Good afternoon, I'm going to wait just a minute to allow some of our people jumping on a second to connect, and then we'll go ahead and get started. So stay tuned. All right, welcome everyone. Happy Wednesday to you, day after election day. Hopefully, things are settling down in your part of the country. My name is Joel Sauer. I'm an Executive VP with MedAxium, and I'm joined today by David Meir from Sentara Heart, who's going to talk to us about a new program they've instituted with Moonlighting Solutions, and we're calling this From Burnout to Balance. First of all, just want to say thank you to all of you for attending this afternoon. A little bit of housekeeping first. We are on a Zoom platform, and there are two features that are important to you. One is the chat. In the chat, we will place the slide deck that you are seeing this afternoon. It will be in a PDF format, and you can find that in that chat box. That is also your place to ask any technical problems or technical questions you're having, such as sound issues or visual issues. And then the next one is the Q&A button, and you should see those on your Zoom platform kind of at the bottom of the screen, and hopefully they look very similar to what you're seeing here. But the Q&A is where you can ask any questions during the presentation. We are going to take all the answering at the end, so we will go through the content first and then answer questions at the end. However, you can feel free to type in those questions at any time. You don't need to wait until the end. Neither David nor I have any disclosures to make. And here's how we are going to kind of cover the hour. I will take us through a brief state of the industry that kind of tees up the information then that David will present from some TerraHeart, and then we will close it out with some Q&A. And again, you use the Q&A feature in the Zoom platform in order to ask those. We will not be taking any audio questions, and you will notice that both your microphone and your video camera are automatically turned off. So here's what we're all dealing with in our cardiovascular industry. When you consider the number of physicians who are either retiring or slowing down or moving into administrative positions, et cetera, that number exceeds the new fellows that are coming in through the other end through recruitment by about 500 a year. And whether that number is 200 or 1,000, the point is this, we are simply not keeping up with the number of physicians who are departing our profession. We're not turning out new cardiologists fast enough to offset that. And that's against the backdrop of a pretty significant increase in the demand for our services. This is driven largely by the aging population, the baby boom generation, as you all are very aware. That age wave that we have been talking about for more than a decade is really upon us now. And we are looking at annual growth rates, AGR, of anywhere between 8% and 12%. So even if you do absolutely nothing in terms of your market share in your area, you would expect to see somewhere on the order of an 8% to 12% increase in the demand for cardiovascular services. And this was detailed in the study that you see referenced here just a year ago. To show the kind of the impact of that deficit, both you have an increase in demand, but a decrease in supply. What happens in that scenario from an economic standpoint, the price of that resource goes up. And we have seen that with a more than doubling of starting salaries or starting income, I should say, for new cardiologists, where now in 2023, a new cardiologist is earning 90% that of their peers across the country. If you go back just a few years, that was less than 40%. So we have seen a dramatic increase in the value of new physicians as expressed by their starting income. And I know David's gonna talk about that at Sentara and the challenges with recruitment across the board, regardless of the subspecialty type. In response to this, we have a mathematical problem. So the industry has not sat idly by. It has evolved or adapted. And we are increasing the utilization of APP resources and care teams because the physician count per 1,000 active patients is actually dropping. And we see that in the data with the dark blue or dark line at the top. So we're increasing our utilization of paraprofessionals and APP resources. And decreasing our reliance on cardiologists. Said another way though, or looked at from another perspective, is that the burden of panel management is increasing on our cardiologists from an overall supervision standpoint, which can lead to burnout and other factors that are critically important to us as we go forward. And that's another consideration in today's presentation. You all have probably seen this, but more than a quarter of the cardiology workforce is age 61 and older. And what happens at that end of the career spectrum is those physicians tend to take less call than those who are in the earlier stages of their career. And that's expressed in the graph here. So dropping to 70% when they get in that 61 to 70 cohort. And believe it or not, we still have a fair number of physicians practicing into their 70s, less than half of them take call. Importantly, is the burnout challenge about a quarter of physicians by a recent ACC study found that a quarter of cardiologists express some level of burnout. And as you all know, we have introduced a lot of new technologies into cardiology and all of those technologies need to be managed and they need to be learned, which can increase that level of burnout. And then we all know about the inbox and how much physicians love managing the EMR inbox and the challenges that that presents just from a workload standpoint. Call is a kind of a universal, universally unliked burden of cardiology. It's very, very necessary. We are a 24-7, 365 service, but it is no fun to be woken up in the middle of the night to come in and perform a life-saving STEMI procedure or even just to see a patient who's crashing in the hospital or something. And we place as an industry, a very heavy value. We ascribe a very heavy value to that burden of call. You can see here the median falls from almost 700,000 for physicians who are fully participating