Welcome everyone to our first day of Member May. This is the Pediatric and Patient Rehabilitation Networking session. I'd like to just go over a few housekeeping notes. The views expressed during this session are those of individual presenters and participants, and do not necessarily reflect the positions of AAPMR. AAPMR is committed to maintaining a respectful, inclusive, and safe environment in accordance with our code of conduct and anti-harassment policy, which is available on our website, aapmr.org. All participants are expected to engage professionally and constructively. This activity is being recorded and will be made available on the Academy's online learning portal. An email will be sent after this activity with a link to bring you to the recording and an evaluation. For the best attendee experience during this activity, please mute your microphone when you're not speaking. You can raise your hand or you can use the chat feature to ask a question. I know this is more networking, so it might not be as formal. Please note, time may not permit for the panel to field every question. Thank you very much, and on to Dr. Mann. Welcome, everyone. I'm Koby Mann. I'm a Peds Rehab attending at Children's Hospital of Colorado in Denver. Christina was telling me we had about 18 people sign up, so I'm going to give people time to join us. As I know, sometimes stopping the hour is hard for everyone. How are people doing today? Good. How are you? I'm good. Wishing we had warmer weather in Denver. It's been up and down and mostly rainy here lately. I know. I have storms going on right now, too. Oh, there you go. We're all still waiting through spring. It sometimes skips here. It's like cold, cold, cold, and the next thing you know, it's like 80, 90 plus for five months. Where is spring and fall? Can we just have a little in-between for a while? There was an outdoor carnival at my elementary school last Friday, and I was begging my children to leave. It was so cold. They had these two women doing face painting, and they were literally shaking. You could see how cold they were. I was like, we need to call this. It's like, how can I bribe my children to leave? That's okay. I have the children that go and bring buckets of water outside to play in now that it's 50 degrees, and they always pick the cold days to do it, too. My soon-to-be four-year-old keeps asking when we can turn the hose on and we keep telling him it is too cold. But they were also outside playing in their underwear this past weekend when it was like 50, so they seem to just not feel it. They're immune to temperature. Yes. I'm just going to wait till like 11.05 unless people think we should get started. It's really to get to know each other so. For those of you who we've been talking about this member committee are already I just threw together some quick slides that you'll see nothing fancy. They may doing board examining. I was I was wondering how many people were missing because they were interviewing. I know I just happened to work out my head clinic today so I didn't sign up for today but then all my patients, somehow canceled or something so it all worked out. Dr Pruitt. Hello, welcome. Ford Ford's worked out for me I had all my sessions all day yesterday and then this morning so now I'm done. It's nice perfect timing. Sue's got her like post it note on the door she's just kind of like reviewing I think but she's she's doing all four days. All right, we'll get started. Like I said in a way a few more people signed up. Let me just share my screen. So welcome everyone who joined. We are really excited to have this member community within a PM and our to focus more on those of us who do pediatric inpatient medicine both consults and inpatient units. I think, you know, from my perspective we've had some really nice robust conversations within our, our Facebook group and trying to find a way to expand that and have more support for some of the things that I feel like we constantly talk about or ask about. So, we are just getting started with this group side so I have a very loose agenda for today this is just networking getting to know each other, what we can do with this member community to support what we all do. Think about how often we want to try to meet as a community. And then just a little plug for the annual assembly. So we can just start with introductions name where you're from, like, clinical responsibilities like how much time you spend inpatient versus consoles versus clinical and why you joined today. So I will, I will start. I'm Toby man I'm at Children's Hospital Colorado University of Colorado School of Medicine. I am the inpatient medical director here so that's part of my time and clinically. I no longer do any outpatient clinics I'm all hospital based doing inpatient. And do you want to go to. I'm Kim Hartman I am currently at Children's Mercy in Kansas City. for my training but I'm originally from the great state of Michigan. And I am also the medical director for the inpatient programming out here. We are still in a model where our inpatient attending or faculty member covers our consults as well. We have started to divide that up a little bit between two faculty members, but haven't quite made a full split. And so I kind of oversee all of that anything in patient slash console related. And I do that about six months out of the year. And then I have some other administrative responsibilities with our fellowship program and medical education. And then I do a handful of clinics every month as well. One across my screen, Sarah. So, I'm Sarah legal, I'm at the University of Wisconsin and Madison so Madison, Wisconsin. I'm also only inpatient essentially in the medical director of our inpatient service. I spend about three quarters of my time doing our inpatient then one quarter, working at an offsite location that's kind of like a sub acute or L tech type version of rehab for kids and adults. And I'm interested in this just because we also have a joint like inpatient and consult service just run by one attending but with somewhat smaller hospital so we have widely fluctuating numbers and, you know, I think it'd be helpful to coordinate with other people on how do we kind of help support and like develop programs knowing I'm a smaller program that I'm at, and kind of moving forward with developing