- [Tricia Kitzmann] Welcome to the 21st installment of Building Health Equity Webinar Series, Advancing Health Equity in Home Health Care. Some of our objectives today that we're hoping participants can walk away with is discuss the most pressing concerns and issues related to home health care through the health equity lens. Address specific populations that are the most impacted by home health care challenges, the elderly, disabled, rural communities, et cetera, and explore potential partnerships or strategies to improve home health care services, and access among diverse populations. I'm Tricia Kitzmann, I'm faculty here at the University of Iowa College of Public Health. I work with the Institute of Public Health Practice Research and Policy at the university. We do encourage folks to interact, we'd like to be able to answer your questions. We know you're here for a reason. Feel free to raise your hand, if you wanna ask a question as well, or feel free to use the Q&A box. I will go ahead and let our speakers introduce themselves briefly, and then we'll kind of jump into more detailed questions. Stefanie, do you wanna go first?

- [Stefanie Wagaman] I sure can. Hi, my name is Stefanie Wagaman. I am the Director of Cedar County Public Health. I've been here for about two and a half years, so I'm just continuing to learn as we go.

- [Tricia] Wonderful, thanks Stefanie. Sara, you're the next on my screen.

- [Sara Krieger] Hi, I am Sara Krieger. I'm the CEO of Iowa City Hospice and Visiting Nurse Association. I have been with this organization for 20 years and have been in home health for 22 years, and I'm also a nurse, so I'm very excited to be here, thank you.

- [Tricia] Thanks, Sara. Annette, we'll have you go.

- [Annette Lee] All right, thanks Tricia. I'm Annette Lee and I've been in the home health and hospice space for my goodness, 33 years, I think and seen lots of changes. Now, I work as a consultant and work with CMS and with agencies across the nation who are dealing with these different health equity issues.

- [Tricia] Wonderful, well welcome. And all of you, thank you for taking time today to spend with us and dive a little deeper in discussing health equity. So you've all shared a little bit about your organization you work for, but if you could dive a little bit further and tell me more about your background, a little bit more about your role and what brings you here today to talk about? And again, if there's any type of projects your organization is currently actively pursuing or doing, this would be a great time to share that as well. Does somebody have a burning desire to go first?

- [Annette] Well, this is Annette. So I think I'm probably representing kind of the bigger picture from CMS, the Center for Medicare & Medicaid, and how they're actually paying attention to these health equity issues. It is a big initiative for them, and it started in hospitals and they've been working on that for 10 years, and now it's actually being published and, you know, there are ramifications if we're not bridging gaps. And it's finally, trickling down to community care, dealing with home health and hospice, and they're gathering the data. And so I think I would love to try to shine light on the things that they are finding that have direct impacts and that we are all already gathering data on. And we'll be adding more data in 2027, and I'll also share later about how home health agencies can actually find information about the impact in their own agencies to ensure that your outcomes are as good for patients of color or who are, you know, on Medicaid. So there's poverty as a social determinant of health to be able to see, you know, where are our outcomes? Are they different for these populations or have we been able to bridge the gap for them? And I'll be bringing hopefully, that bigger structure and thinking about that. These ladies are gonna bring the real how-to and what they're doing in day-to-day.

- [Tricia] Wonderful, thank you, Annette. Stefanie, you wanna go next?

- [Stefanie] Sure. So, like I said, I am the director of Cedar County Public Health, but my background is in nursing. I previously worked at the university for about eight years with cancer patients, and this job opportunity opened up here in the county that I was born and raised in and currently reside in. So I thought be a great opportunity for me to expand my role, expand my patient population. I have a place in my heart for cancer patients, but I think it'd be awesome or it is awesome for me to be able to work and live in the county and give back to my community in that way. Our organization, we have public health on one side of things, and then we also have home health within our department so we are very, very busy. Our public health is where we are involved with immunization clinics, WIC, we do a lot of education within our schools within the county, but then for home health is where we really provide that in-home care to keep our clients in their home as long as possible. We also have homemaking services and respite, which is a big need for our residents we've noticed. We provide transportation within the county. We go grocery shopping for our clients. We try to do anything and everything we can to keep people at home. So that is what we do.

- [Tricia] Wonderful, thank you, Stefanie. Sara.

