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greetings everyone this is eric glaser welcome to our live recording of bright spots in healthcare produced by shared purpose connect we bring together leaders to not only inform you our audience but most importantly on earth successes bright spots at health plans at hospitals at medical groups at various other health care organizations around the country our goal is to identify as many bright spots as possible so that you the listener can determine if those bright spots shared today during this episode can be applied at your organization or at least reshape your thinking at your organization we believe that this approach of finding a bright spot and cloning it is the best way to improving health care in our lifetime if you are not yet a subscriber of bright spots and health care what are you waiting for go to your favorite podcast app search for bright spots in healthcare please subscribe please give us a rating a five maybe even a comment uh for your fellow potential listeners about the show this is the best most effective way more and more folks in the healthcare industry could find the show and take advantage of all the bright spots that we are able to bring to you each and every week our topic today is an incredibly important one and i believe pretty confidently that it's going to be a huge topic in 2021 we are just hitting it early it is called the super determinant the digital divide and we will discuss both how to identify some of the root causes of the digital divide and then solutions to drive better outcomes per usual we have brought together a super star panel for you a hat tip to our senior producer sherry kills who's so instrumental in producing this great content for you to save time we've emailed you their bios we're also going to uh post them in the chat if you are listening to this on a recording and you want to check out the incredible qualifications of the four experts you're about to hear from you can go to sharedpurposeconnect.com click on recording and there'll be a list of all of our shows and next to each show is a link to the bios of our roundtable experts so you can read up on all these folks as you're listening to the recording okay uh we are able to provide you programming each and every week due to the incredible support we receive from all of you uh when you show up i know we don't charge you but your participation enables us to hand pick organizations to both financially support the program and also provide unbelievable content and add to our discussion so i want to uh thank revel health who's our sponsor today they're one of our awesome partners of the bright spots and healthcare show they've been with us for quite some time we love working with them uh you've heard me talk about how we have a big echo chamber in our industry and we need to often look outside of our lane to come up with new ideas to come up with bright spots when you think about important issues that we all grapple with like engaging the consumer you should be looking at companies like rebel health they are doing things unlike traditional health care companies they're actually taking a very individualized approach to population health i'll tell you more about what they do later on the show sarah ratner who's on our panel today is one of our most frequent guests and one of the most thoughtful and smart healthcare strategists in the industry and along uh with doctors uh ali ramzetti and rodriguez are going to provide you with a lot of insights and thought-provoking ideas on how to best bridge the digital divide for your population so let's get to it i want to uh sarah since i already talked to you i'll bring you in first and just for everyone set the stage how you define the digital divide sure well it's important to to put out a definition to levels that what we so at a very high level it's the uneven distribution and access to and the use of technology in the internet and this impacts many different areas these days we see it all the time but especially healthcare with the increased acceptance of telehealth however it's not only the hardware in the technology but its connectivity and the literacy that is associated with accessing it as well so we've studied this in in great detail and there's a couple of interesting facts that i throw out there so first 62 percent of the counties in the us don't meet the government requirements of broadband access the bandwidth that's necessary that's to me shocking that this is the united states and we still do not have the minimum broadband speed to serve our communities also fcc research has recently shown that many rural communities with the highest diabetes prevalence also have the lowest broadband access and the highest obesity rates that are 6 to 10 points above the national average are in areas with low broadband access so we know this is a massive issue that impacts health care and so this is why we refer to it as a super determinant of health because it really is a a limiter in accessing health care so as plans providers and social service agent organizations work together it's a it's absolutely essential to take an individualized approach in in addressing this and so for us the first step and and critical to this is the micro segmentation before you even create the solution and when i when i talk about micro segmentation it's really understanding at an individual specific level the variables that influence health action and it's the lens through which we need to understand and engage in individuals and every area is different recently we're looking at different trends in internet access and and we looked at a specific area in louisiana and it was in the city um two blocks apart and the the two block difference in internet access was astonishing with one not having the rate of of no internet access was five percent two blocks away it was 15 and then that also corresponds to people's response rates with um different types of things like surveys and getting back to um the doctor so it it's in developing techniques in order to start this it is absolutely critical to break things down in the most granular way and while it's um can be tedious and difficult in order to get on top of it that's the way we have to look at it a quick psa we have a q a module in at the bottom of your screen we have a fairly sizable live audience right now so i just ask you the favorite of using that to ask your questions i think we'll have time to get to a bunch of your questions today so feel free to ask them and sherry and i will kind of incorporate them into the conversation but don't use chat for the questions that's a really important distinction because we'll lose sight of the questions through that thread so much better in the q a module so thank you in advance for that i'm going to bring in uh dr anita ramzetti she is the medical director and faculty advisor of a really interesting clinic down in south carolina called cares she's also also the director of student services learning at the college of medicine at the medical university of south carolina so anita can you talk about