Hello everybody. Thank you for joining us. I am going to share my screen, and then we can get going. Okay, there you go. Yes, you see it. Yes, I awesome. Thank you. Great. All right, well, I can't thank everybody on a Tuesday evening, take time out of your busy day to attend our, our session now, some very informal, it's not a lecture. I mean obviously have cool slides and everything and show you this do a show and tell because some of these things is kind of fun to see. But at the same time if anyone has any questions you want to make it a dialogue you want to ask like pause anywhere just raise your hand or put in the chat box, both of us will be keeping an eye on that and. I mean, I'm excited to kind of have at least what so far 1415 people here on Tuesday evening and I think might even grow further. So, we'll get going. So hopefully we talked about technology and some acute rehab, some of us, usually they don't go in the same sentence but hopefully by the end of this you will get a better idea of that. So, let's get going. So let's talk about disclosures. My name is Dr. Azan Tariq. I am the chief legal officer for Madrina. And I'm doing. And I'm doing Florida I'm a consulting physician with Madrid. All right, and we're going to have our discussion and direction after a few slides, actually this was it this was like an induction so my background with sub acute I started doing something right out of fellowship back in 2012 I've done this for a good 1213 years primarily doing this four days a week, worked in all sorts of different types of sub acute so I've seen it all. And I'll kind of talk about the past and how I've seen it progress over the years and some tech stuff kind of getting involved in the setting but not a whole lot of evolution has happened but I on a day to day basis I, you know, basically manager organization to 600 and something 615 providers across the country and 44 states so there's a lot of day to day stuff I manage the protocols the orientation onboarding billing credentialing I mean there's a whole lot of stuff but, and then I throw in there, the chair of the sub acute society and more, not in any way to promote organization but it's just to promote sub acute physiatry. I personally want more physiatrist working in the setting there's a huge need for patients to be taken care of in the setting. And if you end up working with adrenal great I'm happy to help but if you don't, I just want everybody here to do their best and practice medicine in the setting. And go ahead. Yeah, my name is Juwan Clark. I also joined the adrenal and still nursing facility care, straight out fellowship, I actually started pretty much two months before the pandemic hit. So certainly that was a bit of a challenge but also a good learning experience about systems. Many of my nursing facilities were taking active COVID patients during the middle of it. So certainly we have to learn a lot about how to work with our partners to give the patient's best care. Currently I'm working with the adrenal to develop and grow hopefully our telomeres and presence. We've noticed that there's quite a bit of need in the sub acute setting for patients who have access to physicians to get the appropriate prosthetics orthotics and so that's something I'm working on currently. Awesome. Thank you. Okay, so first slide. So we're gonna talk about background, we're going to talk about. We've already kind of discussed some of that already the past and the present and the future so hopefully we'll finish in about 3540 minutes I know is the busy time of the day for all of us but in the end we'll leave some time for just open dialogue too but again like I said very informal please pause anytime if you need to. So, let's get into the facts and most of you guys know the facts but I'm gonna have Juwan kind of take it away. Yeah, so I'm just some quick facts to lay the groundwork for our talk here 1.3 million patients currently in the US in about 15,600 nursing homes. Our population is old and getting older with 18.2% of the population being at the age of 65 to 74, and at the higher end 85 and older 38.6% of the nursing home population are at that elderly age. It is a $146.9 billion industry in the United States, one in five Medicare beneficiaries discharged from the hospital receives post acute care and skilled nursing facility at a cost 28 billion annually so there's a lot of money being involved here but really what we want to focus in on is this fact, nearly a quarter of those admitted to skilled nursing facilities are readmitted within 30 days. This is associated with a quadruple mortality rate within six months. This should not be happening there certainly can be ways we can do this better. We're here to propose how tech might play a role. Assisted Living. We are also including that in our spectrum of sub acute care. There are about 1 million licensed beds and 28,900 communities, about 90% of these beds are occupied once again. Demonstrating that our facilities are quite busy and quite. There's a quite large demand for them. 14.3% of these facilities have a dementia care unit wing or floor designated 8.7 are dedicated to serve only adults with dementia. These patients with their best age, do you have other medical comorbidities over half have a high blood pressure for intent have Alzheimer's disease or some other type of dementia. And once again, just as with skilled nursing facilities that age skews older. Assisted Living because they require assistance. Usually, our state is about 22 months median, and they need help from everything from bathing to walking to other ADLs. They also once again have high medical comorbidities, a cardiovascular problems high blood pressure and heart disease are issues that for that reason it's important to keep these patients active. Hopefully keep them more well. They have Alzheimer's disease and dementia about a third. Once again, so these patients are how risk for balls and other issues to the safety, and then they also have diabetes. They also have depression, and that's something that's under diagnosed and treated. But once again, this has a tremendous effect on their overall well being, and so it's worth it for us to see how we can address this better. So what's interesting is that if you look at these stats here and if I change that to sniff on the top, that would be the case. About 10 years ago, our sniff patients a decade ago are assisted living patients now, obviously they weren't staying for 22 months. My average sniff patient, about a decade ago was sitting in the facility for 1698 you know close to 80 days 90 days ago it's crazy that I had patients and Dr. Quark I'm not sure if you've ever had that experience in your practice in your, you know, a little bit of a year and a half, two years or more than that. If you ever had a patient stay 100 days. No, I mean, yeah, there might have been one or two but really, it was already at that point, a struggle. So, right. So it was interesting is that when I was practicing like there was traditionally a lot of patients stay 100 days they would say well I came, I have come here to stay 100 days. I'm going to finish my days and I'll go home. That's not the case anymore the day they get to the nursing homes that we do they say I want to go home you know they want to get out as soon as possible. That's one part of it is a significant sniff avoidance on top of that you add in insurance companies don't want to pay for someone's thing 100 days. So, it's, it's interesting because the patient acuity has changed the patients that I had in the nursing home 10 years ago where they're walking their ambulatory sure they need assistance here and there but they were there as a bridge towards going home and be independent and it's a nice thing for them for, for them to have because a lot of times it's the families couldn't handle them or, you know, their house wasn't ready they didn't have a ramp ready or, I mean obviously a lot of times they had real rehab needs that a stroke, but they can actually recover over 100 days versus now it's like 20 days you got to leave, and then get home health so things are changing the sniff has become the step down unit or inpatient rehab almost upon intensity of therapy you get and the services that are given without the facility and the staff being ready for that unfortunately, and the assisted living has become the new sniff, and then the home is going to become the eventual assisted living almost with the combination of technology and their home health and so it's going downstream so that's why we brought in assisted living because there's a significant need of physiatrist in the