Hi, good afternoon and welcome back to our third in the series of our nurse navigator and coordinator webinars. Today we are going to be speaking with some excellent cardiovascular administrators who are thought leaders in the space to share their insights and perspectives. So welcome to all. My name is Jenny. I'm one of the VPs of care transformation, just a couple of housekeeping things. You will note that we do not have, we're not communicating today via voice. We do have our chat button or chat section, which will have the links to the materials. If you have any questions, please use the Q&A section. Please feel free to enter questions at any time. We will be monitoring that and we will have some dedicated time at the end of the session to ask any questions you'd like to, and we'll get those answered. And in case we run out of time, no worries, we will follow up with you separately. So just as a little recap, we've been discussing and learning about these roles and how they fit within cardiology. And last month we heard from a couple of people doing the job. So heart failure, nurse navigators and structural heart coordinator. And we, you know, we're, we're struggling to decide what's the differentiating factors. And so when we go back and see where these positions originated, we really have two definitions outside of cardiology, but I wanted to share them today to give us a little bit of context. And it doesn't necessarily drive clear definitions or responsibilities, but it does give us just kind of a starting point as reference. And so really nurse navigators stem from our oncology nurses. And as you can see, these are medical professionals that have clinical expertise. So we've seen the things that they're all responsible for, but they're responsible for guiding those patients and their caregivers to make those informed decisions. They're collaborating with the multidisciplinary teams, allowing for screening diagnosis, treatment in a timely manner and increasing supportive care across the continuum. And so that's really the main difference is that supportive care across the continuum. That's something very important with this role. And then when we look at a definition for coordinator, it's really stemming from the American Academy of Ambulatory Care Nursing. And so while this is ambulatory nursing, this really focuses on care coordination and transition management across the continuum. And according to them, this is really individualized patient centered assessment and care planning. And again, across settings, providers and levels of care. So not really a clear differentiator there. They're both very similar. It is important to note that this care coordination does not mean case management. So we don't want to confuse it with those things. Very different, very important roles, but not within the scope of what we're talking about for these nurse coordinators. And just as a reminder, we know there's a lot of challenges with this role. And just a refresher from our survey, you can see all these challenges. We have lots of questions about how do we show their worth when we can't really return, show that return on investment because they're not really producing revenue? How do we support them while they are trying to meet the demands of the job? And how do we guide them and help them prioritize in alignment with our strategy and future roles and goals for the system and our subdivisions of cardiology? So as you can see, administrative support is going to be crucial for the success of this role. And at this time, there's really not clear understanding of one, how we obtain these positions successfully. And then two, how do we onboard them and support them from an administrative side? So that's what we're here to talk about today. We want to make sure as we consider these positions that our nurse navigators and coordinators don't feel alone, that they're not out here on the side, that they're actually part of the care team. Now they're not necessarily doing the direct day-to-day patient care, but they should be considered as part of that core team. They are essential in the glue that holds these programs and the patient populations together. So with that, I would love to turn it over to my friend and mentor, Tom Draper, who is our vice president at WellSTAR Center for Cardiovascular Care. And we are looking forward to hearing your perspectives, Tom. Thank you, Jenny. Good to be working with you again. I had the pleasure of partnering with Jenny for two and a half years before she left to go to MedAxium. And although I was incredibly sad, I was very excited for her and seeing her do so well for this opportunity. So thanks for having me here. Jenny, if we go to the next slide. What I want to do is I'm going to take us from a little bit of a philosophical, from an administrator's point of view and sort of what goes through our minds, not lost probably on many of you, but I think it's a good way to start as we're thinking about how to advocate for these types of roles. Jenny outlined well that these are difficult. They're not always black and white, the value that they bring. So getting in the heads of an administrator, whoever it is, they're advocating for these roles is a very important aspect. And then I'm going to go more practical and sort of what is a process that you can walk through in order to get these roles. So next slide, Jenny. So this is just a snapshot of the WellSTAR Center for Cardiovascular Care where across seven hospitals, we, as of September 1st, that will grow as we're acquiring Augusta University Health in Augusta, Georgia, as well as integrating with the Medical College of Georgia. But a pretty big community-based quasi-academic system. So September 1st, the academic piece will certainly ramp up. Next slide, Jenny. So the mind. So the mindset of an administrator. And I like to go, like I said, I like to go through this exercise knowing that in my mind, I'm working very closely with our navigator team or our leadership team, and I understand these things really well. But then I have to put my mind into whoever I'm advocating for or with in order to get the roles or get the resources that I'm needed. So I, you know, always going to be, they're always going to be methodical, data and goal-driven, business-oriented. So as you, the farther you get up in the organization, you're going to have this become more and more prevalent. And then really, you know, the last two items on there, driven by the system strategy, always want to be able to tie it into that and understanding how this role aligns with that. But also, typically, they're not initially aware of the clinical benefits. So there's going to have to be some education, some partnership with your physician and your clinical leaders in order to help educate them on that. Next slide, Jenny. So what is their focus? And so these are the problems. And so as we are advocating, we're trying to figure out what problems are we solving for them. So they're always going to be thinking about, and I put we and then they, and sort of interchangeably depending on what we're talking about, but do we have the capabilities to grow and sustain growth? So is this going to help me with that? Is