All right, well, that's my cue to get started. So welcome, everyone, to today's webinar. Thanks so much for participating. I'm Bruce Hammond. I serve as HMDCB's Executive Director, and great to see so many of you here and so many familiar faces. So HMDCB is excited to host this event in partnership with the Hospice and Palliative Credentialing Center and in recognition of National Hospice and Palliative Care Month, which is November. We greatly appreciate the incredible work all of you do, and think this webinar will be a great way to learn from various members of the IDG. So in addition to thanking you for all you do, I'd like to take a moment to thank our sponsor for our webinar series, Gentiva, who sponsors our whole webinar series throughout the year, and we really appreciate their generosity in sponsoring and supporting HMDCB throughout the year. So I'd like to take a moment also before we get started to share with you that we do have some upcoming events. Our final event of 2023 will be happening in early December on December 5th, which will be a coffee chat led by Dr. Alan Rosen, who will facilitate a discussion about resources that have helped you all in your role as a hospice physician or medical director this year. So please come with some thoughts and ideas there. It will also include a Q&A for attendees to connect with one another throughout the session. The 2024 coffee chats and webinar series will begin in January, so please keep an eye on your email and on our calendar of events on our website to take a look and register for those as those come out. Also we're excited to continue partnering with Weatherby Resources in 2024 to provide a discount for our certificants to participate in some of their hospice educational events. So again, please keep an eye out for those as well. And to learn more about our community events, including our webinars and coffee chats, please visit hmdcb.org slash community and you can learn about all of that there. So before we introduce today's speakers, I'd like to invite the staff from HPCC to share a little bit about the organization. So I'll turn it over to them for a moment. Thank you so much, Bruce. It's great to be here today. My name is Chad Riley. I'm the Senior Vice President with the Hospice and Palliative Credentialing Center. I've been in my SVP role for a little over four years now and I'm beyond excited to share some more information about HPCC today. We were founded in 1994, so next year we're going to be celebrating a big 30th anniversary, which we're very excited about and have some big celebrations planned. Looking at a high-level perspective of our organization, we do have six active programs in our portfolio and our certification programs include areas of nursing, social work, pediatrics, all within the hospice and palliative care space. Through these six programs, we administer over 2,000 exams annually and have nearly 14,000 certificates throughout the United States. We did recently set two programs that are the Corporate Administrator Program and also our Perinatal Loss Programs, but those are maintained through continued education at this time. Lastly, we're very proud to announce that earlier this year we did acquire the Advanced Hospice and Palliative Social Work Program and began administrating that exam in June of this year. So our organization was very excited about welcoming another member of the interdisciplinary team to our portfolio programs. So HPCC has a very bright future and excited to share more about our programs during today's webinar. I'll turn things back over to you, Bruce. Dad, thanks so much and thanks for the partnership on today's webinar. We really appreciate it and throughout the year the conversations and connections we've had have been fantastic, so thanks so much to you and HPCC and Annette. So we're going to turn it over now to the panelists. I do have brief introductions for each of them, so I'll do that and I want to thank each of them for participating today. First is Dr. Todd Cote, who's the current President-Elect for the Hospice Medical Director Certification Board and the Chief Medical Officer at Bluegrass Care Navigators in Lexington, Kentucky. He's also a volunteer assistant professor at the University of Kentucky College of Medicine and the past program director for the University of Kentucky's Hospice and Palliative Fellowship Program, Hospice and Palliative Medicine Fellowship Program. He is board certified in family medicine and hospice and palliative medicine and holds fellow status in both academies. His career has spanned hospice and palliative medicine practice in four states over 36 years and he's also a palliative medicine specialist in the Republic of Ireland and in New Zealand. Previously, he served as the Chief Medical Officer of the Connecticut Hospice, which was the first hospice in the United States. So Todd's going to be moderating today and I'm going to now introduce the remaining panelists for today. Dr. Keishonna Guidry is a California-based mobile physician. She attended Texas A&M College of Medicine, where she underserved patients in the student-run clinic Health for All. Dr. Guidry subsequently matched into the Loma Linda University Medical Center Categorical Internal Medicine Program. In residency, she was selected by her peers to advocate for interns on the Program Improvement Committee. There, she also enjoyed activities in palliative medicine, electives, excuse me, in palliative medicine, which sealed her trajectory towards providing end-of-life healthcare. Today, she serves patients and families in their homes as a team physician for VITAS Healthcare and her private mobile practice, Morning Dove Medical. She also produces a podcast called At the Heart of Healthcare with Dr. G. Her empowering voice is used to help everyday people navigate the broken U.S. healthcare system. Dr. Guidry is a strong healthcare advocate and mentor who's passionate about combating healthcare inequities across medical specialties and providing strategies for success for aspiring physicians. Her goal is to normalize diversity in the pipeline of medicine. So, Dr. G., welcome