first how are you doing things a little bit differently at care since the pandemic maybe even like a quick one minute on cares then how are you doing things different differently since the pandemic as it applies to the application of digital platforms sure so a little bit about um cares clinic itself cares medical clinic is actually a student run free clinic we may have some listeners who are also involved in student run for clinics at their own institutions and to all of us involved we know exactly what this means it means that there is little to no funding so cares generally runs on a shoestring budget almost all of our patients are uninsured so we have three main sites there's a main clinic site where we see all uninsured adult patients three nights a week we also have a rural outreach that sees again largely uninsured patients although that group tends to skew a little bit older than our main site the rural site tends to be above the age of 55 the main site really truly falls probably between 18 to 45 or so and then we have a pediatric immunization clinic that runs every few months which of course is all pediatrics um i'm very different but still largely probably about 98 uninsured children so all of our patients lack insurance that would typically cover a lot of visits and a lot of other things and that's sort of the basis of of who we see that's who we serve so when the pandemic hit all of our services were disrupted as you can imagine all of our staffing is volunteer we have very few people who are actually paid on staff and then we have patients who are already sort of barely hanging on now having even less access to everything so we tried the phone first we tried the the most accessible version of tech that our patients have and as as all of you know telehealth applies to really any format where you can synchronous or asynchronous communicate with your patients so a telephone was worthwhile and many of our patients have a telephone so we tried that first some visits worked great by telephone and some didn't but we were able to at least stay in touch with them that way and make sure that they continue to have care about a month after that we rolled out the telehealth platform and so currently cares runs both care through telephone as well as the doxy me platform so that we can see patients live if they have access to a screen a telephone a smartphone and we're now back to seeing people in person the important thing that we found out it wasn't so much that we didn't know this necessarily but it became even more apparent that even with the forms of technology that some of our patients may have had there were still other barriers that were the issue so for instance the telephone was the first thing we used to reach out to our patients turns out many of them don't have consistent use of a telephone they don't own their telephone they have um paid telephones that run out at the end of a month so if we happen to catch them in between when the telephone had money on it and it didn't we now could not contact them so we had issues like that we found out that many of our patients may have had a smartphone but they don't know how to use a platform built for healthcare as opposed to perhaps buying something or playing games on it or something else all of the other reasons we have smartphones still being able to actually use a phone for a video conference to telehealth with your provider is different and that was a different skill set that many of them didn't have so for us even dealing with a population that had many other issues in terms of access to health care we found these other subsets that really contributed to how equitable it was for them to even use a platform of any type when we were able to try to reach out to them i want to before we get into sort of hardcore solution talk i want to bring in the ceo of a medical group multi-site medical group in trenton new jersey uh called henry j austin health center and and to do that our the ceo dr uh kemi ali uh kemi how how are things being done differently right now in trenton so good morning everyone yes i would say our experience resonates um with the with the cares clinic um so at henry j austin health center we are a federally qualified health center the majority of our patients are 200 percent or more below the federal poverty level so a really significant proportion of our patients are impoverished one in nine of our patients are homeless about a third of our patients are latino and a significant portion of those individuals are undocumented so again you can see we've got a real complex makeup of individuals our demographics that are impoverished that are undocumented that are homeless and so we struggle with a lot of the same issues that dr ramsey just mentioned um very quickly we realized too that we in the height of the pandemic we wanted to make sure that our patients could have some degree of access to the services they really need so we too switched to telehealth telemedicine we also use doxy me and what we saw we were surprised that many of our patients did have a telephone and actually did have a smartphone and that's probably because we're in trenton in new jersey we're in a really inner urban city it's the capital city of new jersey and so a lot of individuals did have a smartphone um and then for those that didn't have a smartphone many had an older flip phone so about eighty percent of our patients had either a smartphone or at least a telephone so like was mentioned before we did realize that a significant part of that population with a smartphone still didn't quite know the other capabilities that you could do with it so didn't know the telemedicine platforms and so one of the things we instituted was working with our community health workers our patient navigators and they would call the patients ahead of time they would reach out to them ahead of time and actually hand hold and walk them through the process show them how to log in show them how to use the video show them how to ask questions etc and found a lot of success with using our community health workers in that way and then for those individuals that didn't have the technology they didn't have a laptop a smartphone or even a regular phone we instituted telehealth kiosks within our center and so that way patients know our centers they could still walk in they would go right to an exam room and someone would help them set up so that they could still through our internal systems telemedicine with a nurse or the behavioral health counselor or a provider and so using those two methods we had quite a good bit of success in making sure that our patients had access to the services they needed uh i questions are coming in uh julie uh i know you're in the audience no you can't talk please let me know if that answered your question i i think it might have proactively gotten to most of the your question there if it didn't please kind of specify where you want me to go and i'll bring it up later on okay let's talk about how you go about we talked to or we've already heard uh the fact that you know broadband uh data plans phone plans in