this navigator role or whatever role I'm trying to get can help me with that? Are there operational efficiencies that I can leverage? So is this going to solve a problem where I have some inefficiencies in the care that I provide? Will it help me capture more patients? Will it help improve my quality? How do our patients perceive us today? Is this going to impact that? And a lot of times these roles are very, very powerful as it comes to that. Financial performance. Obviously, if I'm not targeting my financial or I'm not reaching my financial performance that I want to, is this going to help it or hinder it? That's where a lot of the rub comes in. And then also, as I mentioned, is it aligned with our system strategy? So that's what their problems are. Now we need to help solve those problems. So if we go to the next slide, as we're creating proposals, as we're developing what we want to advocate for, they're going to fall into one of these buckets, probably multiple buckets. But this is where you really need to start developing and telling that story. Is it a quality issue? Is it a cost effective navigator or program or a proposal that you're trying to develop? What is it going to do with the finances? The reputation and referral piece. Don't ignore that piece, especially if you're in a very competitive market. And will this solve multiple problems? So those problems that I showed, will it solve multiple of those? And it should fit into one of these buckets. If it doesn't, then we're probably going to be misaligned with whatever that administrative leadership team is actually looking for. So that's a little bit more of the philosophical. Let's jump in a little bit more, Jenny, on the next slide to that value proposition and how I look at this. So this is more getting into my head and my understanding, because I've been educated by people like Jenny and our physician leaders about the role of nurse navigators and what they can provide. And it's really the impact that they have on their care teams to help to streamline the decisions, the clinical decisions that are being made, whether it's on the inpatient side or whether it's on the outpatient side, guideline directed medical therapies, transitions of care. And I heard all of this from Holly, Hannah, and Emily last month, that they really, really provide, and there was lists, they had long, long laundry lists of the things that they do to support the care teams. But what they highlighted, both inertly and also not as clearly, sort of in between the lines, it's all designed around the patient. It's all designed around the care of the patient, and that's really the value that I think they bring in. And that has huge value to me. Now, what can we show to say, all right, this value can result in X, Y, or Z, and that's where some of these other big metrics come in, readmissions, length of stay, do we get patients in quicker in structural heart or other areas, will it improve my quality or guideline directed medical therapy, will I have more volume, will it improve patient satisfaction? All those things we can then articulate, but we need to talk about that value proposition of what it does to the patient first, then adding in those different data elements. So next slide, Jenny. So data that I look at, and I highlighted some of those, but this is one of the first steps that I always do when I'm working with my leadership team to start a justification for some type of role. And again, nurse navigators roles can be difficult to get because they're not always black and white with regards to the value that they bring from a financial point of view. I just advocated for, you know, three nurse navigators in our structural heart, one in our structural heart, two in our electrophysiology space for some growth that we're anticipating. And the first question I got from our finance leadership, well, what's their ROI? What financial benefit are they bringing? Not all the quality stuff, it was the finance question first. So I needed to come with, and the answer is they're not necessarily bringing in new patients. They're going to help us absorb the new patients we're anticipating. So I needed to change that story a little bit, but the remissions, the penalties, the value-based penalties, and I'll talk about that and I'll show an example of that. Quality is a huge, huge one. We say quality is our first, second, and third priority. Always start with a quality piece. So satisfaction, is it an access time of treatment? And then any care gaps that we're missing, that really is having an impact on our whole continuum of care for our patients. So that's the first step, to really start to bring in that data and start to work with the team on what is it that we want to look at, what's going to tell the story that we want to provide. So next slide, Jenny. So this is an actual example. These aren't real numbers. This is all fake numbers. We actually helped advocate for this. This is when we were trying to expand our heart failure nurse navigator program across the system. And we were working with individual hospital leaders to try to tell the story, but we actually started at the system level to try to get some advocation at the system level before we even went to the hospital level. And the story that we were trying to show at a system level is we have an opportunity in our readmission reduction penalties. We have an opportunity in our QHIP measures and our penalties, or actually our opportunity, not our penalties, but our opportunities with some of the private payers, because we're not reaching our max point. So we articulated that. And if you look from each hospital, again, these are fictitious numbers, but if you look from hospital to hospital, like, oh, wow, we're actually leaving money on the table. Now, in the grand scheme of a $9 billion system, these aren't huge numbers, but this is just one piece of the pie of what the story that we're going to provide. And this also helps to show, yes, these navigators are going to help to justify and really cover their own costs if we can impact these penalties or these cardiovascular measures. So Jenny, go to the next slide. And this is sort of, all right, here's what we need. Here's what we have today. Here's what we actually need. And in the top three hospitals, the top two, we don't have anybody. So what is that going to cost us? And what is, for those hospitals, the dollars realized that we could probably accomplish if we're saying these navigators really execute on their roles? So I purposely put sort of different scenarios. The first hospital, yeah, we probably can attain more than what it's going to cost the navigator. The second one, it's right equal. And the CFO of the hospital may say, you know what, it's not really worth it to me. And then the hospital C said, well, this is actually going to cost me more than what I'm getting penalized. And the last hospital was like, okay, yeah, we really need to do this. So that's the starting point. And then it's those individual stories. So in hospital B, it's like, all right, I know it's pretty much a break even, but let's talk about some of the other things. Let's look at your patient satisfaction. Let's look at some of your throughput