO ADAPT TO OURS AND IT HAS BEEN

1538
00:49:24,178 --> 00:49:25,045
KEY IN OUR SUCCESS.

1539
00:49:25,045 --> 00:49:27,147
SO I GUESS THAT MIGHT BE A ROUND

1540
00:49:27,147 --> 00:49:29,383
ABOUT WAY OF ANSWERING SOME OF

1541
00:49:29,383 --> 00:49:31,118
THAT, I HOPE, BUT I'M ALWAYS

1542
00:49:31,118 --> 00:49:32,653
HAPPY TO ENGAGE, HAVE YOU MY

1543
00:49:32,653 --> 00:49:34,621
E-MAIL.

1544
00:49:34,621 --> 00:49:35,589
SO THANK YOU.

1545
00:49:35,589 --> 00:49:36,890
>> THANK YOU, I WILL
SWITCH US

1546
00:49:36,890 --> 00:49:38,892
OVER FOR A BIT THAT WE HAVE SOME

1547
00:49:38,892 --> 00:49:41,228
OF OUR CLINICAL NURSES CHIME

1548
00:49:41,228 --> 00:49:43,530
NOTHING AND I WANT TO GO TO THE

1549
00:49:43,530 --> 00:49:46,500
IN-PATIENT STUDY WHERE WE TALK

1550
00:49:46,500 --> 00:49:47,534
ABOUT BARRIERS ENCOUNTERED WHERE

1551
00:49:47,534 --> 00:49:49,203
THE SOCIAL NEEDS SCREENING

1552
00:49:49,203 --> 00:49:49,470
PROTOCOL.

1553
00:49:49,470 --> 00:49:53,407
HOW DO YOU ADDRESS THAT?

1554
00:49:53,407 --> 00:49:55,676
>> SO WE HAVE RIGHT NOW,
WE'VE

1555
00:49:55,676 --> 00:49:58,011
SHIFTED GEARS A BIT TO FOCUS ON

1556
00:49:58,011 --> 00:50:00,981
FAMILY CAREGIVERS IN OUR CURRENT

1557
00:50:00,981 --> 00:50:02,783
ARC WORK BUT OUR NEXT PHASE IS

1558
00:50:02,783 --> 00:50:04,351
TO GO BACK TO THOSE CLINICAL

1559
00:50:04,351 --> 00:50:06,120
NURSES AND TRY TO FIGURE OUT HOW

1560
00:50:06,120 --> 00:50:07,054
TO ENGAGE BECAUSE ACTUALLY AS

1561
00:50:07,054 --> 00:50:10,157
PART OF THE CMS REGULATIONS, OUR

1562
00:50:10,157 --> 00:50:12,593
NURSES ARE NOW ASKING SOCIAL

1563
00:50:12,593 --> 00:50:15,129
NEEDS QUESTIONS AS PART OF THEIR

1564
00:50:15,129 --> 00:50:16,997
WORK FLOWS, SO, WE HAVE STARTED

1565
00:50:16,997 --> 00:50:19,066
ENGAGING WITH THEM, AND REALLY

1566
00:50:19,066 --> 00:50:21,902
IT IS ABOUT UNDERSTANDING JUST,

1567
00:50:21,902 --> 00:50:24,838
I THINK THE SELF-DETERMINATION

1568
00:50:24,838 --> 00:50:26,640
THEORY, WE HAVE FOUND IT'S BEEN

1569
00:50:26,640 --> 00:50:27,674
REALLY HELPFUL TO COMMUNICATE

1570
00:50:27,674 --> 00:50:29,209
THIS, REALLY TRY TO FIGURE OUT

1571
00:50:29,209 --> 00:50:32,846
WHAT FEEDS THEIR SOUL, HOW THEY

1572
00:50:32,846 --> 00:50:35,382
-- HOW THEY CAN HAVE TOOLS TO

1573
00:50:35,382 --> 00:50:36,884
REFER PATIENTS, INCREASE THEIR

1574
00:50:36,884 --> 00:50:38,352
COMFORT AROUND THESE

1575
00:50:38,352 --> 00:50:42,055
CONVERSATIONS AND ALSO MAKING

1576
00:50:42,055 --> 00:50:43,757
THEM SEE THAT IT'S SOCIAL

1577
00:50:43,757 --> 00:50:44,858
FACTORS IMPACT WORK FLOWS

1578
00:50:44,858 --> 00:50:47,594
WHETHER OR NOT THEIR DOCUMENTED

1579
00:50:47,594 --> 00:50:49,096
OR EHR OR NOT.