to you as well. Dr. Katie Robinson is an Assistant Professor of Nursing at California State University San Marcos, the Palliative Care Curriculum Coordinator and the founding chair of the Palliative Care Committee for the Nursing Program and a member of the College of Education, Health and Human Services Dean's Interprofessional Task Force. Clinically, she practiced as a community-based hospice and palliative nurse since 2009 and has been board certified in hospice and palliative nursing since 2011. Her research focuses on early identification and assessment of palliative care needs by interprofessional palliative care teams to both increase collaboration among interprofessional palliative team members and improve comprehensive care for patients with serious illness and their families. So, welcome, Katie. And Dr. Allison Harrison is a board certified adult geriatric nurse practitioner with advanced practice nursing certification and hospice and palliative medicine. She attended the University of Iowa College of Nursing for her undergraduate education and Duke University School of Nursing for her master's and doctoral degrees. Allison's professional experience includes working in the intensive care unit, geriatric primary care, as well as inpatient and outpatient hospice and palliative medicine. She currently works at Atrium Health in the supportive oncology palliative medicine clinic and with the inpatient palliative medicine team, as well as at Via Health Partners, a hospice organization. She's an active member of the Hospice and Palliative Nurses Association, where she enjoys serving her profession to help advance expert care in serious illness. She was awarded the Emerging Leaders Award by HPNA in 2021, a designation to celebrate early career hospice and palliative nurses. So with that, I appreciate all you being here and I'll turn it over to Dr. Coté to lead today's session. Thanks so much. Thank you, Bruce. I appreciate that. And Gina and Chad, and certainly to my colleague panelists here, thank you for being a part of this. I particularly want to thank all those who have called in. I've been looking at the number. It keeps going up, more calling in, so that's great. We're going to jump right into our discussions. What the panelists have done is organized about 10 questions, general broad sweeping questions. Some are interrelated to continue our formal discussion with the hope at the end of the conversation we'll have a few minutes for questions and answers informally to all of you. So let's just start right away. Katie, I'll call you. Can you discuss the flow of a typical IDG meeting and each member's unique contribution? Thank you. Yes. Happy to join you all from San Diego today, in case you don't know where San Marcos is. It is in San Diego. So for the IDG meeting, of course, in the IDG meetings, I typically participated in the RN case manager was facilitating and sort of leading the discussion of patients outside of the bereavement moment. To prep for that as an RN case manager, I would typically coordinate with my team members ahead of time to pull together a full report on each of the patients that we were reporting on for that day. So coming in sort of prepared with that. Typically the start of most of our IDG meetings started with a bereavement moment. So an opportunity for us to recognize the patients that we had lost and have a really beautiful moment that was typically coordinated by our chaplain or bereavement coordinator. And I think it was just a lovely moment to come together as a team to recognize the difficult, sometimes difficulty of the work that we do and the patients that we work with. After that, then of course, we went into patient reporting and going through each of the patient reports. I always tried to be very mindful of, while I gathered the reported information from my team members, including aides and volunteers, I always looked to those team members to speak to their own report. So I tried very hard. If a team member was there and represented, I didn't want to speak for them, but typically knew what they were wanting to report at that time and so would do that. That flow seemed to work well overall for the IDG meetings that I participated in and seemed to allow for a lot of nice collaborative discussion around what was going on with the patient over the course of the week since we had reviewed those cases. Great. Thank you, Katie. We'll jump into the next two questions, Keshana. How do you foster collaboration amongst all the members of the IDG and how does improving collaboration of those members benefit patients and families? Thanks for the introduction. So I speak to each team member directly. I call them by name. I ask them about their insights on our patients and facilitate a mutual respect of each other's discipline. And so that's what we do. So if we're discussing functional decline of a patient, I'll ask the hospice aide for their insights, their observations, I should say, during the ADL care if they observed any symptoms. For family drama, call on the social worker to give us some insights and possibly coordinate a care conference and then always inviting the chaplain's spiritual perspective. And it helps, you know, the patients and families because they get the full scope of hospice and they get to benefit from the beautiful holistic care that we provide when we work together. Thank you. So well put. Thank you. Which members tend to be overshadowed from something very nice that Kishana just talked about to the overshadowing that does happen, as we all know? And how do you engage these members that are overshadowed? Yeah, thank you for having me on. I personally, my experience has been I feel like the CNAs are the most overshadowed throughout the IDG conversations. And unfortunately, I think that's just probably a misconception on their part that they don't have valuable information to add, which I think most of us all know that that's not true. And like Kishana was saying, I think that it's very much specifically reaching out to those people, identifying them by name, really putting importance on the value that they do add