I'm going to start one minute early for some announcements, so welcome to the session. I know you've been to lots of sessions before. I'm Scott Laker. I'll be your moderator for today. Please remember, please silence your cell phones. Please complete the individual session evaluations as they're going to help us with future planning for future annual assemblies. They're located in the AA, the annual assembly mobile app, online platform, and the online learning profile. And then please, if you are available tomorrow, join us for Phys Talks. I'll be emceeing that, and that's members that are presenting things near and dear to their hearts. So welcome to today's session. This is Positioning PM&R for Success, Innovative Practice Models that are Aligned with PM&R BOLD. We have three incredible panelists today, Dr. Charlotte Smith, Senior Vice President for Clinical Care for Madrina, Clarice Sin, Associate Professor and Division Chief of Pediatric Rehabilitation Medicine at University of Kentucky, and Dr. James Eubanks, Assistant Professor, Department of Orthopedics and PM&R within the Division of PM&R, Medical University of South Carolina, and Clinical Assistant Professor within the Department of Physical Medicine and Rehabilitation at the University of Pittsburgh Medical Center. Again, I'm Scott Laker. I am at the University of Colorado. I'm a professor there, and I'll be your moderator today. So Positioning PM&R for Success, when we were brainstorming through the idea of this, it was what was going to make a successful practice in 5, 10, or 15 years. The individuals on the panel have been in positions where they've either created or adapted or evolved either a department or a clinical division for themselves, and AAPM&R's strategic focus on this area. As you all know, healthcare is really changing quite rapidly, and if we are not positioned or at least have a chassis to be positioned when that change does occur, I think, and the Academy agrees, that we're going to be quite behind. At least 27%, pardon me, 24.5% of care is delivered in a double-sided risk value-based payment environment, and up to 71, 72% of payers believe that it's going to be even higher than that in the future, and based on everything that we think is occurring in context around us in the healthcare system, value-based care is a reality and is an increasing reality, and the Academy's really dedicated to try to build a framework around how we would move from physician fee-for-service to a more value-based centered location or a practice model. So we can't continue to practice the same way while healthcare transforms around us. In general, we are a fairly adaptable specialty, but there is change management here that does need to be addressed and does need to be respected. As you know, the innovative practice models include positioning with the PM&R. New payment models like alternative payment models and value-based care, we've been really active on that, understanding how this relates to inpatient rehab, to outpatient rehab, also how it relates to our ancillary work with rehabilitation specialists from PT, OT, and speech. And we really want to position ourselves early and throughout the care continuum. I think it's really critical that we think in terms of not, you know, there's a line in hockey, you don't go where the puck is, you go where the puck is going, right? And that's the deal, right? We have what we've evolved into what works for us, but we need to be prepared to evolve in what's coming down the pipe. So as you've heard through our bold mission statement and our bold strategies, physiatrists are the essential medical experts. And the things that we're building in the presentations that we're bringing to you support the idea that physiatrists are essential medical experts in value-based evaluation, diagnosis, and management of neuromuscular and disabling conditions. And indispensable leaders, not that this is something good to have, this is something that every location should have, a physiatrist in every pot, per se. In directing rehab and recovery, vital to optimizing outcomes in function early and throughout the continuum of care. Some things that are pretty clearly in our way, and I think many of you would agree, are awareness of the specialty, both from a patient-facing standpoint, but also from an institutional standpoint. Other areas of concern are certainly encroachment into our ancestral homes, which is in rehabilitation facilities, skilled nursing facilities, and long-term care hospitals. But now that we're competing with other specialties for decreasing dollars in an increasingly competitive landscape, we need to be very thoughtful about how we can prove that we're essential and prove that we are indispensable. Our panel format today, we've given the panelists several questions to prepare their remarks for you. They're gonna do a mini-presentation that describes the practice, this idea of the new role or department that they've created, or an existing role that they've created and expanded to meet future healthcare needs. They're gonna be presenting their practice model in a little bit more detail. They're gonna discuss some barriers, and they're gonna provide the lessons learned. Each of them are gonna have 10 minutes to present, and then with five minutes for questions for each. So if there's time remaining, then I'll moderate some additional questions at the end. So Dr. Smith, I believe you are our first panelist. Wonderful. And they're gonna bring your slides up next. Okay. Thank you. Thank you, Scott. Well, welcome, and thanks, everybody, for being here on Saturday afternoon at the tail end of the conference. I think this bold initiative and what we do and how we flex to meet needs in the healthcare system so that we become the leaders of the healthcare system is probably one of the most important topics we have. I learn a lot from cases and from patients, so I wanted to start with a case study that's a real case study. Let's see if I can figure out how to operate this. Oh, good. Oh, and just disclosure, I'm a senior vice president for clinical care for Madrina. For those of you that don't know Madrina, it's a group of about 700 physiatrists that work in 46 states. We have about probably 250, 300 advanced practice providers. The numbers could all be different for this meeting. And we try to basically provide physiatry services in all the gaps where they're needed throughout the continuum. And I've been doing this pretty much for the last decade. I'm an accidental bold person by working in Seattle and getting pulled into some situations where there really wasn't an established PM&R model. And so over the last 10 years, I've kind of become the person that does a lot of post-acute care and looking at how do we align with networks, acute care facilities, and outpatient providers, and how do we do that with excellence. So that's a lot of what I do with Madrina. And so I want to talk about this case. I think you will get a feel for kind of why we're needed. So this was a man. This happened about two years ago. It was on election night, and he was working at the election. And we had the first snow of the season. It's in a semi-rural area. And his truck slid on the ice onto the train tracks, and he got hit by a train. And his car was crushed. And the EMS responders did a very nice job in terms of intubating him while he was still in his truck. They life-flighted him to the nearest trauma center, which is a level three trauma center at a community hospital. He basically was intubated, and the neurosurgeon told his wife, you know, we're intubating him tonight just because you need to get used to the idea he's dead. He's basically dead. And you need to understand that tomorrow what will happen is we're going to turn off the ventilator and he won't breathe and he's going to die. And he has no brain, nothing functioning. And so, of course, the next morning they stopped the ventilator and he continued to breathe and he opened his eyes. And at that point, the neurosurgeon never came back again. She never saw him. And at that point, anything anyone told her, she didn't believe. And so, ultimately, day five comes as the standard, and they traced and pegged him. And he wasn't completely off the vent. He was still using it at night. And they sent him to an LTAC. And at the LTAC, they said he'll never get off the vent. You know, he's going to vent dependent. We need to just accept that and let him die. And he was off the vent in two weeks. And basically, at that point, they were able to say, well, he's off the vent. We're going to send him to skilled nursing. So he went to skilled nursing number one, and everything could go wrong, did. So the first night, they had him there, and he still had a trach. And they put the oxygen, misted oxygen, on the wrong way, and he plugged, and he crashed, and he goes to acute care. Second place that he went, because his wife didn't want to go back to that skilled nursing facility, crazy things happened. At one point, she calls me. I'm