in our call rotations down to 430,000 for those who come off call. That gives you an idea of that delta. We at MedAxium here ranges anywhere from 50%, or I should say 10% all the way up to 50% of compensation, and that would be borne out here in the data. You also see that we tend to steer business, particularly RVU lucrative business, away from cardiologists who stop taking call. For instance, echo, nuclear interpretations, they may have to come out of the cath lab if they're an invasive or interventional physician, et cetera because we need to match the daytime and the nighttime burden for our services. And a physician who comes off call but stays during the day may eat into lucrative procedures or necessary volumes from a quality and performance perspective or from a skillset standpoint. And so we steer those to the physicians who are fully participating in our call rotations. The bottom line and the very short take home from this is call is a significant burden within our practices. And when physicians want to come off of it, it creates lots of challenges for our organizations. This is just data from a recent call survey that we conducted in 2020, in the March of 2024, so just earlier this year. And we found that most physicians from an interventional perspective have a call frequency. If you look at the middle there, one in four, somewhere between one in four and one in five is the most prevalent call frequency for STEMI patients. So if you're at that left end of this graph where you're having frequency that's less than one in five, one in four, that would be considered a higher call frequency and maybe attributing to some burnout in your physician workforce. These are the types of things that Sentara was looking to address with their partnership with Moonlighting Solutions. And with that, I'm going to pull in David Meir to talk about their experience there, David. All right, well, thank you, Joel. And as I get started, I just want to thank Joel and thank Medaxium for giving us the opportunity to speak a little bit about what we've been able to do to find some solutions to both focus on our patient care, but also physician burnout, reduce some of that stress that Joel covered in his slides coming up into this. And thank you for the audience for taking time out of your day to listen to what we have to say. So just a little bit of high level overview of Sentara if you're not familiar with us. So we are a healthcare system that's been around for about 130 years. We are made up of 12 acute care hospitals, mostly in Virginia and into North Carolina. And we have 13 nursing and assisted living facilities. We have just over 30,000 employees. We have about 4,700 acute inpatient beds. And we also have a health plan side that we cover more than a million members. We are one of the top 20 largest healthcare systems in the country in terms of procedures and things that we provide. And so we stay pretty busy. And so what we want to focus on a little bit more is specifically with cardiology. And our flagship hospital at Norfolk General is also where our Sentara Heart Hospital is. And so some of the things, we provide quality cardiovascular care. We have all the cardiology programs that you can imagine, including cardiac surgery, interventional cardiology, electrophysiology, advanced heart failure. We do heart transplants. And we're also nationally recognized for the excellence in heart health services that we provide. So next slide, please. So just again, a little bit of high level overview of just some of the things that we have to offer. So one of the largest cardiovascular networks in Virginia, one of the busiest heart surgery centers in the country, top 15 in our cardiology program in the country. One in four of our heart failure patients in Virginia are actually treated by Sentara. 60,000 cardiac procedures that we performed since 1971 were active, as you can see, in cardiac and vascular clinical trials. We have over 120 of those at any given time. And we've done about 28,000 heart-related procedures in 2023. So we have about 140 specialty cardiac and vascular physicians, but sort of in the center is really what it sort of boils down to where we were trying to find some of that solution, because this is where the busiest portion of our cardiac and vascular program is. And so that's made up of about 55 cardiologists in the Hampton Roads area. And you can sort of see the breakdown of 22 interventionalists, nine EP physicians, eight non-invasive. We now have four advanced cardiac imagers, six heart failure physicians, and we have just a couple of office-only or flexi physicians. So next slide, please. And so, as you can see, again, just a little bit more about our volume. So about 150, or 15,000 cardiac medical admissions that we've done in 2023, 4,600 cardiac interventions. And you can see sort of the volumes that we have at the bottom. And we're tracking so far this year as we're getting towards the end of the year to exceed all of that volume pretty significantly compared to 2023. And so you can see here that this is sort of a breakdown of our 12 facilities. Those that we've highlighted in the red are really the ones that we focused mostly on in terms of providing some of this call burden relief with moonlighting solutions. And so if you're familiar with the Hampton Roads area around Virginia Beach area, it sort of is where that cluster is of most of our hospitals. And the uniqueness with this area is it's surrounded by a lot of water. And so we have a lot of tunnels in the area, some bridges, but mostly tunnels. We also have a large military naval presence here in the area. And the reason why we have the tunnels is because of our Navy. And so that's a wonderful thing. If there's ever time for them to get in and out in a quick manner, they can do that. The problem is, is that it creates a difficult situation for us to travel back and forth with traffic through the tunnels. And so because of that, it creates this high call burden for our teams because four of our hospitals are on the south side of those tunnels close to Virginia Beach in that Norfolk area. And so we've got two of those hospitals in that area in Norfolk and one in the Virginia Beach area are STEMI hospitals. Then