measures. Let's look at your read emissions. Let's start to look at some of those things and peel back the onion. So this is an aggregate from a financial point of view, that the story is very individualized, whoever your audience is. And in this case, each hospital that we're going to. But we wanted to tell the story at the system level. So our system leaders will start to get the buy-in and then put pressure on those hospital leaders to help us execute this for a system benefit. So it's all playing the game and it's really helping to know who your audience is and what levers you need to push with those audiences. So go to the next slide, Jenny. So now we're going to start to develop that story. So all the data, let's gather that, start to looking at crystal ball, what's happening over the next two to five years? Is there something that is going to happen? You know, we look at structural heart, electrophysiology, all the projected growth. How do we plan through that? You're always going to be asked, all right, if we're not going to do this, how can you achieve what I want you to achieve, meaning better quality, better financials, in some different way? So always think through those alternatives and be ready to answer those questions. Understand all those levers impact finances and quality, such as I mentioned length of stay, other types of metrics that aren't necessarily finances, bottom line, top line, but impacts the overall financial picture and or quality picture. But what is the story beyond the metrics? What are all those other aspects of what these navigators bring from the patient experience, from a physician burnout and experience perspective, from a throughput point of view, from a differentiation within the market, from a reputational? So we have a lot of hard metrics and a lot of hard things, but we need to really think about that story beyond the metrics and how we're going to articulate that. So next slide, Jenny. So what we like to do is start and road, start to do roadshows. I talked about that a little bit with the example that I gave about the heart failure nurse navigators. We started to socialize it and we started to talk about, all right, here's the problems we're going to be solving. Let's educate you on the clinical if you don't know it. Let's talk about our overall program. So not just the value of these navigators and this niche program. Let's talk about the value that our cardiovascular program brings to the organization and what we've done over the past couple of years and where we have executed on ask and we've knocked it out of the park. We have credibility. You should trust us and what we say we want, we'll be able to deliver on. And then summarize, yeah, okay, so this is what we're going to need. This is what we think we can get, whether it's volume, whether it's quality or it's financial, whatever that might be. But we start to do roadshows with key stakeholders who have influence and can help us as we're going to try to advocate for the actual people who make the financial decisions, excuse me, or the FTE decisions that are going to get us the resources that we need. So next slide, Jenny. So now we're ready and we're going to present the proposal for our nurse navigators. Always, always throughout this whole process, leverage your physician leadership. You know, the dyad model is incredibly important to me. It's our whole organization is designed within the dyad model, leverage that. Anytime I'm going forth for an ask, I don't start with the ask. I share where we're going. I talk about the clinical differentiation of that program and what it's going to do for not only our cardiovascular program, but the system strategy. Then I start to outline what are those benefits from quality improvement and care coordination, whatever that might be. That rest of the, you know, that core story, the financial and all those other things, and then the rest of the story and say how it's going to be a win-win scenario for the entire system. And really, it's that's the, you know, how I approach it. Then next slide, Jenny. How I then want to sustain it. So let's say you get those asks. And again, I could talk a whole hour on this topic just alone on, you know, more details of what you put in a performance and all that other stuff. But I'm trying to just give you the steps and sort of how we approach it. But once you get it, that's not where it's done. We really try to be very particular and very deliberate about sharing the story after the story. So talk about programmatic wins, highlights, different things that we've achieved that we said we were going to, but also others. So volume, milestones, certifications, get with the guidelines, shields, all those great things. We had a quality forum this past spring. One of the nurse navigators that we acquired through that process won a top award at our quality forum. And the hospital president was there to support them. And I told him, I said, that means so much to me, but to that navigator, because it shows the support that you have not only just to get that role, but the long-term success of that role. But I always say, try to have formal updates. So you're going to them not only when you need something, but you're going to them, or you're really educating them on your program. And you're telling them, we know what we're doing. So when the next thing comes along, they have confidence in you. So last slide that I'll go to is just really summarizing and the key takeaways. So seek to understand what goes through the heads of your leadership team and what drives them, what concerns them, problems that they have to be solved. Understand the value proposition. So before you even start to ask, or you start to share that story, understand the value proposition and those different data elements and start to collect those data elements and then develop that story and articulate it and socialize it and work it, because these are, as Jenny said, these are difficult roles, but they're a vital, vital component of where we are in cardiovascular care today and where we're going, frankly. These are going to be vital, vital rules and be a storyteller, highlight those wins and not just when you need something. So I went through it very, very quickly, but I want to get on to Anna, because I think she has some great points as well. Yes, thank you, Tom. And we will have some questions for you towards the end. So thank you for that oversight. And please, as a reminder, if you join late, you can access these slides through the chat link and please submit any questions through the Q&A button at the bottom of your screen. So we're going to switch over to our next speaker, my friend and coworker, Anna, and she has some insights in her perspective. She's going to share with us. So Anna, take it away. Thank you, Jenny. And thank you, Tom. That was great. You almost made me miss my old job. So ladies and gentlemen, just to give you some background, and although I work with Jenny now at MedAx, and it's a fabulous role for me in my current state, that being said, I came from Brigham and Women's Hospital in Boston and ran cardiovascular medicine there. Cardiology at the Brigham is one of the largest cardiology