on a plane. She's texting me, and she's like, they're taking him back to acute care. And I was like, why? And they're like, well, his hemoglobin is three. And I said, is he OK? Is his blood pressure, can he feel pulses? Is his color good? Does he have a lot of tarry stools? She's like, yeah, he looks great. I said, it's got to be a lab error. And she goes, well, it's too late. He's already there. And so, sure enough, it was a lab error. And so then he bounces to SNF number three. And this just kept happening. And bottom line is, ultimately, every problem that you can have, he didn't get fed for a long time. He lost 30 pounds. Then they finally start feeding him tube feeds, but no bowel program. And he started getting incontinent, sitting in a liquid stool, and ended up having a stage four tuberculosis ulcer. He ended up having just, they would do things like he'd open his eyes to start following commands. And he got put on, like, Baclofen, with no spasticity. And he went back into a coma. And they said he has no rehab potential. On and on it goes. So ultimately, he goes back to the trauma hospital again. And at that point, none of the facilities would accept him, because he was complicated. And his wife, as you might imagine, was not the easiest person to build trust with, with a skilled nursing facility. And he ends up, essentially, being transitioned to comfort care, because they said, your only option at this point is we can send you to a skilled nursing facility two states away. And if we have an accepting facility and your insurance is paying for it, you don't get a vote. And she's like, there's no way. I'm going to let him go two states away. How do I get involved? And how do I watch over him? So she turned him into comfort care. And I believe this is what I call economic euthanasia. And I don't know if he would have had a great outcome. I don't know if he'd have woken up. I do know I saw him open his eyes and track his wife. But the whole thing was really sad and tragic. And it just showed us that there were so many ways that the places I've practiced, where I did consults in acute care trauma, or in skilled nursing, or in LTAC, some of these things wouldn't have happened. And you realize that if PM&R had been involved in any of these levels of care, there could have been so many things done differently. The shocking thing, from the very beginning, not having the prognosis or anybody talking to her about what this meant, what the potential options were, the potential outcomes were, just building a trusting relationship, all the way down to the last skilled nursing facility when he bounced back, you realize that at each level, there's less and less involvement of doctors and licensed people. And at each level, the risk goes up. And so it just became futile to try and turn the situation around. And this was not a place where I practiced. I didn't have any privileges. I kind of, as a physiatrist, said things like, you guys maybe think you want to feed him? And it was like, stuff like that. But truly, they weren't receptive. They had never had a physiatrist before. So the thing that was the solution, I think, is that every hospital needs to have a physiatrist involved from really point of injury and these kind of injuries, all the way through, until they end up either going home or dying. And what does this look like? Well, you guys here are all very familiar. You would know how to do consults in the acute care trauma facility. We get so much great training in that. And that's really one of our strengths as physiatrists. We all know inpatient rehab. It's these new levels of care where maybe we're getting involved. LTACs kind of look like IRFs. And I think most doctors that are in physiatry feel comfortable in LTACs. But then you start getting into the SNF stuff. And it's not something that very many people get exposure to. And I know when I started doing this in about 2013, 2014, I had to guess at what to do because there were no guidelines. And fortunately, I got put in charge as a medical rehabilitation director for a very large 600-bed facility that had skilled nursing acute, had long-term care, had independent living, assisted living, and it had an outpatient department. And so I learned a lot working there. They showed me a lot of grace. And it was very interesting to realize that there really are standards that we can enforce in certain facilities that make a difference in outcomes. And then the other thing I want to say right now that's really hard, and I think in healthcare today, is finding our follow-ups. So somebody has a stroke or hip fracture or something that takes them to the acute care hospital and maybe an IRF, because now so many of the doctors that do inpatient rehab don't do office care or because so many of the outpatient physiatrists only do spine and sports and musculoskeletal, sometimes there will be a wait of like 12 to 15 months to follow up with a physiatrist that will follow up a stroke. So there's these big gaps in the market. So what are the barriers? Well, the first thing I think has been, you know, really all of us recognize there's not enough team in our doctors. And in order for us to truly accomplish what the bold vision is that Scott was talking about of being present at all levels, you know, the first thing we have to do is link arms and help each other out. And you know, that is something that I was taught from the very beginning that when I came to Austin, Texas, I was the fourth physiatrist and I was told never, ever, ever think of other physiatrists as competition. Because the more physiatrists there are, the more people see what we do and the more need there is for physiatry, the pie does not get cut into smaller pieces, it grows. And I've found that to be true. And I think one of the things that we have to do is really align with one another to meet these needs all the way across, no matter what level of care we're at. The other big thing, and some of you may have heard me speak about this, is just how do we align and work with advanced practice providers? With nurse practitioners, physician assistants, and what is the best model? And then last but not least, something that actually, I coined this phrase in 1996 called co-management. When I couldn't find another physiatrist that would work with me in an 82-bed facility where I had really sick patients and nobody wanted to do inpatient rehab. And we got four hospital groups to each take 20 beds and every single case had to have a PM&R consult and the executive director was a physiatrist. And essentially the model took the number of bounce backs to the ER from about 19% down to four. And we had better care. And everybody at that point, physiatry that was in Austin, were willing to come do inpatient rehab again because they weren't managing medical comorbidities that were very challenging. So those are the things I think that we need to start overcoming with manpower. We really need to start looking at pathways. You know, PM&R education for post-acute is not incorporated in residency programs. I don't know that it ever will be. You know, how do we keep adding more curriculum to our four-year residency without adding years? You know, there's so much that's been added. Sometimes too, it's challenging with the primary team. So you go into a skilled nursing facility and you have an internal medicine or geriatrician medical director and they're not so sure that they really want you. And that can be very, very challenging. That's what happened at the facility where my friend died. Basically they had a medical director and they're like, oh, you know, we've never seen a need for having a physiatrist. And I say, well, you know, American College of Surgeons does. And at that point they're like, well, maybe we should. But a lot of these skilled nursing facilities, there's a lot of threat. There's a fear that if we see the patients that they're not going to get paid or that we're going to take over their job. And we have to explain to them that, number one, nothing we do impacts their reimbursement. And I certainly don't want their job because I couldn't be responsible 24-7 for all those medical complexities. And then last but not least is patients and families. When you look at patients, a lot of times if they get more than one bill for a doctor at a skilled nursing facility, they are worried because they may not be able to pay that bill. And you have to explain to them what your role is and how one of the number one causes of medical bankruptcy is when people that are in skilled nursing have a week go by and they're on these disadvantaged programs and they fail to make progress. And so they get something called nominate, which means that they get decertified, which means that they basically have to spend down their assets either to go home, which they usually can't because they're too much of a care challenge with mobility or other things, or they spend down and become medically bankrupt and then they get long-term care or they die. And so if we explain