we have four hospitals altogether that do the cardiology work. And so we try to cover that volume at the nighttime with both our general cardiology and our STEMI coverage. Because there's those four hospitals and where the majority of our work is, the call burden is extremely high there. And so we really needed to try and focus in on this area and try to provide some relief for our teams. So next slide, please. So this is really just sort of high level of the reasons why we needed to find some solutions. And so as Joel talked about earlier, we're right in line with what he had talked about. Our call burden, it was one in three to a one in four area. A third of our physician workforce is in that 60 plus range. And so we really needed to try and find some solutions for both physicians who are retiring or ramping down or who have stated that they're gonna be retiring in the next couple of years. And so most recently between August and October of this year we just onboarded nine new cardiologists. Seven of those nine are cardiologists that just came out of fellowship. We had a difficult time with recruiting initially because of talking about the call burden and the requirements for that. Because our call burden is so high, it requires our team to be off after call the next day, whether they're interventionalists doing the STEMI coverage or our non-interventionalists doing the general cardiology call coverage. And as I pointed out earlier, nine of our general cardiology call coverage physicians are our EP physicians. And that's a significant problem for us because it keeps them out at the cath labs, keeps them out at the offices. And so it just continues to create this backlog with our EP procedures. And so we were at a point where we were about six months out for our elective cases, which some of those patients then would come into the ER multiple times before they could actually get their procedures. Sometimes they would end up being in inpatient admissions but it would progress from being a elective, outpatient, stable patient to a more urgent situation by the time they could actually get their procedures. Because of the off after call, all of our physicians average around 30 days per year of off after call, which when we look at it from an EP perspective, that is really the equivalent of one full-time EP physician that we don't have available to do work either in the hospital or see patients. We also had some challenges with our length of stay because we didn't have consistent rounding within the hospitals because of all the call coverage that we have to do and the off after call. One of the things that we had initially started this conversation right around the first part of 2023, we had the conversation with Moonlighting Solutions. We found out that they have something to offer by word-of-mouth and so I reached out to them and said, hey here's what we want to get from from this opportunity. And so I laid it all out to them. They had a really good plan but shortly after our conversation started, we actually had to make a quick pivot to have some imaging support. So we had our cardiac advanced imaging was supported by a radiology service that told us that they were no longer going to provide that service to us and they gave us a two-week notice to do that. And so Moonlighting Solutions, I called them right away and told them what we needed. They were able to provide a quick solution for us and within three weeks of that notification, we had both Moonlighting Solutions physicians in person and remotely helping us to bridge that gap. I'll talk a little bit more about that here in a minute. If you'll go to the next slide please. So as it states here, you know, the three things that we are working with Moonlighting Solutions for now and it really started with just looking at general cardiology call coverage. We're also using them for our STEMI coverage and we're also using them for our advanced cardiac imaging coverage as well. And it's been a great partnership with Moonlighting Solutions, very responsive to any of the questions that I have. When I first talked to them, I had a whole sort of a wish list of things that I wanted from them. I asked for nighttime call coverage on a 365-day model for general cardiology. I asked for weekend STEMI coverage on every weekend. I asked for rounding with both STEMI and general cardiology on the weekends as well. And I asked for that general cardiology coverage on the weekend. And then of course then we had to ask for imaging coverage 365 days of the year as well. And they were able to deliver that to us and they were able to deliver it to us quickly. And it's been a very great program and process with them to the point where we're able to scale it a little bit higher than what we had originally had planned. And it's worked out much better than we anticipated. Next slide please. So before we were able to get any of that stuff in place, we had to get some leadership buy-in. And so I had to really create a business plan to present it to our medical group executive leadership team and also to our hospital physician or our hospital executive leadership team and our system leaders to show them what the ask was for, what the cost would be, what that investment would be, and what we would get out of that in return. And it was a very easy proposal for us and it was very easily accepted by our leadership team because they knew the call burden that we were facing. They knew the challenges we had with length of stay. They knew the challenges we had of getting patients into the cath labs because we couldn't fully support those cath labs that we needed with our physicians as much as we would want. And so there was immediate buy-in from our teams. It was very easy to get this process in place. And we looked at it really from, you know, how do we continue to build off of what we're proposing and how do we grow this? And so it was something that we could just turn around pretty quickly and get that support from everyone that needed to provide that support because they knew the impact that it was going to have. And so if you go to the next slide please. Thank you. And so this is sort of the timeline of when we started working with MLS to do that general