like other things or other service lines that we can offer patients. I Ling and please tell me how I pronounced it wrong. If I did. Hi everyone, I Ling Yi Ling, or I also go by the name Emily. So I'm a last year medical student from Taiwan. I just realized that most of the people here are attendings and even program directors from the state so it's really my pleasure to be here today. So, um, I am very passionate about pediatric rehab I just completed two months of rotation in the States, specifically on pediatric rehab and they're all very impatient, heavily related so I have like some hands on experience with that. I'm also the team leader of a student association called Pathways and PM&R. I'm the team leader of the IMG committee. So, I have some experience on medical education so that's also part of the reasons why I'm here today to hear more about the management of inpatient pediatric rehab and trying to convey that to medical students because I do feel like medical students are less exposed to the concept of pediatric rehab. So yeah, I'm just here to learn, and to gain more, more exposure to it. Thanks for joining us. So true. Dave you want to go next. I'm Dave Pruitt. I'm medical director of our inpatient rehab unit at Cincinnati Children's. I'm jealous of all of you who do all inpatient and have all of your time devoted to inpatient. I do probably about three half months of the year, or four half months of the year clinically on inpatient. And then do an outpatient focus of cancer rehab, primarily, and then fellowship director of our fellowship program here in Cincinnati. I think it's helpful to get our heads together as a group from a number of different reasons. I think many of us are CARF accredited and I think as we go through our preparations for CARF accreditation, I think that there's always a lot that we can learn from each other in terms of ways in which we navigate, meet CARF requirements, and think about how we could potentially learn from each other, in terms of how we meet those different standards or how we complain about those standards. It's always nice to also have that opportunity from time to time. Paige and whoever else is with you. Hi, I'm Paige and this is Becky. We are combined pediatrics PM&R residents at Cincinnati Children's. And as we get closer to the job hunt. I know I'm really interested in inpatient rehab so just trying to get a better idea of what things look like at other institutions and how some of the challenges are, I guess, assessed and improved upon is my goal. Great. Becky. It's similar, I feel like just learning from different institutions, it's just really helpful. I've never done member may, or much of the AAPM&R resources before so just trying to utilize more of those as well. Awesome. Let's see. Oh hi, I am going to discuss this sorry I'm like cheating. I'm going to discuss guess I'm currently adult children's in Austin, Texas. I did my fellowship at Cincinnati so Cincinnati love for everybody around the room. I did my residency in in Texas with UT I'm originally from Puerto Rico. And, oh my god, other clinical responsibilities so yes I'm the medical director of the patient rehab unit. I'm also the chief of the pizza rehab kind of like subdivision that we have right now. We currently have. I currently have two additional faculty members that are pediatric physiatrist, in addition to for non physician providers. I would love to mostly doing patient but given being in a small program. I also have to do some continuity clinic. In addition to. I founded and direct this like comprehensive through a policy clinic center hub that I'm developing. I also kind of like direct the comprehensive specificity advanced specificity management clinic with neurosurgery. So I have multiple hats. Currently, the other two pizzeria positions help with consults. So, given that the program has been growing we've been trying to like find ways to cover consoles, provide coverage for inpatient rehab. I think one of the challenges right now is that we all feel that we're doing all the things at the same time so probably going to rotations recycles. So you're just like more busy like this year for a specific period of time. But also kind of like balancing because they're mostly outpatient in, and there's like a lot of needs for growing clinics as well so that's part of what I'm here just to kind of like see how their peoples do manage some of these things I'm very. I like program development so in my short four years with develop a DLC pathway we have spinal cord injury pathways. I've incorporated activity based rehab training for the therapists that do inpatient rehab, and we're currently trying to get car for credit this year for an inpatient rehab program. Awesome. Yes, director of everything. You're up next. Sorry. I'm having technical issues. I'm not just reading Boston. I am a pediatric as I dress in Dallas. I'm at the Children's Medical Center in Dallas. I did my residency in Toledo, Ohio I did the combined residency program there. I am currently the division director at Dallas, I have to rehab physicians who work with me, and I am primarily the inpatient person. While I also do it outpatient clinics as well. We have a brain injury clinic we have a spina bifida clinic, and we are between two hospitals we are in the Dallas location and we also have a location in Plano, which is in the suburbs of Dallas. And I basically joined to see to help collaborate with people and learn more about what's going on. And for the two fellows who are on, we are recruiting, just FYI. Take every opportunity Raji. Yeah, absolutely. Anyone else. Thanks Raji. Lauren you're next. Sorry two screens. I'm Lauren Betzko I am in Madison, Wisconsin with Sarah, I'm I split my time. So I don't know how much she talked about it but there we kind of have a wide variety of kind of ranges of what our individual physicians do but I split my time between inpatient and outpatient. And just here to kind of learn like you said I trained at Texas Children's in Houston so, and was in residency in Cleveland and Metro Health so I'm always just hoping to kind of learn from other individuals. I also do, I'm the director of our Spina Bifida clinic here, and also participate in our cerebral palsy clinic outpatient. Awesome. Did I miss anyone I think I got everyone. Let's see if I can