1580
00:50:49,096 --> 00:50:50,364
YOU KNOW WHEN YOU'RE TRYING TO

1581
00:50:50,364 --> 00:50:52,232
DISCHARGE A PATIENT AND YOU

1582
00:50:52,232 --> 00:50:53,934
SUDDENLY REALIZE THEY DON'T HAVE

1583
00:50:53,934 --> 00:50:56,203
SOCIAL SUPPORT, A RIDE HOME,

1584
00:50:56,203 --> 00:50:57,371
WHERE YOU REALIZE A PLAN OF CARE

1585
00:50:57,371 --> 00:51:00,908
IS NOT GOING TO WORK BECAUSE

1586
00:51:00,908 --> 00:51:02,075
SOMEONE LIVES BY THEMSELVES AND

1587
00:51:02,075 --> 00:51:03,110
THERE'S NO WAY THEY'RE GOING TO

1588
00:51:03,110 --> 00:51:06,113
BE SENT HOME WITH A WOUND BAG OR

1589
00:51:06,113 --> 00:51:07,714
WHATEVER THE CASE MAY BE, THOSE

1590
00:51:07,714 --> 00:51:09,116
ARE JUST SOME OF THE EXAMPLES

1591
00:51:09,116 --> 00:51:09,817
THAT WE'VE SEEN.

1592
00:51:09,817 --> 00:51:11,685
SO IT'S MAKING IT RELEVANT, IT'S

1593
00:51:11,685 --> 00:51:13,854
REALLY TRYING TO GIVE THEM

1594
00:51:13,854 --> 00:51:16,657
COMMUNICATION TOOLS AND THEN WE

1595
00:51:16,657 --> 00:51:19,259
HOPE BY ALSO EXPANDING OUR

1596
00:51:19,259 --> 00:51:20,561
REFERRAL INFRASTRUCTURE TO THE

1597
00:51:20,561 --> 00:51:21,261
IN-PATIENT SIDE WHICH WE'RE

1598
00:51:21,261 --> 00:51:22,629
WORKING ON NOW THAT IT WILL ALSO

1599
00:51:22,629 --> 00:51:24,431
GIVE THEM A TOOL SO THEY CAN

1600
00:51:24,431 --> 00:51:26,166
FEEL BETTER ABOUT ASKING THE

1601
00:51:26,166 --> 00:51:27,301
QUESTIONS, WITHOUT FEELING LIKE

1602
00:51:27,301 --> 00:51:29,136
THEY NEED TO ADDRESS IT BECAUSE

1603
00:51:29,136 --> 00:51:30,137
REALLY IT'S OUR COMMUNITY

1604
00:51:30,137 --> 00:51:31,271
PARTNERS WHO ARE THE EX  PERS IN

1605
00:51:31,271 --> 00:51:33,273
THIS TO BE HONEST, SO WE NEED TO

1606
00:51:33,273 --> 00:51:35,442
JUST FIGURE OUT A WAY TO MAKE

1607
00:51:35,442 --> 00:51:38,245
SURE THAT COMMUNICATION IS MADE.

1608
00:51:38,245 --> 00:51:40,147
SO HOPEFULLY THAT WORRY ANSWERS

1609
00:51:40,147 --> 00:51:40,848
YOUR QUESTION.

1610
00:51:40,848 --> 00:51:41,982
IT'S A TOUGH QUESTION.

1611
00:51:41,982 --> 00:51:42,983
>> IT'S A TOUGH QUESTION
RIGHT,

1612
00:51:42,983 --> 00:51:45,486
IN ORDER TO BE ABLE TO DISCUSS.