cardiology and interventional cardiology coverage. And so just to back up a little bit, the imaging portion of it, we started that in March of 2023. We start the conversations overall in around February. And so we made that quick pivot to the imaging portion. In October of 2023, we started the general cardiology call portion of that. We took a little bit of time to get that up and running because we wanted to build up a panel of physicians that would be able to provide that coverage. So it was something that would be a little bit more regular. We also of course have that credentialing period of time that takes a little bit of time as well. And so on October 18th, we had our first night of general cardiology call coverage. And we had that for a period of at least three days in a row. We had a total of 12 days for October. By the time we got to November, we had about 85% of the month covered. And by the time we started the month of December, we had 90% of that month covered with the exception of those key holidays that happened to fall into December. But by the time we got to January, which was just about two and a half to three months later from our first day of coverage, we were up to that 365-day model of general cardiology call. And it worked out really well. There was just minimal hiccups along the way. And it was something that we had to put a lot of thought and process in place before we started because it was a change for our hospitals in terms of who's calling and who's going to be on call. It really wasn't much of a different process in terms of we still had great quality physicians. It was just not the same physicians that they were used to seeing each day in the hospital. So that was the biggest disruption there. But we provided that feedback, provided the plan of what was going to happen, and it was received well by all the key stakeholders. And we had a good process to sort of roll out along the way. Because the general cardiology call coverage worked out so well, we started an inpatient rounding model at Heart Hospital on March 1st with our EB team. We were able to then, with the use of general cardiology call coverage with midline solutions, move our EB team into all the cath labs and then start that inpatient rounding model. So next slide, please. And so some of the impacts from that. As you can see, our volume increases a little bit year over year, but we really saw a significant impact really mid 2023 moving into now in through 2024 because of having those physicians into those cath labs. A lot of this volume is attributed just the extra days that we've got back from those physicians. Between those nine physicians, that really has bought us about one full time equivalent of a cardiac EP position to be able to be back into the hospital doing the procedures. And so this has been a tremendous help for our patients, primarily because they're getting their ablations and getting their procedures much quicker than what they were able to get before. And they're staying out of the ERs. They're not coming into the ERs as they're progressing in the disease process. They're not being impacted even from a length of stay perspective as well. So next slide, please. And so this is just a little bit of the increase as well from the other non-EP program. And so looking at all of our CT surgeries with structural heart and surgery and others as well, you can see that there's also been that increase in terms of volume. But again, we've seen a lot of that increase from mid 2023 through this year, really because of having more access to our cath labs with our physicians by removing that off after call and relieving that call burden that they've had. So next slide, please. And so this is just an example of what that inpatient rounding model looks like with our EB team. And as you can see, we pretty much have a physician and an APP. The physicians are in that sort of teal color and APPs are in yellow. Rounding as a team on all of our EP patients Monday through Friday. And as you can see, it's the same team as well. So that team doesn't change. It's the same two people every day for that week that we can provide that coverage. This has been really a great step for our team and for our patients because prior to the inpatient rounding model, prior to using mutilating solutions, the physicians that were scheduled in the cath lab were also the physicians trying to round on the patients with the APPs in the hospital. They were also the ones that had to go to the emergency room when they got those ER patients coming in. They were also the ones that had to do, um, sorry. Um, I love those lights that just go out automatically. Um, so they were also the ones that have to, um, also read those stat, um, echoes and those sorts of things if there's something coming through. And so this is very disruptive both to the cath labs, but also to the inpatients and created this length of stay area. So now that we have this inpatient rounding model, it's just the inpatient team that follows those patients. It's just the inpatient team that goes to the ER. This allows us to actually do more procedures in the cath labs because there's more time for those physicians to focus on that. Uh, and they're also getting those patients scheduled who are on the inpatient side for a more timely, um, procedure. We're also now going to add this for our general cardiology team as well, starting in January of 2025. Next slide, please. And so this is the impact that this has had on our length of stay specific to EP. And so that January sort of through April area is really pre, um, using the inpatient rounding model. We started it in March, but it was sort of only mostly two weeks in both March and April because here and Virginia and the Hampton Roads, we have both a public school and a private school spring break, which ones in March ones in April, and it takes half of our team away in March takes half of our team away in April. So we weren't able to do that inpatient rounding model for the full period of time, but really starting in May all the way through now October, we've had that dedicated inpatient rounding team, and you can see that month to month impact. You know, we started the year out with an average length of