to them by us being on their case, we have a better opportunity to help them be successful in rehab so they can go home, ultimately it's penny-wise and pound-foolish not to have us on their case. And I've never had a patient, the one that's explained to them, didn't want to do it. So you know, there's still a lot of problems, you know, there still are a lot of threats to the primary team we've got to keep working on. This is an education. Madrina is actually launching an initiative where they're working with internal medicine doctors that are part of Madrina, that we hired them, and it's a joint package. Because if you go to a skilled nursing facility and that skilled nursing facility doesn't have an internal medicine doctor, they can't stay open five minutes. So they're always going to side with the internal medicine doctor or a physiatrist if they have a conflict or if they have to make a choice. And so one of the things we're trying to do is really align with hospitalists, internal medicine doctors, geriatricians, to really develop this protocol and this program, how we do co-management so that everybody wins. We also have to really look at consistency, like just showing up in a skilled nursing facility and doing what we did in inpatient rehab is not a good strategy. It might get you fired or scattered out of the building because there are such different rules, there's different manpower, there's different resources, there's different things you're trying to accomplish. And so there really is a skill set and it's really important that if we show up in these levels of care that we do something that's useful rather than something that's harmful. Otherwise it really hurts all of us. And then I think developing these models of team-based care. How do we work optimally with advanced practice providers so the physiatrist is still the leader of the team and that we're using the advanced practice providers to extend ourselves but still allowing for optimal quality. And I think there's a lot of work to be done with that. And then last but not least is the data. You know, the way that you get the attention of these facilities is by showing them what we can do to help their outcomes. Every skilled nursing facility has a report card that they have to like show their patient satisfaction, their discharge to the community, you know, their FIM changes, all that stuff. And there are studies out there now that are showing that by having physiatry involved we can move those metrics. Just like we did in patient rehab. So a follow-up to the story, bottom line, when we talk about changes, I think it's really important that we don't have fear. I was told when I first started my practice 37 years ago that, oh gosh, Medicare's going to ruin us. And everybody was concerned and fearful. And I have had to reinvent myself so many times. But the way that I reinvent myself is just to figure out, where can I be useful? Where is there a need that our skill sets are useful? And how can I morph the practice to meet those needs? And how can I find people who are my partners and allies in these situations? And I think if you do those things, basically, you're going to find that you have success no matter what you're doing, because there's so many needs in health care. And there's so many people that really benefit from our care. And there's so many people right now, primary care doctors are burned out. They're spread thin. Sub-specialists are spread thin. And having us available to help take some of these problems off their hands and help their patients makes a big difference. And I think the key thing, too, is that we need to promote each other. Like, when I'm in a community, the first thing I want to do if I'm in skilled nursing is find out who are the inpatient rehab doctors, because we can trade patients off back and forth. Who are the really great pain management doctors out there that I can work with when these people are going to need procedures? Who are the people doing the R out there that will see these people for outpatient follow-up if they need spasticity management and things like that? It's really important. But the way that we do that is by marketing each other, getting to know each other, and really synergizing so these people have needs that are met. And I have to say, I think this is probably my favorite stuff that I've done since I started practice, because there's such a high need, and it's such a reward to be able to be there when nobody else is. And it actually can be very financially rewarding, and it can be a practice where you have a lot of control over your day and how you spend your time and what your work schedule looks like. And it's been something really special, I think, to be able to be involved in something that makes a difference. Just an after story. So just this last week, the wife of the man who died of the train wreck, she had a sudden onset of paralysis. She's 60-something years old, 61, 62, and just started walking and felt wobbly and then just had dense paralysis. And they take her back to that same hospital. And I'm thinking, oh, god, this is not going to end well. But the beautiful thing is they had hired a fantastic physiatrist who took the rein and stepped in. And everything that was a best practice for a spinal cord patient, he did. And the difference in her level of confidence and not having fear and just feeling like somebody is on my side was just completely different. And you can imagine for her with what she went through with her husband, that's dramatic. And I was so proud. And so Glenn House, if you're watching, thank you. You're amazing. And we all make a difference when we do what we're supposed to do because these people need us. So I'll turn it over. You get a couple questions. Oh, I do because I'm over time. I'm sorry. Yes, any questions? I'll ask a couple, actually. OK. Sorry, is this mic on? Yes, you guys can hear me? OK, thank you. So I guess two questions. One, thanks for the story. When I read about it, it was very clear. A physiatrist at any point in that would have led to a better outcome. First one may be harder than the second one. What are some specific data sources that you use to communicate this? Lots of us talk about brain data, but what's the toolbox that you use? Sure, so we're still doing a lot of work to get very specific of how we make a difference in skilled nursing. And there is some of that data there. But the number one way that I find out what a facility needs and how we can make a difference is going through the CMS Nursing Home Compare website. So you can type in a city or a facility or a zip code, and it will give you a facility, and it'll tell you what their scores are. And this is mandated. Every facility has this. It'll go through things, three buckets essentially. How are they doing with quality? How are they doing with staffing? And then how are they doing with inspections and complaints? And what you'll see is that every facility has data about, number one, how many of their patients bounce back to the emergency room or have to be admitted. How many have avoidable complications, like CAUTIs and decubitus ulcers? What percentage of the people actually meet their goals in rehabilitation? How many patient complaints do they get? And how often, when they have a patient complain and it triggers the state complaint nurse, are they sanctioned or fined for things? And so that's one piece of data. And that would be the first thing. When I'm talking to a facility and I'm making the pitch for why we could be useful, those are all things we can help with. And most of the time, there are barriers in place that are not being addressed that we can address. What was your second question? Second question is this. Where have you found unlikely allies? I mean, we have big groups that we typically align. Yes. But what are some people that you've partnered with that were surprising to you? So unlikely allies, a lot of times, are the people in the facilities. The number one person that's gonna help you in these situations is the rehab director. So every skilled nursing facility has usually a PT or an OT that's the director of rehab, sometimes a speech therapist. And what you'll find in skilled nursing is, you may have the PT do the initial eval, and the rest may be like physical therapy assistants, it may be CODAS. And so they love having a doctor, a physiatrist that can guide them. And they have these required meetings called Medicare meetings, utilization review meetings. And to have us on the team to help take care of things, like the things that are really stressful for them is there's no schedule. So when a patient's in skilled nursing, they don't know when the PT's gonna come by to see them, and they get one shot that day. And if they haven't had their pain medicine, like a typical thing is you've got someone that's fallen, has a hip fracture, and the PT comes by, and they're like, let's go, this is our shot, we're gonna go to therapy. And they're like, no, I haven't had pain medicine. And then