to the patient's care and their perspective and how that impacts the comprehensive care that we provide. So having mutual respect for each member of the team, knowing what each member of the team's role is, and how they add value to the team. And then really, as a leader on the IDG, really trying to speak life into that. And so identifying each person and, you know, sometimes the CNAs do know a lot about the family drama too, because they're in the home for a long period of time providing very intimate care. And so the patient speaks to them the most, you know, they really develop close relationships with their patients. And so I've had many instances, you know, where we're doing like an ALS spent withdrawal, and I've actually gotten more information from the CNA about how this patient feels about their life, and how long they've been contemplating, you know, discontinuing their advanced life support, and all of their feelings around it even more than their partner or significant other does. And so I think just having a great appreciation that we, we each bring valuable information to the patient's care, and really trying to pull that out of each person. Thank you, Allison. So for all the panelists, what are some of the strategies to best support different IDG members? Physicians supporting nurses, nurses supporting physicians, chaplains supporting social workers, and so on, so on, back and forth. Any thoughts and comments on both experiential and, and any, any ideas? I'm happy to speak from my perspective, I think, for me, particularly when I'm looking at it from a research and education perspective, I'm looking at how do we remove hierarchies among the team? And we know there's a lot of historical hierarchies among professions. I frequently hear from social work students who say, I'm so nervous to speak to the nurses and physicians and give them report and have nursing students nervous to speak to physicians. And so really removing any of that hierarchical dynamic and however you can do that as a team. I worked on teams where we very intentionally went around and identified how do you want to be called? Do you want to be called by your first name? Do you want to be called by your last name with your title? To again, sort of get rid of any remnant of a false hierarchy that we even get just from what we call each other. It seems like a silly thing, but I feel like whenever I was on a first name basis with all of my team members, including my physician, those were the really collaborative teams where we really worked really cohesively together because we really felt like we were all equal members of the team who were able to speak into that. So that would be my perspective. Great thoughts, Katie. In teaching hospice and palliative medicine fellows, we try to do a lot of reflection on the nature of being humble, particularly the drive in our education process and our residency process is becoming really confident. And then the attention you get, particularly in the acute care hospital setting, and just reminding us that I think the best approach to develop and self-reflect on is being humble. You can be assertive, but being humbly assertive is kind of what my mantra continues on. And I think that's something that particularly from a physician perspective, we need to think more about with ourselves daily, by the way. Any others? Keshonna, were you going to talk? Yeah, go ahead. Yeah, I have some strategies. So number one in all caps, I wrote communicate. We have to talk to one another. So we'll create a group chat for particular patients to help keep each team member in the know of what's going on. And so we're all empowered and not blindsided by information. And so that helps a lot. I have to mention the LVNs because they're the unsung heroes. They're the runners. They're all over the place doing everything. And sometimes they don't have time to report back to the RN case manager before they can get the answer in a crisis. And so I do my best to reassure them and let them know that I'm here. They can call me directly. I'll hop on a telehealth visit and we can solve problems and figure this out for our team. So I do that. And the other part of that is hopping on the telehealth visit during crises or situations where the RN case manager's at the bedside and there may be a caregiver on the brink. You know how it go. We all know how that is. So those type of things, they can kind of prevent a revocation or they can settle a family when we hop on the video. Because a lot of times, I don't think people understand how much we know about them. How much we talk, we're on call, we meet every week, we talk to each other all day. And so when we're able to get in front of them, then they get it. And my last thing is care conferences. I'm all about care conferences with the whole team. Thank you, Kishonna. It reminds me experientially to those negative episodes when we gather in a meeting where we may notice that one of our colleague members of the IDG seems stressed or angry or burnt out. And so although we're more virtual now, but I always miss in person coming to that person after the IDG meeting to say, you know, you seemed stressed or how are you doing? That's, I mean, just simple human connection and communication, as you mentioned, I think is really important too. Although it's, you know, negative, but we're just human. And sometimes you have bad days or bad weeks or really just have bad trials and tribulations. Personally, that it's hard to keep away from particularly end of life care discussions, that are stressful in and of themselves. So thank you. Any other thoughts from anybody? Yeah, I would just add in having an idea of everybody's experience level, so that you can support one another. You know, if you have a brand new physician right out of fellowship, and you've been, you know, doing this for quite some time, you can really help them, you know, go through all the different things that we've already been through with families. And same with social worker and chaplain. And so you have people who are just entering the profession, and then we don't want them to leave. And so we