The unique demands of urban America

Mylynn Tufte (00:00): Good morning. Thanks for being here today. My name is Mylynn Tufte. I am the partner and leader of the population health practice within our Optum Advisory Group. I'll serve today as the moderator, as well as the speaker. Our session today is to address the unique demands of urban America, especially addressing social determinants of health within Brooklyn, New York. Our session will discuss leveraging partner expertise in technology, data, and community-based partnerships, especially in the urban setting, as healthcare systems tackle social determinants of health and drive improved patient outcomes. We ask if you would silence your phone, please, and then save your questions to the end. We will have some time to address them at that time. When you come to the microphone, when you ask questions, if you could identify yourself, that would be great, as this session is being recorded. (01:02): I'm really privileged and honored to introduce my clients and, and colleagues. Delphine Mendez de Leon, who serves as the Chief Strategy Officer for University Hospital at Downstate and Mohamed Rami, Dr. Nakeshbandi, he is the Chief Medical Officer at University Hospitals at Downstate. Just a couple things about Delphine and I won't go into her lengthy bio here, but Delphine is a leader at University Hospital Downstate. She does lead the strategic plan which includes strategic growth and service line and network development initiatives. She also holds a BS, an MBA and an MPH from Columbia University and sits on the board of trustees for Columbia University School of Nursing. (02:01): As I said, I have worked for Optum and have over 25 years in health care experience both on the payer and provider side. Before returning to Optum Advisory in 2020, I led the Department of Health for the state of North Dakota and have a nursing degree from Case Western Reserve, and a business degree from Arizona State University. I also serve as the leader for our Optum Center for Health Equity. Dr. Nakeshbandi is the Chief Medical Officer for University Hospital of Downstate. He is a leader for the high reliability organization journey that they've been on and the health equity initiatives for the institution. Before assuming his current role as Chief Medical Officer, Dr. Nakeshbandi was the Chief Quality Officer at Downstate, where he was instrumental in leading the planning and executing and implementing of the quality measures and regulatory compliance. Dr. Nakeshbandi has received multiple awards. He also has a Master's in Healthcare administration from Columbia University. His doctorate is from Aleppo University school of Medicine, and has done fellowships in residency in West Virginia and SUNY Downstate. So today we're gonna talk about the unique challenges for University Hospital at Downstate, the partnership between UHD and community care of Brooklyn. We'll go into the initial outcomes and our lessons learned and finish with Q and A. So next, I'm gonna turn it over to Delphine. Delphine Mendez de Leon (03:59): Thank you. Thanks so much, Mylynn. Good morning, everyone. I hope y'all are awake, and thank you so much for being here at eight o'clock in the morning after all that bourbon last night. Oh my God -- and I'm not a drinker, so if I'm like this, no, I'm teasing. so thank you all for coming. I do wanna just check in with you to find out if you're like me, perhaps one member of your family at some point lived, went through Brooklyn, anybody? Yeah. My grandparents, both hail from Brooklyn. This is my second stint working in Brooklyn. I was there early on in my career working for a hospital. I spent many years in consulting, and I'm back there, and I can tell you that Brooklyn is like shifting sense culturally, ethnically, demographically, economically. It's really an amazing, amazing place, and it's an amazing place to live and to work 2.7 million people. (04:55): Imagine it's the fifth largest city in the entire country. So we have a challenge, and our challenge is, and our mission is health equity. And what we've learned is that we can't really do this alone. Our patients are very, very different. First of all, we have languages that, you know, 10, 20 languages, 30 languages. We have to deal with people who are economically very, very diverse, et cetera. and they all flow through our institution. We're kind of like a family working in Brooklyn. So I'm really very proud of the fact that we, we hail from Brooklyn, we work in Brooklyn, et cetera, but we really have a lot to really overcome in terms of ensuring that our patients have access to healthcare in an equitable fashion, regardless of where they come from, what language they speak, or how much money they make. (05:41): and the other thing you should know about Brooklyn is it's still changing dramatically. We have huge numbers of development there. every single block that you drive down in Brooklyn now has a building being built. So you can expect that those changing population statistics will change even more. and there are more people that are moving into Brooklyn. So it's a challenge. But in that sense, we are very cognizant of and very focused on the social determinants of health, because we see it every day in our patients. We do. And you'll hear more about that from a data and statistical perspective, but it really has come to our tension that we need to be more focused about our efforts related to social determinants of health. And as an academic medical center, we also wanna remember that we are both clinical and educational and research. (06:26): So we're trying to bring all of those elements together. So again, we are looking at us. The regulatory scene, you all know, has changed and is changing