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Aug. 19, 2019

Steven Littlehale on PDPM

In this episode, we meet Steven Littlehale, a colleague of Mark Zimmet of Zimmet healthcare who was recently on the show.

As we discussed the new Patient Driven Payment Model and how this change will benefit everyone, Steven also pointed out the challenges with the current payment model for this industry.

He is very concerned with the number of people actively dying and not mentioning it in their plan, thus, they are sent back to hospitals.


Steven was privileged enough to have known what he wanted when he was young. He took up nursing and realized that he wanted to be involved in caring for the elderly, being someone who was close enough to live with his grandparents.

Then took up a graduate degree in Gerontology.

Steven also worked in clinical care in Hebrew SeniorLife in Boston. He then transitioned in research and training institute and became a part of the development team for other projects where he developed the importance of standardized clinical assessment, its reliability and validity, and the power of what can be done in the datasets for this assessment.

Recruited to Pointright, he started studying the data and creating proprietary algorithms to help operators, nurses, and other professionals to have data driven insights about the industry.

This has given the professionals and stakeholders with real-time, actionable information.

Being involved with a lot of information and assessment data, Steven realized his passion in filling the gap between the quality of clinical outcome and the lack of fully grasping the financial aspect .

It was then that he joined Zimmet Healthcare, with his enthusiasm for analytical thinking on the reimbursement models and how to best equip their clients and was appointed as the Chief Innovation Officer to lead the Zimmet team in discovering new ways to help the providers and stakeholders in achieving great nursing service.

Steven has pointed out the sad truth of the current payment structure, which doesn’t motivate people to think about a systematic approach to end of life. He gave various examples showing that should have been of financial advantage, elders would have been given better care.

Shmuel shared his insights on how the system has been rigged with thinking that the financial impact gets the better tilt on the scale as it provides viability to the business, overlooking the quality of services that it should have been prioritizing in the first place, as it was the major force to improve the financial aspect of the business.

Steven explains how the PDPM is an improvement to the current healthcare system that will be beneficial to everyone involved in the business, since nursing is more fund-centered.

As he goes teaching classes for PDPM, he points out the mix of people included in seminars that is involved and interested in this model, and he appreciated how well aligned these people are into listening and getting as much information as they can to prepare for the common goal.

The Therapists’ Role in the SNF

A great example that he mentioned are the therapists being boxed in their reimbursements per minute.

For him, therapists are one of the most commonly overlooked health care provider, and they are being valued only per minute, even though they provide healing and rehabilitation, which are incredible.

PDPM will allow them not only to be reimbursed with the timed service they provided, but to be comfortable in giving the quality service that is required of them without the hesitation of being underappreciated.

The new model allows everyone from the management to skilled workers to join together, be in the table together and discuss the appropriate care needed for the patients, which minimizes the tension in between departments.

PDPM Concerns

Although beneficial, Steven still emphasizes his few concerns with PDPM. Since it will be all about the patient, he believes that behavior will have to change come October.

Terms will also have to change accordingly. In nursing facilities, residents will no longer be called “residents” but “patients”.

He also acknowledges the importance of documentation as it will be heavy in implementation of PDPM. This change will also mean taking the rules of the past and trying to apply them to the future.

If you want to gain a better understanding about PDPM and how this new model works, listen to the podcast as Steven and Shmuel intelligently discuss about this change and gives their deep analysis about it.

Steve’s final thoughts on PDPM:

I hope my passion and excitement about this change comes across. I just think that we are in such an unbelievable inflection in our industry.

PDPM is not certainly propped for success. PDPM is here for five years before, it will be replaced by another system, and that other system is already foretold. We are going to site neutral reimbursement where all institutional post-acute settings will get the same rate.

PDPM and the data that we are now collecting is really going to demonstrate that we are the best game in town.

We’re providing the best outcomes at the lowest cost. So this is just a simple stepping stone, if we crush this we are going to do exceedingly well in the future.
Shmuel’s Take on SNFs

People come in completely paralyzed and walked out the front doors; we get the trimmest, leanest reimbursement, and many times we get outstanding results, and if that (PDPM) is the way to the future, then that is really amazing news for providers.

Key Takeaways:

08:24 When the clinical results and the clinical product have a direct financial impact, that’s when everybody wins; that’s when the residents win, that’s when the operators win, that’s when all the various partners win.

10:34 How can it be that in the industry that is created to care for elders, how can we be so bad at identifying someone’s at the end of life? How can we struggle so much with identifying people who are in pain. It is because our system does not reward that.

17:40 You push on one side of the water bed and the other comes up.

32:16 CMS believed PDPM will be budget neutral and there’s no way it’s going to be budget neutral. These changes are never budget neutral because behavior changes, we play by the rules, we change our behaviors, we start documenting things we never documented before.

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Transcript

00:05.037 --> 00:08.647
We, the caregivers, are also suffering when we complain about

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the negative rap we have. I honestly believe it's attributed

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to these really ill conceived models of reimbursement.

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What I love so much about PDPM is there is

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no difference between financial success and clinical

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success.

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Welcome to the nursing home podcast. Your goto

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source for professional insights in the longterm care industry.

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Hear from leaders and experts as they share current and practical

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insights to help make the most of your day. I'm the Longterm care financial specialist.

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What that means is I help people plan for the inevitable.

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Nobody wants to think about getting old, but it's possible that someday

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we might need a little bit of care. Here's your host. Nursing home Administrator Turnpodcaster

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Schmoel, Septimashptimash.

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Welcome to this episode of the nursing home Podcast.

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The podcast which is geared to the nursing home professional

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to bring you the very latest and the very greatest

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in the nursing home industry, where we speak to professionals,

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operators, vendors, and anyone else who can

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shed light and make your professional journey that much more successful.