general are a big issue but how do you go about anticipating other root causes behind the digital divide beyond devices and and phone plans anita why don't you go first how are you guys looking at that so so you know kemi and i i think had a shared experience where we realized oh even if you have the phone it doesn't really necessarily translate into knowing how to use utilize it for this purpose so i think that was the first thing that jumped out where we thought oh this is going to need some teaching not not necessarily that unlike having a glucometer to a patient and saying hey now you need to start checking your blood sugars well they might be able to figure out a couple of the buttons but to track it to do those other things that you might want require some teaching so i think that was one of the first things that jumped out where we thought okay access to the device and access to broadband does not necessarily mean access to telehealth they are not the same thing even if you have the equipment so education was still necessary support was still really necessary and for i think probably many of our mutual patient populations what we found also was that there was some degree of skepticism and we learned quickly that we had to really really work on building trust with our patients on looking at this more broadly i think it's beyond only our very underserved patient population it's possible that it's more of a problem for ours but you know there's a paper that i'm hoping that we'll be able to share with everybody that interestingly was called do patients trust telehealth it came out in 2015 and it may be different now but five years seems like 10 000 years at this point this year is so long but um at that point when they asked patients would you trust the diagnosis that comes by telehealth about 75 of all the people if you add them up across all the age groups had some degree of a negative answer the highest the highest percentage came from people who are over the age of 65. and if you think about our aging population in this country that's really something to pay attention to so first we have the issues of access broadband wise then we have the devices and then we have the knowledge but even if we fix all of that there has to be some degree of trust in your health care system and your provider and that is at the core of all of our relationships with our patients so i think as providers we know this and if we are now in a situation where the technology might be a little unusual and the access is unusual and they don't trust the diagnosis that's really a problem so what we've been doing particularly for our patients is we've been asking lots of questions and doing a lot of listening in on individual basis on small group versions and trying as much as possible to encourage trust in the system and what i have found at least is that in part that also means really disclosing the shortcomings so for instance for some reason over the earlier part of the pandemic we had several patients call in with complaints about a new rash and new ear pain none of those are easy to diagnose with a conversation or even looking at it over video and it was really at that that you know that point where you had to say i'm really sorry i cannot accurately diagnose this over the phone or over the video i need good appropriate healthcare i can't see the rash and i think our patients appreciated that instead of being told this is what we think it's probably going to be and this is the best we can do so for us it's been a combination of a lot of support similar to what can be brought up of walking them through trying to figure out where the holes were either in knowledge or access but also really working on building trust for our patients so that they understood no matter what the platform we would be honest with them on both the strengths as well as the shortcomings and we would still try to get them care however we could do that let's um bring in uh dr jorge rodriguez he is the health technology equity researcher and he's also a hospitalist at pregnant women's hospital in boston how are you guys in boston how are how is the brigham looking at anticipating root causes is it similar to what they're doing at cares or is there some different approach no thank you for having me i think it's a lot of the same themes and i'm excited to hear sort of similar experiences across the board i think the way i've been thinking about this is we've been sort of structuring this in that sort of a easier hopefully easy to remember way sort of the three a's of uh digital health equity and on the first day really focusing on on access which we've talked about a lot about internet access broadband access and in terms of you know there's a lot of great kind of uh solutions to those i think that you know up front and just to kind of like you know say what what's important to do i think that the big thing is like screening which it sounds like uh my co-panels have been doing just like we're screening for other social terms of health you have food insecurity housing instability what's your what's your technology you know access like and then being able to report out those metrics as an organizational level is really important for us to be able to make make uh make that uh a change one one example that we've had is that especially as a hospice discharging patients i've assumed that they have a discharge appointment and and to some extent i've been like oh as long as they have a discharge appointment we're all good but what if that's a virtual discharge appointment or telemedicine decision appointment i don't know if they have access to the technology or not and so that's sort of impacting continuity of care so i feel like if we include some of the screening access pieces early on just part of standard care it really goes towards and we sort of have a pilot going trying to get that trying to get that going to understand that and be able to report out at an organizational level i think that the um the other component to this the second a is all around adoption and we've really sort of focused on some key pieces of a digital literacy being such an important piece that sense of of trust uh with uh from from patients as well i think the other things our ad i'll add that we can really advocate for are sort of the usability pieces i think as a as a health care system we don't have to feel reliant like whatever tool we got this is we have to make do we have to we have i think there's an important collaboration that needs to happen between healthcare systems clinicians uh and the the vendors the telehealth vendors whichever one that is to be like hey you know you've developed this very complex system my patients can't do that we're not serving them we're not serving them right and i don't i feel like we don't we shouldn't just be like well we have to you know it's on the patient we have to teach them sort of it's multi-level so we really have to engage the vendors and saying like can we iterate on this a bit this is not like you know there's some good work to be done here um i think that that's a key piece of it in