relative to social determinants. There are more incentives that are coming our way. CMS is requiring reporting of social determinants, social determinants of health coming up. And we need to respond. We need to react accordingly. And so what we learned kind of early on is that we really weren't structurally prepared for, for this construct. And we need to kind of look at it holistically, and we need to look at it in terms of developing a system for being able to assess our patients, et cetera, manage risk, develop process flows, operationally change, et cetera. This is an undertaking for us, but we're really rising to the occasion. Hot off the press, this was August 7th, governor Hoel of New York State announced that in fact, this 1115 waiver amendment has passed. (07:23): And in fact, they have assigned and developed a social care network organization that's gonna manage Brooklyn, in fact, the same public health solutions that is going to manage Brooklyn, Kings County, Manhattan, and a couple of others. and that's great because what we're thinking of here is that we can work together. So, you know, they say it takes a village, well, it really does take a community in terms of us working together. We have approach this unsystematically, I'm gonna call it. We have CBOs with that. We work with, we have IPAs that we belong to. We have payer partners like Health First that we've worked with. But really it has, it, it's not coalesced yet into kind of this structural component where the patient's in the middle and you really understand the needs of the individual, and you have everyone kind of working around the particular needs of the individual. (08:10): So we're really looking forward to this 1115 waiver and working with the social care networks and working with others in the community so that we can advance the construct of social determinants of health. lemme go on the payer mix. I, I'm, I'm not gonna get into it, but you can see there. And it really reflects our community, which is that we're largely Medicaid population. We have managed Medicaid, we have fee for service, Medicaid, and we do have a number of, of older patients as well in the Medicare. So our community really, and our hospital reflects the community in which we live. and we really need to work together. So here, we've worked with Optum for the last year on social determinants of, of health, if you will, SDOH and looking at various models. And we initially applied their algorithm to understand nature of SDOH in our particular community. (08:58): And lo and behold, as you can see here, we do have needs particularly in the area of, of transportation and finance. And we've been working on those. We understand it. So, you know, real life examples for our patients every day is they don't have enough money to get to the hospital, or they don't have enough money to get home, and they may not be wheelchair bound. and so therefore, they may not meet the criteria. And the amount of time and effort that our staff spend in trying to e at least get transportation set for our patients. You know, a patient comes in, they can't get home, the staff has to do preauthorization to try to see if their Medicaid eligible. The clerk has to look up the preauthorization, the care manager has to look it up, and you know what ends up happening. (09:36): Believe it or not, our staff end up paying outta their pockets to get these patients enough money to get a bus or a Subway to go home, or a car service to go home. So for us, it's, it's, you know, it's every single day we have these kinds of needs on top, of course, of all of the clinical needs that our patients have. So this just highlights our, our efforts and are really looking forward to working together with others. We have. And one of the things that we've learned, and you'll get into it, is we have many relationships with CBOs in our, in our neighborhoods, if you will. And wherever the patients are is where we wanna go. So, when we talked initially with our care managers about, you know, how do they and social workers about how do they refer patients for needs in the community? (10:17): What we found is that each social worker kind of has their own list. So that's really interesting. So each one has kind of their own agencies that they like to work with for sending their patients. So this is one of the things that we discovered that we need to kind of look at and say, okay, well, how do we bring this toge? How do we bring this together into one, into one kind of structural infrastructure based approach to identifying needs for patients? And beyond the algorithm that was provided by Optum for our community, what we need is we need to screen our patients individually. And that was kind of the emphasis for this whole project for us, is being able to develop an infrastructure, which they'll get into on how we can actually identify what this particular patient needs. The other issue we had is Z codes. (10:59): And you all probably have the same experience, although they've been in place, they haven't really been used. And so we needed to understand, you know, how do we actually optimize the efforts, not just related with identifying screening for patients, but being able to code them appropriately to be able to gain whatever incentives come along with that. And again, we're an academic medical center, so this is not just a matter of kind of putting the codes and making them available for coders to pick up on, but ensuring that the documentation is there. And so, when we talk about education, it's education for everybody. It's not just nurses and social workers and care managers and how to identify the needs of the patients. Think about it, it's interns and residents and hospitalists, those providers that are