manage as many screens as I have. So I think people already mentioned things but I kind of wanted to open up a smaller group of us that got together for anyone who's on the Facebook group when I put out the call of like, who wants a peds inpatient group because I want more support. So I think kind of the same things people mentioned, we kind of started like just the few of us like what are the clinical topics. And then I also just have like what are like research or scholarly topics that like we want collaboration on or we want to know what other people are doing. And then also kind of program development. But also kind of like leadership mentorship like what are the things that this group, like using our knowledge base and expertise reaching out to people who can like what is what is the content or the goals that we want to have so I really want to open it up. You know, unmute yourselves raise your hand. And I'm, I'm trying to take notes at the same time so as I'm multitasking grace, please. I might jump in and say, and add something to the group that might be helpful for us to talk about at some point and that's thinking a little bit about program breadth and growth in terms of inpatient rehab. I'll share with you like our numbers from a census standpoint, haven't seen growth, and many years and you know we've actually seen decreases in the number of kids that come to inpatient rehab. Over the last five years and we're diving into that in our strategic planning that we're doing right now to kind of think a little bit about the reasons for that, you know, and that's even with developing programs so we have four. CARF accredited programs we have a cancer rehab program of pain program. Brain injury program and our regular peds rehab program. But even with the development of specialized programs, you know, we don't see that we have our census that you know our full 11 beds full all the time and there are times when our senses can even dip down into the four and five numbers and. And so like, as we think about things you know and have kind of I'll just share with you, as we've looked at drivers to that you know some, you know, one of the drivers to that is our surgical population source, our previous seizure surgery population was a big driver, or a big number of patients that came to rehab and our surgeons have appropriately, you know, transition to not doing as many hemispherotomies and corpus callosotomies but doing more laser ablations. And so not having as much hemiparesis and, you know, issues that evolve into needing inpatient rehab for our patients. But like as we start to look at these numbers and kind of think about why we're where we at we're kind of thinking about how do we grow and think about other populations of patients that might be good candidates for inpatient rehab and I feel like we have tapped into a large number of patients. And the patient populations probably that we don't see as much coming to our unit that might be part of your units and it'd be good conversations are really the more medically complex patients, the post transplant patients, the cardiac transplant patients, the liver transplant patients, the, you know, we do a little bit of bone marrow transplant patients with our BMT unit and what we call a modified program in which they stay primary BMT but we do a rehab program for them. I just think it would be helpful for us at some point and whether it's now or later in the conversation to have a little bit of discussion about how we have gone about thinking about growth and development of patient populations for inpatient rehab. I love that idea. And second, you might be experiencing that you're stagnant and we've been trying to grow for a long time and can't figure out where to reach out to other populations and having an even smaller inpatient census, you know, one to four, when we get down to one we can't even maintain a unit and like a core team. And I've noticed some of that as well that we're getting a lot of these more medically complex patients that we didn't have before that's the next group to reach out to. So I think that'd be awesome to hear about what you're doing or what other people are doing to manage those more medically complex patients that you know like I feel I can't manage on my own. And you mentioned having that, you know, BMT being primary and seeing how do you work that dynamic out. Yeah, I think that's interesting because we have like a specialized cancer rehab program for the kids that need to stay on the cancer floor so it's like both sides of the coin like you admit more medically complex kids, and we recognize that maybe we shouldn't be primary on the more complex kids so we build these separate patient populations, but then we may be like taking away our own business. So, and the one thing that is a little bit different about us in Dallas is our, I am not the primary attending on these rehab patients. We have a hospitalist program. And from a medical complexity that helps me with bringing in more medically complex kids because they have the updated, since I mean even though I trained both with Pete's and PM and are my pediatric knowledge is obviously not where the current So that helps me in bringing a lot more medically complex patients. And I also have the luxury of having the technologies also have a ventilator program on the same floor. So we are able to bring in a lot more medically challenged patients and that that helps us with our census as well. anyone else with. And by no means am I advocating for that, but I'm just telling you what I have, that's all. I don't know that I have anything new to add to that conversation. We're just more solidarity. We're in a similar situation. I feel like our consult numbers have continued to climb and climb and we're seeing more patients, but it hasn't translated into us necessarily admitting more patients to our service for a variety of reasons. So we are also looking at that right now. We're also looking at our unit is currently in the main hospital and to get more space and more equipment, we are looking at moving to our kind of one of our other main campuses, which will be still a hospital with lots of the same features, but not quite. So we won't have like an ICU and that kind of level of support at that facility. And so what does that look like in terms of, again, some