divisions with over a hundred cardiologists, super niched group of doctors. So I did that for a number of years, a few too many years possibly. So I learned a lot. That being said, I'm going to have a very different, but also parallel perspective than Tom. So hopefully between what Tom has to say and I have to talk, and what I have to say, it can kind of help you piece it all together, but I'm going to focus more on just the nurse navigator, like how we even get to that. You know, I'm coming, sorry, Jenny, if you don't mind going forward. So thank you. So yeah, we're going to talk about building the right program and really learning from failures. And I'll be honest, I have a lot of failures that I've experienced and been part of over the years. As an administrator, people always want, want, want, and we often, you know, unfortunately respond to the squeaky wheel, right? And a lot of the mistakes that I've learned have been because I've put too much value in the doctor that's yelling at me, right? He's passionate, he's on to something. So we're going to talk about that and how not to do that. Jenny? So, and I, and again, I don't want to say that the doctor's perspective isn't valuable, but it's not the whole story. And to do this properly, you need everyone's perspective, right? We need to be thoughtful and honest about what the needs are. And often what the doctors want isn't actually going to solve the problem. Is that really the solution? Often it's because it's going to help them or they want to do something, but it's not necessarily helping the system. So that's what we always need to take a step back and make sure we're not being reactive, right? Often there's a really bad weekend, a patient didn't get in, or a doctor didn't admit a patient, it gets to administration and suddenly it's a fire, but it's really not, it's just a fire alarm, right? There's other systematic problems. So we often need to stop and think, is this really going to be the solution, right? And we want to make sure, again, that most importantly, that we're taking everything into consideration before we throw our resources into something. Jenny? So again, sorry, we can go back one. Thank you. Again, making sure everyone's perspective is at the table when making the decision, right? These roles are so critical to mission. And I'm coming from a world where the nurse navigator for Structured Heart was a research program when I first started, right? And the EP and all these programs, they were all research programs that eventually became regular programs. So it's creating these positions along the way. So again, you always need a physician champion, right? Bottom line. And then whoever, I truly believe nursing should report to nursing, right? So that nursing perspective needs to be at the table. And for every institution, we have different titles, we have different roles, but all the key stakeholders, everyone that this person is going to interact with, whether it's inpatient or outpatient, making sure all those people are there together to think broadly about how this role is going to impact the institution, right? Not just one group. Jenny? And the job description. Once everybody comes together and says we really need this, honestly, I think one of the most important contributions is this job description, right? Because I feel like we often set up these nurse navigators to fail because it's not entirely clear how they're going to interact with inpatient or how they're going to interact with ambulatory practice or people expecting to schedule the appointments or you expect them to refill prescriptions or do the inpatient notes or the ambulatory notes. There's just a lot of work where people say, well, why can't they do it? Well, hence why we all need to agree upfront what that role entails. It's critical, right? So it's finding, again, creating the job, right? Thinking it through and putting it on paper and not finding the person. Because that's been another one of my failures is doctors come running and say, I have this amazing person, I need her to do this. Or this person's going to leave, we have to create a job. So you want to make sure you're not doing that because that never works out well, right? I also come from a previously, my institution was unionized. So it's a lot of work to work with the union to create these positions for nursing. So again, you want to make sure you're doing it for the right reasons. You're putting your energy to the right solutions, right? So creating the job description and then you try to find the person, not the other way around. And again, we also want to build the job description for the future, not for today, right? Because that never works out well. Because again, we're building programs, we're not just solving today's problem. And then again, stakeholders, everybody's input, right? The job description's created, send it to everyone so everyone knows what exactly the plan is, right? What the expectations are for this individual. Because that's often the problem is you hire somebody and somebody gets wind of it and says, oh, can you do this? So again, clear expectations. We want to set this person up to succeed. And the only way that happens is if the expectations are clear to everyone. Jenny? And then of course, as an administrator, financial implications. They're at the core of all of this, right? And again, I always say we build programs, not because we're planning to make a ton of money, but because there's the value in these positions, right? And the reality is nurses are super expensive. And once you bring on and you add those new FTEs to the bottom line, it's a responsibility. And it's not just salaries. From an administrator, it's the benefits, it's the fringe, it's vacation time. It's that whole package. So when you add a couple, it quickly adds up. So again, you want to... And the other two sides to that is you're taking away from something else. You're not building something else. And so we need to be incredibly thoughtful, right? And you want to just take a step back and make sure you've built a program to succeed, a program for the future to actually solve the core problem, right? And again, that could be because it's best for the program, it's best for the patient, it's best for the system, multiple stories, right? And often that's what you want it to do. You want this nurse navigator to tell a story, to be impactful to a number of people, not just one program. And then obviously, Tom mentioned this in critical, the hard data, right? How are you gonna measure programmatic success? Because guess what? People are always coming back to you to figure that part out because the people at the top only see the numbers. And I always say, we need to tell the story and the numbers tell the story, but we just need to make sure we're planning and pulling the right data. And then how are you gonna... Critical to success too is measure this employee satisfaction, right? This new nurse navigator that you've thrown into the system. Did you set it up properly? Is she getting the right mentorship? Is she reporting to the right people? Are we living up to our expectations, right? When she goes on vacation, do we set her up to fail because we