actually directly taking care of the patients who need to provide the documentation to support the Z codes as well. And in our ambulatory care side, it's providers who are actually filling out, filling out the forms to be able to code those patients and what's wrong with 'em. So it's multifactorial to be sure. And we're really excited by the work that we've done in the last year, and you'll get to hear a little bit more about it going forward. Thank you. Mylynn Tufte (12:09): So Delphine went over the importance of SDOH and the impact to the patient's health. For us, the partnership between Optum and UHD is longstanding. This was the fifth year of a partnership between Optum and UHD. And the commitment from the leadership level for this project and initiative made it a success. The leadership from Delphine and Dr. Nakeshbandi, all the way up to the CEO Dr. Berger. So the approach that we talk took, and there were three areas of emphasis and focus. The first one being SDOH infrastructure implementation, and really reaching both within the organization and external to the organization. We'll talk about that interface into the community. The second part was around building the infrastructure for reporting and being able to show the impact and the level of need for social care need of the patients looking at the population, because we knew from Dr. Nakeshbandi and the team that the demographics within the Brooklyn area were different than the population that was being served at SUNY Downstate. And lastly, the third area of focus was around quality improvement and really understanding that interaction between the SDOH burden and the key quality metrics, and making sure that those were documented and being able to be reported. (13:49): This process flow or or timeline looks at some of the work that we did, mostly in phase two, but you'll see the phase one implementation of the work for SDOH screening and referral started way back in November for the inpatient with a go-live of January, 2024, which was the CMS requirement to do this SDOH screening. Then as we went into phase two, you'll see that we broke out the phase two implementation with ambulatory clinics, ED being its own separate work group and entity. And then making sure that we had adequate time for workflow documentation education, as well as the community building aspect with the partner that was identified. some of the challenges that we needed to understand and overcome were during the middle of this implementation it had a blackout time for the EMR this time that they used for maintenance upgrade and those types of things. (15:01): So we had to make sure to build our design and get that to the IT team so that they could work that into the process that they had. the IT team was small but mighty and was a great partner for us. I think that some of the other things that you'll see that I'll talk about is just making sure to have the right stakeholders at the table and, and being able to get their voice. So as we were designing the system, some of those priorities and focus areas were around making sure to center this work around the patient and the patient's needs. making sure to streamline this process for the care team, knowing that the care team is already overburdened and wanting to make that easy, not duplicative and within the workflow of the systems that they have. And then from the Downstate perspective, also, they wanted to make sure that the solutions invested back into the community and the community partners that they had. For SDOH, as you may know the closed loop referral system is the gold standard and is the standard that we strove for for SUNY downstate. (16:19): So the partner that was selected for this closed loop referral system was Community Care of Brooklyn. And Community Care of Brooklyn is part of the IPA and, and a partner to UHD. so they all have a lot of experience in, in taking care of patients and members for this space. They don't charge for their services, and they make their services available regardless of insurance status. As you look at this you'll see the workflow was codesigned and really took into account the frontline clinicians and staff, those social workers, the care managers, to make sure that we understood the process that they currently had, and then trying to build a process that was integrated into their workflow. And as I said, not duplicative. So making sure to co-design with the frontline staff and commissions was clinicians was important. (17:21): We got that feedback, we had multiple sessions to make sure that the goals were aligned and that the individuals that were going to be doing this work understood what the workflows were and the priorities. So that required both training and a lot of communication from the leadership team as well as from our team working with them. When we looked at the data sharing opportunities between UHD and Community Care of Brooklyn in that closed loop referral process, we thought that it would be easy, easier because both of these organizations use an instance CarePort for their, their documentation, unfortunately, that instances and the interoperability between those CarePort systems wasn't able to be achieved. So what we did make sure to leverage was the UHD EMR for their healthcare system, so that when the screenings occurred, there were automatic referrals that were triggered off the SDOH responses. (18:37): and that those went to the community care CCB patient navigator. and we'll talk through the process because there's a continuous IM improvement evolution that, you know, as we pass some of that data across to CCB, we realized we for pediatric patients weren't including the, the parent, or they, they didn't see the indicator that the person was the patient