of these more complex patients, how will they have access to all the services and make sure that we can still provide the appropriate services to all the kids, regardless of what kind of team they are on. How much of that do you guys think is more insurance driven that we are not getting these kids? I don't think it's, at least in Colorado, I don't think it's super insurance driven. I think there's a handful of kids when their insurance takes longer that sometimes they get good enough to go home. So we're missing like, and I think one of the, I'll add to that, that we have a one week minimum for inpatient rehab here, just like the amount of things you need to get done in order to actually deliver an inpatient rehab program. And so I feel like that may limit us sometimes when we know it's going to be a short stay, but like when we have kids come for three days, like I don't know if other people have instituted a minimum stay, but it's just, so I think it's like catching those kids early enough. And I think like when I haven't done, like we haven't started like digging formally into our numbers, but I think there's also, we get a lot of concussion consults that are actually moderate to severe TBIs, but we're not getting consulted until days after their admission. And so I think we're also missing the window because then it's like the therapist is like, oh, a couple more days and I think there'll be ready to go. So I went a little all over the place with that answer, but another- No, I would agree with you there. I think that we also, we get consulted pretty quickly on those TBI kids. I think that just in the discussions that we've had most recently on this issue, I think there's a little bit of a culture issue, right? In terms of the referral sources, the referral, the therapists that are seeing the patients on the acute unit, sometimes making decisions for the referring services or for the families to say, your needs probably don't, you probably don't need to stay in the hospital longer. Your needs can probably be met by high frequency outpatient therapy services rather than going to inpatient rehab. And I think that's true in a lot of cases, but I think one of the challenges and one of the cultural changes that we have to kind of think a little bit about that is, while that may be true, there is oftentimes a delay in that transition to high frequency therapy services from inpatient to outpatient, but also, you know, there are insurance barriers, right, to the number of therapy services that a patient can get when they go to outpatient, most times being 20 PTOT speech services in a calendar year. And so, you know, I feel like one of the things that we need to tackle, you know, as we move forward with our strategic plan and trying to increase our census and increase our numbers is kind of working on culture about what inpatient rehab can do, even with briefer stays. We don't have a limit of one week per se, and maybe one week is the right amount of time, but I do think that we have been resistant to taking kids who are going to be a shorter stay because of some of the challenges of meeting all of the things that need to be completed in terms of either DME or neuropsych testing or, you know, all of those things, and can you accomplish that in a time period that's less than five days. Absolutely. Glenda, please, you had your hand up. Yeah, no, I agree with a lot of that, and one of the things that I've been working for the last two years that I still, it's not quite there yet, is actually developing acute therapy rounds. So, once a week, I meet with the acute therapist in the hospital, and we go through the census in order to help, basically, that dialogue of who truly is an inpatient rehab patient. One, advocating for them because sometimes there are these patients that are sent home even without therapy evaluations, so making sure that we are capturing, that we are educating the other teams, either the hospital's team or the trauma team or the other, like, surgical teams, but there's a lot of, especially because when I came, there was not even, like, an established rehab position here. Therapy was providing this position, and they have been providing this position for a long period of time, and sometimes they truly don't understand what inpatient rehab is and how we can offer, so that leads to consultations, sorry, to referrals for inpatient, for patients that actually don't qualify because they're just so sick that, you know, that they just won't be able to tolerate therapy or for clearing the patient too quickly, even though the patient would benefit, and a lot of these services, a lot of our peers outside of rehab, they're lacking in that system-based competency that Dave was talking about. They just think that every therapy is the same therapy, that if they discharge, they can just access therapy next week, that they will be able to get three times a week, that insurance will pay for it, like, their expectation is not going to be an issue, and I think that we do have a role for advocating for access and to make sure that the plans that are being developed are practical, realistic, and pragmatic as well because we do know that these patients that end up with longer disabilities, they do have other challenges, psychosocial challenges at school and all these things, so we are the best people to do that. I think it is a changing culture, and it requires a lot of time and education and going back and basically saying the same thing over and over, but acute therapy rounds have been very useful in which there can be that very kind of level conversation, and having specific cases to discuss, I think other people actually learn about what rehab can do better case-based than on a presentation or something like that, which is something that they sometimes ask, like the pediatric residency can ask us to do a presentation of who is an IPR candidate, but it just goes through one ear and goes through the other because it really needs to be specific examples. How do you structure your acute therapy rounds? Do you have a full list of patients that are seen, or do they only bring up patients they have questions about? So I was able to do it more consistently in my other job than here, just because of all my multiple hats. When I run rounds here, I try to do it as in the other