- [Sara] That leaves me. So again, I'm Sara Krieger. I have been with Iowa City Hospice since 2005, and in 2021, Iowa City Hospice and the Visiting Nurse Association of Johnson County merged, we really realized that there were a lot of things we had in common, one of which is our passion to help people to stay at home and live as well as long as possible, and to help them meet what their goals are. And ultimately, that's why I have chosen to stay in the home health and community-based care. I worked in a hospital and it's really important work, but I realized the majority of healthcare happens outside of the walls of the hospital, and I wanted to be a part of that and helping people to meet their goals. I love our organization because we are not-for-profit, and we serve everybody so regardless of their payer, hospice, regardless if they have a payer at all. And we'll talk a little bit more about, you know, how that's working out in the world and how different organizations allow different patients to be on their roster versus others. So some projects that we're working, we have a lot of projects we're working on right now on. One hospice side, we're really focused on better understanding the Hispanic population, what their needs are, what we need to do within our organization to serve them well. And really what we have discovered is, we just need to have more people that speak Spanish, first of all, so that when they access our care, you know, it's in their native language and they feel comfortable. So we've had some focus groups within the community to better understand that and have been intentionally hiring people that speak Spanish. On the home health side, working to decrease our re-hospitalization so that once somebody comes into our care, they can stay at home, which is our ultimate goal. I mean, obviously people can go back to the hospital, but our goal is to help them to stay at home. And then we just recently opened an outpatient therapy program at home on the home health side, because one of the big barriers to home healthcare is that you have to be homebound and everybody kind of interpret that differently, but what this allows us to do is to continue to serve somebody at home, even if they may not be considered homebound.

- [Tricia] Wonderful. What are some of the current issues, and concerns related to home healthcare from an health equity perspective? Are there certain populations facing more barriers to accessing services from your guys' perspective? If so, what are you seeing? What are those populations that are being most impacted?

- [Sara] Well, Annette probably has the data, but I have the anecdotal situations. So Annette, do you wanna start with the data and then we can tell you what it looks-

- [Annette] Thank you, Sara. CMS is still gathering the data right now. They know from a big perspective that absolutely, things like health literacy and transportation, and again, race, ethnicity, poverty level, all of those things are big impacts of outcomes and we know that. But as far as in the community care, we're still working on the data. So I'll let you take it away, because yeah, we know in real life situations, we see it every day.

- [Sara] So what we see within our population is oftentimes that both the visiting nurse side and on the hospice side, we're accepting patients that other organizations are declining. And there's a myriad of reasons for that. On the hospice side, it may be because they're expensive, their care is expensive, they're seeking cancer treatment, they may not have a caregiver, some hospices will not serve a hospice patient if they don't have a caregiver that they can state is able to take care of them at home. We also, both on the hospice and the home health side, patients that don't have a home, so we take care of homeless patients. On the hospice side right now, we have a patient at the shelter house. We have a patient that meets us at a certain place every day so that we can take care of them. And then also what somebody's home condition is like, people live differently and they have different resources, financially, mentally, physically, to be able to take care of their home. And there are some people that can't get the care that they need because their home condition doesn't meet that regulation standards. We also see, like I mentioned earlier, the Hispanic population, there's a lot of data that shows, especially in Iowa, that the Hispanic population is largely underserved. We're investigating why, you know, and which would make sense, there's a lot of cultural reasons for that. And a thing that's really been interesting for me since I've reentered into the home health world is payers, a lot of places will not accept patients who are on Medicaid and on Medicare Advantage because the pay rates are so low that organizations lose money. So on the home health side, for every Medicaid patient we accept, we lose about 25%. And if you don't have the payer mix to support that, you know, the good payers that can be difficult on an organization and especially, a smaller organization. If they don't have grant support, which is also drying up, there's not as many grant opportunities right now. So Stefanie, I see you shaking your head or nodding your head like yes, yes, yes. So I'm sure you're experiencing the same thing.

- [Stefanie] Well, Cedar County is kind of unique. We don't have a hospital, so a lot of our care we provide is critical for these residents who have barriers like transportation and financial. So we live in an aging population, finances, transportation, it all goes hand in hand. So what we have to do is try to be creative and provide ways that we can serve our residents so they're not missing out on the care that everybody deserves. So you say like, where they live, their living conditions, and I completely can relate to that because we go into these people's homes and we try to provide a cleanly area for them to live in, and we try to provide all the resources we can, and it's very eye-opening. So our biggest barrier is though, within our county, not having a hospital close by would be the transportation to get the care they need. And then of course, that insurance piece of it, the financial aspect of it, so.