was a pediatric member. So there were some things that we continuously learned and, and improved upon as we passed those referrals over. And then from the reporting perspective to make sure that that closed loop referral system and the reporting that was coming back to UHD from CCB was inclusive of all the things that the team at UHD wanted to know. (19:36): So I, I talked a little bit about the success, what made this success, and having the right stakeholders at the table, making sure that communication was thought through. And there was a planned approach for communication as well as education and training. those were things that this executive sponsor team emphasized and we were able to achieve with the partnership making sure that there was good stakeholder identification. that took a lot of upfront planning, as you can imagine. making sure that we had the co-design and review and socialization, making sure that there were the go live announcements and the post go live announcements and the follow up so that the clinical staff could see the impact of the work that they were doing. from an educational approach our approach was to make sure that there were the virtual training sessions, because there were, you know staff that were seeing these, these patients across the 24 hours, making sure that that training was done, both for the nursing staff as well as the providers. the nursing staff was the staff that does the SDOH screening within UHD. We did onsite visits for making sure that there were the training kind of at the elbow, and that was very well received. And then the ongoing follow up, you know, as we put in structured meetings to make sure that there were any questions that were addressed, any issues, any areas for opportunity for improvement took place. So I'm gonna let Dr. Nakeshbandi continue on some of the outcomes and lessons learned. Mohamed (Rami) Nakeshbandi (21:31): Thank you very much, Mylynn, and thank you everyone for attending the session. And thank you for the MESC for inviting us to give our work or speak about our work for addressing social determinants of health. I'll take you through some of the results for the work we did to address SDOH in our community. And as Mylynn mentioned earlier that we start first with inpatient. we saw that in January, and our screening rate was 96%. It's been ranging between 96 and 98. And the interesting part that immediately after we implemented the SDOH screening tool in the electronic medical records, we realized we found that the screening positivity rate was 95%. And that will give you an idea how engaged our staff and addressing those issues with our patient population. 33 patients out of the total number of patients who got screened they were not able to answer any of the questions. You know, in the inpatient setting, sometimes patients are sick or in the ICU and they're unable to answer questions. 65% of the patients who answered the questions they had one or more question that they didn't want to answer. And, we found that the most common question that the patient didn't want to answer were related to violence or safety at home. So we realized that this is an opportunity that we built that relationship between our nursing team and our patients to make the patients comfortable addressing those issues. (23:01): 21%, 122 patients, they had at least one or more social needs or positive social determin of health. The positivity rate was 21% as expected. and when we looked a little bit more into the data, we found that transportation and housing insecurity were the highest in terms of the social needs in our patient population. after we implement successfully the SDOH screening for our inpatient we built the process to do the screening for outpatient and ed. and we started that around June, and we were successful as well. so the last few weeks from June to July, were able to screen close to 300 patients in the ED and around 75 patients in the emergency room. Those are the patients who were not getting admitted to the hospital. And we found again, that utilities and housing insecurity was the highest among the social needs among those patient population. (24:04): and as we mentioned earlier that we utilize the Community Care of Brooklyn as a platform to connect the patients with the social needs to the appropriate community-based organization. And since this process is add its emphasis for the outpatient and the ed there are some opportunities for improvement, more education to get more referrals into the CCB. So we referred around 144 patients in the outpatient setting, and out of those, around 28 patients, close to 30 patients, they got referred to community-based organization. However, there are around 50 patients we were unable to connect with after they left our institution. So this is an opportunity that we need to have a better process in getting the appropriate contact information for those patients after they leave the institution. And very similarly in the emergency room. And as Mylynn mentioned earlier, one of the objectives was to not just address the social needs, connect the patients and refer the patients to community-based organization, but also to see what the relationship between the social determinant of health and the quality outcome. (25:14): And since this process has been at the beginning since January, and some of it was in June, so we couldn't use the data actually from our screening tool, and that's why we utilized the Optum propensity a personal level propensity risk score. This risk score it's on a personal level, it's very similar to the other SDOH risk scores that used nationwide, which is based on zip code or census data. This is based on a large data from the household or the person themselves to get what's