setting to, we can't even begin barely cover the SNS let alone the else but there's definitely a need for that in the future so something to keep an eye on. So, you know, from my perspective, you know as paper charts only until 2015 so I still remember and some of you might end up on the call might remember is having these, you know, medical charts you have to sort through and find them HMP and make copies or just jot down notes even my notes were all like checkboxes and handwritten so thankfully we transitioned away from that to now the major player in the market is point click care and most people are aware that the work in the setting. It's really a MR bill bill for nursing staff and for billing and medication management not necessarily for physicians there's no templates I mean there are but they're really really bad. There's a lot of clicking and you have to basically pick like seven eight times before you even get your note in. You can't copy forward your last note, you can't put orders in there it's really not built for physicians and matrix care is worse so you can and there's a few handful other providers out there, Mr is that are out there but nothing unfortunate is that that great and is, I don't think it's going to change anytime soon. But is it better than paper, absolutely any day of the week. So and still one to 3% of facilities have paper chart, and the reason for that is no mandate there's no mandate that how it was for the hospitals or outpatient clinics that they would initially get incentive and then you know, get a get a fine if they were but at this point in nursing homes, they have no mandate so they have to spend a lot of money to make this happen and when they do that is primarily because it is better to have a Mr. Better for the patients, the families, the, the providers, the staff, everybody so you know also historically there's no incentive for the facility to innovate they weren't really competing with the hospital they weren't competing with each other for innovation. They weren't competing to have the best readmission rate or the reduced lowest readmission rate, or the lowest rent to stay, or the produced er was this, it was just like at that point you keep the patient you have them have therapy, and you keep them as long as you feel like you want to, but those are the days of Medicare only now like 50% of our patients are managed care or even higher in certain states. So, in that case like you're always fighting to improve the outcomes, keep the hospital happy keep the patient happy keep the families happy you got all these different things you got to keep happy, so you're almost forced to innovate, which was happening right now is that historically no innovation. And there was really rare use of telemedicine I mean before COVID I never almost never heard about telemedicine, set up in a suburban or urban area, rural markets yeah maybe but even that was really archaic and as any of you might know work in the subject setting Wi Fi almost always horrible in the settings. So, you know, to manage that and to manage the patients and the dementia and their, you know, staffing issues like it's really challenging to do. If you can tell medicine in a sniff setting you can do it anyway that's how challenging it is. And then therapy is not incentivized you know a lot of times, you don't really tend to recruit the, the brightest therapist they tend to want to work in the hospitals or outpatient setting and therapy you know historically was not really even focus on modalities are all based on the number of minutes and, and also in there's been a significant trend of new physical therapists, again as anecdotal evidence from my standpoint coming out of school now that are taught in school to not really focus on modalities that much. And because I can obviously some of them the evidence is conflicting is the gray area like it's not very clear some things we do know work, but there's a significant push towards productivity to be productive to actually see more patients to build the codes that are more based on not modalities but therapeutic exercises data systems modalities ADLs, those all those codes pay 567 times more than using a modality but the same amount of time. And then also, you know, modalities like are not really functional in a sense you know they're more for pain and disability obviously different things for inflammation there's a time and place for it. From a therapy perspective, they had no incentive to use technology, but that is obviously started changed now. The best you would see as a new step if you want to consider technology, or maybe ultrasound or 10s unit. So that is changing. So 2019 post post COVID or right before COVID happened there's a significant change from the billing perspective, which went from the, the minutes of therapy billable to now into PDPM which is patient driven payment model, and most of you work in the setting, the ones who want to work in the setting should know this. It's all based on medical complexity analysis based on the number of diagnosis a patient has the issues they might have their hospital, of course, their isolation their feeding their wounds and formula that they've created that basically the the reimbursement is more nursing based versus therapy based out. There's obviously a significant number advantage Medicare advantage and managed care plans and ACOs and bundles and hospitals like having their own, you know, plans is, you know, everybody's getting the game of like managing the patient's life, obviously for some good reasons some bad reasons but what ends up happening is that these are quick cutter kind of set up that hey you get 20 days, you know, do what you can and not everybody's set up that way everybody has complex issues and socio economic issues and a lot of different challenges that you don't have enough time lot of times to get people better so you got to use technology as best you can facilities have to take a lot more complex patients, including many that I work in that in house dialysis, there's taking ventric. They're starting to keep take more cancer patients or transplant patients, exactly what happened in acute rehab decade and a half ago when I was an inpatient. rotations, because we were just getting sicker and sicker every day, my call is getting more and more difficult. So, there's more specialized facilities now that focus on your muscular condition over Parkinson's Center or where a stroke center. That's going to keep on happening. There's a significant reduction let the stay as I mentioned, there's a readmission penalties now. So before facilities get away with that but now if there's above a certain metric and they get penalized, but if they're below they get incentivized. So there's incentive for that. But, you know, you're never going to have like just the nurses in the facility, be able to just fix that you know it needs providers physicians APPs and P's all the stuff to kind of help out with that all hands on deck. And then you have sniff avoidance that's that really exacerbated during COVID obviously it was kind of starting at that point before COVID to, but then COVID cause like well I don't want to go down nursing home and people were literally dying nursing home during the COVID. So, because, but then after that, there's been a significant avoidance not just from the patient side, the families, the peers, the hospitals, like everybody they're pushing everybody to home care, but they realized pretty quickly that a maybe we should not do that we should bring people to sniff because there's some a cohort of patients that do better than that. Of course, acute rehab is acute rehab is a need for that. But acute rehab also does not want to send patients to sniff because metrics along that too they want to have discharge to community. So there's a cohort of patients will always be that quarter patient that will need the sniff care, but the sniff avoidance has mostly gone away now most of my facilities are running at 75 80% of capacity they used to be 90% they're kind of coming back up, but for that to happen they have to start taking sicker patients, keep them for a short amount of time, have more specialists kind of managing patients and have shorter length of stay have more margins. It's, it's a lot for them so I do what I can to help my operators my facilities because they're going through a lot of work. outpatient procedure so Medicare started paying for outpatient knee replacements and then the spine fusions and across the line, everything's going to be pretty much outpatient except as a severe complicated spinal surgery or complicated knee