terms of adoption the other thing i think is really sort of um it's workflow so much of this we talk about the tech aspect of it but a lot of this is around workflows and one of the kind of key examples that i like to think about is sort of the third party or the interpreter workflow for our limited english proficient patients that's such a key component of the way we deliver care and a lot of these a lot of these tools make it a big challenge and i know that sort of it's a work in progress and we're working on it and we sort of had to switch but i think establishing those clear workflows are not not only important to the way to appear but get you clinician buy-in right a clinician as soon as like you start putting up workflow buyers you have to click here go there it's confusing i have 15 minutes to see a patient if i have to spend the first five to ten figuring out how to bring in a third party i'm there you're not going to have buy-in right that's the sort of peak that we've seen in telehealth it's going to quickly go back because the systems are just not there and then i think the other thing i'll say in terms of the third day is around assessment and i think there's two components at least for me to assessment one of them is around looking at an organizational level maybe even a national level not just this binary sense like who's using telehealth and who's not what do those patients look like right i think in the quality and safety world you there's increasingly this push towards looking at patient demographics across things like catheter associate utis or kind of these quality metrics that we look at we want to look at who's experiencing those things similarly for telehealth who isn't using telehealth what are those demographic looks like who's using the frozen visits what does this demographic look like who's using video visits and what are those demographic looks like and should we report that out especially when we're talking about like you know cms should we report that out at a national level to really make these like bigger changes to if we're finding that most of our patients of a certain demographic are using uh a telephone visits is there a push for things like you know policy changes like universal broadband and pushing in that direction so that it's not left to the healthcare systems to say i need to figure out how to connect my patients this is if it's really a social determinant of health we should make these larger social changes and the last thing i'll say is really around looking at this as you know our ultimate goal here and i think my parents will agree is really around health equity right like my goal is not really does that mean my goal is digital equity but it's really as a vehicle to get to health equity um so i think just making sure that we're we're assessing and and and checking the effectiveness of these tools because we've kind of picked them up very quickly because we had to but making sure it's getting out to the ultimate goal of you know what it was sarah was talking about a lot of the diabetes outcomes making sure that using these tools we're improving those those um those outcomes so i think those are sort of the kind of the three a's and the things that uh that i'll mention quick follow-up know you mentioned health equity uh we ran a session on health equity about three weeks ago and incidentally this topic of today's session was a spin-off based upon the attendees feedback to cover this topic directly and so that's a reminder to me to let everyone know that in about 15 minutes or so at 12 15 east coast time you'll receive another email from me asking for your feedback on today's show and it includes specifically other topics we should cover as we carry out the rest of the year moving in 2021 so i thank you all in advance for taking it it takes about two or three minutes to complete and i will send you multiple emails if you don't complete it so i thank you in advance for that you mentioned uh jorge access adoption and assessment and when you were talking about access you you'd alluded to that you were starting a pilot do you mind telling everyone very quickly what the pilot is uh is about and and and how you're going about it in case folks want to learn and maybe even clone that idea sure though so the pie we were looking at with my with my colleagues uh esteban gershein and catalina and dan kavanaugh is really looking at um on the inpatient side we just um uh we just realized that as we were discharging patients from the hospital we were assuming they had a discharge appointment and and and not realizing that what kind of appointment was it was it virtual was it in person with a phone and not having a sense so what part of our pilot is just starting to include that as part of our conversations one catalina uh one of our admins helps arrange discharge appointments so just including that as part of her workflow asking patients hey do you have like kind of going through those questions uh uh and and making sure that the patient can not only like here's your virtual follower point but like will you be able to actually make that appointment because it doesn't matter if you have the appointment listed if in the end the patients may be like i can't access that so just taking more of us and they're sort of down the line there are other and the clinics are doing the same thing to make sure but we just wanted to take an active role as we're discharging a patient to make sure that like hey we did our part to make sure they were able to make their follow-up appointment so we're just starting a pilot to just understand where our patients are with the hopes that we'll then be able to um to then offer them some of the services that uh that uh that anita and the rest of the group have talked about that's great so it's a reshaping of the questions you need to be asking upon discharge so it's really changing your diagnostic tool if you will or your discharge tool to be asking the right questions and creating a process around that for everyone to follow if it's effective right exactly yeah just part yeah part of that theme of like if we're treating this as a social return of health you know one of the the models that we often have traditional health we screen for them and we refer to a resource so applying that same kind of thought process to um technology access if we're making this sort of like a central part of care um i think it's important to do that okay and then you know this this is why this is why it's so great that we have such a great audience so we have a couple follow-ups for you so you're measuring obviously digital equity and health equity could you share with us some of the key performance indicators or even some of the leading indicators you're looking at to recommend you know that you're recommending that you can recommend the folks to follow if they're going to come up with a similar initiative yeah i mean i think it's i mean for this for this initiative we're sort of early days we're just sort of doing screening early on i think speaking more broadly i think it's just you know looking at at to some extent you