the likelihood that will indicate that this patient will have some kind of social needs. Optum leverage five different social needs in terms of invest looking at the data in our community, which include the housing insecurity, financial stress, transportation issues, social isolation and food insecurity. (26:07): Those are very similar to the SDOH data that we collected in our screening tool. And we got those information, the data predictive analytic data from Optum, and we connected it to a couple of quality measures, including 30 day readmission rate and length of stay. So let's look first at the readmission rate. We did a regression data analytic to see what the relationship between the social needs about our for our patient population and the 30 days readmission. And we found that there is a positive relationship between the readmission and the social needs, which is not surprising. and there was no linear positive relationship for food insecurity. But for the other, there were linear increase. We deep dived more into the readmission based on the ICD 10 codes, and we found that sickle cell disease was the highest rate of readmission in our patient population. (27:05): And as we mentioned earlier, downstate located in central Brooklyn, it served a diverse immigrant patient population. A high number of our patients come from the Caribbean or West African. And sickle cell disease has a high prevalence among those patient population and we found that this is actually one of the highest rate of readmission based on the ICD 10 codes. We deep dived also more into what are the reasons for those patient population to come back to Downstate for readmission. And we found that there is also a positive relationship between the social needs for those specific patient population and the readmission rate, and that was for all the four actually all the five social needs except the food insecurity. So that will highlight a very high opportunity to address the clinical care that we provide for the sickle cell disease patients and specifically to address their social needs while they are outside the hospital. We looked very similarly, the second analysis was done for length of stay and delayed discharge. And we found very similarly that there is a positive relationship between increased length of stay or delayed discharge and the social needs except for food insecurity, which is not surprising as well. So, in summary, we're very proud of the hard work that we collaborating with Optum to streamline and standardize the process of screening for social determinant of health in our patient population as a safety net hospital in Brooklyn. (28:37): The goal was to improve our clinical care, to improve our quality measures, and also to be prepared for the CMS mandate and the CMS potential adjustment payment adjustment based on the social needs. And we believe that the process that we created was very powerful because it engaged the frontline staff and made them the part of the process and part of the design for the screening. Our nurses start the process for screening for SDOH, from the time the patient hits the institution and goes through it through while the patient is in the hospital and after discharge. Even though we did a great job, I think there are some opportunity that we need to address one of them. We wanna make sure that we create that relationship and by enforcing the education and training for our nurses to make sure that they create that trust and relationship with the patient.(29:30): so they can be comfortable addressing some of the safety at home and violence at home when we ask that those questions. Also, the other area for improvement, I think we need to address the process, how we find an alternative way of communicating with the patients if they don't have cell phone or phone at home, so we can make sure that we refer them to appropriate CBO after they getting discharge. And the last opportunity at the sickle cell disease, as I mentioned, that we create a wholesome structure, how we manage those patient and address the social needs after they get discharged from the hospital. We build a great dashboard. We communicate that dashboard with our community providers, with our community leaders with the leadership in the institution. And I think the whole process is positioning the Downstate in a very good place to be operational with the social care networks after the passage of the 1115 and Medicare from the New York State to serve the patient population in New York State and specifically in Brooklyn. Thank you very much. And we will be happy to answer any question. Mylynn Tufte (30:38): Feel free to come up for, for questions. That would be great. Delphine Mendez de Leon (30:50): I will say one thing... Mylynn Tufte (30:51): Can you turn on your microphone, please? Delphine Mendez de Leon (30:56): I can. Perfect. I'll just say one thing that we've done in understanding our patients and their needs after the fact is we've kind of looked at the concept of what happens to a patient after they're discharged, besides the referral process, and what happens to patients in the outpatient setting. So we've actually contracted with services to support us. So every single patient after discharge is actually trying to be reached by text or by phone or by email to understand, you know, do they have another appointment? Do they have an issue with medication, et cetera, et cetera. So that's a really important concept for all of our patients actually, in terms of follow up after discharge to ensure that they're doing what they need to do to, again, prevent readmissions. Similarly, with the outpatients trying to understand, do they have an appointment? Are they gonna get to the appointment? (31:41): Do they need the