stay of around 5.6 days for our EP inpatients were now down to about 4.1 days. And so about a day and a half you can see is really what that drop is from the average length of stay, and you can see the month individually impact as well. And so it's this has been a significant impact for us from a length of stay perspective, also from a patient satisfaction perspective, because they're getting out of the hospital quicker, certainly from, you know, all the administrative portions of that, looking at that as we're now freeing up access to other patients that need to get in and come over here for procedures and and also decreasing those length of stay opportunities. So next slide, please. And so these are some of the outcomes that we've been able to achieve with Moonlighting Solutions. And so while we still have the same amount of general cardiology call, rarely for our physicians who are on general cardiology call, do they actually get called? In fact, we don't even publish who is on call for our team to our hospitals or to those who are paging our teams when they're on call. The Moonlighting Solutions team have that. Our administrative team has that if they need to be reached, but we don't publish that because we don't want them called, and they rarely are they called. We're having STEMI coverage every single weekend, which has been a great relief for our interventional team. Because we have three STEMI centers on the south side, there's always STEMIs that happen every day. On the weekends, there's usually two or three, sometimes up to as many as 10. But having the Moonlighting Solutions team here gives our team the ability to then round on the patients and spend some more time with that care to either set them up for procedures on the Monday or or even get back home with their families a little bit more and focus more of their life around life outside of work sort of a thing. And so this has been a great solution for us from the interventional side as well. They also provide full weeks of coverage when we need it, and so all of our key vacation times, the spring break times, those key holidays as we're heading into Christmas season and those sorts of things, they're providing that full coverage for us. They also cover any other of those single holidays, Memorial Day, Labor Day, those areas as well. Because our goal is to, one, mostly provide high quality care for our patients, and we're getting the high quality physicians from Moonlighting Solutions to do that. But we also want to reduce that burden and that work life balance increase for our physicians. We're able to achieve that now with Moonlighting Solutions. We've reduced that off after call for both interventional and general cardiology, as I mentioned earlier, which means that obviously we're getting patients into our offices a little bit quicker. We're also getting patients through the hospital, both on inpatient and outpatient side for procedures. We've gained more than one FTE, but one FTE specifically from EP, but now that we're using that for the additional STEMI coverage and others as well, we've gained a little bit more of those FTEs by reducing that off after call for our team. And so our interventional team still has it to some degree, but not nearly as much as what they had before. And it's also, again, as I mentioned earlier, it's been able to give us this consistent inpatient rounding. I know in healthcare, length of stay is something that we've talked about since the beginning of the healthcare system, and it's something we'll continue to talk about, something that we always focus on for all the reasons that we know. But this has been a tremendous help for us to reduce length of stay. And this isn't the only thing that truly impacts length of stay, but this has been one of the biggest things that we've been able to impact with length of stay, to the point that we are now scaling it out at all of our hospitals to do the same rounding model. And certainly this actually sort of created a problem for me, because once all of our hospital presidents and others saw the impact that this had, you know, they wanted to get in line and said, hey, when is this going to happen for us? What about us? When can we do the same thing? And so I appreciate their patience. They had to be a little bit patient for us to get there, but we've got got there now. And so starting January 2025 is when we'll introduce that to all the hospitals to do the same sort of rounding model. But it also gives us the cath lab access and OR access that we need as well. You know, we're now able to consistently staff all of our cath labs and our ORs Monday through Friday with all the resources that we should be providing from a physician perspective because of reducing that off after call and having that support from Moonlighting Solutions. And it's also allowed us to expand our imaging program. You know, once Moonlighting Solutions provided that advanced imaging coverage for us, they were actually able to do a lot more volume than the previous group was able to, and they got a much quicker turnaround time. We asked them to give us a 24 to 48 hour turnaround time, and they're giving us less than 24 hour turnaround time for non-stat studies. And of course, the stat studies are reading those right away as well. But it's helped us to grow our program because they've increased the access for us by having that availability. And they're available to read for us seven days a week. We've now hired some of our own advanced imagers, but we're still partnering with Moonlighting Solutions to continue to provide that support. We weren't able to do that without having their support. And so because of using Moonlighting Solutions, it's allowed us to grow organically as well to provide even more care and better care for our patients. And importantly, and maybe one of the most important things for our physicians, it's helped us to recruit better. It's also helped us to achieve that work-life balance and retention with our physicians. At the end of 2022, heading into 2023, there was a significant burnout with our physicians, and you could see that on their face, and they verbalized that, and you could see that they just needed a break, and we could not provide a break