don't have to change your your key performance indicators too much in terms of your health care outcomes right if your ultimate impact is to say i'm going to improve the care of patients with diabetes you know checking in on their a1c levels if they're primarily getting their care through through the virtual setting making sure they're getting their screening right one of the things that we do with a lot of folks with diabetes uh like anita was mentioned earlier was you know was sort of like you know making sure their blood pressures are getting checked their lipids are getting checked they're getting their you know their eyes checked they're getting their feet checked so all of those things are really tough to do over a phone or video and so how you know what we i can i can chat with you i can help you titrate medications but if you don't have a at home blood pressure cough or blood pressure cuff anywhere like how do how am i going to be able to do that so just making sure that having the visit and having access to care remotely is one thing but there's so many things that we need to do you just need you know laying of the hands as we say to be able to get these things done and so i think just i don't think that we don't reinvent the way i think just looking at the similar similar metrics just making sure that if patients are really relying on the virtual gear we're sort of meeting the metrics that we've already established is what i'd say okay and you don't have a written model that you know like you've put together that that you're able to share right that's another one of our guests are asking uh a model in terms of in terms of like what to look at or yeah like well or just even the list of new questions that you're proposing in your pilot is that public information would you be willing to share that or yeah i'd be i'm happy to share the questions that there's also um i can i can share a few different resources we sort of collated from other few other resources of of other kind of like tech literacy so i'm happy to share those resources um with uh with a group maybe we'll um what's the best way of doing that i i guess we'll just send it in our our follow-up email share if you can make a note of that we'll follow up with dr rodriguez and include that in our follow-up to folks uh and if you want yeah let's do it that way and and you want us to um you'll tell us offline the best way folks who want to contact you and maybe they have feedback for you too who knows maybe you get some product research out of this yeah yeah now i'm happy happy to happy to happy to happy to chat so so uh thanks for that uh let's talk about uh uh creating a more formalized process to help organizations and practitioners create a more i would say a personalized approach to digital care so to bridge that divide uh and i'll bring back uh dr anita ramsey to talk about what are you guys using to uh at cares to fundamentally decide you know what does you know what does eric need what does jorge need and and and are there differences in our needs what does chemie need do you have a diagnostic tool for that so i get dibs on contacting jorge because he's working on something that we are sort of working on as well i call dibs on this um so what we're working on here we haven't implemented it as yet we are trying to develop what we've sort of nicknamed the digital vital sign um it will be similar to what is currently referred to as the hunger vital sign some of you may know what this is it's a two question validated screener for food insecurity and that was developed and validated based on a much larger document that was used to screen for food insecurity but it's only two questions and it actually is quite useful for screening for patients so we're starting from the ground up which is why i'm going to be contacting jorge after this because what we're hoping to do is to develop a tool where we can screen and apply this to everybody probably on an annual basis as a screening tool but encompassing all of the aspects that go into what we think of as practical digital and tech literacy so there are other tools out there um for instance there's a scale called the the e-heal scale that really measures um electronic health literacy but it's more geared towards patient comfort level and knowledge in terms of looking up and finding appropriate health information on the internet but it doesn't necessarily address um use of a device and what this actually means trust in the device accessibility of the device so what we're currently building with our research team here and and the we i refer to is actually a colleague of mine who wrote a paper with me earlier this year on the digital divide she's the director of our 529 clinic which is a clinic for individuals who are housing insecure so between our clinic cares clinic and her clinic we have a lot of patients who overlap and who have the same the same limitations so what we're looking to develop is a scale that really measures a couple of those factors that are important knowledge is one access is another but access also needs to include the stability of the access so as i mentioned some of our patients have access to a phone this month and not next month and that has to be taken into account we want to really find out the usability and some way to rate that and the way i think about that is for instance for my patients who are given prescriptions for insulin pens sounds great for those of us who can dial something up and inject it but if you have manual dexterity issues then this is no better than me handing you another device to give yourself insulin and you have to know that when you're trying to ask someone to use an actual device and the last part of that is trust so we're trying to develop a larger survey get that validated and then shrink it down to something that is relatively quick because as jorge also mentioned workflow is critical if you throw out a 50 question survey providers don't have the time to do this patients will not answer it and then it's pointless so we're at the very beginning stages but we're hoping that we come up with this very useful digital vital sign that we can use for all of our patients and based on that either as a rating a score a level or otherwise we can then come up with a menu of options for both how their access to health care is appropriate as well as what can be done it could be that you find out oh we just need to refer this person to a community-based specialist who can spend an hour with them and teach them how to use the device they have and we're good to go it could be this person needs a referral to ot so that they can work on their manual dexterity in order to appropriately use a device they do have access to without looking at it more holistically i think we'll continue to just sort of throw out lovely big ideas but it will not bring equity to the table which in the end is what we all really want so the digital vital sign that sounds like a journal article waiting to happen yeah doesn't it so listen i'm sure there's going to be a lot of people anita that want to want to learn more about this is