appointment to be changed, et cetera. So we're trying to maintain that communication that, that folks are speaking about here as kind of a central theme to our patients is really developing the patient at the center and understanding and developing a very personal relationship with every patient so that they know that they can trust Downstate for whatever their needs are, you know, while they're getting the service there. And also afterwards. So when you talk about SDOH, it's really just maintaining a continuous relationship with the patient and kind of pulling the forces together to really support that patient in the community. Mylynn Tufte (32:13): Thanks, (32:13): Delphine. Mm-hmm <affirmative>. Angela, you were gonna ask a question? Speaker 4 (Angela) (32:17): Yeah. Can you speak a little bit more about how being a teaching hospital impacts some of your work? Mohamed (Rami) Nakeshbandi (32:24): Okay. Thank you very much, Angela. I think this is a really great question. you know, as a teaching hospital, we have students, we have medical students, public health students, nursing students, residents, fellows, and they're all an important part of the clinical care when we provide to our patients. And in the past, we had a lot of work done, but it was in silos. As an example, we have a clinic called a Free Brooklyn Clinic. This is a students run clinic, and usually there is a one physician who managed to help and address some of the issues, but it's all operationally run by the students. And in fact, actually they had their own process. They just presented a week ago in another conference, their social determinant of health work that they've done, and they did a fantastic work. They serve, of course, this is a free clinic, so they serve a patient population either don't have insurance or they have a maximum like Medicaid insurance. So they, they, they service a certain patient population that they have a lot of social needs, and they they have their own workflow, how they connect those patients to the CBOs. you know, bringing all those people to the table, including our nurses, our frontline staff, our students and residents to be part of the process and learn from their experience when they did their process helped us a lot in streamlining that process across the board. I'm not sure if Delphine you want to add to this... Delphine Mendez de Leon (33:46): Same thing I mentioned, you know, students and residents, actually, one of the residents just did a, a study on his own as part of his, yeah, as part of his work process. looking at and evaluating how the residents are actually identifying SDOH. and what he found is that they're not really they're not really focusing. And so there's a lot of education there that's required to understand the survey that we have built into the EMR, which is an assessment tool completed by the nurse on every single patient that's admitted. How does the intern or res or resident access that information? And how is that information then incorporated into the documentation of that individual so that there's a full understanding of what the needs are for the patient? And then furthermore, how is that integrated into the discharge summary of the resident. (34:36): So again, it's baked into the documentation. And so he did a great job as a resident understanding the nature of the problem relative to residents, and how do we bring those individuals into this process as a whole. I, you know, when I say holistic, I mean it, I'm not trying to be trite. It's really a, you know, this is a process that involves everyone both from a communication standpoint and from an activity standpoint. Baking it into the EMR is important. I cannot underestimate the importance of our, our it. and creating those interfaces and those automated referrals to social work for any positive response that's generated within the EMR survey that's completed, that's critical to us. And our team was just amazing in terms of helping us kind of pull this flow together and really make it work from an interface perspective. Mohamed (Rami) Nakeshbandi (35:27): Angela, as an academic institution, it's actually part of the requirement for the residents and the fellows to include quality and health equity as part of their educational platform. So that was a great opportunity to get the residents to be part of that process. when we implemented, when we partnered with Optum to streamline the process of screening. Delphine Mendez de Leon (35:48): Yeah. I'll add one more thing there. 'cause we really are looking at this from all schools perspective, and we're working with the School of Public Health, for example, on the concept of lifestyle medicine. And if you haven't learned about or know about lifestyle medicine look it up because it's becoming a curriculum that's based actually in academic medical centers going forward, family medicine in particular and internal medicine as well. And we're really jumping in to the concept of lifestyle medicine, developing some pilots now for coaching, for example to incorporate. And the school of social of public health is working with us to incorporate how do you identify patients and get them involved with free, free for them. active, real time based lifestyle coaching that really addresses SDOH in a practical manner for patients within the community. So, as I said, it's, you know, our entire academic medical center is, is totally consumed and focused on this concept of health equity, and we work on it together. Mylynn Tufte (36:52):<laugh>, no, wait (36:54): A second. We'll get you, Delphine Mendez de Leon (36:55): She'll jog <laugh>. Speaker 5 (36:59): Hi, I am Jen sars. I lead the HIE in the state of Connecticut. And I have sort of two questions that I heard. I heard at the