- [Tricia] What resources are available to support some of these underserved populations in accessing home healthcare? I know you guys have talked a little bit about some of the services you provide, but thoughts or ideas that we can share with our group today on how to access them so that's not a barrier?

- [Stefanie] So here in Cedar County, we provide a sliding scale fee for our residents. So we take a peak at their finances, and then we're able to gauge how much they would be able to afford so they're not turned away from our services. And then another thing, we provide the transportation within the county so we can take them to any doctor's appointments or even grocery shopping or whatever they need to do within the county, but we also link them up for volunteer services or other transportation services so they're not missing appointments outside of the county. So that's just a couple things that we do here.

- [Tricia] Wonderful.

- [Sara] Those are all great, Stefanie. What I think is really important is making sure that your access points to care understand your services because they're the ones who are interacting with the patients that we will eventually serve. And it's confusing. I mean, our healthcare world is confusing, you know, and we live in it every day and I'm still like, "Oh, I don't know, I gotta check on that." And just imagine somebody that is sick, you know, tired, you know, they have so many things that they're trying to manage every day. And then also trying to manage the support that they need and how to get that. So we try to partner, I feel like I'm constantly out in the community not only to talk, but to listen. Because I think that's one of the most powerful ways you can get somebody to want to listen to you, is to listen to them. And so I talked to our doctors and our hospitals, and our senior centers, and our rotary club, and our Kiwanis, I feel like I'm constantly on the move, but understanding what are the challenges that they are seeing and then helping them to see how hospice and home health can help them to meet those needs. And I've learned a lot of, oh, well maybe, that's a program we need to think about 'cause you know, our healthcare system, it's a bunch of siloed, disparate services that don't really always communicate well with each other so people fall through the cracks. and we've all seen that, we've probably lived it. So how do we work together, educating each other to be able to refer to each other and guide that person where they need to go, hold them by the hand and make the call with them. Don't just give them a prescription or give them a phone number. Help them to make that call, I think is really important.

- [Annette] Sara, I love that you said that because so many times we just think, you know, we just hand over another instruction, right, and so to partner with the patient, partner with the family, but also, your community is huge. And to your point, every community is different in how we're trying to meet those needs and some do better than others. For instance, I'm here in the Des Moines metro area and in Des Moines proper, you know, it's going to be more difficult for some, although we have bus waivers and things like this, you know, but that's still difficult. But in West Des Moines where we moved my parents to strategically, they have some amazing programs like transportation for the elderly to go. You literally, you just set up an appointment and they'll take 'em to their doctor's appointments and you know, they don't have to qualify for any, you know, certain program. It's just a service of the community. So really trying to leverage those partnerships is huge. And you know, in trying to bridge those gaps, making sure that we find them all, like you say, we're so siloed. So to even create, you know, ourselves, these cheat sheets that we can share with patients and families, and then again, take the next step and help them make those connections. It's a daunting task, but it is very rewarding when you find what your community might have for them. We don't have to be at all, right? That's the nice thing is in home health, we can't be it all. And so knowing that I'm going to hook them up with all these additional supports that are gonna be beyond what I can do, and even after I'm gone.

- [Sara] One thing that I really focused on, and we have a really great United Way in Johnson County, is like really trying to understand all of the different organizations that are partnered with the United Way and what they do. And then, you know, going to lunch and coffee with these different organizations and saying, "Who do you serve? Okay, what gaps do you see?" And then we can start to find ways that we can network together because it is good that we have different organizations doing different things, but the challenge is how do we work together to make sure people don't get lost?

- [Tricia] 100%, and I think that that's a key thing with today and talking about this and why it's so crucial is the fact that not one organization can serve one population, right? As we talk about all the time, it takes a village. It's not about one organization taking the lead, it's making sure that we are collaborating, communicating, and sharing resources. Because whether we're talking transportation resources or we're talking financial resources, there's not enough for all of us to do what we need to do. So it's crucial that we're taking care, we do it for our kiddos, it shouldn't be really any different when we start talking about our aging parents. What strategies or methods have you seen be successful in helping these populations navigate or access resources to improve their health at home?