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Today we have the opportunity of speaking with the

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Chief Innovation Officer of Zimmer Healthcare.

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For those who recall, we had Mark Zimmer of Zimmer Healthcare on the podcast

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a couple of episodes ago, and he was able to convince coerce

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Stephen Littlehal for coming on the show with us today.

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So, Steven, welcome to the nursing home podcast.

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Thank you. I'm really excited to be here this morning.

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I appreciate the opportunity. Thank you for taking some time and

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for coming on the Nursing Home Podcast. Really excited to have you here.

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Now, there are listeners who are very familiar with who you are.

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There are listeners who don't yet know you. So if you don't mind,

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for our audience, can you briefly describe your professional

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journey from where you are to how you evolved and are now

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part of the Zimbab team? Absolutely. I think I'm one of

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those rare people who knew all along what I wanted

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to do with my life. In high school, actually a junior in

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high school, I decided that I wanted to be a nurse. And as a freshman

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in my undergrad program, I decided I wanted to focus in

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on elder care. And I really attribute that to having amazing

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relationships with four grandparents and two great

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grandmothers, all while growing up. It was just extraordinary.

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So I have a graduate degree, I'm a clinical nurse specialist

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in gerontology, and for the first ten years of

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my nursing career, it was direct clinical care,

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Hebrew senior life in Boston. There I transitioned

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into their research and training institute and was part of

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the MDS 2.0 development team along

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with other projects. And there I really developed

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a very deep sense of what standardized clinical assessment

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was all about, the importance of reliability and validity

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and the power of what you could do with these standardized

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clinical data sets. I was then recruited to

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pointwright, then ltcq as

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their Chief Clinical officer and then later their Executive Vice President.

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And pointwright takes. All of this data clinical data,

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regulatory staffing, financial,

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basically any data that we can get our hands on

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and creates proprietary algorithms to really

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help give great insight into variants,

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to help operators, nurses,

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clinicians, lenders, attorneys have

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deep, data driven insights into what

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is most important to them to help answer

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very key questions that are most pertinent to

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their work. In most instances, that means providing

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MBS coordinators, clinicians,

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administrators, directors of nursing therapists and

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their stakeholders, nursing home stakeholders with

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realtime actionable, data driven insights.

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So after being at pointwriter for 21 years,

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I decided and some people refer to this as my midlife

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crisis. Maybe it was, but I decided that I

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really wanted to, one, get a little bit

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closer to providers. One step back to

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my roots and also really fill in

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a gap that I was well aware existed within

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my own learning and experience. And that is reimbursement

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and the financial aspects of providing clinical outcome

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care. Honestly, that insight became really

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more paramount since healthcare reform was

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signed into law. When we see that those two worlds

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are coming together, clinical outcomes and quality

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is in fact coming together with financial outcomes

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and financial success, and I delight in that, I think

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it's fantastic. So, you know, suddenly a clinician like

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me has a different audience. So that's really exciting

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for me. So I joined them at Healthcare services group.

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I've known those folks for Gosh almost the

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whole time that I've done that point right. I've been really excited

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with their deep analytical thinking around

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reimbursement models and how to support their clients

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and achieving success, which again today means how

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do you achieve success? It's through providing excellent clinical

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care. And I joined that team, that extraordinary

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team, as their Chief Innovation officer,

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to think about new ways in which we could support providers

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and other stakeholders in the space.

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So that brings me to today. Well, thank you for that

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complete background.

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Before we jump into some of the other questions,

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I will just tell you that being the host of the Love Your Nine to

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Five show podcast as well, which you may or may not be aware of,

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which is a career podcast. It is astoundingly unique and

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refreshing to hear someone who knew so clearly,

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so early on and you were able to exactly what

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you wanted to do and you further narrowed it down and

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you had the luxury of being at that stage in

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your life and continuing down the path further and further and

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further to accomplish what you have already accomplished.

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It's just so exciting to hear that. I can tell you how many conversations

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I've had with potential candidates for various

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positions where a big piece of their struggles is that

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their midlife crisis was finally figuring out what they really wanted to do and having

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the courage to do it. So I had someone who

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was in finance, but not clinical finance like regular working

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in a bank or whatever for 25 years, wrecked a marriage and

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a lot of other relationships, and financially broke, and finally said,

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oh, I always knew in high school I wanted to become a nurse.

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And finally she became a nurse, I think NLTN in mid forty

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s, or maybe even later, finally became a nursing

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home nurse, starting at that level. And I asked her, why didn't you

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start as a nurse? Then imagine where you would be. Your name would

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have changed to Stephen Littlehel at this point, as in that example.

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But I said, you could have been so much further down. She said, well,

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my dad wasn't financed. My mom was what was expected. And she didn't

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have the opportunity to think for herself, or she

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didn't allow herself the opportunity to think for herself and to open

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that up. So that is one piece that's very exciting. But getting

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back to the nursing home podcast, I remember hearing this point

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being made, I forget right now from home. That when

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the clinical results and the clinical product has a direct

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financial impact, that's when everybody wins. That's when the residents

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win. That's when the operators win.

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That's when all of the various partners that we all have win.

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Because at the end of the day, we're providing excellent care and

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we're getting reimbursed, hopefully appropriately, based on the care

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that we're giving. So before we jump into PDPM,

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let's discuss a little bit about the current payment model and what the

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challenges is in this system and what is

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the push to move to this new payment driven payment model?

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Oh, sure, absolutely. Just to kind of start,

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I cannot wait for this transition. This is going to be

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one of the happiest days in my professional career come October

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1. And that's a really bold statement.