replacement I really ever see a simple knee anymore. Back in 2013 14, I had a whole orthopedic unit is a 30 bed rehab unit that had nothing but knees and hips, so you can imagine like it was such an amazing around and see patients because it just became so obvious afterwards. And then, you know, staffing staffing is an issue now continuously issue and you want to talk more about that but that is a significant issue and my prediction is that unless there is a significant unemployment increase in the US where desperate for jobs, no one wants to work in the setting, or unless there's some parody and how much to get paid or they're actually incentivized to work well, it's not going to change it because no one wants to like work in a nursing home anymore. And my first job in college was a CNA so I know what that feels like. But, you know, it's a challenging time in that sense, but good. So, Dr. Tariq did an excellent job of kind of describing the challenges that we faced in 2019, and it should be no surprise to anyone that a lot of people think the workforce situation has gotten worse. Anyone who goes to an acute hospital and sees a number of traveling nurses coming in what proportion they make knows that we're still having that problem. And the problem is during COVID a lot of people quit. Also, there was a lot of just burnout. And I also think that people just are not ready to come back, still to the working situation and for that reason, there's a lot of challenges for nursing homes where they're facing these new challenges. Next slide. So, this problem is also extremely severe, as you can see, over 80% are saying it's marred through high staffing shortages. So this remains a significant issue for our partners in the facilities. And this will of course lead to financial repercussions if you don't have the staff to be able to take care of your patients efficiently, and the patients are increasingly complex, they will get readmitted, this will affect your reimbursements, and then you will be operating at a loss and we're really seeing that happen currently. So we have to find new innovations in order to help out, which leads to the next slide. Yeah, I want to add one thing about that is that a number of facilities basically they could not even take admins because they don't have any staff to handle that even if they were using agency and paying like two and a half, three times what a normal nurse would do. But that has gotten a whole lot better the last year or so but it was a significant issue for a while. So, go ahead, please. I think it's my slide yes okay. So what is innovation and where can I buy it? So now I'll give you all the stuff and you have all these challenges. And I think challenges basically breed innovation. I think there's people like us on the ground level, we're actually seeing these issues happening. And you know, where a lot of times the operator, the facility therapist, or the administrator, they're just so busy in the day-to-day stuff. And they're trying to basically survive day by day-to-day that they don't have the time to even look outside to see what is the solution for that. And then to even look at to see what's the best solution, and then who pays for that, and how do you actually integrate that building in? There's a lot of challenges there. So I think for people like us who work in this setting, we're there every day and we're seeing the challenges. I think that's where we can kind of step in and say, okay, we have a solution. And it doesn't cost you anything, hopefully. And it helps your outcome. So we want to be the helping person, helping hand. So some of the issues that we'll talk about in the next few minutes will be falls, rehab outcomes, readmissions, how to prevent that, how to reduce that, specialty programs, and then physiatry. So I might have jumped a couple slides, but it should be okay. So falls. Falls are very common. I don't tell you about this, but there's a lot of falls that happen. And a lot of times they will happen multiple times. And then they cause a lot of serious injuries and hip fractures. And they also cause a lot of insurance issues and malpractice issues. So 75% of insurance claims with payment in the senior living setting are because of falls. So obviously for them falls is a big deal. And the big issue is that in the SNF setting, you're not allowed to have basically anything to hold the patient back. The word I'm forgetting is basically any alerts or any kind of restraints. I'm sorry, restraints. You can't have anything, no mittens, you can't have anything like that. So basically these patients are already transitioning from the hospital to the subacute. That's a big issue. It could be an issue of metabolic encephalopathy or UTI or confusion or stroke. I mean, there's so many different variables there. And then sometimes the facilities don't even have a low bed. They don't have any mattresses around. They can have railings, but it's just a very, very, it's a perfect place to have a fall in the sense that it's not perfect, but it's like everything is set up so that the patient has a fall. So how do you get involved? And obviously from physiatry perspective, we evaluate the patient before they have a fall. We do all the preventative things like examining them for foot drop or knee instability or neuropathy. It could be orthostatic. It could be vertigo, stroke, arthritis. I mean, the list goes on and on and on. So you have to kind of rule out some of the things that you can or at least help out with that and put them on therapy. But honestly, like the best way, and as you guys know, the best way to basically help with falls is to prevent falls from happening. Because once it happens and the fear to fall is in spiral, and then it gets more and more challenging. And considering how much money you spend on this, the amount of percentage of falls are going up, and they've gone up 30% in the last 10 years. So it's not getting any better. And the silver tsunami is here. Patients are getting older. It's going to be more and more. So I think it's a serious issue that we need to think about solutions. So that's what I started thinking about about four years ago. And I started looking into like, what are some solutions out there that can help with this? Sure, we can have therapy and you can have the proper AFO, but there's got to be something better. So at that point, I thought about airbags and such a joke, that's not going to be feasible. But that actually is a real thing out there, that airbag deploys when someone falls down. This is not feasible, not in our setting and not for our patients or my parents. So let's talk about where the AI and the VR and some of the tech comes in. And this is exciting part of the talk here. So there's a company out there called Virtu Sense. They have this device that has a LIDAR. And a LIDAR basically is laser rays that actually goes in, hits the patient, doesn't penetrate the body, reflects back into the sensor. And in a real time basis, as the patient walks five to 15, about 15 feet or so, they could be in a walker, they could be in a parallel bar, they could, not in a wheelchair, but they could be walking with a therapist with them and it evaluates their gait. And it tells you their swing and their stance phase and if they have to learn to work or if there's forward posture and all the things that all of us obviously will do. But I don't know if I'm comfortable enough typically when I'm in a patient's room in a nursing home that I'm going to do a gait analysis on them. It's just so unlikely because I'm so worried about falls. I'm the only person there. Maybe if I have a therapist there, maybe if I see him in therapy, that's all fine. But the thing with this is that using technology is that it balances out or reduces the user error and the variability in that. And then you have official metrics on that. And again, this is more for prevention. There's not enough physiatrists out there to see every single patient to evaluate their fall risk. Not enough therapists out there too, but if you're doing a grand scheme of things, you can actually do a lot of management once you predict if they have a fall or at least throughout the process. So what does this device do? It quickly basically analyzes your risk for fall all based on data. And then it looks to see if you need to have therapy, wellness, or if you're medium risk to have therapy and group therapy and also physical therapy and physiatrists ideally, or a neurologist or a physician. Usually it's going to be hopefully a physiatrist every single time, but it's not enough of us. And then if you're high risk, then it's going to need