- [Sara] Well, one thing that we're really focused on right now and kind of resurfacing is goals of care conversations. The conversation is so powerful in helping people think about how they want to receive care, where they want to receive care, how they don't want to receive care. And then documenting that in a way that it can be honored. It makes it easier for all of the people involved in that person's care to know what decision to make or at least, feel better about the decision they have to make. And it starts to make you think about, "Well, oh mom, if this is what you want, what kinds of things can we start thinking about now and put in our tool belt even though we don't need it now, thinking ahead so that we're not having to make all these connections and all these decisions in a crisis." I think that's really powerful and something I'm hoping to do more of in our service area.

- [Stefanie] I think that's very important as well, Sara. And also, if you have some of these clients that have been a client for years to continue to check in to be sure that their goals have stayed the same. And if they've changed, then you need to make a change to their goals, which I think is very important too. So just continue to have the conversations, maybe not at an initial visit, but just continue to have the conversations and make sure that the patient understands like you're a part of your care. Like you are gonna be telling me what you want us to do for you. So I think that's very important.

- [Tricia] I would agree. I think one thing that the older population forgets that they're the customer, right? Like it is about their care, they get a voice in that decision. And I think that's something that I've witnessed with my own family, right? That they get to be active participants in those decisions and I love the discussion of having those conversations now, so they can, so it is in a crisis mode. And those caretakers that are actively involved know what that intention is. So again, as those more tough decisions need to be made, it's never gonna be easy, but you feel more confident that you're following the wishes of your loved one and I think that that's a crucial piece in this.

- [Sara] It also really impacts your grief journey after that person passes, if you can look back and say, "I feel like I did what mom wanted it," it helps you kind of bring everything together in a healthy way. Grief is grief, it hurts. And I can speak to this personally. I lost both of my parents to cancer when I was 28 years old, nine months apart, it was a rough year. You know, one of them, I knew what they wanted, we'd had conversation, we had time. The other one, I didn't. And just the grief journey between the two of them, it was very different. And I always say that having goals of care conversations early, often like what you said, Stefanie, just keep talking about it 'cause as your condition changes, your situation changes, your goals may change. And that's good, you know, we're not static human beings. It's really a gift that you give your family to let them know what you want. So yeah.

- [Annette] When you approach that, I think, Sara, what a perfect time. Because when they go to verbalize some of these wishes, whether we're talking end of life or even goals for, you know, rehabilitation, you know, they're going to identify many times that, "Well, I'd love to do this, but that's not realistic." And maybe, it's a barrier again, about one of these social determinants of health. They don't think they can do this or that because they don't have the means or the transportation or they don't speak the language or, you know, all of those. So I think this really then lines up with being able to empower them with those conversations and then finding the barriers and figuring out how do we bridge the gap there for them? You know, what resources can we find for that?

- [Sara] Absolutely. Like with the therapy, I see patients, when they know what they're doing the therapy for, I think it motivates them. I mean, from my father-in-law, it was so motivating. So my father-in-law is in assisted living, he was in assisted living, he wanted to get into independent living. It's literally like, you know, 20 feet from where he was, but he wanted to get into independent living. And man, he was focused. Every day, he would go and he would do his therapies because he wanted to move 20 feet from where he was. So I just think, you know, understanding what their goals are can be motivating for them and help them to have better outcomes.

- [Tricia] 100%. I just wanna pause for a moment and ask our participants if they have any questions. Feel free to put that in the chat or raise your hand or you can put the question also in the Q&A, but I do wanna just pause for a brief moment to make sure we allow for our participants asking questions that they have. All right. I am not seeing anything come in right now, but again, please feel free. I am monitoring the Q&A in the chat, so if you have some questions as we're moving through, please feel free to reach out or even a comment or something to share. Again, this is how we learn is sharing information. So I kind of have two questions here. So what are some of the additional resources that individuals or families need in these services that they should be exploring? And how can local public health agencies help eliminate some of these barriers? Stefanie, I know you work for local public health, but I know obviously, there's other areas that we need to be addressing and making sure not only our rural communities and public health are taking an active role, but what can other public health departments across the state be doing to help promote and ensure that there's equity for our aging populations?