beginning, Delphine of your presentation when you talked to caseworkers and, and social workers that they sort of all had their preferred CBOs or places they referred to. and then it looks like what you guys ended up doing was sort of having this community care organization be the place where you funneled referrals to ... how did you get the social workers or sort of what was the process of getting them comfortable with we're sending it here, you know, and even though you love, I don't know, CBO of Brooklyn that's one question. And then the second one is that one of the things that, that I'm learning sort of in, in my role in, in working with CBOs in the state of Connecticut is there is a very real fear of any sort of electronic referral process because they feel like they can barely handle the workload they have today. Mm-hmm <affirmative>. So sort of getting, being put on someone's list to manage referrals, and then realizing I don't have the staff to manage all of these referrals. Yeah. So I'm gonna be blamed ... Delphine Mendez de Leon (38:05): Yeah. Speaker 5 (38:05): For a, a, a referral that doesn't happen, or services that aren't provided when I really just can't take this fire hose of information. Delphine Mendez de Leon (38:13): Great questions. And they're related, if you will. So I'll take them kind of together. and let me just explain. We have inpatients and we have outpatient and ed, and you're absolutely right. Our care, our care managers and our director of care management and social work is like, this is gonna be too much for us. We're not gonna be able to handle all of this. However, they felt that they, it would be important for them to retain the concept of referral and the practice of referral for inpatients. So that's one. and then the outpatient and ED was gonna be too overwhelming for them, and that's where we've contracted effectively with CCB to make those automated referral processes there. But back on the inpatients, again, to answer your point, yes, they had favorites. And what my Lin and Optum was, was able to help us do, is to effectively bring those lists together and create what I'm gonna call, it's not quite a preferred provider list, but that would be what I would like to do ultimately. (39:10): And that has to work with the 1115 waiver, et cetera, but brought the list together. And in fact, we're embedding them in CarePort so that, the other thing is we don't know, unless you're going to dig into the notes for the care manager where the patient was actually referred, or if the patient was referred, now they're gonna be able to use a dropdown on CarePort to be able to identify where, and those organizations are listed where the patients are referred, and we're gonna take that, and that will be embedded in the EMR. So we'll be able to generate a report to show not only if they were referred, but where they were referred, and start to bring the group together in this concept of, you know, let's make sure that as an entity, as an organization, as a hospital, we have, we understand which organizations that we're working with and what the options are. (39:52): It is patient based of course. Right? If somebody lives over here versus over here and their food banks in both places, you know, where are you gonna send the patient? so again, inpatient wanted to maintain control out, direct control. Closed loop is still, we're still working on that. And by that I mean, we have a grant that we've submitted. Hopefully we'll get it to add a social worker and a community health worker to actually actively maintain that relationship with the CBOs until such time as 1115 waiver automates the whole thing to maintain the relationship with them to be able to get that re return or reply, if you will, to close the loop on the inpatient side. On the outpatient side. CCB is able to produce a report to tell us where the patients were referred and get that back to us. So it's a work in progress. We've just started it, but we understand the concepts of trying to underst to kind of fully develop our network, I'm gonna call it. And I think the 1115 waiver's gonna help us with that because they're gonna be the centralized body for the entire kind of borough of Brooklyn that will help kind of maintain and develop these networks on behalf of US providers, if that helps. Mohamed (Rami) Nakeshbandi (41:00): I, I would like to add that, you know, bringing the frontline staff and the stakeholders from the beginning, and that was actually for sure, they requested to do it an electronic referrals because they thought, you know, our nurses team, like the nursing team with the care management team, when they were on the table together, they realized that if we are gonna do, we real rely on the care management team looking for the referrals or looking for the patients who have positive social determinant of health, they found that it's gonna be actually more work. And they found that doing that electronic referrals based on their capacity. And that's why we decided that just, just to do it with the inpatient services, that they found that it will be the easiest way to address those issues. So, you know, having the frontline staff right away at the beginning of the process helped us a lot making that decision. Delphine Mendez de Leon (41:46): And he's right. And one final point, two interesting process. Truly, everybody was so involved, it was fantastic. our nursing assessment tool was taking an hour to complete. so one of the corollary and nice things about this is they were able to clean that up and reduce it and make it more efficient. So it was a time savings for them, even though we added this section, it was an overall time savings for them. So they were very happy about that. Speaker 4 (Angela) (42:19): John's