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But for 20 years plus,

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many of us have been swallowing down the

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whole idea that the current model

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is motivating the wrong care, the wrong kind of care,

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and who suffers? Our nation's elders. What we

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don't realize is that we, the caregivers, are also suffering.

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When we complain about the negative rap we have in our

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industry. I honestly believe it's attributed to these really

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ill conceived models of reimbursement. Wow. So let me

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be more specific. Let me be more specific.

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From looking at clinical data, I'm able

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to look at the numbers of people, elders,

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residents, who are actively dying and

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who do not have that identified on their care plan and

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yet get sent back to hospital. Because we

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don't we, the clinical leadership in the facilities,

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don't recognize that they're actively dying. We don't know what's going on.

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We haven't prepared them or their family, and we

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send them back to the hospital. And sometimes,

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many times, unfortunately, they actually die in the hospital. Well,

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how could it be that an industry that is created

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to care for elders. How can we be so bad

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at identifying someone at end of life? How can

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we struggle so much with identifying people who are in

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pain? It's because our system doesn't reward

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that. It doesn't motivate folks to

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think about how can you systematically assess

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for end of life? For over 20 years now,

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there has been an existence in MDS based model for identifying people

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at end of life. And I say that to folks, and people on this

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podcast are probably shocked to learn that it's been in the literature.

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It was updated with MDS 3.0, it's in the academic

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literature, and it's been commercialized as well by not

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only pointwrite who has its own scale, but others.

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And yet we still have when you

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look at the stats and you look at the number of people who

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are properly identified at end of life, on palliative care,

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on hospice care, it's tiny. It's tiny.

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But yet when you look at the number of people who are getting therapy

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minutes, no problem there. We see that there's

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a tremendous amount of people who are getting three different types

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of therapy in minutes every single day.

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So the current system is motivating the

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wrong behavior. Again, it's a dramatic statement. I didn't have

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that clarity 20 years ago, but I sure have

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had it for the last ten years. Congress has had it for the last ten

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years. Med Pack has had it for the last ten years. Many of

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the people listening on this call today are all nodding their head, saying,

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we know what the right thing to do is. We have excellent clinicians.

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Maybe their skill set to identify

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these things is a little rusty because it hasn't been

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valued in our system. But many folks on this call

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are nodding their head and they're saying yes.

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One other quick example of this I was a

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co author of a research study which looked at

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the use of tube feedings in

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people with end stage dementia. And we looked at

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the impact of being in a state whose

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Medicaid system rewarded the use of tube feeding.

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And we just asked a simple question. In this population

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where there is no clinical justification to be using a tube

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feeding, if you happen to be in a state that

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pays off a tube feeding, is the prevalence of tube feedings

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in this population greater? Is anyone

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surprised to hear that it was? So if you're in a

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case mixed state or a state that motivates financially, rewards financially

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for the use of two feeding, sure enough, there they were. They were

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being used more in this end stage population

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with dementia. How sad is that?

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Now, I don't think that clinicians are sinister. I don't think administrators

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are sinister. And they're rubbing their hands together thinking,

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how can we figure the system out and provide inappropriate care

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for financial gains? But a great example

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to bring it to transition to PDPM, a great example

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is today you can get PDPM

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training in any number of places around

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the country. Some of it's good, some of it's bad.

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Some of it is saying, let's actually just focus on the

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financial drivers and teach you about the financial drivers,

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the PDPM, some of the education is

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saying, isn't it wonderful that depression is now being financially

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rewarded in PDPM? Let's teach you how to do a depression

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assessment, how to capture the data appropriate and provide

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the right kind of care. So two different extremes,

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but that's how we've ended up where we are today. Okay,

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just to jump in there for a minute, for providers, for operators,

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and for people who are focusing on, just on the financial side,

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they're panicking because we know that what we've done in the

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past is no longer going to reward us financially the same way that it has.

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So we must get ahead of this financial piece

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in order to survive and be able to be a provider,

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period. At the same time, like we mentioned earlier,

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at this point when the financial and clinical

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measurements and the way that the success

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markers are kind of leveling out,

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this is a time when clinicians come to a financial meeting,

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the financial people don't put their fingers in their ears and say geek talk.

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They actually care because what the clinicians are saying are

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going to impact how we're going to operate. And that impacts directly

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the financial results. So tell me if this makes sense.

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Both parts are true. If someone's a CFO,

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specifically of a large nursing home chain,

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he's got to make sure that when it comes year one, that they are

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at least surviving. Not necessarily. Again,

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probably part of it is a transitioning or maybe transmitting

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the same culture into the PDPM, meaning that

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we must make sure that we're financially viable

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in order to continue in the future. And then we'll figure out the clinical part

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and figure out we'll have our clinicians and we'll have our point,

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right? Partners. And Zimmer Healthcare Partners will show us

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how we can balance it out and make sure we're also providing

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for the the residents highest level of care. Which you're calling a bad

16:10.180 --> 16:13.792
model. Which is true. But that's probably where it's coming from. It's the same bad

16:13.840 --> 16:16.807
rap that people had for the old model of care.

16:16.885 --> 16:20.377
And they're going to be operators who are going to probably just focus on that.

16:20.470 --> 16:23.272
And again, the system is rigged in a way, so to speak,

16:23.380 --> 16:26.572
where they're going to have to provide great clinical outcomes in order

16:26.605 --> 16:29.917
to get that their focus may be financial, but the

16:29.965 --> 16:33.727
healthier approach again, I'm thinking this through and you're going to tell me

16:33.745 --> 16:37.392
if this makes sense or maybe adjust it a little bit. But the healthier

16:37.452 --> 16:41.317
approach is, you know what, there's a reason why these changes are happening.