trying to get the nurse to get the pain medicine, and then that is a refusal. And again, if a week goes by and they've made no gains, boom, long-term care or home. And so the rehab directors, one. I think the hospitalists too, the internal medicine doctors, they have so much regulatory stuff they have to do. And for us to take some of the burdens off of them, and they don't know a lot of times what a rehab plan of care looks like, or how to optimize it, or how to help people be successful. And when we do those things, they A, have less hassles, and B, they have less complaints and happier patients. Thank you very much. Clarice is up next. I also, I forgot, I neglected to mention this. Dr. Smith is our newly elected Vice President of the Academy as of about 12.30 this afternoon. Okay. All right, hi, I'm Clarice Sin. I work in pediatric rehab medicine, and I work in academia and have my whole career so far. So I'm currently the Division Chief and the Medical Director of Pediatric Rehabilitation Medicine at the University of Kentucky. So I graduated from fellowship back in 2015. My first job was at Baylor College of Medicine in Houston, Texas. But then in 2017, an opportunity came up at the University of Texas Southwestern Medical Center. They wanted somebody to create a consultation service. Although they had Peds Rehab there, there was no presence in the hospital. As you can see, it's a very large hospital. So most people didn't even know we existed. My partners were mainly outpatient, and we did have an inpatient rehab unit. However, it was freestanding. So it was two miles up the road. They would occasionally send kids there, but there really was no consultation, and there was a huge disconnect between the rehab unit and the consult service. I think we had about 500 patients in our hospital. So it's a decent-sized hospital. A few years prior to me starting there, they did have somebody who did the consults. And I was told, never met the person, but that they had a very polarizing personality. And so when I started the job, I was told, lots of people said, here we go again. Like, we don't know what to expect with PMNR. How's this going to go down? But I was able to take it from, they would have maybe four consults at any given time on their list. The time I left earlier this year, my list was anywhere from 50 to 60 patients. I could be consulted on any patient in the hospital, whether it's the NICU, pulmonary, the psych unit, you name it. Once they learn what you can do, kind of the floodgates open. And then it was a great way to funnel into our clinics, because even if these kids didn't go to inpatient rehab, they needed a rehab follow-up. So they would either follow up with me, or if one of their diagnosis fit in with one of my partner's specialties, or what they enjoy doing, I would kind of funnel them that way. So it really exponentially grew our program. And I think a lot of people in the hospital thought I was the boss. I was not. But because I was there. My face was there, that's who they saw. I was the face of rehab. When I started the job, I made sure I had at least 50% of time to dedicate to the consult service. The two years between the person leaving and me coming, it was one of the outpatient doctors, who did full-time outpatient, and a consult would come in, so they'd run over to the hospital at like 5 p.m., see the kid real quick and leave. And there were no follow-ups, unless the team specifically called. And then earlier this year, an opportunity came up at the University of Kentucky to help create the division there. Although they have a great PM&R department, it's on the adult side. They really had no pediatrics whatsoever. And I'm kind of learning things are different back in the Midwest, since my whole career has been in Texas. They did hire their first pediatric trained, or sorry, pediatric physiatrist fellowship trained a year ago, right out of fellowship. However, they wanted somebody to come in who can kind of help mentor her, guide her, hire more people, and build the division. Because at the time, as it is stands right now, there's one pediatric rehab unit in the state of Kentucky, and it's in Louisville. I can't pronounce it right, I'm still working on it. Louisville. And I'm not great at geography, but it's on the very western tip. And there is nobody taking care of eastern Kentucky for the kids. And Tennessee does not have a pediatric rehab unit either. So we're getting kids from all over. So right now, if I'm seeing a kid in the hospital, we're either sending them to Louisville if they need inpatient rehab, or they're going up north to Cincinnati. So I was hired to come in and try to develop a pediatric rehab unit. New to me being in Kentucky, we have to get a certificate of need. That was not a thing in Texas. So my boss this week has been in trial, trying to get us more adult beds, as well as the first pediatric beds. And she said it's going well. So fingers crossed I can start the unit, and get us up running. My other goal is to start, once we have an inpatient unit, I wanna start a pediatric rehabilitation fellowship, because there's very few of us out there, and we need to grow. I think at Peds Day the other day, they said we're just tipped over 400 of board certified Peds rehab docs. So how did I get here? How did I position myself to be in leadership? I found that mentorship is important. My mentor here is Dr. Bob Rinaldi. He was my mentor, he was my colleague at Dallas, and then my friend for the last 15 years. He is well known within the AAPMNR. He's been the president of the Peds Council. He volunteers with ABPMNR. So I asked him how do I get involved? How do I kind of work this career out? And he's like just be involved. It may not be the committee you wanna be on right away, but just get your foot in the door. You get to know people. It's a great way to network. You meet people from all across the country who are either Peds or another, and you learn a lot from those people. Next thing I did is I decided in my second year in practice, I applied for the AAPMNR Future Leaders Program. I think that's what it's called now. I think it was just the leadership program when I was in there. I think I was the third class. They take 10 candidates every two years. I was the only Peds person. The new incoming class who just started at this conference, there's two Peds people, so that's exciting. But what it does is it sets you up for a leadership position. So when you come out of the academy program, you get put in one of the committees and kind of what you choose to do with that. I got put on the Reimbursement and Policy Review Committee, so we kind of help out with billing and coding for all of our participants. We also, with me and my partner, Dr. Matthew Grierson, we are the physiatry representatives who sit on the AMA RUC. Most people have no idea what the RUC is, but we're the ones who value the CPT code. So basically, we help you get reimbursed for the job that you're doing. PM&R has never had a seat at the table. In 2019, we won a rotating seat for the first time ever. And then in 2021, PM&R now has a permanent seat at the table. Thank you. So that's Dr. Grierson and myself. So it went from 28 voting members to now 29. And as long as we don't mess it up, I think we have the seat for life. For physiatry, not us personally. And then the other thing is, I went ahead and got, during my fellowship, I decided to get a master's. Because I realized in med school, you don't learn anything about business of medicine. And it's very complicated and confusing. And so I decided to get a master's of health care administration. At the time, I had no idea what I was going to do with it. But I felt like it would be a good skill set to have. And I thought one day, I'd probably be in administration, not 100%, because I like taking care of kids. I want to have a good mix. But that's what I decided to do. And it helped set me up. And then, like I said in the previous slides, I kind of helped. My first foray into program development was starting that consultation service. And then also, while I was at University of Texas Southwestern Medical Center, I was responsible for all of the trainees who went through the pediatric medicine rotation. I think we had 32 residents at UT Southwestern. We had nine residents at Baylor. And then I set it up for multiple subspecialties to be able to rotate through with us. So if you guys are in academia, I think it's really important. So all of our peds neuro, the peds ortho, palliative care, they all got to do month rotations with us. And they really learned what we do. And that also brought in a lot of referrals, because they just thought we did just spasticity, or we did just inpatient rehab. They didn't realize all of the facets that we offer. Pediatric physiatrists are kind of like generalists in that we see everything. They're just under 18. So what did I have to overcome? Like I mentioned before, the previous provider was very polarizing. So I had to kind of rebuild those bridges that