need to raise up and support them, you know, from us veterans who have been doing this for a little bit longer. Thank you. I mean, it's so important, right, with especially turnover and just trying to get new people in. And, and we all know those eager people that come in, but don't have a lot of background or experience. So it's so important to identify that, as you know. Well, very good. Katie, we'll jump into some of your research. Based on your research, what interprofessional areas need to be further researched? And how would this benefit the IDG, the meetings we're talking about, but also the hospice field in general? Great, thank you. Yeah, so my research is really looking at how do we make, how do we make collaboration easier? One of the things that I noticed, sort of applying my practice to my research, was that from a nursing perspective, we love, we love really, we love screening tools, we love quantifiable data, but we also are just really strapped for time. So how do we, how do we create mechanisms that clue, clue disciplines into we need help from someone else? We need to draw on our team members in this particular case, whether we're looking at something like spiritual distress or social or emotional pain, things that we know contribute right to the overall whole person experience of the dying process. I think research that could really focus in on those screening measures and ways that we can just very quickly get referrals to other professions is really, really going to help. I work with, I work with a panel of chaplains who are palliative chaplains who are working on trying to identify screening tools for spiritual distress. And one of, one of the things that I, I speak with them about is you guys have these excellent tools, but they're 30 item tools. There's 30 questions to the tool. And then an admission nurse is already spending four or five hours on that admission. You're never going to get the buy-in from nursing to do, but if we could have an instrument that pulled data for that, you're already collecting from the EHR that said, this person's just at risk. Let's refer them to the chaplain. So the chaplain can come in and give them the 30 question screening tool. Would that be more effective and actually increasing swift collaboration and perhaps avoid overlooking the need to involve our other team members to help with that whole person care? I, you know, and in terms of how this benefits, I think that's just it, right? It's, it's increasing the speed in which we do collaborate especially by quantifying some of these things or giving us alerts. And now in electronic medical records, we have the ability to pull data right in a very smart way that could quantify these things again, in a very simple, quick fashion. And, and anytime that we can increase the speed of collaboration, I think we all understand in our line of work, speed is of the essence, right? When someone has been given a six months diagnosis, suffering for two days longer is two days too many. And so that's, that's really the heart of my research. And I think where the research for interprofessional collaboration at end of life really needs to be looking again. So with whoever is the gatekeeper for providing care, let's look at how do we address the needs of the gatekeeper to that collaboration. Thank you, Katie. It reminds me of a hospitalist group that has locally come to us for those Friday night admissions of patients that are very hospice eligible and appropriate. How do I talk to the family members? You know, so it gets in deep, you know, tools are wonderful to assess, but scripting, I know that we've all heard that word, something that in academics, we certainly try to teach to our trainings, but the hospital's group really just wanted a 10 minute dissertation on how do I introduce the conversation? How do I script it? That can save me time. It's about what you're saying. And so, right. Yeah, I agree. I think we've really, you know, hospice is, you know, in the palliative upstream side, time is of the essence and a particular acute care setting and hospice is presumed to just take a little more time, but not necessarily particularly in acute care hospitals where you have more and more, particularly geriatric patients that are extremely frail and maybe near death that need an honest, good discussion, particularly with family members. So yeah, it's interesting. Talk about the time issue. Yeah. We can't ignore there's sort of the nice to have and the perfect, like in a perfect yes, we would all be able to spend as much time as we need to look at these things. But I think considering the really practical element of what's actually happening with boots on the ground helps researchers really understand how do we, how do we address the needs from a really practical standpoint? Thank you. Perfect. Allison, I'll ask you a little different twist on questions. How can clinicians communicate with the patients and families to encourage the use of everyone? And we've all had those struggles of, I don't want a chaplain, I don't want a social worker, I don't want a doctor, but the nurse is okay or, you know, or something. Yeah, I think talking each other up, you know, really praising each other as, as, you know, well, they know more about this than I do. And so if you really want to get a better idea about how to manage this, I think we need to engage other team members. That's always a good solution. Sometimes I don't necessarily give an option and I don't mean to sound paternalistic by that, but I just will say, you know, if I'm identifying a lot of spiritual distress, then I, I'll just say, you know, I'm going to have our chaplains stop by and see you next week and just come here to give you additional support. They're not going to, you know, do anything crazy. They're not affiliated with any specific religion, you know, just kind of eliminate those barriers that, you know, everybody kind of tells you right off the bat. So that's another strategy that I use. I also will, and the best example, clinical example of this I can give is with total pain. So, you know, I've gotten to a point where I've