didn't build infrastructure to offset the vacation time? You wanna make sure all of that is taken into consideration and have two-way communication, right? Actually, it's more than just two-way communication, right? It's physician leadership, nursing leadership, their input, our input, everyone working together to make sure we're building. And then obviously everything is about sustainability. Nothing worse than putting a lot of energy and passion into something and then watching it fail slowly because you didn't build it correctly to begin with. So we're always looking for sustainability. And Jenny, Tom, everybody will agree, these folks are critical to mission. They're the glue to building and to the future of patient care. But that being said, we're constantly working on that story and starting and putting the effort into building it correctly on day one. It's worth the value, it's worth the time, it's worth the energy because you're setting it up for success. Opposed to eight months later, there's budget cuts and we haven't been able to tell the story. Consequently, those folks get cut. Jenny, so that's my story. And so in summary, again, making sure the right people are involved. So before we go to Tom and put together the story, who's writing the story? Who are those people who are thinking about the problem? And not because it was a problem Saturday night in the ED, but because it's a reoccurring theme that we're having, right? So making sure everybody's at the table, writing that job description that is so important. In fact, I would argue that's the number one mission to success, right? Is writing a proper job description so that the expectations clear, accountability is clear. And then obviously financial impact. We need sustainability. We're not gonna make millions of dollars off of this role, but we need to be able to show that it's impactful to a system. So in summary, that's my story. I hope that's a little helpful. And again, it's a team effort, but it's no easy role to fall into because there's so many variants of the job, right? Because every program is slightly different. Every institution is slightly different, but ultimately it's communication and working together. Thank you, Anna. That's very insightful and helpful. And we've got plenty of time now to ask you guys some questions. So just as a reminder, those of you that are wanting to ask questions, please use the Q&A button so we can see those questions. So question for both of you and I have many, so I'm gonna try to stay focused and make sure we get to our Q&A time. To our viewers questions as well. We get a lot of questions about what's the right organizational structure. And Anna, I know you mentioned nurses reporting to nurses, but there's so many variations of, does it go to a service line? Does it go to quality within the hospital? Does it go to nursing leadership? Is it associated with a specific unit? I'd like both of you to tell us your thoughts on the organizational structure and maybe you've learned what works well or not and what you would recommend. So I guess from my perspective, again, I came from a hospital that was very unionized. So reporting to nursing made the most sense because there was consistency and we made sure we were abiding by the rules, right? I also, prior to that, worked at the BI and their nurses were not unionized. And a lot of them reported to physicians. And the problem with that, again, every situation is different, but often when they report to a physician, not all nurse navigators are treated equally, right? It's based on that position. And that, to me, creates job dissatisfaction along the way when everybody has their own sweet gigs, right? Then they come back, but she does, well, and again, everybody means well, no one's trying to be malicious or do anything bad, but it's just the reality of how physicians manage, right? They're not, most are not trained and that's just not what they do is manage. So they allow, for example, in some cases, the nurse navigator to make the decisions and other ones, other physicians don't allow it. So again, it just creates conflict. So as long as there's consistency in a system, I think that's what works, right? Yeah, I would definitely agree with what Anna's saying and you got a lot of perfect timing. They're cleaning my window as I'm doing a webinar here. So the guy's literally suspended from the roof of our building cleaning my window. So a little bit distracted, but no, I actually completely agree with what you've just said. They have to be all on the same page and it has to be consistency. In the three organizations that I've been in, it's been all different models. One was a unionized environment up in Michigan that had very, it was very clear. Nurses reported to nurses, nurses reported up through the structure. Last organization, a lot of stuff reported directly to the service line. Here, it's much more matrixed and the hospitals have much more of the reporting structure. So I've worked in all three, there's pros and cons with all of them, but I do think as long as there are clear expectations, and Anna, I love what you said about the job description and everyone's on the same page. If everyone is in agreement with that, the reporting structures don't really matter. And plus, I also believe too that as a service line, a lot of our role is as subject matter experts. And we can do that in a direct reporting relationship, or we can do that as a system influence matrix role. As long as you know you have the leaders that are in those positions that understand how to work in gray space and how to work in matrix roles and how to partner with the appropriate stakeholders and don't feel like it's all mine, it's all mine, it's all mine, but understand the bigger picture and can influence other leaders to get them into the, get them on the same page with where they are. So that's a very vague answer. I don't think I really answered it, Jenny, to say what is the best model. I think it depends on the leadership and you have to be incredibly deliberate as a leadership team to be on that same page. And if you're not, then it doesn't matter who's reporting to who. You know, these navigators roles are, they influence a lot of people regardless of reporting relationships. So if you don't have all the stakeholders on the same page, it doesn't matter who they're gonna report into. No, and I do appreciate that. And I think one of the things we have to be cautious and aware of is this, these roles don't fit into an exact mold, right? There is no black and white way to do it. You do have to consider what your resources are, what your dynamics are, what your population needs are. And that goes true pretty much with every area of this because there's so many things that we tend to shoot, you know, pull them as arrows and shoot them at, but they can't do everything. And so this is really what we're looking towards as a framework to help guide them, but your needs are gonna adjust, including organizational and clinically based on your organizations and your populations. And so I think that falls in line with kind of what we would expect, that there is no clear answer, but there's good things to consider so that when you're