had been burned down previously. And we also had to teach people, what do we do and what do we bring to the table? I was able to expand the consult service to other hospitals. So not only was I at Children's Medical Center Dallas, I expanded to Parkland Hospital, NICU, as well as Presbyterian Dallas. And at UK, I've just started four months ago, but it's kind of the same thing. Because they haven't had peds rehab, it's getting our name out there. So I've already met with NICU, PICU, the hospitalist service, the pediatricians out in the community, the acute therapist, neurology, I'm sure I'm missing a lot, rheumatology, orthopedics, neurosurgery, because we collaborate with so many patients. And let them know that we're not here to take your patients, we're here to share and help. How can we make it better for our patients? So what am I still facing? Like I said, I just started at University of Kentucky. So it's kind of getting everybody to know what we do and how we can help. It's going pretty good so far. We're already starting two multidisciplinary clinics later this month, the abusive head trauma clinic that I will be in, as well as a neuromuscular clinic and neurogenetics with neurology. We're hoping to get more clinics, but I need to hire more people. Because the two of us can only do so many things at once. And also, as I mentioned before, we're working on getting that certificate of need. So hopefully very soon that will get approved and we can offer more care to the children of Kentucky. And then also, the acute therapists at Kentucky Children's, they have never done inpatient rehab. And from a therapy standpoint, the goals are different when you're being an acute therapist versus an inpatient rehab unit. So there's going to be a lot of training that we need to get up and going. Same with the case managers, all of the team. My partner and I, we know what it takes, but it's just bringing everybody else up to speed. So lessons learned. The biggest thing I've learned is you need to build rapport and the trust is going to follow. Like when I started at Children's Mercy, I showed up, every patient who was agitated, baby, older kid, they got put on clonidine. No idea why. And I would find out they would start this kid on clonidine. And they said, don't worry, PM&R is going to manage it outpatient. And I was like, excuse me? One, I didn't start the medication. Two, I never would have started the medication. And three, no, not going to. But after a couple of weeks, I learned, you know what? I'm going to play their game. Let's do plan A. They're on clonidine. But if that doesn't work, let's try plan B. Let's try propranolol. Let's try something else, you know? And then by six months in, when I'm getting the consult, it was, should we try propranolol? You know, versus they're now on clonidine. So it's a lot of education. It's just taking the time, being present. Same with all of the, my, you know, GMFCS-5, very complex, CP kids are on a vent, trach. They're agitated. I'm like, well, of course they're agitated. They have pneumonia. They have fevers. Their tone's worse. That's to be expected, you know? So I've kind of trained them to the point, like, have they pooped? Do they have an infection? You know, and it got to the point a year in that when they called me for the consult, they knew, we have already done X, Y, Z. now we don't know what to do. So I'm like, all right, the education piece worked, that helped. Because I also learned, if you go in kicking the doors down and say, this is not the standard of care, it doesn't go over well. So you got to kind of play the game, slowly get your education piece. At least in the pediatric world, for the most part, everybody's nice. So if you go in being mean, it doesn't go over very well. Let's see, so yeah, that's kind of, don't be too pushy. If things aren't done the way you would do them, it's kind of a gradual change. And usually, people will follow suit once they see. Another thing I did is I made sure I was available. I was on NICU rounds. I was on trauma rounds. They see your face, you're there. And all of a sudden, they're presenting a patient. They're like, wait, is this somebody you should be seeing? And I'm like, absolutely. Because if you're there, they're seeing you, you're in the back of their mind, and then they see what you do with one patient, then they're going to call you first off on the next patient. So I've mainly built my career around acute care, a lot of ICU work. I'm kind of changing it now, going into administrative role, but that's kind of what I've done. Thank you. Another wonderful presentation. I'll ask you this one. It's kind of related to workforce and P3MS. I would assume that the demand for your services greatly outpaced how quickly you learned how to clone yourself. Correct. So maybe if you could speak to how you prioritize, or if you prioritize, or how you leveraged your expertise in probably an environment where there were not enough PRM specialists. Yeah. Luckily, when I was in Baylor, there were like nine of us, which is unheard of. And then at Dallas, there was five of us, and it kind of fluctuated. Now there's two of us. So it's kind of one of those, once the floodgates open and they realize what you do, it's how do you manage it? Because there's so many patients flying at you, especially on the inpatient side. I'm like, OK, just call me. We'll talk about it. Is this somebody I need to see now? Or you're going to get ready to discharge them. I'm going to squeeze them into the clinic. It's just trying to see what's best for them. And I never turn down a consult or referral. What they're asking may be inappropriate. But once I get in there, I'm like, well, yeah, I don't really do that. But actually, I do all of these other things, and this is how I can help you. And I also joke with my families, I'm your cruise director. I'm going to make sure you get everything you need. Is the school piece, do we got the equipment? Oh, wow, you got cortical vision impairment. You've never seen ophthalmology. It's just kind of making sure that they have everybody in the team. I work very closely with palliative care on a lot of my patients. So it's just kind of knowing what I can do. And if it's not me, how can I utilize my colleagues out there? Maybe a follow-up question around that never turn down a consult. And that initial strategy of aligning, going slow, building. Maybe if you could use an example where you had to change gears and maybe have firmer boundaries or a more crucial conversation with either referring service, hospital executive, because the slow build of the collaboration was not working or not working effectively. Luckily, at UT Southwestern, it worked very fast. It kind of blew up overnight. And I was a team of one. Most services, they rotate every week, every month, whatever. And when they call me, be like, I don't think you, I don't know if you know this patient. It's like, I followed him for nine months. I know who the patient is. It's me. It's always me, unless I'm on vacation. UK, it's a little bit different, because it's kind of smaller. But I met with Nicky last month. And literally within the hour, I had six new consults. So it's just going to be, hopefully, we'll be able to manage it pretty well. Knock on wood. Last question. I asked Charlotte about unlikely allies. Maybe were there any unlikely areas of friction and conflict that you weren't expecting that you had to deal with? Yeah, it was kind of weird. Neurology is our main ally, I feel like. But in Dallas, we had so many different niches. And there's neuromuscular. There's neuroimmunologies. There's the stroke team, epilepsy team, and all of that. And neuroimmunology loves us, wanted us involved in everything. Same with the stroke team. Neuromuscular, where I trained in Kansas City, we ran that clinic. No neurologist was even in the clinic. You get to Dallas, and they're like, thanks. No thanks. We got this. So it's been kind of challenging. It just kind of depends. Some people are open to what you bring. Some aren't. I don't know if we ever broke them down in the eight years I was there. But the others enjoyed having us. We're going to do questions for the panel right at the end, just to kind of keep us on, if that's OK. But you can be first in line. We'll hold you. We'll save your stature. All right, thank you. I saw a lot of heads nodding when you were discussing that last one. So thank you very much, Clarissa. Mm-hmm. Thank you. And Dr. Eubanks is our final presenter. OK, so I'm Jim Eubanks, and I am now at the Medical University of South Carolina. I'm going to talk about two different experiences that I've had, and translating one of those experiences at UPMC into my current role. So just for some background, as you have heard probably many times, spine-related disorders are a top cause of disability and cost. Most of these cases can be best managed non-operatively. PM&R physicians have a wonderful opportunity to step into this role and provide service of value. And our current system is