quick enough. And so even as we talked about talking about that call burden, that was a deterrent for physicians. You know, we have a lot of great programs that we offer here and a lot of great physicians doing that work, but thinking about that call burden and thinking about the time spent away from family, that's a turn-off. And it was something that they realized. But once we were able to get Moonlighting Solutions in place, and we could show very quickly how that had a positive impact both on the rest that our physicians are able to provide or get. The time away from work and spending meaningful time with their families, but also helping to create some of that access with our patients. They were able to see that, and so that's been one of our best recruiting tools. It's also been one of our best retention tools. Having conversations with some of our physicians who said prior to doing that, they talked about they were really actively looking for other areas because they just were burnt out. Since we brought this in place, they have completely changed their mind. In fact, I've had a lot of our physicians tell me that this is the best thing that we have brought to Sinterra in the last two or three years, and I appreciate hearing that, but I hope that it's not the only thing that they feel is a good thing, but we hear that all the time, and our physicians sing praises about this because of the value that they've received from this, and the time away from work that they can focus time on their families and not still thinking about work. And then, as I mentioned earlier, we will do the same sort of IPR model at all of our hospitals starting in January of 2025. And so next slide, please. Thank you. And so some of the lessons that we learned, and so it certainly wasn't without some hiccups along the way but they were very minor hiccups. One of them was the credentialing thing, and so, and part of that was more so on our side than not even Moonlighting Solutions, and credentialing is, at least everywhere I've been, is sort of like a four-letter word that it's never an easy process. It's always painless, something we have to go through, but it is what it is. And so the big thing for our credentialing team also, which I learned along the way very quickly that we had to provide that education to them as well was it was a foreign concept to them to know that, hey, here are these cardiologists that we want credential to do the same thing as what our cardiologists would do, but most of the time they're gonna be sitting remotely doing that. They may not even be in Virginia doing that coverage. And so that was sort of a foreign concept for them, and so that was part of the hiccups along the way. We figured that out pretty quickly and started having weekly meetings both with our credentialing team and with Moonlighting Solutions, which was able to eliminate those barriers, get us all on the same page and move forward. And then, again, it was just some of that communication. Again, because we're a 30,000 employee facility, it's hard to get all that communication to everyone that needs to have that information in real time. And so it was just some of the communication both with the physicians providing coverage of sort of the Sentara way of doing things, because again, these are all physicians coming from other institutions that they're working as a full-time physician at those locations. And so their way of doing things might be slightly different than ours. And so it was a little bit of that communication. So we started creating some documents that really sort of outlined those key things that would be something they would encounter throughout the course of the night. And if there was someone they had to call or page or escalate things to, we sort of created that pathway for them. We also provided that same communication to our teams as well. And then what we also said was, you know, when patient, or excuse me, when physicians are coming here in person, but certainly even remotely to provide coverage, we provided those full days of orientation. So they had to go through the same orientation as our physicians would do. They had to go through the same EPIC training. We use EPIC for EMR and do that same training. And for those who are in person, especially for those interventionalists, we actually require them to come here Thursday and Friday before they provide coverage through the weekend and actually have them do cases. We wanna see them do cases and make sure that we're all aligned, that we're comfortable that they're gonna provide the same quality care that we would. I believe that we're over 90 physicians now that Planning Solutions has sent to us in over, in the last year, year and a half. And I think at least 85 of them we have used without any concerns whatsoever. And there was just a couple, and maybe a couple that came out of fellowship that we just felt like because we're so busy, maybe they weren't, it wasn't the right position for them, but nothing that concerns at all. And so Moonlighting Solutions has done a really fantastic job of providing us exactly what we've asked for, providing us with the quality positions that we've asked for. We really haven't had too many issues along the way. And Moonlighting Solutions even took the time to come up here and visit our hospitals and visit our site and talk to our teams, talk to our leaders, talk to everyone who's directly involved with this process to make sure that they understood fully what that situation was, if there are things that they could be doing better, anything like that. And so again, Moonlighting Solutions has just been a fantastic company to work with to help us find some work-life balance and some better access for our patients. Next slide, please. And so just to sort of wrap things up, what we're looking at now with 2025 and beyond is we're not looking to move away from Moonlighting Solutions as a temporary sort of a thing, but it's really what I would say is our next phase. And how are we building from what we've already got from Moonlighting Solutions to provide this better balance for our physicians, better continuity of care for our patients and better recruiting and those sorts of things. And so what we're gonna