there a way without kind of bombarding your inbox that people could reach out and connect with you on this yeah i'm afraid of onboarding my inbox is probably the best way so um i'm happy i'm happy to connect with people that way i think um putting all of your together is probably best can we share your email in the chat is that okay yeah it's it's ramsetti musc.edu so sherry will throw that in there because i'm sure people are going to want to learn more about that as it evolves and progresses and all that who knows maybe you get some feedback and enhances like your product development as far as your d your dvs as i'm calling it now uh real quick because we're going to jump into solutions now and i just want to i promised you guys i wanted to remind you a little bit about what rebel health does our sponsor of today's program they are a great fit for today because they work on behalf of health plans and accountable care organizations to take a very sophisticated approach to focusing on an individual's needs so not entirely different from what nida was just talking about so if you've ever talked to the most accomplished madison avenue ad agencies the ones that drive behavior change for the biggest brands that we all know and use revel they take a much more like sophisticated approach to influencing our behavioral change and most of us do in health care and that is only until now because revel health is taking very much that same approach around understanding a individual's values well enough to truly influence how uh they could change their behavior and so in healthcare that that is one of the sort of uh the keys to driving better outcomes uh especially as we're thinking about the importance of social determinants of health and an individualized approach to that so we haven't been that sophisticated until now revel health is taking the highest cost patients for you and figuring out unique ways to communicate with them that drive change so if you want to learn more about them you can check them out at revel-health.com they just merged with novu that's novo.com so you could check them out on either website i believe they're one of the new bright spots in healthcare so check them out i i want to talk about now some of the key components to overcoming health illiteracy uh when using the digital platform so sarah as with all your work you're doing with all your clients what's the best way to be thinking about addressing this problem so first i want to just um kind of second dr rinsetti sentiments around the need for these really short and targeted surveys what we found is that getting those done as early on in the patient journey as possible and updating them with um you know measured frequency is is critical to understanding people's orientation and also the changes that they're going through these are not these are very fluid things and they the the situations shift and so we need to keep on top of people and you know what's happening in their lives in order to be able to respond with solutions that are appropriate um the other the other aspect that i would um comment on is in order to overcome health illiteracy what we have focused on in great detail is cultural orientation how you speak to somebody the phrases that you use and the integration of cultural norms um there are specific ways to communicate and somebody in the northeast who lives in an urban environment may communicate very differently to somebody who is rural or on indian reservation so we need to be aware of how people are their cultures their norms and craft communications and engagement strategies around that um there's also situations where people don't trust technology and you have to know that so it would be ridiculous for us to try and engage somebody in a in a digital pure digital solution if that's not the mechanism in the vehicle that they trust to communicate with their providers and so really trying to craft that and drill down into this micro segmentation is is critical and i would i would give an example that that recently happened we were trying to engage a population in a very small area of the bronx and we just could not figure out why they were not responding and what we actually noticed is that there was a high polish population and the communications that we were sending out were they they couldn't understand and there were much different ways of accessing care than what we were recommending or suggesting and so we had to shift and pivot really quickly understanding that this is this is something that is not we're not going to enable them to take the right action at the right time the right place one of the other components that i would i would comment on that we've been speaking about is you know the need to to get people to these surveys and to get people engaged um the the other component that i've noticed is that there is a lot of regulatory action in this space right now um good and bad so some states are incenting providers and health plans to engage patients in this way others are creating a more punitive approach and so i find it interesting to see how this is evolving because there are this is adding an additional cost burden in order to help solve for this and for especially some of these community clinics there needs to be a reimbursement structure whether it's the state or some type of value-based arrangement where there is there is a payment structured around being able to deliver this and so while it's slow to evolve that's some of what we're seeing and potentially a bright spot to help encourage um solving this problem you know i i love this to you sarah but anyone could jump in i'll call it a jump ball which is one of my cardinal rules of things not to do in moderating but i'll give it a shot here uh one of our audience members i think it's a great question or a quick suggestion is schools are dealing with many similar issues as well and sometimes it's the kids obviously onboarding their parents with some of these tools can you partner with any of them or has that been done um we have seen that it's not something that we're currently doing there's a lot of social service organizations that are trying to do that but we know that education and education level is so highly tied to health and if we don't engage people in school and continuing to stay in school and access the technology then they're going to fall behind and that has also catastrophic health care consequences and so we recognize that we've spoken on it it's not something that we've solved for or engaged in but i think there's a huge opportunity to help partner with organizations like that and connect them to providers and health plans to start working holistically to get students engaged yeah i would completely agree so here in trenton henry j austin is partnered with our trenton school district we have a mobile health unit and so we've been using our mobile health unit to visit schools particularly at the beginning of the school year we have an immunization drive that's going on right now one of the unfortunate consequences of covet is that many children are delayed on their vaccines it's actually