hospital, but the therapy team have not been keen into trying to incorporate the way that I want rounds to happen, so how I did it in the other hospital was, so I would basically, we would print the census of the hospital, and the therapist would mark which patients they are treating, and we would also kind of like mark which patients have been in the hospital for more than a week. You know, like anybody that is for more than a week, there's like some sort of like medical complexity, right? And yeah, you have your NICU, and you have your own kids that are, or some of your CICU CARDS patient that just are kind of like long-termers, but we can see through the list, like who is staying in the hospital for a longer period of time. I also look at the diagnosis for admission. If someone comes with a brain injury, or like a skull fracture, or like whatever, I'm like a UTI, and they've been here for two weeks, like something it's not jiving, right? So I make sure that the therapists are, so I go through the list, basically. I kind of like highlight everybody that is staying in the hospital for more than a week, and make, and kind of like a diagnosis, or like, hey, this is a kid with a brain injury that just got here. We need to make sure that they get consults with you guys, even if they don't get a rehab consult, right? And then, so I typically ask them if their specific patient case that they want to discuss, but I like to go through the list to make sure that the patients are getting the therapy, and that we don't need to be involved sooner than later. We just instituted like a consult rounds. Our hospital is too big to print off the census, and we, but we still try to elicit like from the therapists, or from the med team, like who we want to discuss, and for us, our, I think how your therapists are organized, that drives a lot of how we can structure the meeting, because PT and OT are organized similarly here, but speech is different, but we had to like have a meeting of the minds of like, okay, we can do like the NICU and developmental therapists, then we have a heart institute, then we have ONC, and then our acute therapists kind of co-manage with our inpatient therapists. So I think that's like just the scheduling logistics that I recently, you know, took us months to come to agreement, and then like how much time you take from everyone. Here's a separate question out there, like when do you meet for all these programmatic things, when our therapists really have this push to be treating all the time. So every single meeting we run is from 12 to 1, which I personally dislike. I like being able to eat lunch, not in a meeting, but otherwise we're treated exactly, so. I was able to basically advocate for 11 to 12 meetings for our inpatient rehab team as a core responsibility of inpatient rehab therapists. So every time that, so therefore we try to schedule family meetings, initial planning meetings, and team meetings, so basically like team rounds are on Tuesdays, so that's Tuesdays 11 to 12. Initial planning meetings or steering meetings or IP meetings, I don't know, like each of us, each of our institutions call it something different, but then we have that blocked for Monday, Wednesday, Friday. So we have it blocked, and if there's not a meeting, they just have an additional hour to treat, but they are blocked currently in their schedule. And then because I had a new program and I wanted to make changes. Thursdays are kind of like units or kind of like programmatic meetings. So they're not patient-centered, but we talk about like the discharge process or like, hey, we need gym renovations or something when I arrive with like a discharge because we change times or whatever. So anything that is programmatic or like system issues from the team, it comes on Thursday. So we have two Thursdays of the month that happen for like inpatient rehab kind of like units with the people that treat the patients and nursing and the clinicians. We have one Thursday of the month that is leader programmatic. So like the charge nurse or the therapy manager or something. So people that can make changes to staffing or something like that. And then we have another Thursday of the month that is for like journal club or something like that. So more educational. And that was easier than trying to find a chunk for the therapist to go to a meeting for a family like in different time, at least, you know, like from a leadership perspective, they felt that that was going to be efficient enough that they were allocated that time. I can't talk a lot, so I'm trying to not cut them for anyone who has been in other meetings. I was also just looking at kind of the list we had generated before. I think there was some interest in like EMR and how we can share what we're doing, you know, whether that's epic things and like what we're able to build or like how you utilize flow sheets or to me it also ties into CARF, like what education you've given, like we've been trying to use the education tab here, which is really a nursing, like more in the nursing role, but because the education tab exists, Epic would not build us other things. So I think that's like another great area that we could all explore more about how we share what we're doing across institutions. And Kilby, I would add just so we keep it on our list or invite Ashley Jaffe at CHOP. She is leading through Epic a lot of, she's doing a lot of clinical informatics right now and she's doing a lot of the leading about rehabilitation changes within Epic so that, you know, those types of advice pieces, I struggle with that education tab too in terms of CARF accreditation and having a place in which we're all reading the same thing in terms of what's being done from an education standpoint. That might be a really good invitation if we decide, and I hope we do decide to have some consistency to this group getting together. That might be a really good meeting to have is to kind of provide her an opportunity to talk about some efforts and to give her some feedback about some things. Dave, yeah, that's a really good point. I'm part of that committee, Ashley is leading it, but yes, I'm part of that committee as well. And we are really getting, she did a really great job of advocating just for PM&R because we didn't have a steering board like OB-GYN and everybody