- [Stefanie] Yes, so I think like we kind of talked about being active participants in the community, getting your word out there, going to coffee, lunch meetings, like this weekend, I'm participating in a veterans event just to get our pamphlets and what we do out there so people know we are here to help them and the services we provide, because some people think, "Oh, home health or public health, they only do X, Y, Z," but they don't realize that we provide all sorts of different services. So just continuing to educate the community. And honestly, that's our biggest advertisement is word of mouth for us. So just being public, we host a health fair every summer and we pull in people from within the community or surrounding communities to allow them to share their resources. And we just really have to play an active role in allowing others to know what we do. We can't really take the back seat in this aspect or else people will lose their access 'cause they won't know what they have available to them. So I think the most important thing is just continuing to stay active, be involved in the coalitions, go to the centers and attend lunches and go and just get your word out there and allow them to know who it is too. You know, you can run an advertisement in the paper, but they wanna see a face and so be the face of who you are so people know what they have available to them. I think that's the best way.

- [Tricia] And public health agencies, we have services, we do things, but we're also a connector, right?

- [Stefanie] Yes.

- [Tricia] Like we're kind of that connecting agency that is trying to coordinate, provide additional, so the more we're out in the community and able to put a face with a name, a face with an organization, but also that again, carrying that burden isn't just us, it's our community partners, it's getting people involved.

- [Stefanie] And coordinate is a great way to put it because I may not have the actual resource for you, but I can link you to what you need. And so that's very important. Within our schools, we have what we call, Resource Navigators through our CCAC grant and they have been instrumental in providing kiddos with the resources they need and just another person that they feel safe with to talk to about things is great. So just the amount of community services and getting out there and just letting people know like what we all have to offer or what we can help link to them has been great.

- [Tricia] Yeah, I think a lot of folks forget that we are a connecting agency, not just a doing agency, but we're a connecting agency.

- [Sara] Something that for overcoming barriers, I guess from a boots on the ground perspective is I really challenge my team with trying to figure out how we can do something. There's always going to be 400 reasons we can't do something, but, you know, we just gotta find that one way we can. And that comes down to, you know, when referrals come in, when we first merged with the VNA, you know, it was just too difficult to come onto our services. There were just too many reasons why, you know, we may not serve somebody and understanding that it's not our role to necessarily, you know, pick the perfect patient. But it's finding a way to serve everybody. And there are some really challenging situations and cases and you know, people that are at home that probably shouldn't be, but they don't necessarily have another option and maybe that other option wouldn't actually be better for them. That's something that I work with my nurses a lot, you know, while they're at the wrong level of care, they would be better if they would be placed. Well, maybe, maybe not. What can we do here? What are the barriers? Have we done the work to try to help them? Because if we don't help them, who will? I mean, like I said, the visiting nurse association especially, we're the one place that will accept everybody. And if we say no, there isn't anyone else and they're gonna end up in the ER and, you know, continue with that cycle of in and out of the ER and they're not getting better. So what's the best we can do with the resources and situation that we're currently in. And you know, it can be really rewarding when you are able to find ways to overcome a lot of those barriers, but it's challenging and can be exhausting.

- [Tricia] So we do have a question that came in, Lisa, thank you. This is probably for Stefanie. What funders, payers do you receive to support home health, especially, homemaker services?

- [Stefanie] So for homemaker services, a lot of our clients, I would say are gonna be the sliding scale, they don't really go through their Medicaid or Medicare for that, but I'm pretty sure it's Medicaid, Medicare. Some of our grants like our LPHS grant that is changing from the non-population to the population health though. So we have to be creative and how we are gonna be able to utilize that type of funding. We are coming up with something through our public health department, we've kind of reached out to surrounding counties to see how they are doing this, but it's by utilizing our public health nurses and creating a partners program. So being able to offer services to clients through our public health aspect instead of our home health aspect to be able to capture, because like Sara said, there's a big homebound status and it doesn't always allow for our clients to qualify for certain resources. So I mean, we accept all types of insurance.

- [Sara] We also serve homemakers and the majority of our patients are Medicaid. And that again, doesn't cover what you pay doesn't cover the full cost, which is why so few organizations will do homemaking so we actually write grants to help fund the gap so that we can offer, you know, some patients Medicaid. And then we do also have, we have private pay, there's some patients that want to do private pay. So we have a few private pay patients and then we have a block grant, the Johnson County block grant that allows us to serve some patients at a sliding scale, which could be from zero to, you know-

- [Stefanie] Yeah, yeah. And we're always addressing the sliding scale to be sure that it's still a realistic amount with inflation and everything that's going on in the world, we don't wanna turn away anybody, but we do have to address that every few years. And so we try to grandfather our folks in that have been on the sliding scale for a while so they can continue to get the resources they need at the cost that they've been paying. But we work really closely with our community resources gals down the hall. They make a lot of our homemaking referrals and they also help those folks, you know, with the resources they need for their Medicaid and making sure they're signing up for everything they need to get their benefits still, so.