16:41.440 --> 16:44.737
Let's embrace the fact that our

16:44.800 --> 16:48.567
goal is equal not just financial viability

16:48.702 --> 16:52.257
and profitability, but great clinical outcomes,

16:52.347 --> 16:55.422
which have always been important, as we mentioned earlier, for every operator.

16:55.467 --> 16:58.702
But that should be all the way up there on the pedestal. When we have

16:58.720 --> 17:01.702
financial meetings, we now will be able to for the first time,

17:01.720 --> 17:05.077
we'll be able to financially afford to provide the care we

17:05.095 --> 17:08.632
always wanted to get. Does that make sense? Yes, it does make sense.

17:08.710 --> 17:12.142
It does make sense. I would say what I love so much about

17:12.190 --> 17:16.362
PDPM is there is no difference between financial

17:16.437 --> 17:20.002
success and clinical success. They're one and

17:20.020 --> 17:23.502
the same in PDPM. I think the model is brilliant.

17:23.607 --> 17:27.172
If you set out on the journey of how can I figure out how to

17:27.205 --> 17:31.287
financially gain the system? Frankly, it's near impossible.

17:31.437 --> 17:35.182
If you push on one part of the model, the other part of

17:35.185 --> 17:38.697
the model gives way. Someone that I can't remember who uses

17:38.742 --> 17:42.547
analogy of a waterbed, you push on one side

17:42.580 --> 17:45.652
of the water bed and the other side comes up and I see that in

17:45.670 --> 17:49.262
the model. And that's the first time I actually read the proposed rule.

17:50.587 --> 17:53.947
I was geeking out. I was all excited and I'm like, oh my God,

17:53.980 --> 17:57.307
this is amazing. As a clinician, it's amazing,

17:57.460 --> 18:00.922
like how incredible it is for the facility to be able

18:00.955 --> 18:04.647
to do the right thing and get financially rewarded.

18:04.767 --> 18:08.332
And nursing is more front and center before

18:08.485 --> 18:11.577
they were relegated to the back of the bus and it was all about therapy

18:11.607 --> 18:15.587
and therapy minute. It's not to turn therapist into a villain.

18:16.087 --> 18:19.882
Our industry is so regulated that we have become

18:19.960 --> 18:22.932
rule followers. So we follow rules.

18:23.022 --> 18:26.787
Behaviors change, just like behaviors will change with PDPM.

18:26.937 --> 18:30.412
But these behaviors that are going to change are going to be

18:30.550 --> 18:33.432
so much the behaviors we want, the behaviors,

18:33.522 --> 18:36.972
the behaviors that I learned about in graduate

18:37.017 --> 18:40.977
studies and excellent elder care and studied Hebrews

18:41.007 --> 18:44.227
in your life in Boston. This feels so right

18:44.320 --> 18:48.372
for nurses. And I would say the greatest

18:48.417 --> 18:52.417
challenge we're going to have right now with PDPM transition is

18:52.615 --> 18:56.037
changing how we think, changing our framework

18:56.112 --> 19:00.172
for thinking about care. And let me be very specific.

19:00.355 --> 19:03.682
I go and I teach about PDPM quite a bit.

19:03.760 --> 19:07.672
And one of the coolest things for me is in the audience, I can

19:07.705 --> 19:11.217
have a lender from a commercial

19:11.277 --> 19:14.917
bank. I can have a hug lender. I can have a REIT sitting next to

19:14.965 --> 19:18.597
the director of nursing, the quality improvement nurse,

19:18.717 --> 19:22.122
the owner, the administrator, the ambulance coordinator.

19:22.242 --> 19:25.647
It has never failed. Each and every time I've done a PDPM

19:25.692 --> 19:28.852
class, that the mix of people and they're all hearing the

19:28.870 --> 19:32.752
same information. I have to be careful with the jargon I use as

19:32.770 --> 19:35.917
a clinician, but we're hearing the same information, we're getting

19:35.965 --> 19:39.982
the same goals. So the alignment is there. But anyway,

19:40.060 --> 19:43.567
to the point I was making, people will ask me about,

19:43.690 --> 19:47.487
for example, therapy, whether the role of therapy

19:47.562 --> 19:51.725
or even therapy contracts and what they should look like and

19:52.087 --> 19:55.552
here's a great example of taking the old world of

19:55.570 --> 19:59.322
thinking about care and applying and trying to apply it to PDPM

19:59.367 --> 20:02.150
and how it doesn't work. So folks will say,

20:02.887 --> 20:06.342
I will reimburse my therapist if it's a contract therapy,

20:06.402 --> 20:10.267
for example, I'll reimburse them based on my

20:10.390 --> 20:14.047
Ptot and speech therapy components and that's it.

20:14.080 --> 20:17.647
So they'll get a proportion of whatever that is. And I

20:17.680 --> 20:20.647
look to them in a very tactful, diplomatic way,

20:20.680 --> 20:24.097
say, you know, that's just keeping sister in the box. That is

20:24.130 --> 20:28.117
basically saying, I value therapy for a minute and that's it.

20:28.315 --> 20:32.077
And my point is that take the box away.

20:32.245 --> 20:35.677
Therapists are often the most skilled person

20:35.770 --> 20:39.117
in the building at any given time next to the physician.

20:39.252 --> 20:42.472
And how often is the physician there? They are the most skilled, they are most

20:42.505 --> 20:46.072
often doctorately prepared. And they not

20:46.105 --> 20:49.192
only can they provide rehabilitation services,

20:49.390 --> 20:52.677
but they're fantastic at cognitive assessments,

20:52.857 --> 20:56.622
they're excellent at wounds care and wound assessment.