maximized what I think I can in terms of pharmacologic and non-pharmacologic management of someone's physical pain. And it's very obvious that they're having emotional and spiritual pain that's contributing to their physical pain. And so I will use that as, you know, hey, when I'm talking to a patient, hey, I have done about all I can do from my toolbox to manage your pain. And I think right now you are having some emotional and spiritual aspects of your life that are contributing to your pain. And our chaplain and social worker are really great at working through some of those things with you and providing support. And so, you know, I want them to engage into your case now so that we can get this managed the best way possible. So if you really try to frame it from an aspect of we're, you know, we're here to help you. And if you just ask, you know, hey, is it okay if the chaplain comes? You know, a lot of people just say no. One of the reasons I think too is because they don't want to seem like they're a burden to anybody. You know, I already have all these people coming in and checking on me. I don't, I don't want to, you know, seem like I need another person to come here and or my case isn't that complicated or, you know, all the different reasons that they give us. But, you know, really just building each other up to the patient and referring to each person's expertise and their care. Thank you, Allison. I think we probably all have had the experience and with family members that are reluctant to see one of the other team members because of a certain personal issue, religious issue, social issue that's been problematic. Sometimes there's sensitivity or a social worker because of Child Protective Services histories or their cousin was involved and all those kinds of things that kind of goes obviously to what is fundamental to hospice was, which is an empathetic, open approach to evoke information from families before we just kind of, but as you say, there's, you know, being kind of, well, this probably is the best for you. Why don't you give it a try? So there's just finding that way. Right. Well, and like, like you said, asking the question, Hey, is there a reason that you don't want the social worker to come? Tell me more about that and walking through that with them. Yeah. Great. Thank you, Allison. Appreciate that. Okay, Shauna, back to the team. Now, specifically, do you have any tips for how to effectively communicate with different members of the team? You're muted, Kishonna. That's right. No problem. Yeah. Sorry. Yeah. I think I may have mentioned it a little bit, but I'll reiterate addressing each person by name goes a long way. We talked a little bit here about, you know, removing the hierarchy, you know, in involving people in the conversation and just calling them out, you know, Hey, you know, Hey, Katie, what do you think, Katie? You know, what do you think, Allison? It just goes a long way. And secondly, I'll say, you know, while I'm doing that, just ask them what they think, you know, so they don't, so they don't just say, you're the doctor, like I don't want them to do that, like that's kind of one of the things I hate to hear because our work is collaborative. I know I'm a doctor, I know I'm a physician, but they have insights that I need to use for my decision-making and again, we're looking at the patients holistically, so I want to know their gut feeling about some things, you know, what they're sensing. They may have seen them, well, they have seen them more than me. All the teammates see them more than the hospice physician, so I'll say, what do you think? What do you think is wrong? And, you know, that just helps them open up, keeping these open-ended questions and they spill their guts. Thank you. Katie, how can the hospice field support academic training of students on interprofessional dynamics and what training opportunities are available out there for IDG to attend? So I always tell my students that interprofessional collaborative practice is just palliative in nature, right? Like we've been doing it the longest, so therefore we are the best model for what this looks like and with our focus on whole person care, that makes a lot of sense because we need different disciplines to address the whole person. So as we're doing, to give you some context, interprofessional education is becoming increasingly in the spotlight on the academic side. So, educators are at this point basically demanding that we include interprofessional education efforts throughout the entirety of our curriculum, and this is across health profession programs. So whatever accrediting body is, you know, for nursing, we have a huge focus right now on palliative care and interprofessional collaborative practice are both being called out as necessary for preparing entry-level nurses into the profession. Those are also included in advanced practice nursing standards for accreditation, and again, this is the same for social work, speech language pathology. We're seeing it now in physical and occupational therapy, it's starting to show up there, and we know that it's been there in medicine. So at the end of the day, this is happening on the academic side more and more because we're now being required to do that. What I see is we don't have opportunities for students to practice this in the clinical setting in a lot of times. So particularly in hospice and palliative care for a lot of reasons, namely because just the capacity to support students in a largely typically understaffed, under-resourced program that can be difficult to then support students on top of that, but really that's sort of where the rubber meets the road for students is when they're learning these things theoretically in the classroom, they're learning these practices perhaps in a simulated environment, but to be able to show them what that looks like in real life is really where we see the magic happen from a learning perspective. So however, as hospices or palliative care teams, you can be partnering or looking to academic institutions to give students the opportunity even to just come and observe an IDG meeting