often siloed, fragmented, inefficient, and we have opportunities to change models of care. So that's the background. So I did a fellowship at UPMC in value-based spine care with Chris Standard, who's been doing this kind of work for a long time now. So 70% of my time was clinical, and 30% I spent in a structured training program in conjunction with efforts at the UPMC health plan, which is an integrated delivery and finance system, meaning that the insurer division and the health delivery division are the same entity in a very important way. So early access to PM&R for spine care can hopefully achieve the following. And this was true at UPMC, and I'm in the process of hopefully translating a lot of this to a new institution. But delivery of evidence-based medicine, care that works, patient education and empowerment, patient satisfaction, and an affordable team-based paradigm. So we can bring value to institutions through increased throughput, access, and stratified care. And this is what we are able to add to new and emerging payment and practice models. So at my current institution, some barriers were identified. There has been uncertainty about the role of PM&R. So UPMC is very different from where I am now at MUSC. UPMC is a very established, mature PM&R program. It's in an integrated system. The current system I'm in at MUSC is not an integrated delivery and finance system. They do not have their own insurance division. And historically, there has not been a clear role for PM&R. There has not been a robust presence. And so there was an opportunity for me to go back to the Carolinas, where I'm from, and help Dr. Amit Nagpal and others build a new program and try to problem solve and figure out how we can add value through PM&R to an old, storied institution. It's the ninth oldest medical school in the country, MUSC. And so these are the questions that we have to address. Are we non-operative orthopedics? This is all, of course, from an outpatient perspective now that we're talking. Are we pain docs? Are we sports? Are we OCMED? Are we some kind of primary care for disability? What are we? And these are the questions that the institutions struggle with, our colleagues struggle with. And we have to help define this. So yes, we're kind of those things, but we're primarily rehabilitation physicians. And we're able to comprehensively manage patient populations. And in this case, we're talking about spine. And so we started to explore this concept of primary spine care. And this is part of my training at UPMC, was in a new clinical model called the Program for Spine Health, which I could speak about for quite a while and give you the nuts and bolts of that. And I'm happy to talk to you outside of this forum about that. But the idea is that PM&R can somewhat own a patient population, which is necessary for our sustainability in an institution. Another barrier is an absence of stratified care. So you think about stepped care. Stepped care is sort of what insurance companies might expect, so no matter what, do the PT first. If that doesn't work, maybe you do an injection next. If that doesn't work, then you can go see the surgeon kind of thing. Stratified care is hopefully more thoughtful than that. And it's getting the right patient to the right person with the tools that they need to solve their clinical problem. And I think that PM&R is in an optimal position to help with that. So currently, there's too many doors through which patients enter. There's also escalating costs, and part of that is because of guideline discordant care. And this is something that we can hopefully help address. We might be able to reduce costs if we practice in a health-promoting paradigm, for which we are hopefully best suited. I'm working on these issues at my new institution, and so I'm leading a spine health task force, which has buy-in from the C-suite. And the reason for that is that I was able to identify problems that some of which they knew they had and some of which they had not really reflected on, but it resonated with them enough that we are now investigating opportunities for PM&R to help solve some of these problems. We still have some barriers to address, and hopefully some of these make sense to you. So PM&R docs may not always see themselves as rehabilitation experts and know how to practice comprehensively, particularly in an outpatient setting. An easy example is if you think of yourself as an interventionalist, that is not necessarily a unique position to be in, because we have lots of competition in that space. So we have anesthesia pain, and we have interventional radiology, and that has been a problem for institutions to understand our unique role or value as PM&R. So there's the absence of the stratification that I mentioned, and so we are moving from profession-centered practice behaviors, that is thinking about ourselves as a PM&R doctor delivering care, and we might move towards patient-centered practice, which allows us to take advantage of our team-based focus or sort of orientation as we start collaborating. And so it's just a shift in how we think about our activities within an institution. And in terms of the escalating costs and the kind of care that is often discordant with the evidence, there are some opportunities for new payment models to perhaps allow us to take advantage of new opportunities in a practice setting. And so this is like the value-based care or alternative payment models that we have mentioned and are important for us to explore as a field. So lessons learned so far, you know, and this was brought up in a previous lecture, and Chris Standard, my fellowship mentor, was very good about this, but even before the data collection, we have to understand people's motivations and what is important to them. And then we can collect data to make a case, and we can say, here is where we are today, and now we can set some goals and maybe move towards that in the future. We really need to take advantage of our team-based orientation. As we try to define our value as a field, it has to be in concert with everyone else who is necessary for comprehensive care to take place. And so we might think of this as all boats must rise. We also need to explore and formalize our workflow and really understand how we can comprehensively operate within the system. In doing so, we create a long-term role for ourselves as physiatrists. And then taking these steps, as mentioned, might allow us to move along new paths, such as those that are afforded by emerging payment models. There are three stages that a health system might be in. One is that they are really stuck in historical fee-for-service models, and they're not ready for change. One is that they are aggressively investigating change and trying to participate in the evolution that's occurring. So an integrated delivery and finance system might actualize that kind of motivation for a health system. And then you have other systems that realize change is happening and are open to exploring new ways of organizing themselves. And so that last model or stage is where my current institution is, MUSC. And so I was able to convince them that we should start moving in this direction because there are goals that they had that we were able to identify. For example, direct contracting with employers who have their own insurance. And in order to get there, they know that we have to create a superior spine care product. And that is a lever that I was able to use that was different from my previous institution. And so one of the things that I think is really essential for us to recognize is that there is not going to be one model or one approach that's going to work. It's going to be quite diverse in terms of what institutions need and what we as physiatrists are going to have to do to position ourselves optimally within those systems and get them to move forward with change that we think would be better for the kind of care that we're trying to deliver for patients. Okay. All right, wonderful. I guess the question that I had for you without going into detail you're not comfortable with, how are you finding recruiting for people into these types of models? I mean, it's counterintuitive for people that are coming out of fellowship to hear that you don't have to do all of this all the time as quickly as possible on everybody that you see. So how do you communicate that? How are the compensation models for your new hires? Yeah, so I'm not directly involved in hiring at this point. But I think what you have to do is you have to really show others what is possible. One of the things is that trainees and others may not be aware of different ways of practicing as physiatrists in the outpatient setting. And so we have to do a better job showing what that might look like and how it can work in these different health systems. The fellowship that I did was intended for that. Certainly. Right, so I was trained in a model and in a clinical program that was set up to show how we might behave differently as clinicians. And