20:56.817 --> 21:00.502
There's just so much that they can do that we don't bring

21:00.520 --> 21:03.622
them to the table. I've studied this in the past and I can

21:03.655 --> 21:07.272
see facilities that have higher proportion of physical therapists

21:07.317 --> 21:10.187
in the building have lower rates of rehabilitation.

21:10.687 --> 21:14.002
So we don't need to just value them for the

21:14.020 --> 21:17.247
minutes of therapy, bring them to the interdisciplinary

21:17.367 --> 21:20.557
team and have them as equal players. So what I

21:20.560 --> 21:23.967
was going to say is that famously, there's this friction

21:24.027 --> 21:27.427
between the nursing staff and the therapy staff. Part of it is

21:27.445 --> 21:30.957
because, like you mentioned a lot of times, the therapy staff are technically

21:31.047 --> 21:34.057
part of a different company. And as much as they try to bring everyone together,

21:34.135 --> 21:37.537
that doesn't always work. But there's also the nursing staff are there

21:37.600 --> 21:41.452
24/7, they work very hard, very long hours, and sometimes

21:41.545 --> 21:44.722
double. And we can't say it out loud, but we know sometimes people may even

21:44.755 --> 21:48.997
do triple shifts, which they can't do, but in a way they feel very

21:49.180 --> 21:52.602
devoted and they feel like almost in a way, like the mothers

21:52.632 --> 21:56.202
or parents of the residents, and these are our residents.

21:56.232 --> 22:00.097
And then you come in here, the therapist, with your expertise and your

22:00.130 --> 22:03.022
skills, then you're telling us to do this and to do that.

22:03.130 --> 22:06.517
And instead of embracing the skill that they bring to the

22:06.565 --> 22:10.197
table, sometimes you have that friction.

22:10.317 --> 22:13.627
But again, this is probably another example of where we

22:13.645 --> 22:17.682
can include the dietitian, like you started mentioning,

22:17.772 --> 22:21.277
and the therapists and really cash in, so to

22:21.295 --> 22:25.462
speak, on their skills, their expertise, their experience and work

22:25.525 --> 22:29.317
together, because now the goal is to provide that level

22:29.365 --> 22:32.387
of care for the residents and we're not competing.

22:32.812 --> 22:36.217
And again, the therapists don't have, oh, well, I need the resident for minutes.

22:36.265 --> 22:40.137
So you'll do meds later. And everybody knows

22:40.287 --> 22:43.417
the holy minutes, that's our bread and butter. So,

22:43.465 --> 22:46.677
yeah, okay. Even within the vessel, like you said, when you speak to the crowd

22:46.707 --> 22:49.977
of such a diverse group of people who are receiving

22:50.007 --> 22:54.072
the same information from a clinician. But from a clinician standpoint,

22:54.117 --> 22:57.867
and truth be told, from anyone who really cares about residents,

22:57.927 --> 23:00.922
that is such an exciting concept that they all need and care about the same

23:00.955 --> 23:04.257
information. But I think it goes again, this is the administrator

23:04.272 --> 23:07.687
and me speaking that within each facility there's also

23:07.750 --> 23:11.707
different stakeholders, so to speak. You have the banker in the facility, maybe the

23:11.710 --> 23:15.457
business office manager. Yes. And you have the owner in

23:15.460 --> 23:19.047
the facility, which might be the administrator. You have the clinician

23:19.092 --> 23:22.752
team and you have therapy team. This kind of even within the facility

23:22.857 --> 23:25.897
brings everyone closer to the same page because you don't have the people who are

23:25.930 --> 23:29.817
just ensuring that let's maximize therapy benefits and let's

23:29.877 --> 23:33.412
maximize the things that used to be the biggest payment drivers, but now

23:33.475 --> 23:37.422
we're kind of shifting that out. Yes. I love in your description,

23:37.542 --> 23:41.817
I love with what you just said, pardon me was use the term cashing

23:41.877 --> 23:45.922
in on the therapist skill and whether

23:45.955 --> 23:48.982
you intended to or not, that's exactly my point,

23:49.135 --> 23:52.702
is in PDPM, you are cashing in on

23:52.720 --> 23:56.847
the therapist skills. OK, so now I'm taking off my nurses

23:56.892 --> 24:00.067
cap and I'm putting on I'm opening up my

24:00.115 --> 24:03.877
accounting ledger and yes, it is cashing in on

24:03.895 --> 24:07.357
the therapist skill, but now the financial people

24:07.435 --> 24:10.672
can delight in that and so can the clinical team.

24:10.705 --> 24:14.337
And there doesn't need to be the tension that you so rightly described.

24:14.412 --> 24:17.842
The tension exists because we created it. They don't teach you

24:17.890 --> 24:21.502
to be at odds with in nursing school. They don't teach you

24:21.520 --> 24:24.642
to be at odds with physical therapists and vice versa.

24:24.777 --> 24:28.122
We taught that. We brought that in our current rug

24:28.167 --> 24:31.242
system, we created that. So unless

24:31.302 --> 24:35.427
you would like to go in a different direction, there are some things that although

24:35.457 --> 24:38.287
I delight over PDPM, there's a couple of things,

24:38.425 --> 24:41.302
probably more than a couple of things that I'm a little concerned about.

24:41.395 --> 24:45.297
And I want to kind of share the cautionary tale with listeners

24:45.342 --> 24:48.822
on this call, if I may, please. So in PDPM,

24:48.867 --> 24:52.777
as I mentioned, it's all about the patient characteristics and

24:52.795 --> 24:56.157
CMS is very clear to call the person the patient.

24:56.247 --> 24:59.797
And we should all delight in that. It's really the first time it's ever

24:59.830 --> 25:03.552
been acknowledged that we are caring for patients in our residents.