making these choices, you know what those options are and you can make better choices for your organization. So thank you for that. We've got a couple of questions coming in. One is about, says a lot of our populations in CV are chronic and or care needs that exist outside the walls of the hospital. Do you embrace the care continuum with responsibility expectations outside of the hospital's question? That's their question. Yeah, so if I'm understanding that correctly, and if not, do we, cause we've sort of talked and gave examples about navigators that sort of live within the hospitals, heart failure probably being the biggest. Do we have navigators that are outside of the hospitals, meaning within our offices, within our practices and absolutely structural heart's the biggest one. But we've actually sort of taken that to even other levels and we found the value in it. We have a pulmonary hypertension navigator that we've just hired. We're recruiting for an autonomic clinic navigator with EP navigators. So we've seen the value in structural heart outside of the hospital walls has been the biggest example of that. And we do embrace that. And that's where there is a little bit more alignment with reporting structures because it's more ingrained with your practice or within your service line. But yes, the value is tremendous outside of the hospital walls. And actually, frankly, probably easier to try to push forward because the metrics may be a little bit more aligned with the service line than just at service line hospital, et cetera. Yeah, and I guess, and the only thing I have to add to that is I think it's cardiovascular medicine, granted I'm biased, I think it's the backbone to a lot of hospital services, right? And I think it's really our job to be innovative and nimble and think through what doesn't exist now, right? And a lot of taking this care outside of the walls of the hospital is kind of our job because somebody is gonna define it for us. And I'd rather you guys be the one to define it, right? The nurse navigators within the cardiovascular world because it crosses lots of different worlds in cardiology. So they're the gatekeepers of all this knowledge. So I think we absolutely agree to it. I think there requires flexibility and hopeful that they embrace it too. All the cardiovascular nurse navigators to help write the rules of engagement, right, for the future. Well, and I think we are currently in that process too, right? We are seeing more and more and a lot more intention around supporting this role. And so I'm with you. I could talk to you all day about what we learned and how we failed until we got successful at kind of figuring out that it is not a clear defined role, but there has to be some guidelines for them to be effective. And so we are kind of writing that script and still figuring it out. And that's something that we want within this framework to give some context and direction to not make it so prescriptive, but we know that there is a place for them within cardiology and we've got to figure out what that looks like. And so we can really promote it, especially as we're moving into this future of shortages, right? And we want to focus on disease management and we are so specialized, but they also cross over into other specialties. So it's a lot of moving pieces. So thank you for that insight. We do have kind of a comment. I'm going to ask you to kind of also comment on this. And it's really an agreement with the different buckets, especially using navigators and EP. So they used to support various programs, meaning AFib lead management. And they did say, don't forget, don't only engage the physicians, but also fellows and APPs because that does reduce the gaps for inpatient and clinic visits or missing meds. And it's a great presentation. So just to support that, I think, you know, we do get specialized and within cardiology, we're kind of going back to that very specialized care. And I think that's the direction we have to go, right? With the complexity of it. Sometimes I hear about these positions and they are kind of cross covering multiple cardiology diseases. What are your thoughts on that? How would you determine if that was something feasible or you want them to be more focused on one specialty? Yeah, I mean, at least the approach that I've taken, and this is from Rich, who goes, Rich and I go way back to our cardiac rehab days. I've known Rich for years. So thank you, Rich. But it's, we've taken the approach that it's, it really is in a subspecialty way, not a ton of crossover. And frankly, navigators are almost used when we're in the launching of a programmatic stage. Now I'm talking about outpatient mainly. So structural heart, I mentioned the electrophysiology, I mentioned the autonomic. So it's like that next phase of we're ready to really launch, put a flag in the ground. This is a program we're going to grow. The navigator is a huge part of it because they are the linchpin to the APPs, to the physicians, to the nursing staff, to the outside. And, you know, and many times they're, they become the face of the program, both internally and externally. So I tend to have them subspecialized because then they're, they're usually assigned with growing a program and launching a program. So, yeah, I, I agree. In an ideal state, it would all be subspecialized, right? I mean, but the reality is that sometimes you have to start small and unless, depending on volume, the volume drives the workload, right? And the manpower behind it. So, you know, and I don't know that it's right or wrong, but sometimes we've had to start, start with folks who are, you know, covering a couple of different disciplinaries within cardiovascular medicine in hopes that eventually they kind of all go up, they become big enough that they're sustainable on their own. But yeah, that's the ideal world, right? Is that everybody is subspecialized and works with everyone. But I also want to add to that, you know, pharmacists, right? I'm just a fan of throwing pharmacy into this, because again, there's a lot of work that the NPs and the RNs and the docs shouldn't be doing that. In fact, they're quite capable and with the right guidelines, they can actually manage the patients on their own. So that's something that right now, a lot of that work, a lot of those phone calls fall on the RN, right? Those poor nurse navigators get overwhelmed with work that somebody else could be doing. So a huge fan of bringing pharmacists in to alleviate the nurse navigators from a lot of work that they shouldn't be doing. That's a great call out. That is, that's why it's really great, because when we're talking about team-based care, we're not talking about just the physician, the APP, and the nurse, we're talking about any healthcare team member, right? And so that does pharmacists, I think, within cardiology are severely underutilized. They have a huge, we have a huge opportunity, and we're seeing more and more programs that are set up with pharmacists and nurses running point on that, and they're being successful. And yes, they're expensive, but they're, you know, the value with them just financially to free up your physicians and your APPs to see those new patients or