I think that, you know, that's part of what our mission is. But you can accelerate that process by better aligning financial incentives. And so that's where the intersection happens with emerging payment models. And I think that's got to be something that we explore moving forward. This will be my last question. You guys are welcome to queue up so that we're ready to go. But my other question, you mentioned kind of those three, you know, phases of change acceptance for the hospital. Do you think there's value in approaching hospitals that just aren't ready for change yet? Or do you have to be somewhere where there's at least fallow ground to start having a conversation? Right. Yeah. So my impression is you probably have to have some interest pre-existing with the leadership to make that work. I'll change spots with you. Dr. Anaswamy has a question. Thank you. Did you have a presentation coming too? No. Thank God, no. I have two questions. One is a more general question perhaps anybody or all of you can answer. Second one is for Clarice. The general question is about a lot of the examples you mentioned adding value without any clear group of people or person that loses. And in one instance you mentioned the pain management interventional radiology might be potentially losers. You know, in any business model, you have to account for that. That, you know, as the system gains, there may be a group or groups of people that loses something. So how do you, do you acknowledge that and address it or do you like leave it unaddressed and let them figure it out? So that's sort of the general question. The smaller question, more specific to Clarice, is about when do you think there might, you might reach a maturity where you may not be needed for all inpatient, you know, acute care consults where you can, they might know the way to where they can refer appropriate patients to the appropriate post-acute care facility without needing you to see that individual patient. I can answer that one. Sure, I bet. Well, that never happened in Dallas. The consults kept coming. But when I did get referrals, sometimes it was way more specific what the referral was because they knew exactly what I did versus just that random, please evaluate my patient. And it just kind of depends. One thing that was funny when I started at Dallas, the therapy department before we were there was called physical medicine and rehab. So a lot of the consults, I was like, do you actually want me or the physical therapist? And so sometimes, you know, you had to kind of tease it out. But hopefully down the road, once they know more what we are, all of the referrals will be appropriate. So I'm hoping I never lose consults for that reason. I can't imagine a world where we're not needed to discern and determine what the next appropriate level of care is for a multitude of reasons. So you think about like in an acute care hospital, and this is mostly adults. I've done peds as well. You know, first of all, you've got to determine, is this person safe to go home? You know, if not, what's the next level of care? Do they meet the criteria for inpatient rehab? Is it a funda situation? So many of these Medicare disadvantaged programs do not have an opportunity for inpatient rehab. So then let's say they're going to go skilled nursing. Which one is the best fit? Because there's no level of care with more variability in quality and outcome than skilled nursing. There's good, there's bad, there's ugly. And if we have these alliances, like let's say you're the acute care consult doctor in a big teaching hospital. If you know where the skilled nursing facilities are that have physiatrists, you're going to feel a lot more comfortable advocating for those. Because patients don't know. They get a piece of paper with like 200 facilities and they have to choose. They're like, heck, I don't know. They're going to ask you. And I think you also have to recognize that a lot of the bedside care that's happening in hospitals right now is not necessarily MDs. So you may have other providers who don't know the answers to these things. Or you may have new therapists or new nurses and a lot of turnover. And so I just, I can't imagine a world where we're not going to be needed in that situation. And then when you think about the pressures that the acute care systems have where one day there's a difference between black and red, you know, I think they're going to always need us. Again, Penny's wise. That might be the reason. The throughput and the efficiency and the numbers game. We may not, there may not be enough of us. Correct. But I think that, you know, handing that off only to mid-levels is probably not the wisest thing unless they're exceptionally trained. To your more general point about how you ensure that everyone benefits, right, or minimize the losers, so to speak. One tip I learned through my fellowship is that we have to go and talk with these people and understand what their needs are and expectations and try to find partnerships that we can maintain and discover new ways that they might win. So if they do lose in one way, there might be another way in which we can benefit them. And that has been quite successful at my current institution. So immediately when I joined, I was put on the spine leadership team, which is, it represents neurosurgery, orthopedics, and PM&R. And so I had a voice among that multidisciplinary setting. And I got to know more about what everyone needed to thrive. And so as we started exploring change opportunities, we were able to bring them along in ways that made sense to them. Now, occasionally it's still difficult, and that requires extra work. And so I have to have more conversations, and it might be slower. But we also happen to have a spine and specialty services chief at the moment who is completely on board with our efforts and is able to sort of get people in line. So that helps. And we really have to have those powerful allies in the right positions to make something like this work. Sometimes there's incentives, too. When I was the chair of the medical school in Austin, we had a situation with neurosciences where we did an initiative where we screened every patient that came in with a stroke diagnosis and then determined which ones needed to see an orthopedic, and looked at length of stay, and shaved one day off the 13 hospitals, which was $13 million in savings. And then my department got a percentage of that. So we weren't seeing every patient. We were screening, and we had a lot of hands going at it. But those are some of the really, I think, interesting ways that you can have revenues come in, but you're actually working less. And so I think that there's a lot of opportunities here for unique models where everybody wins. Thank you. Next question. Similar question. Similar question, and Dr. Eubanks actually started talking about it a little bit. But what are things that y'all have done for the pediatric neuromuscular doc, the internist, the surgeon, to kind of allow them to take a chance on something new, and something that is just very different from how things had been done at the institution you were at? For me, because I'm an academic, I get invited and I do a lot of presentations. So I speak at Trauma Grand Rounds. I speak at Neurology Grand Rounds, whatever, and just kind of introduce what we do. I may do a case presentation to show. I feel like the best, in my instance, has been actually the proof in the pudding kind of thing, actually seeing what I do, showing the patients. And I think that's kind of helped a lot, getting them on board. For the most part, they are. There's just a few, like those neuromuscular docs who, you know, kind of stuck in their way. But I think it's really just showing the outcomes of how you can help. I once got consulted on a girl with Friedrich's ataxia, had only been managed by neurology and pain management, kept getting admitted with intractable pain. I met her, I added some stuff, and basically they were able to wean her off all of her pain meds. I mean, we're just talking Tizanidine and Botox. I wasn't thinking crazy outside the box here. But I became this family's favorite patient. Pain management loved me because, you know, they couldn't control her pain. They started sending me all these consults. So I think it's just getting your foot in the door with one or two patients where you can really show, this is how I helped. She's not being admitted as frequently, and I think overall it kind of reduced her overall health care costs. I'm going to ask a follow-up question, if I may. One of the things I think that many of us notice in our institutions is services that can and should be doing things are not doing them and punting these hyper-complex things to PM&R, right? So if it's really not complex and it's Tizanidine and managing it, is there some give and take about, like, this is yours, you guys need to own some of this? Because there are other locations where access is a monstrous problem, and we can't be having, you know, every