else. And I actually saw Ashley earlier this week. So we're still very much like in the early stages, but I will say that I do feel like, at least on the Epic side, like they are interested in helping and like figuring out. I think we're still kind of this specialty that confuses them a little bit, which is understandable because we do a lot of different things and we don't fit nicely into a box, but they are, I think, interested in helping. And there are some tools that I think they are developing that will help. I'm thinking the ones that come to mind are outpatient, but like that I think will help like down the line and that they even presented this week in Epic that like, I'm really excited about that. You know, it'll take some time to get to the user side, but I think will be really helpful for our really complex patients as well. And for the smart forms they use at CHOP to like how they track, like who they're bringing to inpatient or not and insurance authorization. And coming up on your accreditation or reaccreditation, internal consult tracking was something we were not doing very well. So I have talked with lots of people who do our Epic changes here about how we could build something to track. So kind of related to your Glynda-Lisa like central capturing of things, even within my institution is currently hard. But like I showed some people those screenshots of smart forms from actually like, oh no, we can't do this. So the next person was like, oh, this looks really nice. Maybe we could do this. I think along those lines too is all of the double documentation that has to happen to be compliant with CARF, right? Like in Epic. Like Epic isn't a system that has worked really well to make sure that we're not having to have our therapist or our nurses document stuff where it carries over nicely into a team conference note or to this. I mean, I think that input is gonna be really important. And I think it would be really helpful if we as an inpatient page group could have some input for your group, Lauren, as you guys are working with Epic to think about things. Sorry about your PTSD, Kim. Here's my, oh, maybe this is related to CARF, people who are interested. Who does your CARF, who's your CARF lead? Ours just left again. So I'm happy. Ours is retiring next week and it's so sad to see her retire. And I have to tell you in this world that we live in with all of these economic changes and so forth, getting approval to rehire a non-clinical person was nearly impossible. And luckily by a lot of threats and a lot of push, I got somebody hired to fill that position, but I worry about like, I could never imagine going through CARF without a CARF coordinator, without a program person who kind of runs all of that. I mean, it's, for those of you who do it, and I saw you raise your hand, Kim, I can't imagine what a nightmare. This is why I have so much PTSD because we do not have that person. It is myself and one of my admins and I have 0.05 protected time for that, which is two hours a week, which I think I used all two hours a week for the last three years in the past three weeks just trying to get everything ready for it. So yeah, we're working on that, but yes, we have had that issue for many, many years of how do we hire somebody to do that? And then they want us to keep doing clinical work, but then there's nobody non-clinical to do the non-clinical work. And all of those reports and all of, I mean, like it is a lot of work. A lot of work. And with our disjointed support, ours were not standardized enough for them. So for anyone who's got their time, develop a template, use it for everything. So we can probably talk about CARF forever and just drive Kim crazy. I think we also had, I know we've got some kind of, we've got at least a couple of combined residents that are one medical student. If y'all have thoughts on what would help you or as you've kind of met as groups and what's something that could benefit from more input. Sorry, what was that question? We were dealing with some patient care messages. Thank you for joining us and taking care of your patients. I was just wondering if there's anything from like the trainee experience. It's, I mean, y'all are both combined residents. Is that right? And you've also, you get exposure to two programs and lots of different services. So just curious if y'all have any input. You can also, I'm not trying to put you on the spot. That's okay. One of the things that I think sort of alludes to what Dr. Pruitt was mentioning that we've been working on is trying to update a lot of our stuff in Epic and just making it easier both with the way our notes are built and our templates and making sure that sort of our plans or recommendations for different patients but the same repetitive consult question all sort of match to create some sort of running theme for the patients who are consulting us. And then one challenge that we have that we've been sort of trying to figure out how to improve which really applies to both the adult PM&R and the Peds PM&R world is sort of streamlining and I guess like improving communication with outside transfers and admissions just with poor documentation of what's going on or not getting complete sort of medical pictures and how that affects their care pretty acutely when they arrive. So that's one of the big things that's sort of been on our radar for the past several months. And I think one thing that I'm just thinking about listening to this conversation, especially about CARF and the regulation of things and certifications of things, like going from my role as a trainee to then in a few years my role as like an attending, like understanding the logistics of that and like how to learn and prepare kind of what I can do now to like learn about like the future and like what those logistics are. Cause I feel like I'm just very aloof to them. Like don't really know like the behind the scenes of everything that goes into that as a trainee. Especially if you come from a place that is not CARF accredited but you're interviewing somewhere that is, I think that's a really great point. I think that it's also as a medical director and having gone through CARF, I think there's some things I get asked about that the answer is it's a CARF standard, which maybe isn't the most satisfying response and it kind of goes