actually start doing is we're gonna start instituting an admin day. And it's sort of like the off after call, but not really, because the physicians are still working, but this is what we would call sort of the pajama day. And so they can work from home. They would be the ones that are sort of on call if maybe a physician gets sick or they have four flat tires or some reason that prevents them from coming into the hospital. Well, these physicians who are on admin will be the first one up. And so that would minimize disruption to offices that we would maybe have to close an office to ship someone over or even another hospital if there's a subspecialty within one hospital that needs to move to the other. But that also gives them time to get caught up on all the non-patient facing work. And so again, rather than going home and having to take time away from family to read echoes or read EKGs or get caught up on the charting or the in-basket messages, we wanna give them a day every two weeks that they can do that from home. And so then really our goal is to minimize that time away from family and to maximize that time that they can spend refreshing and getting renewed to be able to come back to work the next day and having some of that break and that separation from work and from life. And so we wanna continue to support them any way that we can. And so that's one of the things that we're gonna start again, 1st of January, everyone will have the ability to take that admin day every two weeks. We're gonna continue using them for general cardiology call. We're gonna continue using them for our STEM and coverage on the weekends and those key vacation points throughout the year. It's been a tremendous help for us, tremendous help for our patients and helps us to achieve a lot of goals that we want to. Internally by using Moonlight Solutions for that coverage. And we found that we've have a lot of the same consistent physicians who are providing that coverage. And so we've grown to get to know them pretty well and they're part of the team. And now it's really, it's difficult to even separate the Moonlight physicians from our regular employed physicians because they're here so much, we're speaking with them so much that they are now fully integrated as part of our team. And really again, our goals are to continue to find other ways to reduce that burnout. As Joel mentioned earlier, patients are living longer, they're living sicker, the number of cardiologists are decreasing, they're also aging. And so we're gonna continue to use Moonlight Solutions to find other ways that we can continue to help reduce some of that burnout, reduce some of that extra work that they have to take home each night, enhance their work-life balance, and also be able to provide care for these patients longer than they would have. And so I think that the possibilities of using Moonlight Solutions beyond what we're doing, it really is endless. They've been a great organization to really just step up and listen to everything that we've asked. And when I asked for all the things that I asked for, I walked into that thinking if I achieved half of that, that would be great, because it's much better than what we had. And I didn't fully expect that we would have the great response that we had and the great support of Moonlight Solutions, but they have certainly far exceeded my expectations. But I think that's all that I have. So I appreciate everyone, appreciate your time, and happy to answer any questions that you may have. Great, thank you, David. And just a reminder, two things. One, in the chat box are the slides that David just went through. It's in a PDF format that you can download. And you can type any questions you might have into the Q and A box that should be at the bottom of your Zoom panel. First question, David, and you kind of touched on it a little bit towards the end there, but what are the characteristics of these physicians that you're getting to cover this call? Are they, you mentioned some were straight out of training, but like, do they tend to be physicians who are in slowdown mode? Are they locum's physicians? What kind of give us a general sense of who's covering for you? So that's a great question. So I don't really consider them locum's physicians. I guess by definition they would be, but I don't consider this that, because I've used locum's physicians in the past. And sometimes you get a good physician, oftentimes it's someone who is not really the same person that we would want to provide high quality care for, and we have to dismiss them early. We haven't had to do that with this team. And these are folks who, a lot of them are living in Virginia, living around the area. So our teams already know them to some degree, but they're invested in the communities and invested in what they're doing. And they're mid-career folks who are seasoned and have that critical decision-making and the skillset to cover our patients that we can sleep at night and feel comfortable that our patients are in good hands. And they're really invested in helping us to continue to grow as well. And so they've been a great group of physicians that come to us. We really haven't had, as I mentioned earlier, we really haven't had anyone that we really have had any concerns with or had to really provide much feedback on or anything like that. It's really just, they've done a great job providing exactly the physicians we want. And these are the physicians that I would hire. If we had a need to hire these physicians, I would in a heartbeat hire these physicians and bring them on as part of our team. Okay. And then related, but from the other side with that team, what's been the reaction of the patients from a satisfaction level? Have you seen any impact there or any concerns there? We have. And so typically our patients rate our physicians nearly perfect. And so it's never been a situation of they're not happy with the care that they provide. The area where we struggle is access. And that is the one thing that patients have always complained about. If there's ever a complaint, it's your access is terrible. And we have no argument for that because it is. But this has helped tremendously for those patients who are