or be able to go and shadow with different team members and see how each of them function independently. Any of those things really, again, do help students feel like they can see practically what this looks like. In terms of training opportunities for IDG members, there are a lot of organizations that offer post-licensure and post-training opportunities for education in interprofessional collaborative practice. The CSU Shiley Haynes Institute for Palliative Care offers a whole suite of courses specifically to interdisciplinary collaboration. CAPSE offers courses as well on that, and I have provided some links and resources to the panel moderators that they'll be able to send out and provide for all of you if you're interested in more training. But there is training out there, really good, high-quality training, and so if you want to take a deeper dive, I do absolutely encourage everyone to look into that. Great. Thank you, Katie. A lot more in the future, I hope. Yes, I agree. Our last formal question, are there different methods you have implemented as a leader to help strengthen your IDG? And I certainly had a lot of thoughts on this, which I think are prevalent, hopefully, amongst all of you, just simple things such as new, Alison mentioned new employees to hospice. I'm not just speaking for clinicians, but we in our orientation program for our hospice organization do a mock IDG and kind of on the stage in front of the new orientations each time a group of new employees is coming. So whether they're in janitorial service for one of our buildings to one of our clinicians, they kind of have a feel. I think that's very powerful, and it's simple, and it's, you know, 15, 20 minutes of a hypothetical dialogue between the hospice core team members. I think that's really something to always think about and worthy of time. The other thought is maybe prevails over all of our discussion, which is just developing the culture of teamwork. Again, as a physician, I wasn't trained that well to work within a team. We were, you know, multidisciplinary, where we'd sit at a table with different disciplines and everyone would give their opinion, and there's not much about consensus or working together. The IDG from a regulatory standpoint has, I think, challenged us to be very formal and collect the right data during that every two-week typical time period from a Medicare hospice benefit standpoint, which I think is important, but we kind of get mechanical about that and don't realize that, well, this is just a simple example of a broader culture of the hallway discussions, HIPAA-compliant hallway discussions and such amongst yourselves, amongst certain team members, not everyone all together formally, although, again, I think it's wonderful to come together. I think most of us are probably doing that virtually now, but it used to be coming to church, I used to kind of say was the IDG is very important time period, but little IDGs throughout the days and weeks to come are really important, too. And then Katie, I'll lastly say, talks about interprofessional dynamics, and I heard about that at the University of Kentucky when we started the fellowship program, because they were just into that. This was quite a number of years ago, and, you know, all the program directors were trying to figure out how are we going to involve, just like Katie was saying, how are we going to involve nurses and chaplains and social worker departments and, you know, how are you going to do that, you know, but I've always liked the transdisciplinary concept, which kind of preceded the interprofessional, which in all truth, and I think there was even a comment to that by one of you attending here, that we have a lot to learn from each other. And so when I started hospice many years ago, I was the doctor, and so the doctor gives the in-service, you know, if there's a 10-minute in-service about shortness of air or pain, it's like, well, that's fine, yeah, but I like to hear from the chaplain who's been here for 10 years and end-of-life care, and how do you do spiritual assessments? I want to learn that. And by the way, I want the chaplain to maybe be able to do a simple survey assessment for pain, for physical pain, because then they're going to say, oh, well, you've done pretty well with that, but I think there's more existential or spiritual pain going on, so on and so forth. I think you all kind of get that picture. So what we've done is try to rotate our in-service, if there's a 10- to 15-minute in-service, time is of the essence, of course, then we will have our other disciplines that give, and typically they prepare, but it's concise, and it really, you know, meaningful, helpful information, narrative, descriptive, but also prescriptive with tools that we could use, simple tools to assess a family dynamic as a doctor, you know, I think there's just a lot more growing science in non-medical that we need to kind of cap on, particularly as physicians too, so any other thoughts on strengthening your IDG, any other activities that have helped? Yeah, I'll chime in, just kind of to piggyback off of what you said with the mock IDG, I think it's great when companies have each member of the team go with another member of the team for the day, and their orientation process, so, you know, physician goes with a social worker, chaplain, nurse, CNA, and vice versa, you know, everybody kind of has a day with each member of the team, so they get an appreciation of what they do, and then they can kind of give them little tidbits of knowledge, you know, in that day that they spend together. Allison, it's always nice to have the CEO or the CFO go out with the teams too, I'll tell you that, we've all hopefully had that kind of leadership experience too. Lastly, I'll just talk about the timeliness, I think Katie talked about time, and, you know, the time for particularly hospice medical directors and hospice physicians involves just more burden with, not really burden, but more documentation time needed, not only regulatory, but just documenting what's going on, and so we continue to work on the efficiencies of an IDG meeting, that kind