back to your point, Dave, of like some double documentation or like why do we have to write this out so like this specific way and it's not always clinical things but we have to meet these standards. And I think that's hard, especially like balancing your like learning and experience and education on the unit with things that just have to get done. Even expanding on that, we recently started a new program and we modeled it off after what you have in Kansas City of like a subacute type of rehab and had a lot of questions that came up from the team of, well, is this a requirement from insurance to have these amount of therapy hours or to get this prior off and things like that? And there are some of these questions I go, not really sure where that came from, we just always do it. And we aren't being held to the standard from insurance when we actually go and ask them but we have to like toe that line carefully because we don't want them to come and look at it and then start denying. So just kind of knowing what are all the regulations because adult rehab is so highly regulated but in PEDS I feel like some of it's state by state and some of it is within your institution and I feel like we have a lot more wiggle room. Hi everyone. So I do have some things to share from a medical students point of view. So I came from Taichung, it's the second largest city in Taiwan, and I'm really lucky to my luck, my mentor, she is the very first pediatric rehab position here in my city. So, um, I saw how she like single handedly establish the pediatric rehab system within my city, and she was actually the one that encouraged me to pursue a career in pediatric rehab and like went to the US and see how the system works there. And one of the things I noticed is that, um, like back in Taiwan we do not have a pediatric rehab specialty training. And even in the States, even though like the system is already pretty well established. Most of the medical students I talked to, even those that are already matched into a PM&R residency, they don't really have knowledge or like exposure to pediatric rehab, but my personal experience of working as a clerk in pediatric rehab, it brings me so much accomplishment and I seek so much meaning in it. And I just feel like, um, like, um, how to expose more medical students to what pediatric rehab really looks like and how it really connects the dots in between primary care and also the functional aspects of behind each and every diagnosis and diseases that I think that would be very beneficial to the entire medical education. And that's something that I really want to bring into the student program that I'm currently working with, which is Pathways and PM&R. So in addition to promoting PM&R to other countries, I'm also working on just like how to promote the concept of pediatric rehab to medical students in general, no matter which country they're coming from. I agree completely. That's why I'm one of the people that did AP's residency and then APM&R residency, because of that lack of exposure early on. So, definite need. And I think it's one of the things that comes for us and maybe more on that trainee experience umbrella, it's like, how many trainees can we take on a service, especially like Sarah, like when our census is up and down, it's like how many learners can you have and have a robust experience. And for us, we just built a new unit. So anyone who's in that stage, happy to talk about that as well. But previously I was like, you can't assign us another trainee, I don't have anywhere for them to sit. And I don't think it's fair to have a trainee to be like, you have to go sit in another space, you're going to miss all the education and discussion that happens in what was then a very tiny workroom. It's how do you, how do we build that more exposure when there are some like true space limitations, or like even patient census exposure. Exactly, exactly. Love that Glendalise, who all is on the team. I just saw you mentioned the roles of like NPPs and balancing efficiency collaboration access, we used to have a nurse practitioner that was on our inpatient service alongside an attending physician. And they, they ended up quitting but we couldn't get, they moved on to a different position we couldn't get that position replaced. And part of it was our hospital system kind of made this mandate that NPPs need to be used to the highest of their abilities and, you know, can't kind of work more in that role of like resident might, where we have this co-management, they kind of have to manage on their own. But then we would have to oversee as well and our physicians kind of wanted to still oversee everybody so we really struggled with how would we divide up what we're doing. And then we, since they moved on we pivoted and went and got a role for a nurse navigator that kind of does all the non-clinical things for us. That's like going back and talking with the family and talking with the teams to coordinate like plans between everybody that offloaded a lot of the like non-medical work that we as physicians were doing that really helped a lot. But it's still, you know, how do we expand our team without adding physicians is a tricky part too. So I have four nurse practitioners. We are primary, but they feel very stressed, it's really difficult for them to take care of more than four patients each. So that's where I feel like. That's where that's the context of that comment is how to support the relationships that they have with like beyond the inpatient clinician team. So I'm someone that believes in physician led practices, and the nurse practitioners do a lot of work on their own, but at the end of the day I touch and see all the patients every day, right. So we've established a way to build that. But at the same time, they spend a lot of time out there talking with nurses or talking with consultants, etc. And that takes a lot of the day and the efficiency out. So that's kind of like, like I would love to also, you know, think of how we're, because there's not that many of us in terms of pediatric rehab physicians, like, how can we build frameworks that are safe physician led, so we can lead into non-physician providers safely and for our patients who still have access appropriately to the physicians when it's needed. That's great. I'm going to pivot us a little