- [Sara] There is a much greater need for homemaking than is even being close to being addressed by the current resources available. We hear from Johnson County Public Health and from Medicaid that they have so many more people that need help and there's not enough agencies that are doing it. And that's because we're being asked to do it at a loss and there isn't currently enough funding to help cushion that so it is a great need and if we were to look at how the social determinants of care impact overall health costs, it would be much cheaper if we would just pay for some people to help people keep patients, keep their homes clean and safe and not go into the ER. It would cost Medicaid much less money if they would just fix a little bit more to help these people stay at home.

- [Tricia] 100% agree with that, for sure. One of the things that I would like to touch on is I think you guys have talked about several local partners, but again, local or state partners, should organizations be collaborating with, with the advancement of health equity and home health care? So ensuring some of those social determinants of health are being addressed not only with local partners, but let's be real, we also need to be working with our state partners as well?

- [Stefanie] We do a lot with Heritage Area on aging, they've been great. The Iowa Healthcare Association has been phenomenal. I can go into the public health aspect, there's an Iowa Public Health Association and then as well as, the American Public Health Association and then Nacho, the National Association of County and City Health Officials just signing up for, well, number one, being a member of those. And then you get all of this information loads and loads of emails, but loads and loads of educational opportunities as well. So that's been instrumental in helping even just like Annette talked about earlier, OASIS Changes, so just continuing to seek the educational opportunities that are literally in our inbox has been helpful to collaborate with those people.

- [Annette] Tricia, can I take that opportunity and show the new things that are coming into OASIS?

- [Tricia] Well, you must have been reading my mind 'cause you were the next person I was gonna be like, "I think you have something to share with us." So yes, please.

- [Annette] Oh, thank you. She teed it up perfectly, didn't she?

- [Tricia] She did.

- [Annette] Thank you, Stefanie.

- [Stefanie] You're welcome.

- [Annette] All right, so we have a few new measures. Again, we have some in our current OASIS and CMS lays out five strategies for really pushing health equity in the home setting. And I just wanted to touch on those as well because I think they're great because we're kind of in priority one, unfortunately, we are way behind hospitals and such. So priority one is expanding the collection, reporting, and analysis of standardized data so they can really understand what is the impact. Again, we're getting our first sneak previews right now, if you are a home health agency, you can go into your IQ system and look under my reports and you can see your reports for two health equity measures. One is looking at our patients being able to be discharged from home health and be able to stay out of the hospital for at least, 31 days. And they're comparing and contrasting your general population versus those of color or those that are medi medi. Again, capturing those folks who have poverty as a major health barrier. And so you can really congratulate yourselves if you can see that you are able to raise up those patients to have the same sort of outcomes as the rest of our population. So that's exciting to see because all of the folks that I've worked with so far, looking at those reports, you have been able to maintain the same outcomes, which says volumes to me about what home health is doing. You know, we are making a difference that like you say, we are connecting and ensuring that we are getting the patient those services that they need. So beyond things like health literacy, which is included in our current OASIS, they are looking at do patients have a steady place to live. So looking at housing security will be our next addition to the OASIS. Unfortunately, we have to wait till '27 to see these, That feels like a long runway, I don't know why it takes so long, but this was just finalized in the final rule that yes, these will be added. So you can see that they're asking, do you have a steady place to live? Are you even just worried about this? And you'll notice this trend is, is it a true problem right now? Is it a potential problem? Is the patient worrying about this being a problem? And they do the same thing with looking at utilities, is it a potential problem or is it something that is a threat or is it already an issue that their utilities have been shut off? Transportation, we have a current item in the OASIS, but this will be adopted as the other settings are using it. So that way, we're all being consistent in the gathering of our data. And it's looking back for a full 12 years, or I'm sorry, 12 years, 12 months, looking at reliable transportation, not just for medical appointments, which is what we focused on right now, but true health equity is being able to look at big picture, right? About the quality of life. And so here it's also incorporating other sorts of needs to get out and about, meetings or work, or getting other things that you need in your daily living. And then lastly, food insecurity, which is a huge one. And I know in our home health sector, we are constantly connecting. Some folks even have food pantries, they have pantries where new mamas can come and get diapers and things. I work with a a bunch of you, I saw your names popping up when you were logging in, so I know you're making a difference out there. But this food insecurity is a big deal, unfortunately and you know, if you don't have the ability to have good nutrition, that wound is not going to heal. If you don't have the ability to be able to get to where the food might be, again, you aren't going to have the same outcomes. You are not gonna be able to sustain the same ability to, you know, heal when you have a surgery or to rehab when you need therapies. So these are the items that they are implementing. Again, CMS is putting us kind of at priority number one, gathering the data, but then priority two is to assess what is the cause for these disparities and why do we have these gaps. Priority three is what gets me excited. They say, they are going to put resources into building capacity in healthcare organization and providing resources as needed to try to bridge those gaps, even with looking at home health. So that's what gets me excited. Thank you so much for that key in there.