a lot more interventions. Maybe you need PT, OT, physiatry, disorder nursing, puts you on an area close to the nursing station. And then basically you follow up on these, sometimes biweekly, I'm sorry, every month or so, then sometimes every three months and analyze to see if they're improving, the balance is improving. And is there any evidence behind this? Yes. Very strong evidence that said that 41% reduction in two quarters after VST was integrated. And this is virtue sense. And then 73% reduction of falls and 85% improvement in mobility. And I think some of that has to do with the fact that obviously people are put on therapy. Another thing is that people were, had a real number idea about my risk for fall. So they, you know, sure. I have a friend of mine that fell down or I almost had a fall. Now I don't want to fall again. I'm just going to stay in my wheelchair. Like there's a significant issue with the fear of fall. So if they have a real analysis of, you know, what the risk is and they can have proper education about that, people become more mobile in a safe way. So this really showed us, and, you know, we work with a lot of therapy companies or I work with a lot of therapy companies that have this as part of their protocol in which they actually record the patient on admission, if they can ambulate, mostly for the senior living or the assistant living setting. But obviously for our SNF patients too, some of them can ambulate, but they need a lot of help initially. But it gives you real data on the improvement of this. But that itself, if you go back to this, you'll see this big device here and it goes on a card. It's not that big, actually, if you think about it, it's just a small box. It looks like an Xbox connect. It's got a keyboard inside of the screen on top of it. Very simple, very, very simple. And basically it's scanning the body and creates these dots like a stick figure and then can analyze the movement in a pretty quick way. But that's gotten even easier. So now there's literally devices out there. You can, it's an app you can download on your phone and use your smartphone or a tablet and using computer vision, AI, machine learning, all the stuff you hear about, all the buzzwords, it actually analyzes based on these points that are created, like the patient's gait speed, their get up and go, their tux score, their, you know, if you kind of, we can modify things here and there, you can go on different surfaces and see what their gait speed is instead of that. It's amazing information doing it so quickly. It does it less than a minute. And then it's real data, objective data in front of me that I can actually analyze and then kind of make a plan for the patient, put them in therapy or not therapy. So again, for the facility level, very useful and it's getting easier. Another product that I work with is called OneStep. OneStep basically plugs into the iPhones only, if you're Android, they don't work for Android, iPhones accelerometer. So the patient, all they have to do is have their iPhone in their pocket and it doesn't have to be their own iPhone. It could be the clinician's iPhone and they walk with that and that movement of the iPhone will do the exact kind of stuff that the AI would do or the virtual sensor, the LIDAR does. So again, analysis of gait in a really quick way. It's only going to get better. It's only going to get smaller. You might even actually have a sticker or a small sensor you put on you and they can analyze that. But again, it's real data, objective data that can be used to analyze someone's risk for fall. Other stuff out there, there's things like cameras that are in the patient's room. Some cameras are more radars than cameras and they don't show the patient, they just show a stick figure, they kind of block it off. So it's a privacy thing. Some of the cameras actually have a sensor that closes when the patient's not in the room. So there's a lot of different things that can be done. A Care.ai also has a sensor that basically scans the patient's room and if someone's about to have a fall, it lets the providers know or the patients know or the clinicians know. So a lot of different things out there. Again, some facilities might be aware of this, sometimes they're not aware of that. And I think maybe it's our job to review these, talk to these providers, think about it, see how they fit into our facility and then go from there. Okay, so the cost. Good question. It's hard to kind of give an exact number. Something like a VirtuSense, and I don't want to go back all the way, so that is very expensive. I'm talking about like, well, if you think about the cost of a fall, they're not that expensive, but they're $1,200 a month. And typically the therapy companies are paying for it. Something like the Extra.ai, Extra.ai, that app that you showed, that for my recollection is less than 100 bucks a month. It's not very expensive. SafelyU is based on a camera per room, so it's maybe a couple hundred bucks a month per room. Care.ai has got a very similar type of a model, but they all have different models based on the providers asking for it. If you work in a system that has 10 buildings or five buildings, it's a very different pricing model versus as a provider, I go in and try to get it. But these are only the things that I know of. There's probably other devices out there that have this, but I was focusing on the one that primarily focused on the post-treatment setting. Great question. So another product that we can do is called Xandr. Xandr is basically a device that goes on the wall. It uses ultra wideband rays and scans the patient's room, primarily their bed, and actually it can tell if a patient's about to leave the bed, but it does a few more interesting things. It also does respiration and heart rate. Other stuff that I talked about is more focused on just the mobility and the movement, but this does beyond that, which is kind of interesting because you can actually catch things like UTIs, pneumonias, COVID, prior to them happening. So six to eight hours before those inciting events, your respiration, heart rate trends up or down based on conditions, so you can actually catch things. So this is only going to get better and smaller over time, but it's really, really cool to be able to see this in a SNF setting and actually have real data to prove that it works. So I've got a couple more slides and you can use assisted gait. Obviously with these devices, a lot of acute rehab hospitals have that, some of my SNFs have that too, and then you have VR that's kind of interesting and cutting edge. The VR stuff, obviously from my facilities, typically the VR is based on like this, your patient's standing in front of the device. And again, it's got the connect type of setup in which they can kick and balance and throw a ball or play ping pong, those kinds of things, or play Tetris. And it's nice because it's very unobtrusive, you just walk in front of it, there's no device on the head. Some of my high-end facilities will even have a zero gravity treadmill, but it's not used that often. So again, the providers, the therapists, the operators are trying their best to innovate, but sometimes the idea sounds good, but it's no one to actually start the process and do a pilot and think about that stuff. Juwan, I'm going to take this one. Sure. So there are other modalities and technologies that we have talked about in particular, smart connected exercise systems and modalities, that could be anything from an iPhone to an exercise equipment. People have those smart cycles that can connect virtually and collect data. So these are all things that we can use to monitor patients' fitness levels and stability and safety, both in the facilities, as well as even at home after they're discharged. There's also dysphagia solutions such as S, E, and G's and 10's. These are all things that can really help out our speech therapy colleagues in order to assess if patients will need help with dysphagia. This, of course, being a very important thing in the nursing homes in particular, because once you involve speech therapy, there is an increased level of complexity, you could argue, right off the bat. And lastly, smart ice machines, certainly these hyper ice and other such devices have been used for rehabilitation. There's a good amount of data about post-op recovery that seems to kind of help that along. So while we don't see as many simple orthopedic procedures, still polytrauma and other such situations, these devices can absolutely be helpful in getting the patient to participate more with therapy. Sheldon, can you ask one? Yeah, I'll