25:03.657 --> 25:07.297
So what's going to happen is, come October 1,

25:07.405 --> 25:10.777
behaviors are going to change. I've worked for companies where

25:10.795 --> 25:14.077
we were trained and educated not to refer to them as

25:14.095 --> 25:17.487
patients, partially because some of them are long term residents.

25:17.562 --> 25:21.217
This is where they live and this is their house, homelike environment and all that.

25:21.265 --> 25:24.042
So why is it that you delight that we refer to them as patients?

25:24.177 --> 25:27.592
Well, I think what you're referring to is the

25:27.640 --> 25:31.042
nursing home of yesteryear. I think that

25:31.090 --> 25:34.812
we care for both patients and residents in the same setting,

25:34.887 --> 25:38.272
for better or worse, richer or poorer. We're caring for

25:38.305 --> 25:41.662
patients who have absolutely no intentions of staying in our building

25:41.725 --> 25:45.492
and are going home. And they are as acute as the patients

25:45.552 --> 25:49.177
that are in an altar or an earth. Sometimes there is acute as

25:49.195 --> 25:53.427
the person in the hospital, as some of us are admitting people directly

25:53.457 --> 25:57.087
from the Er. To call them residence is inappropriate.

25:57.162 --> 26:00.292
They don't like it. And it doesn't really do

26:00.340 --> 26:04.197
us well when you look at just their data. And we start commingling

26:04.242 --> 26:07.822
it with our long stay people who

26:07.855 --> 26:11.422
are residents and who are with us for the duration. Got it.

26:11.605 --> 26:15.147
So words are important. You can have a person come in as a patient

26:15.192 --> 26:18.652
and transition to a resident. And why don't we just draw that line

26:18.745 --> 26:22.087
at 100 days? Or why don't we draw that line when their

26:22.150 --> 26:25.597
source of payment changes if we want to? Got it.

26:25.705 --> 26:28.947
Okay, thanks for clarifying. Yes, my pleasure,

26:28.992 --> 26:32.577
my pleasure. Words are important. So here we are with PDPM

26:32.682 --> 26:36.922
and October. Behaviors change and in

26:36.955 --> 26:40.902
some instances here is going to change as well. But behaviors

26:40.932 --> 26:45.267
change. So the behaviors, I mean, are documentation predominantly.

26:45.402 --> 26:49.662
I know for a fact from my time at Point Ride and more recently

26:49.737 --> 26:53.362
at Zimmer Healthcare Services Group, I know for a fact that

26:53.425 --> 26:57.372
certain care is being provided, but it's not being documented in their medical

26:57.417 --> 27:01.687
record. Let me give you an example, okay? So if you look today

27:01.825 --> 27:05.392
in 2018, all right? So last year

27:05.515 --> 27:09.492
and you looked at five day assessments, Medicare assessments,

27:09.627 --> 27:13.707
and you look at the nation, we're providing mechanically altered

27:13.722 --> 27:16.492
diets about 24% of the time.

27:16.690 --> 27:19.912
OK, so why is that important? Well, when you actually

27:19.975 --> 27:24.042
go in the building and you start looking at trees as they're being delivered,

27:24.177 --> 27:28.025
or you start looking at care plans, you see that no,

27:28.387 --> 27:32.457
24% is ridiculously low. Mechanically altered

27:32.472 --> 27:36.297
diet is chopped foods. It's softened foods, it's pureed

27:36.342 --> 27:39.307
foods. It means many, many things.

27:39.385 --> 27:42.852
It's not 24% of the time, it's closer. Maybe it's triple

27:42.882 --> 27:46.147
that. If you talk to the speech therapist in the building and you

27:46.180 --> 27:50.122
say, what proportion of your patients are people in this

27:50.155 --> 27:54.027
building getting mechanically altered? She'll say recently,

27:54.057 --> 27:57.157
I tested this out, and she did say, oh,

27:57.235 --> 28:00.877
you know, it's probably a couple of dozen people in

28:00.895 --> 28:04.312
the building, but frankly, it's closer to 70% of the building

28:04.375 --> 28:07.462
actually get it. So why is that? Well,

28:07.600 --> 28:10.572
there was no motivation to document it. Who cares?

28:10.617 --> 28:14.857
It was in the care plan. It never made it to the MDS. So now

28:15.010 --> 28:18.672
mechanically altered diet is going to increase your case mix

28:18.717 --> 28:22.467
index in the speech and language pathology component.

28:22.527 --> 28:26.017
So basically you're going to get paid for it. And why shouldn't you? You're doing

28:26.065 --> 28:30.222
it. You're assessing someone's swallowing disorder. You're putting an intervention

28:30.267 --> 28:33.877
in place. So damn, you do it. So what

28:33.895 --> 28:37.117
is that going to look like? What's that going to look like? Let's take those

28:37.165 --> 28:40.522
two components swallowing disorders and

28:40.555 --> 28:43.712
mechanically altered diet. Swallowing disorders,

28:44.212 --> 28:47.797
the nation's at a rate of about 3.7%.

28:47.980 --> 28:52.227
But if you look at the literature, in the literature that talks

28:52.257 --> 28:56.272
about studies in our population that we're talking about,

28:56.455 --> 29:00.357
they will talk about Dysphagia or swallowing difficulties

29:00.447 --> 29:04.012
being anything from 40% to 68%.

29:04.150 --> 29:07.627
But today, according to NDS, it's 3.7% from

29:07.645 --> 29:11.212
the analysis we did at the point right, a few months ago. So,

29:11.350 --> 29:13.777
wow, what's real here? 3%,

29:13.870 --> 29:17.352
40%, they're both real. So what's going to happen October

29:17.382 --> 29:21.552
1 is we're going to start saying, well, now I documented,

29:21.657 --> 29:24.742
there's a motivation for me to document it. So I start

29:24.790 --> 29:28.197
documenting this. And we go from 3% swallowing disorders

29:28.242 --> 29:31.902
up to 40. We go from 24% mechanically altered

29:31.932 --> 29:35.397
diet up to 50% mechanically altered diet.