those follow-ups and communicate. You can work off of protocols. I mean, those are the types of things that we've really got to start moving to, to be sustainable in the future of our healthcare system. So I love that you bring that up. And I think even beyond that, we've heard of opportunities like Emily talked about last week about an administrative support person to help, you know, our navigators, let's face it, they end up doing a lot of administrative meeting minutes, organization, you know, PowerPoint presentations for their monthly meetings that they're, you know, supposed to do. And so we're hearing about different types of roles, like an MA, lead MA, that is somebody that's been, you know, dedicated and wants to show growth. So what, do you guys have any experience or thoughts on, on maybe, you know, we, we kind of think as the nurses, the support staff for APPs and physicians, but maybe they need support staff. Yeah, go ahead, Anna. I apologize for jumping in there, but no, I come from an academic model. Everybody has admin support. You know, the doctors specifically, right. But RNs, NPs, pharmacists, doctors, we pay them to see patients, we pay them to take care of patients. So nothing pains me more than watching them sit in the office and put PowerPoint slides together, right. Or do the minutes, write the agenda. You know, to me, that's not cost effective. And it's, you know, needs to be pointed out, right, with the, you know, the, the actual dollars, right, that are associated with their time. And when you have them doing that, and not that the MA or the admin, you know, is beneath that, but it's just a different job, you know, skill set, right, that's part of their job is support system. So I don't, I don't at all advocate for individual admin support for anybody, but rather programmatic support, admin support programmatically. I think that's how the dollar should be spent. So I'm a huge advocate for that. Yeah. Yeah, same. It's, you know, it's the type of license you want, you want people working at top of license, putting together PowerPoints and doing all that stuff is not top of license for a navigator. And, you know, we're paying them well, we're expecting them, there are patient navigators. So we expect them to have interaction with patients. And a lot of this administrative stuff does sort of bog them down. Structure Heart is the best example for it. Those PowerPoint presentations, all the work that needs to go into those Heart Team conferences. A lot of programs that I've worked with in the past have have gone that route, and have gotten an administrative role to help them and administrative assistant type role to help them with those resources. The other side of it is scheduling these very heavy, procedurally based programs that have navigators that again, are providing education. They are, you know, I, they're trying to align all the schedules are trying to align all the all the tests that that that need to be done. But when it comes to actual scheduling, schedules are another very, very valuable resource as it comes to some of these programs that get so complex, but can also pull a navigator away from the patient care. Absolutely. And when we start talking about costs and how expensive these roles can be, we know that's a huge pushback initially, right? But we can, you know, I think maybe to get one started, but always thinking ahead and thinking strategically, and maybe considering this as part of that plan so that they can be successful and grow. And I think as you've seen, Tom, once once the system sees the value there, they buy in. And so it sounds to me like your program knows the value, and then you're not getting so much pushback, it sounds like. Right. And what we're trying to do is, is tell the multi year story. So, you know, like I said, if we're putting a flag in the ground, this is the program that we're going to grow, let's start with a navigator. And as Anna was saying, it sort of grows and grows and grows. But what, you know, what thresholds of volumes, whatever that metric might be, do we need then the next resource, the scheduler, the admin assistant, whatever that might be. So we're trying to tell the five year story, versus just the I need this now. And that's another piece, I probably should have highlighted a little bit more as I was, you know, going through my presentation. But that's an important piece. But usually it starts with that navigator to help because typically, you seek out individuals for programmatic navigators that probably have more than entrepreneurial sort of spirit, that are great nurses, great with patient care, but also understand what it takes to build and grow a program. And so they're sort of, again, they're that linchpin at the beginning, and the program sort of grows around them with the clinical team. And then you start to add in those, those support resources as the program grows. I agree. And I will say we've learned and I'm glad you mentioned that because the personality of the person you hire is critical to the success, right. And if you hire the wrong person or a nurse that wants to be kind of behind the scenes, and they think this is a good way to step away from the bedside, that's not the right fit, you use need someone who is willing to still be very much not, you know, very visible, and not expected to do direct patient care all the time, but they are the glue. And if they don't have the buy in, and they're not, you know, seen as part of the team, it will it will not work. I just from personal experience, it fails. So you do need to make sure you have that right person. I love how you say entrepreneurial. And it is that great opportunity to kind of maybe build your own program. And again, if you've got someone, you got to make sure that that's something that lights their fire, and it does not make them timid. And it's not for everyone. And that's okay. But definitely make sure you're getting the right fit for for the role. And I think that's just a great point. So I thank you for for bringing that up. And I did have another couple of questions. Because we you know, we've been focusing on the administrator, of course, you know, at MedAxiom, we really support the the dyad leadership model. So I know we're looking at the whole care team, but what is your experience with physician, your physician dyad partners and their interaction and support of this role? Anna, do you want to start with that one? Sure. So I'll be honest, the roles don't exist without the physician champion, period. Because the reality is, everyone goes to the physician for their input. And if the physician isn't supportive, or doesn't see it useful, honestly, you're working against the tide, right? So that's who you need to start the conversation with, right? But at the same time, as I said, you know, when earlier, it's not just that perspective, right? He thinks she thinks this is really important. What do you think? Right? And what do you think? So it's definitely part of, you know, the, it's not just the future. It's, you know, this is how it's been going. And this is, you know, the current state where it's this community value based care, we're all in it together. And without that position, honestly, I