start. Okay. So yeah, just because like this is something that I've been really, really involved with is... Exactly, I was your baby. I wanted to let you have it. That's all good. So there's a lot actually software out there. And some of your SNF operators might already have this, or there's a thing called PCC Insight. There's Realtime. There's other software that lays on top of the EMR or connects to the hospital or connects to the facility's EMR system to analyze metrics like infections, falls, basically return to hospital, length of stay, people with pain, how much pain they have. There's a lot of stuff out there. Again, some of these are pretty expensive. Maybe your current subject already has it. Maybe you can actually introduce the idea of like, hey, should we consider that? It's very challenging because we're not typically employees of subacute and we don't have a whole lot of leverage. We are consultants typically, and some of us might be primary, might be medical directors, but it's somewhat of our job to kind of get the facility to think about these things and then think about the pricing and stuff and the ROI that comes along with that. But I think the way that I leverage this is that, hey, yes, it might be expensive at the beginning, but think about your metrics. Think about your return to hospital. Every empty sniff bed that you have is 500 bucks a day. You can market this stuff to the hospital. You can talk to the payers about this. Obviously, patient satisfaction, all the stuff that goes along with the liability. So you have to sell it that way and saying that this might be something we got to think about because we have other costs that are coming up. But anyway, some of these softwares out there that look at infection control, they look at hospitalization risk, but they also connect with, like I said, the EMR and actually can cohort patients based on risk. So based on their diagnosis, age, their vital signs, their medications they might be on, their prior hospitalization, and looking at all the data and using AI to kind of clean that up and basically cohort patients that are highest readmission risk, at which point that the facility and you as a provider will have a better chance of making a change because now you can spend more time on those patients or you can see those patients first off because you might end up seeing 25, 30 patients that day or 20 patients. But if you spend more time with the highest risk readmission and Medicare reimburses appropriately for higher risk readmission, and then you can actually basically make a bigger impact. And then you can use this information as a data for the facility and come back to them saying, hey, since physiatry started, this is what it was before, this is what it was after, or things like that. You can kind of move that around. Go ahead. This is for you. Yeah, sure. So other technologies to consider, smart EMR, this is actually something that we've been particularly interested in in the billing area to see if EMR, for example, could help us a better capture complexity for our partners to get better reimbursement for more appropriate reimbursement for PVPM. So in general, EMR really can help us. One thing you will notice about all this AI and machine learning is that we need data points and ultimately physicians will understand those data points and how to analyze those probably better than anyone else in the health care center. So I would argue that EMR will play a huge role in the future, especially if we want to use things like machine learning to help us, which I think we will. Bedside ultrasound, this is anything, anyone who's done a pain or musculoskeletal residency or fellowship now will probably have some experience with this. Technology is constantly getting better. The reason why we think this talk is important, why we think technology is an important thing to consider in nursing facilities is something called Moore's law, which essentially in the history of science states that technology tends to double every two to 18 months to two years and that the price usually halves. This was true for the past 15 years, slowing down, but still anyone who knows technology, even look at your kids' video games, look at how much that developed in the past decade or 20 years. Medical technology will be moving that quickly too. And so the sooner you adopt it, it's probably going to be adopted longer term. And so you want to be kind of more ahead of the game, ahead of the boat versus other colleagues, or at least I think it's always good to be ahead of the game. Virtual assistants and scribes help us with all the paperwork that we're expecting to do right now. It does feel like a shame that we're spending so much time on paperwork. So this is one way that we can offset that. A lot of our physicians do utilize this kind of program. Telemedicine, that's something I'm personally very interested in. One of the biggest issues in America right now is simply access. There's people who have the insurance, know what they need to get, and they're somewhere rural or they're somewhere that just has too much long lines to get in. Telemedicine will help kind of facilitate them getting care sooner. And lots of chat, GPT, AI, anyone who's played with this knows that this will probably be the future directions. At least most major tech companies would agree with that. And that could be really useful for us for a field that believes in evidence-based interventions. I think that this is something that we really should be utilizing to do higher end analysis of data to see where we could help and where what isn't helpful. Next slide. Yeah, I want to add something in about the documentation part. The data just came out, a data study from Medscape that's put physiatry at number one for something you should not be proud of. And I think maybe I shared that with you, Dr. Clark. It was that physiatry as a specialty spends the most time spending, most time on documentation. And it was 20 hours a week. Now, and I talked to a bunch of my academic colleagues said, yeah, it's more than that. So, and some, obviously one said less than that. But I think across the board, like we are spending way too much time in documentation, especially if it's needed. So you have to leverage smarter EMRs versus scribes. There's a lot of really cool AI-based stuff that's coming out that's gonna help us with documentation even more. Significant changes happen in billing and documentation requirements on January 1st this year that should help, but I think some of us are so used to the old way of just typing and typing and dictating almost like a full essay that I think that it's gonna take time for that to transition, but we have to use some of the technology to help out. Robotics, another big part of the future. Robots are moving and progressing much faster than I even expected. In other countries such as Japan, they're already using robots for social interactive actions, doing group yoga exercise activities, just giving social interactions like telling jokes or responding to kind of emotional prompts, and even transferring patients. At least in Japan, I know of at least a couple of nursing homes that are now using Sony robots to transfer patients from bed to wheelchair, et cetera. So I think this will absolutely become an increasing part of our practice, both in the subacute setting, acute setting, and also even at home. I really think that this will play an increasing role in what we're doing. I'm gonna go back to that comment about the documentation time. So it was in Becker's Hospital Review. That's what it was in. And then the number one was PM&R 19 hours. Number two was critical care. And number three was internal medicine. If you're spending more than two more hours per day, I mean, per week on notes, there's something really wrong with that. So, but that's the case right now. So what can we do as physiatrists? Really, I think the biggest thing is we've gotta be more passionate about adopting these technologies. We have to be more aware of what's going on. So thank you, everyone who attended here. Hopefully we taught you about something that you didn't know already. But I think that the more that we adopt these technologies, the more they get useful. And the more people that adopt them, the more these companies can stay in business, the more their data sets are intact, and the more we can make these useful. So really go out there, see what people are doing, and adopt the technologies you think are useful. I think the more people who do that, the better it's gonna be. Like Dr. Tariq said, we are being transitioned more and more to increase complexity