- [Tricia] And Annette, thank you for sharing, that is I think crucial for a lot of our participants to be able to see that and know that that resource is out there.

- [Annette] Yeah, thank you.

- [Tricia] I think just double-checking that I didn't miss any questions. All right, feel free again, if you have questions to throw those in the chat or in the Q&A. For organizations or individuals who are new to home healthcare, but wanna contribute to advancing the health equity and addressing social determinants of health, where would you suggest they start? I think you've touched on this a little bit and I think we've been drilling this in, but to ensure that we've actually addressed this.

- [Annette] There's a lot of amazing articles out there that do discuss, first of all, get yourself educated, right? That discuss those key factors that have the biggest effect. CMS does cite a stat that says, 30% to 50% of poor outcomes are related to social determinants of health. That's huge. And so getting educated, what are those? And then I think taking it back to what the boots on the ground ladies were saying, making the connections, you know, ensuring that we know we can't fill every gap, but we know we can make a connection with people who can and resources who can. And if you find that there's an area that our community doesn't have that resource, that's a great conversation. When you're out meeting those folks in the community about, "Hey, there is this need, what can we do?" And those of you that are on here with county public health, I mean, we have an additional ability to really make that known. And if our county supports it, you can be that catalyst.

- [Tricia] Absolutely. I think it's crucial to think about when we're looking local public health agencies doing their community health assessments, really identifying some of those needs and those gaps and knowing that either advocating for services or making sure we're partnering with those folks and saying, "Hey, this wasn't on our radar, this has popped up now. How can we continue to collaborate? How can we expand that collaboration or expand this partnership or programming?" Right, so sitting down and really being able to hone in on that. If we don't ask the questions, we don't know. So it's really partnering with those agencies that have some of that data. And some of it might be local public health, some of it might be the United Ways and some of it might be state partners that have that data that is really leaning into what are those forces that are driving poor health outcomes. What are some of the entry points or resources that we should be telling our community partners, whether it's new local public health agencies, directors, or new agencies in a community? Where should we be pointing them for the entry points for some of these individuals, who should they be partnering with, with that?

- [Sara] So you mean, entry points as far as, who may be directing patients to go to different, I mean, well for sure, I mean, they're medical provider, but the challenge with that is at least in our area, there's a lot of transient physicians, they don't have the longstanding relationship necessarily that we used to, so that they may see them once and then they're gone, you know, so I think that's been a challenge. So we have been really focusing on direct to community education as well. So educating caregivers on what resources are out there rather than just relying on the kind of overtaxed, I mean, our healthcare partners, they're busy. We're asking more of them than we have in the past, they don't always have the time to have some of these conversations. So how can we empower and educate our caregivers and the individuals? Different ways that we've done that is, you know, caregiver support groups, reaching out to the senior centers. Johnson County has a really active, beautiful senior center, a lot of great resources there. United Way, your discharge planners at the hospitals, they see a lot, they know a lot. They have a lot of great information to help identify gaps as well. They know the patients that they can't get placed where they can't get them help, why they can't get them help. I've learned a lot from our hospital discharge planners. Stefanie, what about you?

- [Stefanie] I would say to kind of piggyback off that, our nursing homes, our independent or assisted livings, the clinics here in town have been wonderful or here in the county have been wonderful. I say, in town 'cause we don't have too many throughout the county. And like hospital discharge, I mean, that is key. So I'm trying to think of more and I think Sara hit most of them.