gonna make me run. Mylynn Tufte (42:26): He warned us that he was gonna heckle us. <laugh> <laugh> (42:28): no, I won't do that. John Campbell from Optum, I'm not a plant very well. I'm just, I'm actually really curious about the, the sickle cell program and whether the, the scope of your program is including either now or in the future, some of the genetic genetic treatment programs that have been approved by the FDAI, I know these cost north of $2 million per year. (42:57): Yeah. Speaker 6 (42:57): ...And and perhaps connecting these patients with resources that can help facilitate garnering that treatment Mylynn Tufte (43:05): Sure. His question was around the sickle cell program, either today or in the future, have we, have you considered the new cell and gene therapy treatment programs or models that are coming out and, and how do you improve access in that way? If I said that correctly, James, John. Mohamed (Rami) Nakeshbandi (43:24): That's, that's a great question. And, you know, we're in the process of rebuilding the service line for our hematology oncology department, partnering with maimonide. and a big portion of the restructuring is the focus, the focus on the sickle cell disease patients in terms of follow up appointments, genetic therapy addressing their social needs, making sure that pain control, that's another major issue where a lot of those patient population come back to the emergency room because they don't have an adequate pain control. And they get into that, that, you know, circle where, you know, they addressing their their, their pain control need, and at the same time making sure that they're not getting into the addiction portion of the pain management. So we're looking at the whole process of managing the sickle cell disease patients very soon in our patient population. Mylynn Tufte (44:16): And I think that there's the policy aspect and working with the state to make sure that, you know, that those new models of care get rolled out and, and address the populations that SUNY Downstate serves. Delphine Mendez de Leon (44:30): And Mylynn add one more thing. There's another population that we serve, which is the renal population. We're the only transplant program in Brooklyn for renal, for kidney transplant. Similarly, the model there is changing. The issue is to identify these patients even before they go on dialysis and put them on the transplant waiting list because the, the success rate and the longevity rate is much higher, is much higher for patients the earlier they actually get a transplant. So the concept of SDOH and it, and we have an entire team that's associated with our transplant program patients trying to identify them early, understanding what their needs are in the community, et cetera, and getting them on those lists early. So there's another example of trying to understand your cohorts and how to identify them as a population based approach. Yep. Mylynn Tufte (45:28): Well, thank you very much. it's been a One more Oh, one more. Okay. Speaker 7 (45:33): I have a quick question on the James from Optum. (45:37): I am James from Optum, also not a plant on the SDOH models. I know that there's been some, I don't know, controversy if the consumer database models are effective in low income populations. And it, and it seems like they, they, you had a good mix of low income folks in here. Did you find that to be the case where they effective and, and secondary questions? I'm also interested in how the transportation model performed. Did, did you also find that one to be effective even though it was tailored for folks that are over 65? Mohamed (Rami) Nakeshbandi (46:19): Yeah. (46:20): Yeah. I can start talking about that consumer data, the person level data versus the census or the zip code related data. So, you know a a lot of models using the zip code or census data, and we found that this is not very well representing our patient population. especially in a an urban community like Brooklyn where there are a mix of patient population in the same zip code. They live in the same zip code, including student residents or even young professionals who work in Manhattan, but live in that area because it is cheaper. so we realize that a lot of those patient population, actually, they seek care in Manhattan because they work in Manhattan. and the patients, they come to our institution the specific patient they come to our institution, actually, they have much lower social determinant of health compared to other patient population who live in the area. So this model could work in in a much, in, in, in suburban area or not like an urban area like like Brooklyn. but we found that in Brooklyn that you have to look at the person level social needs because that would represent the actual need for the patient population. in terms of transportation. I didn't get the question. I couldn't hear the question very well.Speaker 7 (47:43): yeah, the, the question is also with the SDOH model for the transportation insecurity model. the, that one is, was built with over 65. Did you see it performing well in this population even though you probably had like folks younger than 65 in the sample? Mylynn Tufte (48:07): Yeah. Can I address this? so I think the opportunity is now we're gonna do the matching between what the actual individual, the patient says their social care needs are, and then match that to the predictive modeling to see, you know, how accurate that is for this population. Speaker 7 (48:29): Okay. Thanks. That'd be super interesting work. Mylynn Tufte (48:31): We're interested in it too. We're too, Speaker 4 (Angela) (48:32): That's our next step. Mylynn Tufte (48:36): Any other questions? Thank you. Thank you all. Mohamed (Rami) Nakeshbandi (48:44): Thank you.