1613
00:51:45,486 --> 00:51:46,920
I THINK THIS 1 WILL PIGGYBACK

1614
00:51:46,920 --> 00:51:49,456
PRETTY WELL TO THE 1 WE JUST

1615
00:51:49,456 --> 00:51:49,723
DISCUSSED.

1616
00:51:49,723 --> 00:51:52,559
SO YOUR RESEARCH FOUND THAT 29%

1617
00:51:52,559 --> 00:51:54,862
OF PATIENTS ASSESSED BY RNs

1618
00:51:54,862 --> 00:51:56,497
HAD LESS THAN ADEQUATE

1619
00:51:56,497 --> 00:51:57,564
RESOURCES, SO GETTING MORE IN

1620
00:51:57,564 --> 00:51:59,533
THE DISCHARGE OF A PATIENT, WHAT

1621
00:51:59,533 --> 00:52:01,068
HAVE YOU FOUND THAT HAS WORKED

1622
00:52:01,068 --> 00:52:02,936
IN TERMS OF INTERVENTION TO

1623
00:52:02,936 --> 00:52:04,738
IMELEMENT AND IMPROVE THE

1624
00:52:04,738 --> 00:52:05,272
PATIENT'S HOME RESOURCES?

1625
00:52:05,272 --> 00:52:09,443
>> SO WE FOUND THAT THE
NURSES

1626
00:52:09,443 --> 00:52:10,410
AGAIN, WERE IF THEY KNEW ABOUT

1627
00:52:10,410 --> 00:52:12,112
THE INFORMATION THIS, IS ABOUT

1628
00:52:12,112 --> 00:52:13,413
MAKING IT SYSTEMATIC AND

1629
00:52:13,413 --> 00:52:13,680
UNIVERSAL.

1630
00:52:13,680 --> 00:52:15,616
WE KEPT USING THAT TERM OVER AND

1631
00:52:15,616 --> 00:52:17,384
OVER AGAIN DURING THE STUDY, IT

1632
00:52:17,384 --> 00:52:18,919
IS ABOUT HOME HEALTH, IT WAS

1633
00:52:18,919 --> 00:52:21,321
ABOUT, YOU KNOW SKILLED NURSING,

1634
00:52:21,321 --> 00:52:23,390
BUT WE ACTUALLY DO HAVE A TOOL

1635
00:52:23,390 --> 00:52:26,493
THAT WE ARE BEGINNING TO TEST

1636
00:52:26,493 --> 00:52:27,761
IN-PATIENT SIDE WHERE THE

1637
00:52:27,761 --> 00:52:30,697
PATIENT IS ACTUALLY AN APP, IT'S

1638
00:52:30,697 --> 00:52:32,766
TO HAVE THE PATIENT COMMUNICATE

1639
00:52:32,766 --> 00:52:34,768
OR THINK THROUGH THEIR PARTIT

1640
00:52:34,768 --> 00:52:35,636
PATTERY PLANNING, GET THEM

1641
00:52:35,636 --> 00:52:36,537
THINKING ABOUT THE RESOURCES

1642
00:52:36,537 --> 00:52:39,640
THEY HAVE AT HOME AND ALSO

1643
00:52:39,640 --> 00:52:40,807
ENGAGE WITH 211'S RESOURCES TO

1644
00:52:40,807 --> 00:52:44,545
SEE IF THEY CAN FIND RESOURCES

1645
00:52:44,545 --> 00:52:45,612
WITHIN THE COMMUNITY SO THE PLAN

1646
00:52:45,612 --> 00:52:47,614
CAN BE SHARE WIDE FAMILIES.

1647
00:52:47,614 --> 00:52:48,649
SO THAT'S AN INTERVENTION WHERE

1648
00:52:48,649 --> 00:52:52,152
WE NEED TO ENGAGE PATIENTS MORE

1649
00:52:52,152 --> 00:52:53,387
PURPOSELY AND MORE PARTICIPATORY

1650
00:52:53,387 --> 00:52:54,555
PLANNING AND WE'VE HEARD THAT

1651
00:52:54,555 --> 00:52:55,856
FOR CAREGIVERS AND PATIENTS

1652
00:52:55,856 --> 00:52:56,790
AFTER DISCHARGE, WHY DIDN'T I

1653
00:52:56,790 --> 00:52:59,226
KNOW THAT I NEEDED TO DO THIS?