29:35.517 --> 29:39.232
And we're doing the right thing and we're documenting it

29:39.310 --> 29:43.117
and we're getting reimbursed for it and we're evaluating our care

29:43.165 --> 29:47.137
plans constantly. Everything is great. Then someone comes by

29:47.275 --> 29:51.437
and that someone usually has initials such as Oog

29:51.787 --> 29:54.922
or CMS or fill in the blank and they

29:54.955 --> 29:58.827
say, oh, look at these providers, look at them gaming

29:58.857 --> 30:02.287
the system. And it's we're not gaming the system,

30:02.425 --> 30:05.632
we're playing by the rules. And so what do

30:05.635 --> 30:08.887
you do with that dilemma? We have some providers that are saying,

30:09.025 --> 30:12.322
I get it, and so therefore I'm going to slowly change my

30:12.355 --> 30:15.397
behavior. And then other people that are saying,

30:15.580 --> 30:18.742
I'm going for it, I'm going to do it right from the beginning on day

30:18.790 --> 30:22.282
one. I'm not going to say one way is better than the

30:22.285 --> 30:26.262
other, although I have to say the sort of insipid changing of behavior

30:26.412 --> 30:29.692
is really easy to identify when you're looking at data

30:29.740 --> 30:32.997
and analytics, so it doesn't provide protection.

30:33.117 --> 30:36.472
But anyway, we're in a dilemma. We're going to have all

30:36.505 --> 30:39.822
of our nation's nursing homes changing their coding

30:39.867 --> 30:43.272
practices and documenting care differently.

30:43.392 --> 30:47.017
I strongly believe the care has been given all along,

30:47.140 --> 30:50.602
but we're documenting it for the first time. So CMS is

30:50.620 --> 30:53.797
aware of this. CMS knows that.

30:53.905 --> 30:57.507
I guess this is a question. The reason the push

30:57.597 --> 31:00.742
for the change, as we already discussed, is to

31:00.790 --> 31:04.327
balance out the care in a way that is in the best interest of

31:04.345 --> 31:07.792
the residents and make that also in the best interest of

31:07.840 --> 31:12.087
the facility. It should be that much financially reward.

31:12.237 --> 31:15.877
There should be an expected outcome. OK, I think

31:15.895 --> 31:19.887
I'm getting it. Now, in other words, CMS is going to assume, or whichever

31:20.037 --> 31:24.297
initials walks in the building or analyzes the data from afar

31:24.417 --> 31:27.922
is going to assume that we're documenting everything.

31:28.105 --> 31:32.532
We always have been documenting everything. So if you're now increasing,

31:32.697 --> 31:36.472
assuming that what the data will say is that, you know, we used to not

31:36.505 --> 31:39.622
have so many mechanically altered diets and now

31:39.730 --> 31:43.197
we started giving everybody pureed food and because we're

31:43.242 --> 31:46.732
being financially incentivized to do so, that is

31:46.810 --> 31:50.302
a problem. And really, the truth is there's a lot

31:50.320 --> 31:53.662
of things that we. Always do. But the people who

31:53.725 --> 31:58.302
push for the accurate documentation, and not just accurate versus inaccurate,

31:58.332 --> 32:02.322
but complete documentation is when the rubber hits the road in the financial

32:02.367 --> 32:06.097
office, they see a problem. They're going to go back to the clinicians and

32:06.130 --> 32:08.797
say, you better make sure you do this. When you're doing it anyway, you better

32:08.830 --> 32:12.762
make sure you document. So that is a problem. Oh my gosh.

32:12.837 --> 32:16.602
So what's going to happen with that? Yeah, so CMS believes PDTM

32:16.632 --> 32:20.067
will be budget neutral and there's no way it's going to be budget neutral.

32:20.127 --> 32:23.292
These changes are never budget neutral because behaviors

32:23.352 --> 32:26.817
change. We play by the rules. We change our behaviors.

32:26.952 --> 32:30.367
We start documenting things we never documented before.

32:30.565 --> 32:34.542
And someone from afar who's looking at macro

32:34.602 --> 32:38.622
data sets, they're going to see the shift in coding

32:38.667 --> 32:42.652
practices. They've never worked a day in their life in

32:42.670 --> 32:45.697
a nursing home. They've never been in a nursing home. They don't listen to your

32:45.730 --> 32:49.357
podcast. They don't follow my blog on McKnight. And they are

32:49.360 --> 32:53.197
going to say they're clearly gaming the system and

32:53.230 --> 32:56.527
changing their behaviors. And they'll also say, look what they did

32:56.545 --> 32:59.847
in the past. Look at all the providers who went up to ultra

32:59.892 --> 33:03.847
high providing 720 minutes, but never 721

33:03.880 --> 33:08.017
minutes. And I'm being overly dramatic because there

33:08.065 --> 33:11.472
was tremendous variation in the therapy

33:11.517 --> 33:15.575
minute provision. There were some bad actors out there who

33:16.012 --> 33:19.687
got caught and others who didn't. But by and large,

33:19.750 --> 33:22.972
the majority of the industry was doing the right thing. And I think that will

33:23.005 --> 33:27.622
happen now. But PDPM is so profoundly different

33:27.805 --> 33:31.342
that unless you are looking through the change with the right

33:31.390 --> 33:35.932
lens, I'm afraid the conclusions you'll draw will

33:36.010 --> 33:39.517
not be flattering. And that's what we as

33:39.565 --> 33:43.827
providers and investors and REITs and attorneys

33:44.007 --> 33:46.972
and caregivers need to be prepared for.