of official every couple week meeting, and that's where technology comes in, EMR, can you access, can you multitask a little bit by hearing different team members, and then assimilate a recertification narrative, that sort of thing. We find that's very helpful for hospices throughout the country, they're smaller and have kind of a part-time physician that's kindly showing up at the formal IDG, and to offer some ability to write a narrative, and the ability to do so, of course, sometimes it's technology, being able to assess medications and all that, but boy, what a better time to talk to people face-to-face, video-wise or in person, to get some insight into what's going on and to assimilate a recertification or even a certification, CTI, so that's kind of helped us too, and I'd love to hear from some of the callers if you've had those kinds of experiences to affect, you know, again, 36 years of doing this, we used to not have to write CTIs, we always documented for medical necessity visits and such, but the IDG, we talked about the same things, we just didn't have to create narratives, which is important, I agree, it kind of assimilates the team decision-making and goals setting forth, and whether the person is really eligible or not, which I think is really crucially important, so very good. Well, good, I think we can open it up for any questions, Gina, I don't know if there's any questions came through on the chat or if you'd like to unmute now, we'd be happy to either answer questions or hear your thoughts and concerns and issues and anyone. Now, we do have one question in the chat from Noelle Steven, and she's saying her hospice opted to transition to an IDG where a single representative of each team, nursing, social work is present with her, so the social work will get to sign out for each patient and report the sign out, and she's curious if anyone else does this and how she can make this feel more informative and collaborative. I saw that question, and I didn't really understand or grasp what that meant, maybe you could clarify a little bit. Yeah, I'm here, so I've worked with this hospice for three years, and to be clear, I'm a hospice physician and I do not have decision-making ability in my hospice, I'm supportive in the team, and about, actually it was June of this year, the administrative folks decided that we would have one person from each team come to IDG because that's all that's required by CMS is that you have a nurse and a social worker and a spiritual care and a physician there, but we have several nurses on the team, so that one nurse reports for the people that she knows really well, and those are great conversations, but that nurse also has to get sign out from her colleagues, and she just reads off their sign out of what's happening. The reason for this was because we have a super big area in New York State, we cover a very broad territory, there's a lot of very rural places, and what we were finding is that on IDG days, there were very few admissions getting done, and then Thursdays were awful, and Fridays were catch-up, and we were having trouble staff-wise, so what they have found is that since June, the number of admissions on IDG days has gone up, so the administration looks at that as a plus. I find IDG limited in performing it in this fashion, we can't have conversations because sometimes I do not have a single member of my team who's actually seen the patient, they're available to me to ask questions, and I don't know if this is a trend, I don't know how my hospice decided to start doing this, and I want to work with them, I know it's a financially driven decision, but I don't know how to make it work well. Any comments on, I have heard of this phenomenon. There's opinions, I think we all have opinions. I might just encourage your ability to, encourage you to have ability to sit with the leadership and talk about your concerns and thoughts. I think even in this 30 some odd minutes of our discussion, you can see and feel the value of people coming together effectively. And this does not have to take two to three to four hours. Matter of fact, time efficiency is key, even teaching each team member how to present briefly. And that's a work in progress, but I think that's really helpful to minimize the time. Cause if they're relating mission time versus just sitting, another thing that I've pushed for in leadership in not only where I am now, but in the past was with the CNA, the Certified Nursing Attendant. They didn't want them at the meetings cause they need to go out and do the four hour visits and such. And we kind of grouped together as a team to go to our leadership and say, well, show us what you mean by that. And it really just had to do with the efficiencies. And it's like, well, we need the CNA's input. As I think Allison and others have said, they touch the patients more than anybody and we actually need them to come in, but they don't have to come in for two hours. I mean, they can come in for 30 minutes and give during the IDG and give input. So I really think it's important. And so I just encourage you to stand your ground a little bit and challenge that issue. It's hard, easier said than done, but I think as the physician, I think you need to be heard too. Anyone else to reinforce or thoughts on that? I think perhaps in lieu of being able to make systemic change amongst the leadership or in the meantime, until that change can happen, maybe trying to have those smaller IDG meetings, right? Like we were talking about sort of the hallway conversations where maybe having conversations with each of the nurses, even if they're not gonna be in the meeting, you know, like, hey, could you call me, you know, the day before, two days before and just give me like an overview on some of your big, the big issues we really need to address. And same thing with maybe some of your other team members. So perhaps you at least, as those patients come up and are being discussed, you know what the hot button issues were for the team members that aren't present. And perhaps then you can advocate and speak a little bit more and have a more meaningful