at each level. Everything got pushed down. And I think that one of the things as assisted living, what we considered assisted living will now be hospital at home. That will increasingly use tech that patients take home in order to monitor them. But I think in every step of the stage of the process, we're gonna need more technology to help us address all the demand that we're facing. Robotics, like we discussed, also that advances in artificial intelligence, machine learning models, deep learning-based frameworks. If you've seen some of the things that ChatGPP does, they even have predictive models to write down what you already expect to write. Perhaps we'll create some kind of system that will predict what kind of diagnoses you wanna go for ahead of time. I mean, any kind of thing that helps with that, which diagnoses are gonna reflect higher complexity versus lower complexity, they're the same thing. Are you just gonna say that they have deconditioning or do they have natural muscle dystrophy? These things all are gonna make a big difference in how we're reimbursed because the data we put in is how we determine how we're reimbursed in current models. And that refers to the value-based care that we're referring to. Cat's already out of the bat, PDPM is already here to stay. Most of healthcare will probably be joining us in the near future just because our current system can't handle the costs that we have currently. So technology tends to be one of the easier, cheaper ways to actually save money long-term. It just tends to take a little bit of earlier adoption and risk initially. Great. Yeah, that concludes the... Oh, actually there's one last one. So this is what I was gonna talk about. It's like my, this is one of my facilities. Well, actually it's not one of mine. It's one of my work partners facility and I have something similar, but this is the future. There's gonna be a lot of industry consolidation. A lot of the mom and pop nursing homes are being bought off by other groups. Some of the big, big conglomerates of nursing homes are transitioning. There's so much movement that happens in this kind of setting. Like in one facility I work in, like literally we've had three owners in three years. Like it's just back and forth, back and forth. But it's consolidation happening. The cream is rising to the top. Some of the high-end facilities are still focusing on rehab. They're still marking themselves as alternative to hospital, alternative to acute rehab, better option than a home health, you know. So, and they have high-end stuff and they talk about having a physiatrist and talk about, you know, having good outcomes. So this is kind of the future. Obviously like a certain market, this is needed because, you know, let's just say if my mom and dad had to go to the nursing home, I'm gonna look at Google. I'm gonna look at Yelp. I look at every single place I can find reviews before I walk in the door. So patients really care about that. The families care about that. And there's a, obviously like, you know, someone's working in nursing homes just because it's got all the bells and whistles it doesn't mean it's got the best care. But, you know, I think that's where I think in the future and it's already happening. The patients and families and hospitals, insurance companies are requesting that I want to go to a facility that has a physiatrist or a specialist in what my mom has an issue with. My mom was seeing a pulmonologist here. I want to go to a facility with a pulmonologist or a nephrologist. So there's a lot of specialty care that's gonna happen in the SNF setting. There's just not enough of us. And that's a challenge. So you gotta leverage technology to cohort the patients. You gotta spend less time documenting so you can spend more time with the patients. There's a lot of really cool stuff with ambient noise or ambient call, ambient dictation where you basically have a phone and the phone is listening to conversation and writing the whole note and you're gonna sign in the end. There's smart phrases, dark phrases, there's drag. And there's so many different things you can leverage. But, you know, I just hear about providers and physicians and, you know, I'm drowning in notes. I'm not saying that I'm not, you know, the same thing happens to me, but you have to find ways to make your life easier. And, you know, sometimes you gotta, you know, search out of the box. And sometimes you have to spend money to make that happen too. So sometimes you get, well, I don't wanna scribe. I really don't think I need it. But, you know, if that takes away two hours of your working from the computer a day, you know, then it's worth it. So that's something to think about. But, and I kind of mentioned some of these things already. So research technologies, drive early adaption. So, you know, talk to your facilities. And I know it's a lot of challenges there, but you should at least start the discussion, give feedback, lead, and then be bold. Present the programs also to leadership and hospitals and discuss where the need would be fit into and always be on the table. As one of my mentors told me that if you're not on the table, you're on the menu. So be present, talk about these things early on and be the leader. Be the leader for falls and stroke and rehab and function and pain. Because if you're not gonna do it, it's gonna be a therapist or nurse practitioner or a nutrition or whatever, other specialty. So you gotta be present and have the discussions. And then do not forget about the ethical issues, like lack of human interaction. So we can have all the technology, we can have the Siri and the Lexus and the Googles and the cameras all over the place. But, you know, do our patients really want that? Do they understand what they're getting themselves into? And, you know, I think the Surgeon General, former Surgeon General just talked about today that the big epidemic right now is happening is isolation. Like people are just like talking on the computer and they're staying at home by himself. And, you know, that's a big part of it. And not having human interaction is a significant issue. So you always want to kind of combine that with human interaction and the technology. So with, for example, Dr. Quarg, you know, we do telemedicine. We always have the clinician there. We have family there. So that human connection. And there's a privacy issue. Like, where's my information going? Who's gonna have information in my data? The Big Brother stuff and cyber crime, people can steal information. And trust, to get people, since someone trusts you when you're on the other side of the computer on the camera, can you trust them with their intimate medical history and their diagnosis and their stuff? I mean, that's a significant issue, but we always have to kind of bring that along with us as we integrate technology. And that's why the tech companies that I talk to, and I'm an advisor for a few of them, they say, you know, like, I tell them like, you need to like, think about that first. And design the product that fits in the ethical part of it versus like, I'm gonna fix healthcare. On that note, this is our email information. I definitely wanna spend a decent amount of time in open conversation. I do wanna, you know, give everybody the opportunity to basically ask any question. Does it have to do with tech? This is a SNF meeting. It could be about anything. I'm available for the next 15, 20 minutes. So please, if you don't want to raise your hand, you can always type it in the chat box. And if you wanna make it private, you can just directly message me. So I won't say your name. Okay, question is, what percent of your facilities use rehab technology discussed earlier? I mean, it's hard to say what percent, let me think about this one. So I mean, as a corporation, you know, we're in 1200 facilities, so it's hard to say the exact number. Everybody uses something. I think, you know, half facilities, I would say, probably have some kind of fall prevention program or some kind of tech to use. Some are using remote patient monitoring. Many are using the devices that are connected, for example, the hand cycle, like it's got the Bluetooth chip in there. So the therapist spend a lot less time documenting. Almost all of us use some kind of a smart EMR that has smart faces, dark faces, so it helps with that. Quite a few of us use scribes. VR is pretty, pretty present with the facilities. They always have the balanced area, so we can actually do that. So, I mean, it's kind of a mixed bag of things. I don't think any of them use all of it, but it depends on the facility and how much money