mismanaged polypharmacy person that's in a hospital come to physiatry. It won't work. So maybe if you could speak to that. I've definitely punted patients right back, you know, like chronic pelvic pain or sacral pain. It's like, well, they have a fracture. So ortho, that's you. I get up with the rehab and all of that, but I don't manage fractures. Because I feel like, at least everywhere I've been, orthopedics, they do screen, and we get almost all of the orthopedic referrals that somebody did the quick look and said, yeah, that's not us. Okay. Can we go back to, I think you brought up a very good point in your question about, you know, how do we convince, like, for example, internists to work with us? And I think that's so important to know going into what their fears are. So like in the subacute level, you'll have a hospitalist or an internal medicine or geriatrician who's primary. Their number one fear when a physiatrist comes to their settings, they're not going to get paid. If we have two doctors seeing the patient, we won't get paid. And so it's really important to sit down and explain, you know, for example, they're managing congestive heart failure, hypertension, diabetes. We're looking at gait dysfunction, hemiparesis, neurogenic pain. So they have a completely different work list and diagnosis list than we do. And I've seen that both in inpatient rehab as well as SNF, if you follow that, where we stay in our lane and say there's, I've never seen an instance where they don't get paid. So you have to explain that to them. Because that's, you know, a big deal. And the same with administrators. You have to teach them, you know, this doesn't come out of your Medicare Part A reimbursement. We are Medicare Part B. There's absolutely no cost to you. And this is where you get the value and it'll actually help you with your reimbursement because we'll short a length of stay for your admissions, readmissions, that type of thing. But I think it is really important to know the rules of the game and explain it up front and just address that fear, even just practically, because I would say that probably 85% of them don't know that. And then just one point about surgeons. So the other thing is we've got the institutional needs and problems that we're trying to solve, but then there are problems that individual collaborators need solved. And so we try to identify those. And for surgeons, a big one is that, you know, they have to see 30 plus patients a day for two appropriate surgeries, right? So we were able to leverage that and through the stratification that I was mentioning earlier, help it make sense for them that we were going to benefit them if they came to the table by improving the rate at which patients who end up in their clinic might be appropriate for surgery because of what we can add. And so that helped. And that is exactly what we did to get them on board. Thank you all very much for your time. I'm a spine physiatrist. Dr. Eubanks and I have spent quite a bit of time together. The question that I posed for the three of you, you know, we know that we want to kind of push into this new realm of possibility using physiatry. In order to get there, from my experience, we have to have data to do it, right? Because no matter how much we say we're going to save them money or how much we're going to make this process better clinically, data needs to be there. And so where have y'all gone to get that data that you need in that space so that you can take it to those other parties that are within your system and help them understand where we as physiatrists can come in and help in this space? For me in the ICU, we look at outcomes, you know, shorter days on a ventilator, shorter days, you know, in the ICU, shorter hospital stays. There's not as many studies done on the pediatric world, but we'll take from the adult world. So we help push through a protocol for early mobility, getting patients up and moving while they're still intubated, stuff like that. And then we kind of just use the data from the adult population to use it to show. And then we, I was and I still am a part of some studies looking at outcomes for pediatric patients, but luckily some people have already done the work, the research. So that's helped from an acute care standpoint. So because I was able to convince our C-suite, they gave me a data team and we are in the process of extracting all kinds of data from demographic information to referrals, to track where people are going in our system. We are looking at the aggregate of the treatments that they're getting, the imaging, the surgeries, what kind of surgeries. And it's been really nice. And the reason that they're doing that is because we were able to address their questions about the payoff for this. And so once that is clear to them, they will often offer up resources to help get there if they can see that value. We have time maybe for one more question. Yeah, go ahead. Okay. So is there, are there plans to publish that data so that other institutions might benefit, correct? Right. So some institutions are much more open to that than others. And unfortunately sometimes there are excellent institutions that have lots of great data that could potentially help that won't. And so I'm optimistic that MUSC is going to let us publish enough of the nuts and bolts of the process that it would benefit people. But you're right, because that is what we need to be doing. Unfortunately right now we're often treating that kind of information as trade secrets. Any final thoughts from the audience? Nobody's cried or thrown anything back at you, so you got a little room, a little wiggle room. I'm hoping you guys are all feeling more optimistic. Recognizing that our specialty is one of the two best position as we move forward in the healthcare continuum for really being at the beginning, middle, and end. You know, really internal medicine and us are the only ones that are at every level. And I guess the analogous thing would be pediatricians as well. And I think, you know, when you start looking at all the problems that are in the healthcare system, you know, anything we can do to make it slightly better is something that is useful. And I think something that's appreciated by healthcare systems. And, you know, I just feel like if we can see the opportunities and the needs and just meet them when other people aren't, we're going to be demanded. They're going to want us. And it's not been that, I mean, it's been that way the whole time in my career. I think it's just now, it's just a variation on a theme. Thank you for the opportunity. I'm a medical graduate from India. So in a country where rehab services aren't really paid by insurance and there aren't physiatrists in public hospitals that give free healthcare and it's all in private sector, a physiatrist is commonly seen as a guiding angel to poverty who would extend the inpatient care and just drain your money and wouldn't really give much improvement, though in physiatry we learn that we have to appreciate small gains. I just feel lost. What can we do? So if I'm summarizing your question, it's in India, physiatrists are relegated to just the private sector. So patients would save money rather than go to a post-acute care staff. Most of the time. And we may end up like that. You know, it's very, right now, it's very interesting because when people have certain insurance programs, they're absolutely precluded from getting rehabilitation in a hospital. They are going to get rehabilitation in a skilled nursing facility. 85% of the people I used to see when I first started my career, the first 10 years that went to hospitals are now going to skilled nursing. And it's a very different game. But what's interesting is they actually need us even more. You know, and deciding where people get their rehabilitation, there are more and more people coming to us and asking our opinion. And I think that's really helpful because, you know, we can't control the healthcare systems. We can't control if there's two levels. But we can see that there are people, customers, if you will, patients on both of those sides that need guidance. And then it's just a matter of figuring out how can we provide that and still, you know, have a financially healthy practice. You know, and that's the trick. But I think, you know, we're getting better and better at finding different innovative ways of doing that. I'm going to do this. I'll intervene and just say this has been a wonderful panel. I want you to give a round of applause to three people who are as busy as it can be and bring something very innovative and very unique. And I hope you've gained something from today's session. So thank you all very much. I'll volunteer them. I'm sure they'll be happy to answer additional questions. Thank you all for your participation.

PM&R

physiatry

healthcare models

comprehensive care

post-acute settings

pediatric rehabilitation

mentorship

value-based models

collaborations

evidence-based care

healthcare efficiency