conversation given that the team members aren't there to foster that. Really good chat comments from everyone. David, did you have your hand up? Sorry to call you out. No, it's good, I did. And I will admit to being very nervous to speak in this venue, but I do, I believe I'm right when I say that if we read the conditions of participation from CMS, there actually is no requirement for an IDT. The requirement is that we review, revise and document the plan of care no less frequently than every 15 days. So we have all come up with IDT as the really genius solution to make sure that we can meet those compliance guidelines. And then the other thing that we're kind of dancing around is those of us in the business, we know that these meetings are an opportunity for education, for team building, for interdisciplinary support, for giving voice to people who are not powerful like the physician or nurse case manager. So all that to say, not only should everybody be involved whether or not they're presenting their patient, but we should be pulling more and more this year toward getting more in-person IDTs now and then as well. Those are my philosophies and I thank you for letting me speak. No, thank you. Thank you, David. Anyone else? I see two questions in the chat and one is from Dr. Rich and she had asked, I'm sorry, my computer just froze. She said, do you have any members of your team who come intermittently? So like a pharmacist or a psychologist and how do you encourage their participation? We do have a pharmacist, but he kind of rotates through our different IDGs as he's able to, but he has a really good pulse on what's going on with everybody anyway from a medication perspective. So I'm not sure if he's a pharmacist or he's a pharmacist, medication perspective. So I wouldn't say it's really an issue of engagement with him, but sometimes I think just asking, hey, why weren't you at IDG the other day? Like holding each other accountable. Hey, what's going on? We would love to have you. Can you come next week? Or asking them to do an in-service. If it's a psychologist, hey, can you do a 10 minute in-service at our IDG and then stick around and hear what everybody has to say because we've got a lot of patients with this issue and we'd like to learn more about it. Yeah, I would add to that, that I've always seen a hospice pharmacist in that realm. We never used to have them, but now we do as an important equal team member like anyone else. So input, again, easier said than done sometimes. I think in team meetings and the hospice IPU, it's a little easier sometimes to have the pharmacist either call in or be available as an example. But I do think as David was talking about the kind of the regulatory nature has refined us to think even financially about what's really quality important, which is involving team members inside into again, setting a plan for this patient and family. So that involves psychologists, speech pathologists, physical therapists, those things that aren't unfortunately regulatory core services are still services that we need to have available to offer at times. I'm in the opinion that most people need a massage and occupational therapists when they're declining, but that's not gonna go fan well financially. So, but as an example, so I do think it's important. Alan, I think you had your hand up. Yeah, this time it's for real. The other times I wanted to do reactions. With everyone speaking, it's been very helpful and illuminating and to include all the participants. One topic that I don't necessarily hear addressed enough is professional development and even personal development. So if you think about, and many of us have worked with different or multiple organizations, as we grow, how are we increasing the capacity for that change? Whether it's, we need a new team now in the South, who here in all disciplines has the bandwidth to be a leader, an advocate? And so getting back to it's both professional development, but it's also personal and all of us have that obligation, not necessarily only to the organization, but our colleagues that we work with. And I would welcome any ideas, comments, what people are doing to advance that. Alan, I think that's another webinar. Thank you for bringing that up. And I did just wanna quickly share, and Alan, that's a good question. Maybe even something to discuss at a future coffee chat. Is Michael or Dr. Michael Gorby have put in the chat that he's a hospice physician for a small hospice and they only have three med aides. The IDGs are much better when they make it, but often they're too busy to come. They're in a rural area, long distances. So should they be doing an in-service at each meeting? Yeah. Education time is I think always important. It doesn't have to be an hour. It doesn't have to be 30 minutes. It could be 10 to 15 minutes. And when we do that, I think we're a large hospice organization that runs into the problem of, well, each of our offices have their own little business management meetings too. So you have several meetings. And so how many meetings are we having? How efficient can we be? At what time? But yeah, I think a coffee chat coming up, but Gina, I think we have two minutes left. If that's correct. I don't know if we have any time for further discussion. Of course, we could probably go on for another hour and talk about other important issues on the interdisciplinary group meeting. And I see there were a couple of questions asked in the chat and the panelists had answered them. So thank you again to the panelists for being here and for sharing your insights and your expertise with us. I know I learned a lot, so I hope everyone else did as well. And we'll send out a recording of today's session and the resources that Katie shared. And I also just want to thank again, HPCC for co-sponsoring, co-hosting this webinar with us and Gentivis for sponsoring the webinar. And thank you all for attending. We really appreciate it. And if you're interested in attending future events, visit us at hmdcb.org slash community. So thanks everyone. Thank you all. Thank you.

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