they have and how brave they are. I would say about, I would say 100% of my facilities have some form of everything that Dr. Tariq talked about. But a lot of that came from the trust that Aslan kind of talked about as well. You know, initially they didn't trust us to take on partnerships, to take on more technology, to make those investments. But I think COVID in particular actually helped. We helped out them in terms of taking care of all these high complexity patients during that time. And so when that kind of blew over a little bit, they were a lot more likely to trust our advice in terms of technologies, modalities, things that we think would be helpful. And when they found that was helpful, then they adopted other facilities as well. And I really only work with one major company right now, but multiple facilities. So they all seem to have adopted relatively quickly. When one's going well, they tend to talk with each other pretty quickly, I've noticed. So that's wonderful. It opens up more facilities to us as well, because they say, hey, this place is doing really great. We're noticing that with this advice that they're giving, they're not just showing up the same patients, they're being proactive and helping us, you know, progress and modify the system to do better. I find that they've been very, very willing to do that with us because we've established that relationship and that trust. Yeah. Anybody else here who works in a subacute setting has any thing they've seen for technology? I'm always interested. All right. What does it say here? Do you guys use your spore spine fellowship in the setting, or do you have separate practices set up for pain and spine? So at least like from my perspective, and, you know, we have, I don't know, probably 50 or so, or maybe more than that, spine pain anesthesia type of fellowship trained providers that ended up just switching and just doing subacute now. Dr. Poirier can talk more about that because he did a fellowship. With my setup, you know, I do have an outpatient clinic that is separated from the SARS, but at the same time, like the skills that I learned in fellowship are used in this setting constantly because 95% of what I do is MSK related. So it's still the same type of injections and procedures and diagnosis. Sure, you got the other stuff as well, but that's a big part of my practice, but Dr. Poirier. Yeah. Like Dr. Tariq said, I did do a fellowship in sports medicine, did interventional procedures, but never actually ended up doing it in my own practice because I met up with Madrina, learned about their approach and learned about skilled nurse facilities and just felt that there was more impact I could make in that field. I even got an MBA in order to learn more about this. But of course, sports and pain medicine are going to be relevant in a nursing home setting. A lot of those patients have pain, a lot of the reason why they have us in there is because they want us to manage their pain and I think that a lot of it's the judgment of simply who's an appropriate patient for what kind of therapies and treatments. So that's going to be relevant no matter what kind of work we do in our physiatry. But in terms of my own practice, no, I actually kind of went all in with this because I think that there is a lot more demand than supply right now and I see an opportunity to really make a change in a system that's already changing whether we like it or not. So that's where I'm at. Great, thanks for the feedback. And it says, as a SNF physiatrist practice model, is it typical to utilize PA or NP? I don't think, I would not consider it typical. I think it's definitely become more prevalent. There's a time and place for APPs. We are models, but a different sense that we strongly believe in close collaboration between the APP and the physician attached to the hip, if you want to say it, with overlapping and we don't believe in true autonomy. We also don't believe in certain procedures being done by APPs. And there is a time and need for them. There's not enough physiatrists so you have to do something about it. So they might be able to see simple follow-ups and may be able to kind of tell me about some more complicated patients. And I have a multiple number of APPs that help me with that. And Dr. Parag, he has an APP as well or I had one, so you can talk about that. Yeah, in my case, the APP was certainly very, very helpful but that was at a time when I grew very quickly and had a lot of beds that I had to take care of. And frankly, we couldn't get enough physiatrists to help me out. I had facilities that wanted to give up and they're not graduating fast enough or joining us fast enough, especially in this California market right now. So I will say that APP can be useful if you really are territorial and want to keep those facilities and you're feeling overwhelmed. But I also think that this is a demonstration that we really just need more hands on deck with this problem. There just aren't enough physiatrists in sub-acute care right now. Exactly, and there's certain in my market that I practice in, I just couldn't recruit one. I wanted a physician to come in and take over. I was able to get find one but the facilities were begging me to come in and I didn't have enough time in the day. This is what could I do? So I had to go that direction. And then, at least from our perspective, we have a very strong education set up and we go through a whole onboarding and an APP can switch over their specialty in a day. They can become GI to PM&R the next day or back to cardiology the next day. So that's very unique that we can do that, but I'll never assume that the APP can never take over, but I think we still have to be careful with that. So we have our own kind of setup in which we keep a close eye on it. And we've been very lucky that no one has actually gone out of their way and become independent. And I think that's probably not gonna happen. The APPs want to, typically, not all of them, they want to have a physician to be a collaborator with them, a supervisor. What do you call them? They want some mentorship and leadership. But they want guidance. They want guidance. They want education. They're hungry for education and we cannot automatically assume they're hungry for education so they can go be independent. My oldest APP has been with me for eight years now. She has zero intention of being independent because she likes the setup that she can just call me or have me see a patient that she's not comfortable dealing with managing, and I can answer that. So time and place. So I felt that SNFs are not very enthusiastic in rehab notices because nursing staff has to go through my notes and do extra work. I think that's a very common thing. And it's like, if you really are relying on the facility to look at your notes and only follow recommendations you might put in as a consultant, it becomes very challenging. And you know, Dr. Clark, I mean, I did his onboarding orientation. I told him that you can do that for the first month or so. You know, try to get your feet wet and talk to the primary care, what their needs and desires are, like, you know, how you can help them out. But if you end up adding more work for them, they're not gonna want you for too long. You're basically, if you can help them with their more complex patients and take some of the work away from the primary care team and the facility and make them look good in front of their families and patients and hospitals, then of course they would want you. You know, some of my facilities I've been with in for like 10 years now. And, you know, it's, so in that sense, if you're not the one who's talked to the primary care physician and discusses that, hey, is it okay if I start prescribing myself their GABA, their Norco, their Tramadol, their Voltaren gel or do some injections and, you know, I'm happy to communicate with you about the patients, obviously, but majority of primary care is like, yeah, of course, absolutely. That's why I consulted you. You manage this stuff. Don't put more work on me. Like if I have to put every single recommendation and put that in myself and like, where's the liability for that? It's falling on me now. So you gotta find that balance because some facilities want that, but if the facility is not enthusiastic about it, they probably don't want that. Yeah, just to kind of piggyback off of that, I did find that one of the things that helped me when I was trying to bring in new things, whether it was a new EMR, whether trying to bring a new modality company, it was really just about explaining it to the staff. Of course, it's hard to get the