think we lose a lot of leverage. And it's, I think we're set up to fail, right? If that person isn't on board, because the reality is, they're not going to support the program and build a program and send the patient and, and say, go to him or go to her. And again, everybody's efforts are wasted. Yeah, Anna's spot on. We, we, I wouldn't even fathom taking forward some type of proposal like this without having the physician on board with it and the physician there to advocate for it. A lot of times it works as Anna was talking about during a presentation, where you're inundated, because they want, they want, you know, I need five navigators. And so you almost have to like, take them back a little bit and say, All right, well, let's walk through this. But it's, it's typically they're, they're, they're advocating before you even know that it's a need. And so then you, you harness that energy, you harness that passion, and you and you utilize it. So yeah, the, the diet model is vital for this absolutely vital for it. Yeah. And as you just said, Tom, just to add to that the need versus the want for the physician. It's really breaking that down. Yeah. Yeah, you always start, that'll start up here. Let's come back down. Our job is to maybe not like that. But let's figure out how we can get it done. Exactly. A little bit of compromise. Yes. And I think, yeah, that's definitely something because when we first started, you know, Tom, we had many discussions. And Anna, I don't know how many you had is how many patients and how many, you know, what, how do you measure how many of these positions do you need? And so, you know, something we considered, especially our inpatient teams was how, what's the census and how many can they realistically see? And I'll say, we kind of took a shot in the dark and educated guests that they could see about 25 patients a day. That's a stretch. That is, that was, that ended up being a stretch because if they get a patient on the phone, and that could have been any sort of touch point in person or, or on the phone, I mean, these patients take time to talk through and then you're doing work on the back end. So I guess that is something, have you guys figured out kind of any advice on when to assess or how you, do you have any sort of strategy in terms of volumes for when it's time to add another one? That's a tough one, right, Tom? Yeah. You know, the problem is it's specific to disease state, right? You know, Jenny, firsthand heart failure, total different animal to the structural heart patients now, right? I mean, they were complex. Now they're, they're home the same day, the structural heart patients, right? So it's, it's really hard. And you hate to establish those rules too, because they change, right? And people, people forget and they stick to these rules, right? So that's the worst part is kind of when you, you create these metrics and you realize that we set them incorrectly or they've changed, right? So no, I don't know what the answer is to that, but I do know it's driven by the, you know, the disease state and Jenny, you hear me say this all the time for the heart failure team. If I could pay them based on the amount of steps they take in the hospital, we'd all win, right? Everybody would be so happy, but we can't realize, right. Versus the EP guy who was, you know, in the lab today and then went home. So it's all different, right? It's so different, sadly. Yeah. Steps and clicks in the EHR. And that's, and that's why, again, we had no science behind it that, that we've been able to utilize and point to. And that's, that's hard fast. We try to create it. And, you know, that's another reason why we sort of try to look five years is to say, all right, a volume's reached the threshold, which is, again, it's arbitrary, but we think it's, it's analogous to where we are today. And if we double it or whatever that might be, we're going to need someone else. So we try to plant that seed from the very beginning. If we're starting a new program to say, hey, we, when we, we reached this threshold, it's, we're going to need, we're going to need another one. We're going to need it approved quickly. And, you know, we go on from there, but other than that, nothing that, that I could point to and say, this is exactly how we calculate it. That seems to be the answer for a lot in this framework. And that's okay. I think, you know, we are continuing to learn in this space. It's fairly new. And as you said, we've got to look at it through the lens of longitudinal, and we just don't have a ton of data in cardiology with this yet, but we're getting there. And so I think, you know, some of our next steps are around putting some data to it. And I just want to thank you both for your time and your expertise. And, you know, we, we really appreciate if anybody has any questions after, please send them our way and we will get that back to you. And I'm sure there's tons more I could ask you, but in the interest of time, we're going to start wrapping up. So, you know, what do our next steps look like? And here at MedAxium, I'm, you know, dedicated to continuing supporting this framework. And one of those things that we, we have to do is align data with outcomes, financial and clinical. So looking at how we can, can collaborate and work on some of that to show hard evidence for these positions. I think current state, we have a lot of individual organizational internal evidence, but we need more, we need wider, broader, more, more data. Continuing to look at these workflows and best practices for the different specialties, as Anna mentioned, they're all different. They're all unique in their own way, and X does not equal, that they're not the same. So we've got to figure out what those look like, again, in the context of a framework and some of their highest opportunities and things of that nature. And as we've seen, they're, they're doing either a lot of, most of them are either doing a lot of clinical or a lot of administrative. So we've got to kind of work on leveling that out for them and how we incorporate them into our team-based care models. And again, I just, I love to, I want this to resonate. We're not talking about just nurses, doctors, APPs. We're talking about whatever that team looks like to serve your population, incorporating other care providers. It's going to be essential to survive and sustain in our healthcare system moving forward. And again, please, just during this journey, give us your feedback, let us know your thoughts, ask us your questions, they all help. And we've just really, I have enjoyed and hope you have enjoyed this summer series and we'll continue to keep you all posted and look for more webinars and information to come. And just, there will be some further discussion, just a little plug at our CV fall transform. We will be in Austin this October the 5th through the 7th, look forward to continuing this discussion there. And with that, we will conclude just a few minutes early. And again, reach out if you have any questions or comments or suggestions. Anna, Tom, thank you so much for your time and your expertise today. It's been a pleasure. Thank you.

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