impacted, especially from the EP perspective, getting those patients in, because they recognize that. They see that and they know that they're getting in earlier than they would have in the past. Because a lot of these patients are patients that we're monitoring and telling them sort of estimated times of when they may need a procedure, those sorts of things. But they have seen the impact and that we do get that feedback from those patients that say, gee, it used to take me six months or a year to get into your office or to have a procedure done. And now I can get in within a month or some time when it's worked for my schedule. And so that's been one of the biggest impact for me, patient satisfaction is just that timing of getting patients in. Okay. And then along that same theme, did the relationship or workflow with your hospitalist program have to change with this or not? You know, it changed a little bit, but I don't think I mentioned this at all, but outside of our physicians, our hospitalists and our APPs love having this program, especially from that inpatient rounding model from an EP perspective. Because that was one of the biggest frustrations with our hospitalists is you've got a different physician coming in every day. They all provide great care, but they all have a little bit of a different idea of what they want to do with the patient. And so that was part of the reason why the patients were having such a long length of stay. Our APPs also felt the same way because they have a different physician and a different plan each day. And so they really weren't sure what's going on. But now that we have this consistent inpatient rounding model, you know, we have monthly meetings with the hospital years and certainly we talk to our APPs all the time. And so this has definitely been one of the things that comes up every meeting we talk about is this has been such a great process. We love this relief that we've found and they're all looking forward to us now integrating that same inpatient rounding model for all of our hospitals, for all of our cardiology patients. Okay. And then focusing on general call, are you using the moonlighting staff for frontline general call or do you have APPs and nurses on after hours as well? And I think the question is related to weekday after hours call. Yeah, again, that's another great question. So we also have, yes, we have APPs on call as well. And that's always been part of our model. So they are sort of the frontline that are receiving some of those calls first but most of those get then escalated to the physicians. And so we're using moonlighting solutions for all of that call coverage now. And so, as I mentioned earlier, our physicians who are taking that general cardiology as what we would say backup now, we're not even publishing that, it's not posted. And so no one really knows outside of a small group of people who those folks even are. So MLS is doing a hundred percent of that seven days a week for us, general cardiology and nighttime call coverage. Okay. And I'm curious, what's been the response of your executive leadership? Are they happy with this? Are they feeling like, oh boy, now you've opened Pandora's box? Because in your future, you want to expand it to other specialties. Is that seen as a good thing or a terrifying thing? No, it's actually seen as a good thing. And so it's been well-received. And so it's sort of hard to quantify what that ROI is. And so we always are interested in what's the ROI. And because we're using moonlighting solutions, not for one thing, but for multiple different avenues, it's hard to quantify that specifically, but we can see a positive investment or a return on our investment from a bottom line perspective. But we're also seeing it from length of stay. We're seeing it from decreased ER admissions. We're seeing it from improved access on the outpatient side, improved coverage in our cath labs, improved access for our outpatients as well. And then of course, we showed that decrease in that length of stay. And so all those things are positive that our leadership team responds well to. And so they want to continue to add to that. And I have had conversations with some of our other subspecialties, neurologies and other areas that said, hey, can you give me the same thing with moonlighting solutions that you've got with cardiology? Because we would sort of like to do that same thing. And so we are looking at, is there a way to expand this out to help provide some of that relief? Okay. And I presume the response of recruit people you're interviewing or looking at is very favorable. Yeah, it's extremely favorable because oftentimes when we would tell them pre-moonlighting solutions, what the call burden was and then the frequency, they would sort of respond and say, well, that's sort of what I'm doing now in my fellowship program. I was told it gets better, but it doesn't sound like it does. But now that we have this and we're able to provide that to the physicians that we're recruiting, they say, gee, that's fantastic. That's so much better than what I'm doing now. And those who are living at, they also say the same thing as essentially, especially from the general cardiology side, we don't really take all anymore. We sort of feel like we're spoiled and we're getting paid to not work when we're supposed to be on call. And they're not wrong, but we look at that as a great investment for what we've gained from that. Okay, great. Well, David, this has been a very enlightening conversation and we thank you very much for being willing to share your experience there at Sentara. And to our audience, thank you. We've been gotten through all the questions. And so if you are interested in a recording of this, it will be available to our members through our knowledge base on our website. It takes a few weeks for that to show up, but it should be there soon. So without further ado, I'll say thank you again to David Mayer for his presentation and thank you to our audience. And I hope you have a great rest of your week. Thank you.

cardiologist burnout

Moonlighting Solutions

call coverage

workload balance

Sentara Heart

patient satisfaction

cardiac procedures

physician performance

sustainable work environments