a national issue and through that communication we're actually doing exactly what sarah was saying thinking about how can we ensure that children are healthy but also receiving their education at the same time not being isolated receiving the behavioral health and mental health services that they need because they're so intertwined particularly since many children now have been impacted by kovid and particularly since we were talking about the health inequities um many children of brown and tan skin we know covet has disproportionately affected their families so there's lots of of of intertwining between the education mental behavioral health wellness and how they're doing in school so again working with our school district trying to address those needs at the same time and do it thoughtfully these surveys that everyone's referencing just real quick yes no are are questions tied to are any questions tied to financial health as well yes okay that's a question uh real quick uh sherry i'm gonna put you on the spot here i i remember we have access to an e-book called the great divide and it's in the byline has five strategies to bridge healthcare member gaps and uh it's authored by our friends at revel and if you want a copy of that why don't you just put up a poll it talks about precision personalization in population health it talks about perspectives on care and solutions uh to meet people where they are and why partnerships are are so important to doing that so it really covers a lot of things we're covering in detail so if you want a copy of that it's a pdf we have i'll get it out to folks uh who just requested here by the paul uh we'll also give you some contact information to the authors if you have questions or just want to pick their brains uh could be interesting for everyone uh kemi let me keep you on the stand here uh you're dealing with a lot of homeless in your market so how are you reaching them as well as the other maybe they have homes that they're underserved and how are you facilitating just digital care and telehealth in these unsheltered populations in trenton yeah that's an interesting question and i want to say i have dibs on anita's digital survey digital divide survey so we'll be talking this is awesome panelists get preferences interesting um so one of the things um that's unique to henry j austin is we have nine locations as i mentioned one is the mobile health unit so that does go um in and around the city of uh trenton we have um the eight other locations for sort of bricks and mortar very untraditional but the other four are these primary care offices that are actually embedded within a mental health institutions and within a homeless shelter and as such we've been partnering with those institutions as you can imagine um those individuals that have severe mental illness and those individuals that are homeless and also a lot of times they're intertwined individuals that are homeless uh one of the the reasons is because they often may have a mental behavioral health illness or substance use illness again complicating their whole chronic diseases and so partnering with them the homeless shelters and the mental health institutions has really been key and one of the ways we've done that uniquely i think in the city of trenton is this innovative collaborative we have called the trenton health team it was founded back in 2006 and it's represented by henry j austin health center are two local hospitals the only hospital systems in the city and our city department of health and we come together on a regular basis basically with the goal of making the city as healthy as possible one of the um one of the initiatives that we worked on really early on was um communicating between all of these entities in terms of the shared individuals we have so we instituted a trenton health information exchange and that way i could see whenever my patients went to the emergency room and the emergency room physicians could see exactly the notes and the things we ordered within our health center in that we really identified some of these high-risk homeless individuals and we would meet regularly and talk down to the very granular level of how do we help mr smith and it was the hospital systems it was henry j austin and then through the trenton health team we also pulled in a lot of those social service agencies so we pulled in the um the homeless alliance we pulled in the mercer county social service department we pulled in the rescue mission the salvation army so that everybody was really talking about an individual and how we helped that person but then we were also able to then improve processes and failures within our systems that were linked um and that was again a really unique opportunity that we've been able to capitalize in providing services to our homeless individuals wow i want to throw another follow-up and this this person gets the grand prize winner for best question from the audience you win uh a pat on the back for me virtually uh we should do a whole event on this sherry so get this guy what does digital equity look like right that's a that's a that's a whole session right but could you maybe give us a quick like two minute like what does it look like i'll jump in i'll see we'll iteration this is you know this is a safe space we'll iterate on it uh so you know i think you know borrowing from some of the language of like the health equity language the way i've been looking at it sort of like you know for everyone to have sort of a fair and just opportunity to engage with digital tools is the way i've been kind of thinking about it um and you know and part of that you know in terms of like more granular things really involves kind of kind of social changes i think one of the big things that we can really push forward is like universal broadband access right just if we're really pushing towards making this a central part of what we deliver care having everyone be able to have access to to the internet and be an active uh an active participant online i think this is such an important piece of it but i think simply put i think for me is just everyone having a fair and just opportunity to engage with these with these tools that's very broadly speaking obviously um and then all the things we've talked about sort of fall under that what that what that um what that looks like more specifically yeah i think i i would like to tag on to what jorge said and you know part of for us i think integral to cares being a clinic that always seems to be struggling with our own funding we're we're very cognizant to the fact that um materials access all of those aspects that we like to think of broadly will not always be readily available and even if they were they wouldn't necessarily solve everything so we by no means and i think everyone on the panel would agree we know that um access alone will not solve this and at least for us a way of trying to get to this this position of digital equity for us we're trying to tap into the power of communities and really trying to understand culturally and community wise where everyone is coming from so for instance our