33:47.155 --> 33:51.187
Awesome. So tell me another concern that you have

33:51.325 --> 33:54.972
with this new change of PDPM. Another concern?

33:55.092 --> 33:58.850
I alluded to it before, and that is

33:59.512 --> 34:02.827
we take the rules of the past and we try to apply them to the

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future. I'll give a different example and stop using

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the therapy example. So we look at the MDS coordinator

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and we look at his or her job description

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and we don't change it. We say, this person is amazing,

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she's been crushing it all these years, et cetera, et cetera.

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And we don't say, well actually,

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the job description does need to change. It needs

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to change because the MDS schedule has changed,

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the values have changed. So the MDS coordinator

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job description should be less about

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timing and documentation and scheduling

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and making sure everything is done in the right time and submitted, which is

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incredibly important today, capturing acuity.

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They should now in PDPM, they should be care managers.

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They should be very astute clinicians who are

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able to look at very obtuse clinical information

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about the patient that comes with them from the hospital.

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And they have to be able to look at that and kind of spec it

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out and say to themselves, well, this is odd, why are they getting

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this medication or have this equipment in place or

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have this behavior? But they don't seem

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to have an appropriate diagnosis that lines up with that.

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And to be able to stop and say, oh well,

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what are their diagnoses? And then advocate for

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with the physician, a more appropriate diagnosis that

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really captures why the person does have the characteristics

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that they have got it. And that's a very different skill set.

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That's really, like I said, a very astute clinician,

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not necessarily a different skill set. So then I was

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the person who's been there gathering the data from all the

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various departments and inputting everything into the MDS and

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making sure, as you said, make sure everything is submitted on time, which kind of

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has been the role and the focus of putting in

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all those hours of getting it in. Now that's changed.

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And the good part is, I guess, that they have the

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luxury to think broadly, like you mentioned,

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because the schedule has changed and because it's more about the

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bigger picture. But someone who's great at sitting in front of a

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computer all day and getting the MDS is in

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on time and complete and accepted, may not

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be the person who can sit there and look at the complete picture and like

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you said, and pick up on those things that are so important. I kept

36:39.582 --> 36:43.182
your hairway past, I should have. I'm just noticing the time. And it's

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a good thing because providing all of this service,

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all of this material which is so timely and you're so uniquely

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qualified to share this with the listeners, do you have any

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final thoughts regarding PDPM and these changes that

36:57.760 --> 37:00.172
you would want to share with our listeners before we let you go to your

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busy day? Thank you very much and I've really enjoyed spending

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the time with you and I hope my excitement and passion about this

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change comes across. I just think that we are in

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such an unbelievable inflection point in our industry.

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PDPM is setting our thoughts for success.

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PDPM is here for five years. It will be

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replaced by another system, and that other system

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is already foretold. You don't have to

37:28.705 --> 37:31.612
be in Oracle to know that. You just have to be able to read the

37:31.675 --> 37:34.957
Impact Act and understand where we're going to in

37:34.960 --> 37:38.997
this nation. We are going to site neutral reimbursement

37:39.117 --> 37:42.522
where all post institutional, post acute

37:42.567 --> 37:45.217
settings will get reimbursed the same rate. Now,

37:45.265 --> 37:48.322
traditionally, skilled nursing is less expensive than

37:48.355 --> 37:52.827
some of our counterparts, LTC and IRFs. So PDPM

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and the data that we're now collecting off

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of MDS is really going to demonstrate

37:59.637 --> 38:03.252
that we are the best game in town. We're providing

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the best outcomes at the lowest cost. So this

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is just a simple stepping stone. If we crush this, we're going

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to do exceedingly well in the future. Wow. How encouraging

38:13.767 --> 38:17.812
that is for operators. I can just say from my personal experience,

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that resonates with me so deeply because it's always been so frustrating.

38:21.747 --> 38:24.687
And I hear from the residents, you hear from the families,

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they knew that the level of care that we provide with the resources

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that are extremely limited compared to some of our

38:32.050 --> 38:35.547
professional clinical partners, and some of the results are beyond

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astounding. We don't have to go to specific examples, especially because it's

38:39.432 --> 38:43.017
late, but people come in completely paralyzed and walk out the front door.

38:43.077 --> 38:47.002
There are so many examples, and you're right, and we do

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it. We get the trimmest, leanest reimbursement

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for providing many, many times. Again, there are bad apples,

38:55.077 --> 38:58.422
of course, as well, but many, many times, outstanding results.

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And if that is the wave of the future,

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then that is really amazing news

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for providers who have always been doing this for other providers to

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get on the bandwagon. And like I said earlier, everybody went this way.

39:12.430 --> 39:15.637
Absolutely. Thank you so much for the time. I really

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appreciate it. All right, thank you for coming on. If our listeners want

39:19.345 --> 39:22.662
to hear more about some of your writing stories you're teaching,

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where's the best place for us to send them? Is there one place for for

39:26.431 --> 39:29.707
us us to send them? Well, I would say in terms of email,

39:29.785 --> 39:33.457
the best way to reach me is Stephen with a V@zhealthcare.com.

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A simple

39:38.035 --> 39:41.652
Google search will reveal many presentations that I've

39:41.682 --> 39:44.827
done, as well as writings, and I

39:44.845 --> 39:48.412
have a monthly blog in Ignites. Okay, awesome.

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Thank you so much, Steven. This is really enjoyable,

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and we're going to share this enjoyment with everybody

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else. Fantastic. Okay, thanks. Bye bye.

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All right, bye bye. Thanks. Have a great day.