1654
00:52:59,226 --> 00:53:01,094
YOU KNOW, I WOULD HAVE DONE

1655
00:53:01,094 --> 00:53:01,929
THINGS DIFFERENTLY, I WOULD HAVE

1656
00:53:01,929 --> 00:53:03,430
SET UP CARE WITH MY NEIGHBOR,

1657
00:53:03,430 --> 00:53:06,767
YOU KNOW WHATEVER THE CASE MAY

1658
00:53:06,767 --> 00:53:07,167
BE.

1659
00:53:07,167 --> 00:53:08,368
SO CONTINUE TO WORK ON THE

1660
00:53:08,368 --> 00:53:09,670
QUALITY OF THAT DISCHARGE

1661
00:53:09,670 --> 00:53:11,004
EDUCATION AND REALLY TRY TO GET

1662
00:53:11,004 --> 00:53:13,307
PEOPLE TO PLAN AHEAD.

1663
00:53:13,307 --> 00:53:14,975
BUT WE ARE WORKING ON TOOLS TO

1664
00:53:14,975 --> 00:53:16,343
HOPEFULLY HELP WITH THAT AS WELL

1665
00:53:16,343 --> 00:53:18,111
AS TO HELP MEASURE CAREGIVER

1666
00:53:18,111 --> 00:53:23,817
ENGAGEMENT AS WELL, SO FAMILY

1667
00:53:23,817 --> 00:53:24,284
CAREGIVERS.

1668
00:53:24,284 --> 00:53:25,285
>> AND IN RECOGNITION OF
TIME I

1669
00:53:25,285 --> 00:53:27,020
WILL TURN IT OVER TO YOU AND CAN

1670
00:53:27,020 --> 00:53:28,956
IF THERE WERE ANY ADDITIONAL

1671
00:53:28,956 --> 00:53:29,823
THINGS TO SHARE WITH THE

1672
00:53:29,823 --> 00:53:32,492
AUDIENCE BEFORE WE CLOSE?

1673
00:53:32,492 --> 00:53:34,428
>> I DON'T THINK SO.

1674
00:53:34,428 --> 00:53:36,296
IT'S BEEN SUCH A PRIVILEGE TO DO

1675
00:53:36,296 --> 00:53:37,564
THIS WORK, BOTH FOR THE PATIENTS

1676
00:53:37,564 --> 00:53:39,633
AND OUR COMMUNITY SERVICE

1677
00:53:39,633 --> 00:53:41,935
PROVIDERS, THE CBOs THAT WERE

1678
00:53:41,935 --> 00:53:43,136
PROVIDED IN 1 OF THE OTHER

1679
00:53:43,136 --> 00:53:45,105
QUESTIONS, WE ARE SO THANKFUL TO

1680
00:53:45,105 --> 00:53:48,175
HAVE THIS REALLY TIGHT KNIT

1681
00:53:48,175 --> 00:53:49,443
COMMUNITY HERE AFFILERATED WHY

1682
00:53:49,443 --> 00:53:51,778
THE UNIVERSITY OF UTAH, WE ARE

1683
00:53:51,778 --> 00:53:53,380
REALLY TRYING TO EXPAND OUT INTO

1684
00:53:53,380 --> 00:53:56,750
THIS BEING A REGIONAL EFFORT.

1685
00:53:56,750 --> 00:53:59,486
WE COVERED MOST LAND MASS OUT OF

1686
00:53:59,486 --> 00:54:00,921
ANY ACADEMIC HEALTH CENTER IN

1687
00:54:00,921 --> 00:54:02,322
THE COUNTRY, AND SO WE'RE REALLY

1688
00:54:02,322 --> 00:54:04,391
TRYING TO FIGURE OUT HOW TO DO

1689
00:54:04,391 --> 00:54:08,128
MORE OUTREACH AND SERVICE

1690
00:54:08,128 --> 00:54:09,496
CONNECTIONS FOR THOSE WHO MAY BE

1691
00:54:09,496 --> 00:54:11,498
IN RURAL AND FRONTIER SETTINGS.