our rural outreach clinic um is about an hour and a half or so outside of charleston it's about 39 of the families falling under the poverty line very high rates of food insecurity very high rates of chronic diseases of different types diabetes stroke hypertension and for this group what we had planned to do kovid threw us off just a little bit but noting how strong the community ties were there what we have been trying to do is to incorporate a model of care that has been referred to as barbershop medicine where really the health care that is given out there's more in centers where people gather normally and where there's a really strong sense of trust where there's a strong sense of connectivity to each other so in terms of really truly getting to equity we think it also needs to take into account where people find support and trust and so in this model we would embed devices or telehealth devices or access in a school so one of what one of our attendees asked would you incorporate the schools yes as it turned out in st stephen this the two schools that are there the middle school and the elementary school literally are the heart of those communities people are always there and when we started asking would you go to the school to to check in on your blood pressure your blood sugar if there was a community device there the answer was across the board yes and as healthcare providers we always start thinking about all the red tape so the first question was well what about your privacy do you want to go to a place where everybody knows you and you're putting all your healthcare information out there and every single person we ask said yes this is a small community we know each other here we're here to support each other and i think knowing that about different communities it won't be the same for everybody and even within the community it might not be the same but that is a particular cultural strength of that community that i think could be tapped into in order to raise the equity so that yes everybody would have access there it just may look different than access in charleston which might look different than accessing trenton and that's fine as long as we get to that end point that jorge pointed out which is we all have equitable access to it regardless of how we get there i want i see five minutes left so i want to ask one last question to connect the physician to the patient and incidentally uh next week 2 p.m on thursday since 29th typically we're going to be covering a cool topic called innovations and physician engagement and provider learning especially in light of the pandemic and how to keep physicians engaged and on top of their game with new treatments especially around covet right so uh david nash at jefferson college of population health all of you probably know him he'll be on the panel along we're with mary ellen beliveau who's the founder and and ceo of knowledge to practice as well as dr daniel davis so join us for that uh sharia put a link to register if you want 2 p.m live recording on the 29th jorge what about the physician and how are you able to solve this digital divide so that physicians uh are engaged and able to do the best they can to provide the right treatments to their patients so have you jump in and anyone else that wants to jump in uh can right after that and we'll see if we can finish this up in the last four minutes yeah i mean i think it's a lot of it is a lot of the work that everyone on this panel has been talking about it's really setting up the kind of the the workflow pieces and really connecting this with the fact that this is a a standard part of of the way we deliver care and can really benefit their their patients so i think at an organizational level having that set up and physician buy-in and then getting their feedback is is key that's sort of the one thing i always reflect on that sort of the more personal level um is around what my role is as a physician as i'm as i'm sort of on the front lines i'm approaching a patient and there's some data to suggest that as clinicians or just in the general healthcare system we make decisions on who we offer these tools to based on what they look like and you know i always like to reflect back like you can't tell whether someone's going to use telemedicine by looking at them right i'm not able to tell whether you have device access we have internet by looking at you so i think if we really deliver this as part of care of taking a step back and being like you know regardless of who's in front of me if this is a standard part of care i'm going to offer that and have that conversation with the patient and not make assumptions and say like well they're not going to i don't think this person's going to use the portal or i don't think they're going to engage in telehealth or they probably don't have internet i don't know i don't know where this patient's like that's why you have the conversation so i think those are the two pieces i like to to think about and i think the last piece is funny that you mentioned sort of like kind of you know clinician education i think that the other piece that we that's important to reflect on is the fact that like we talk a lot about patient-facing digital literacy but there's a big component of clinician digital literacy that comes into play because this is such a change in the way we deliver care being able to navigate and feel comfortable with some of the tech tools in front of us even from a physician side i just remember like the first time i've joined a new hospital and working on their electronic health record i'm all sorts of you know all sorts of confused and concerned i'm missing something and similarly you you have that experience when you're picking up talent so i think there's some component where like you have to address patient digital literacy very important but there's also that clinician side that's important to address what's that anyone else want to jump on there and things off for us okay i have a bunch of other questions but i know with two minutes left that would be uh a bad move would go way over i want to be respectful of everyone's time uh for all of you who are listening in and watching live and just we we don't take the 60 minutes of your day uh lightly we really uh feel privileged that you took the time with us so thank you uh for being here and hopefully to continue uh to engage with us please provide us that feedback through the feedback form so we can continue to drive the right content i already see a topic on what does digital equity look like and as well as jorge overcoming implicit bias in healthcare delivery i think that would be a cool topic so two two topics from you guys already great job uh thank you to the four of you the time you took to prepare with me the time that you took today to provide all this great content i really really appreciate it uh thank you to the team behind the scenes sherry and friends for putting this together uh this will mark the end of the show guys stick around for a second i'm gonna stop recording thanks again see you next week 2 p.m really appreciate everyone participating