- [Sara] Unfortunately, the hospital discharge planners in my mind, it's too late.

- [Stefanie] Yeah.

- [Sara] We've already had that avoidable hospitalization so again, that's where we're really wanting to focus on how do we have these goals of care conversations with people before the hospitalization.

- [Stefanie] Yeah.

- [Sara] So, you know, we're hoping to connect with people in the community. We provide them for free. We use Honoring Your Wishes form, if you Google it Honoring Your Wishes, the form is available for free for anybody to use. Anybody can have the conversation. I think, you know, how do churches, getting directly to the people and empowering them.

- [Stefanie] Yeah, any outreach that you can really provide in your community will help with the connect the resources. So like I said earlier, boots on the ground, just get your face out there. Let 'em know who you are, what you have to offer and how you can help and that you're there to help, so.

- [Sara] We were at the Arts Fest, we had a booth at the Arts Fest, I met all kinds of people, honestly, it was really great. I mean, go where people are, just go where they are and talk to them.

- [Tricia] I love that you mentioned the churches, right? Like I think that is a crucial piece to get them involved and to have community partners reach out because there's a lot of folks that, you know, they do home visits a lot of times as well. And especially, I think one of the, I don't know if I wanna call it, a blessing or curse, but the stuff online, now so many churches are offering online services, especially, you know, elderly are learning. They might not be able to navigate a whole lot on the internet, but they're navigating pretty well and getting to church online when they can't get there physically. And so I think that that's another avenue. And I think one of the avenues that I was talking with one of my former colleagues at local public health was the fact that the University of Iowa has a great benefit and one of the employee benefits is elderly care and getting prepared to take care of your parents. And I have never, in all of the places I've worked, ever had that as an employee benefit. And so again, not something per se that I'm probably gonna necessarily use totally 'cause my family does not live in the State of Iowa, but it gives me ideas on places that I need to reach out to or make sure I'm familiar with where my parents are. And again, so trying to tap into other resources that are non-traditional who might not necessarily be the elderly, right? Like it's the workforce because it's us that are ensuring that our parents are gonna be taken care of. And so again, some of those non-traditional methods in advocating maybe, with an HR department or a larger organization who has, you know, a large employee base, that is a whole nother community outreach that you can start tapping into. And again, I feel very fortunate because it was not something, I would've never thought about that, but it is an amazing resource and employees here at the university have that. And so working with our business partners, business community, that this is another avenue for a point of entry. Like we might not be able to make the referral, but we will be educating a whole generation of folks that can advocate for their parents.

- [Sara] I have to tell a little quick funny, because my husband is just now starting to be a caregiver to his dad. And he came home and he was like, "Honey, I learned a saying today, I'd never heard this before," he goes, "Have you ever heard of the sandwich generation?" I'm like a nurse and I work on home health and I was like, "Yeah, I've heard that before, honey." He was like, "Did you know that mean, we're taking care of our kids and we're taking care of our parents?" And I was like, "Yeah, that's exactly what we're doing and it's challenging." I just thought it was, you know, I'm sure we've all heard of the sandwich generation, you know. Anyways, I just thought it was cute. I'm like, "Oh, yep, yep, that's what we're dealing with right now."

- [Tricia] Exactly. I do wanna take this opportunity to thank the three of you for spending an hour with us today. Very insightful, very appreciative of all your knowledge and information. This was a great conversation and I really appreciate it. For those who are our participants, if you haven't already, please join our mailing list of Building Health Equity. This was our second webinar this fall. Be on the lookout, we will not have any more 'cause we're getting into that glorious holiday season. So our next scheduled Building Health Equity webinar will be January 14th and we'll be talking about farming and rural health equity. So again, January 14th, farming and rural health equity. So be on the lookout for that. In the meantime, however, if you would like to stay engaged with webinars, please join the PRAC, the conversations on health equity, excuse me, research and practice again, conversations on health equity research and practice on December 10th. Again, all of you, thank you so much for your time today. I really appreciate it. Have a wonderful day and we hope to see everyone next year.

- [Sara] Thank you. Thank you for having us, we really appreciate it.

- [Stefanie] Thank you.

- [Annette] Thank you.

- [Tricia] Bye.