administrator. Of course, it's hard to get the medical director or the director of nursing or rehab, but you just gotta make that time and show up and have this a very quick, you know, they call it the like 10 word elevator speech. And that leads to like a 10 minute meeting to possibly an hour meeting. But regardless, you really gotta put in their mind very quickly, hey, I noticed that you guys are thinking this is not useful. Let me show you how you can make it useful. So when we got our new EMR, I was like, hey, all the billers should be looking at my diagnoses when they're putting in the billing before they actually submit it, because it's all gonna be there for them. They have to look it up all over again. Primary care doesn't have to be as worried about what they're putting in there. It just really helps out in terms of reflecting the complexity. And with anything like that, you've gotta get the buy-in before you actually implement anything or else, yeah, it's gonna be hard for you to stay there because we're all in our facilities by the grace of them. They're not paying us, we're not paying them. So I do think that it's more about getting that relationship and trust with the leadership of that facility is also really, really important. And that way you can explain to them, hey, this is how you should use my services. Hope that was helpful. It was very helpful, absolutely. Don't see any more questions coming in. Wait a few seconds. Sure. There you go. Besides poor EMR and staffing issues, what are the other cons of subacute rehab? Okay, so there's many. It's obviously very valuable work. I've done it for so long. We have like, I'd say it's so many providers doing it. For my low estimate, it's close to 1,000 to 1,100 physiatrists in the country right now, but 10,000 that do subacute rehab. Some part-time, some full-time, for different reasons, but regardless, they do it. The challenging part is the facility itself. It's not the process. It's not what we do for the patients. The patient interaction is the easiest part. Getting the feedback from them, and they're, thank you for coming in. I appreciate you, because they don't see doctors, and you're the only one kind of seeing them. That's the easy part. It's the workflow outside of that, is that how do I document, well, first of all, how do I get the medical records in the hospital, how do I know what's wrong with the patient? Then it's how do I document that? How do I communicate that with the staff? Then how do I build this? And then how do I convince the primary care team this is a good idea? How do I keep the admin happy? And then how do I kind of create boundaries of what I want to do, what I don't want to do? So, you know, what kind of management of pain do I want to do, what medications I'm comfortable doing? So, and then you throw into the staffing issues where you have different nurse every time you show up, throwing the fact that you're not a VIP in the building, you don't just walk in and saying, where's my office and where's my coffee? Like you basically walk in and you blend in and you're part of the team and you do what you have to do and you just take care of the patients. If you keep your focus as a patient and you keep your own process pretty organized, I could walk into the worst nursing home or the best nursing home, it's the same process. So, that's what I've taught a lot of our physicians, like just focus on the issues that you can handle. Can't fix everything. You have a few lists of things that you can help out the patient, help with that. The rest of it is noise and you do what you can and just run through it. It is still vastly better than any practice that I can imagine myself doing, acute rehab, being on call, working the weekends, you know, running pain patients all day, even doing a sports-only clinic all day. For me, my perspective, like it's still way better, but it does have challenges. But even the challenges, typically, and Dr. Kaur, I could tell you more about it, I don't think I ever spend more than six, seven-hour days. Like you pretty much see your patients, do your notes, do all the stuff you have to do, no call on the weekends, and you're done by like two, three o'clock. And it's hard to beat that. So, the flexibility is absolutely insane in this as well. But there's a lot, for me, there's so much more positives and then negatives are noise. Yeah, I've started kind of advising younger physicians joining our group. And one thing that I do think is a bit of a challenge that people don't see going in is that there is a element of system building going on. And there's kind of two systems. One is your own system outside of the nursing home, kind of like Dr. Tariq was saying, you want to be efficient if you want to be able to help enough people and also be efficient enough for the nursing home to feel useful. But the other is your system with the nursing home. You do have to have your group of people in that leadership that you can correspond with and make changes work together. And developing that takes time. I'm lucky I went to business school. So, there are soft skills that you learn in business school on how to start your first 90 days, for example, a famous book. And I don't think that many of us in medical school ever learned that or residency or fellowship of how to introduce yourself to an administrator. How do you not waste their time, but give them the information that's useful once a week, pepper it in so that they feel that you're actually great. You want to kind of create that kind of system of consensus though, because that makes their life so much easier. Whereas if they're ever questioning, you want them to see you as the problem solver. They want to see you as the wolf. They don't want to see you from a pulp fiction. They don't want to see you as a burden. And so you've got to make yourself feel like that because we're not, but they see us as just a guest visiting in. So they are going to automatically be a bit more hostile. So, switching that perspective, switching that view to see that we're actually their allies and we will make their lives easier. That is certainly a part of the job too. Not one that we learn how to do in our training. And most of us don't get a sub-unit exposure at all, or just a little bit of it and really like skewed towards academia and those kinds of things. But yeah, the lack of exposure and not having the right mindset. And I don't like using that word that much, but it's just like, if you don't have exposure to it, you don't know who to look up to. And what's the workflow and you don't have mentorship. And that makes it very challenging because you walk in and say, well, I'm a physiatrist, I'm a sub-acute now. Where are my patients? Like, it's not as easy as just walking in and just fitting in, but not impossible, obviously, but not as- You're not plugged in automatically to the system. My experience, there is no system in place when you walk in. Whereas if you're academic, you walk in, you expect everyone's already having a W2 ready and all that kind of stuff. Here, we have to be a little bit more independent, but I like that aspect of this, so. Yeah, it's not for everybody, but most of us who are entrepreneur and independent and want to be their own boss and stay as your own boss as long as possible until an insurance company buys us or just owns all of us. Eventually, all of us will be Optum or Amazon employees, that's going to happen. But I like the independence of it. And I like the relationship I create with the patients. I like the fact that I can do what's right for the patient within the bounds of what the facility can offer. I'm not bound by, I can do more injections or send more referrals or do more surgeries or prescribe certain medications. And then again, the geriatric population is my favorite, so it's not for everybody, but for me, that's my favorite. Sorry, kind of like went off topic here, but I hope that was useful, Sandy. All right, we're an hour and five minutes in, happy to stick around. But if there's no specific questions, we'll kind of end it. I appreciate everybody. I honestly am shocked and surprised some people showed up. So thank you for doing that. That makes me feel good about the time you put into this. Hopefully, we'll have a meeting in person at the APM in our conference at the end of this year. And then any questions that come up, please email us and we're happy to help. Have a good evening. Thanks.

sub-acute and skilled nursing facilities

patient care and outcomes

PCC Insight

Realtime software

infections

falls

length of stay

pain levels

artificial intelligence

machine learning