1692
00:54:11,498 --> 00:54:12,799
SO IT'S JUST BEEN SUCH A

1693
00:54:12,799 --> 00:54:15,268
PRIVILEGE TO DO THIS WORK.

1694
00:54:15,268 --> 00:54:16,803
WE'RE CONTINUING OUR WORK ON

1695
00:54:16,803 --> 00:54:20,507
BOTH THE IN-PATIENT AND

1696
00:54:20,507 --> 00:54:21,908
OUTPATIENT SIDE AND HOPEFULLY AN

1697
00:54:21,908 --> 00:54:22,743
OPPORTUNITY TO CONTINUE

1698
00:54:22,743 --> 00:54:23,010
LEARNING.

1699
00:54:23,010 --> 00:54:24,478
SO THANK YOU SO MUCH FOR

1700
00:54:24,478 --> 00:54:26,780
LISTENING TODAY AND AGAIN, I AM

1701
00:54:26,780 --> 00:54:29,082
-- I WAS HAPPY TO COLLABORATE

1702
00:54:29,082 --> 00:54:31,318
AND ADDRESS WHATEVER QUESTIONS

1703
00:54:31,318 --> 00:54:34,254
OR NEEDS THAT MAY ARISE.

1704
00:54:34,254 --> 00:54:36,223
SO HAPPY TO CORRESPOND WITH

1705
00:54:36,223 --> 00:54:36,857
ANYONE.

1706
00:54:36,857 --> 00:54:37,791
>> WELL, DR. WALLACE,
THANK YOU

1707
00:54:37,791 --> 00:54:38,992
AGAIN SO MUCH FOR TAKING THE

1708
00:54:38,992 --> 00:54:39,960
TIME TODAY TO SHARE YOUR WORK

1709
00:54:39,960 --> 00:54:42,229
WITH US AND TO ACTUALLY TRULY

1710
00:54:42,229 --> 00:54:46,299
BRINGING A PICTURE TO THE EASE

1711
00:54:46,299 --> 00:54:48,368
AND CHALLENGES OF DOING RESEARCH

1712
00:54:48,368 --> 00:54:50,437
THAT HAS DIRECT APPLICABILITY TO

1713
00:54:50,437 --> 00:54:51,738
HEALTHCARE AND SHOWING WHERE

1714
00:54:51,738 --> 00:54:53,206
NURSING LED SCIENCE REALLY DOES

1715
00:54:53,206 --> 00:54:55,409
HAVE THE ABILITY TO IMPACT OUR

1716
00:54:55,409 --> 00:54:56,610
HEALTH FOR EVERYONE.

1717
00:54:56,610 --> 00:54:58,345
I WILL BE REMISS IF I DON'T

1718
00:54:58,345 --> 00:54:59,246
POINT TO WHAT'S ON THE SCREEN

1719
00:54:59,246 --> 00:54:59,579
RIGHT NOW.

1720
00:54:59,579 --> 00:55:01,114
PLEASE REMEMBER IF YOU ARE HERE

1721
00:55:01,114 --> 00:55:05,285
TO COLLECT CME CREDITS, THAT THE

1722
00:55:05,285 --> 00:55:05,719
CODE IS 57904.

1723
00:55:05,719 --> 00:55:07,087
AND WITH THAT WE WILL CLOSE FOR

1724
00:55:07,087 --> 00:55:07,554
THE AFTERNOON.

1725
00:55:07,554 --> 00:55:10,157
AND THANK YOU AGAIN, SO MUCH FOR

1726
00:55:10,157 --> 00:55:13,026
YOUR TIME AND JOINING US.

1727
00:55:13,026 --> 00:55:23,026
>> THANK YOU.