bit unless anyone has a burning topic to bring up. To kind of what would be the right meeting frequency for this group. Through APNR we will have like Zoom support for when we want to meet. So, I think from some of the other member communities I think some have like a pretty regular cadence like every other month. That seems too frequently, quarterly, pulling the crowd. We have lots of things we want to talk about more. I would suggest at least quarterly. Yeah, I think quarterly or every other month. We can shoot for quarterly and maybe if we don't have topics we will not meet that like every other month. We can set our goals and see what we can do. And then, this may need more thought, but in some other like national committees I've been part of when you're spread out everywhere. Kind of shooting for daytime versus evening time or like having a mix so that every other month you kind of hit a different group of people. I don't know what people's experiences have been or what they've had that's worked best. I agree with that. I think with the national meetings that I've been on most of the time, we've had to kind of think more later in the day to accommodate all the time zones of people who want to participate and who want to add input into it. I think the other challenge is finding a time frame in which people aren't in clinic or aren't on inpatient. When it's daytime, it's a little bit harder to do that and accommodate everybody that might want to attend. But then the other flip side of that is the obvious, which is then you cut into your personal time and your quality time, which is really important to outside of work. You have the who knows what my six or four-year-old is going to say when they walk into the room where I'm sitting. But welcomed again amongst the pediatric group. Yes, luckily I'm in the right group and my husband's work colleagues are all familiar enough with our children joining work calls that they just roll with it. Great. I think, you know, for me, kind of starting this group, our plan will be to always have like a member may event, to always request that networking time at the annual assembly. And then I think my hope is also with having this committee meeting more regularly, we can also support each other with proposals to the annual assembly, so that we can continue to increase pediatric content. I haven't been to AAPM in a long time, but I'm excited to go this year. But I think it's a good home for those of us who do pediatric inpatient rehab. So I hope that we can like continue to kind of grow what's offered. And I think it's really helpful to have these committees or groups where you can connect with other institutions so that we can have multi institution proposals and bring a lot of expertise to the table. I was thinking again about what you said about timing of when we meet. Since this is focused on inpatient rehab and a fair amount of us only do inpatient rehab, we're all very busy over the lunch hours we just discussed. So that might not work for a lot of us. We might want to rule out that time. Yeah. Yes, time zones, right. I think it may be that like changing the morning, midday, evening time here or there so that we're not, you know, if someone is always busy, like if you always have clinic on that day of the week or something that we at least allow people different months opportunities to attend. Thank you, Kilby for taking this up. This is, I think, very welcomed by all of us. I'm very excited. I feel like that we have a lot to offer and a lot that we can support each other with and I think, I think we'll have great conversations and hopefully build great things out of this is my hope with the collaborations and that we'll continue to get more people involved. I will send out either through our community board which I need to use more. I was telling Christina before we started that I did a very good job of focusing on family time on spring break and I'm still catching up with everything, but we'll get there but I will send out kind of a summary of the big topics to also invite other people who couldn't attend today. Thank you so much for your kind of feedback and help our group kind of decide what we want to talk about next. And go from there. I think one, one thing is that I'm part of a lot of communities within a human artists forum, it is really difficult for me to stay abreast of all the information because I really don't check it as often. I think it would be nice to know what the plan in terms of communicating with the team, or with the group is just because this forum has its set of limitations. Other group have developed kind of like a Google group or something like that in which is a little bit more customizable in terms of sharing files and like sharing schedule events and sharing information. From being the past chair of the Latinx in physiatry community, it was a big challenge to communicate with people because most of us are not checking this forum as often as APMNR wants us to be checking it. Yeah, we, like I said we kind of already, we, we, the members of this group submitted a proposal for APMNR so we have a Google Drive, kind of from that and so I think that could be a great starting point to, again, kind of share more files like have meeting notes organized where people can go back and look at them. And I think, you know, we are all over to our Facebook group is very active so I think it's probably, that's a whole nother topic of how you communicate with your team. Secure chat, in person, meetings, but also nationally how we communicate with each other like what's the best forum. You know, my email sometimes is just a mountain of things to catch up on. So, but that's a great point. We could get more feedback from people on that too. I think that's all the things that people wanted to bring up or mention today. We have a few more minutes or we can all have like 10 minutes or so back for today. Okay. All right, well thank you all so much for joining I'm really excited. And I'll work with Christina and APMNR for setting up something for July. Perfect. Thanks again. Have a great day, everyone. Thank you.

Member May

pediatric rehabilitation

patient networking

AAPMR code of conduct

consultation tracking

insurance implications

non-physician providers

EMR improvements

CARF accreditation

inpatient program growth