Podcasts Archive - Page 2 of 13 - Sanford Health News

Thriving in a dynamic health insurance landscape

Courtney Collen (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations and real-world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools and partnerships advancing rural health care and strength in care in communities across the country.

Joining us in this episode is Molly Smith, group vice president, public policy at the American Hospital Association (AHA), alongside Dr. Tommy Ibrahim, M.D., executive vice president, president and CEO of Sanford Health Plan. Together they’ll discuss the future of care and coverage in rural America, including enhanced premium tax credits, drug pricing, the future of Medicare Advantage (MA) and bold, innovative models that could improve accessibility and affordability while making health care more personalized.

Dr. Tommy Ibrahim (host):

Molly, hey, it’s wonderful to see you again. Thank you so much for agreeing to do this. You’ve been such a great supporter of Sanford. We loved having you at our Rural Health Summit this past October. And have really appreciated everything that you’ve done to advocate on behalf of Sanford, on behalf of Sanford Health Plan and for all the great work that you do at the AHA to support our care and coverage strategy.

So, we’ll dive right in and I really wanted to just maybe start with a little bit of background. So you’ve been at the AHA for quite a bit now and you’ve done some tremendous work around care and coverage strategies, care and coverage policy reform. I would love to maybe hear a little bit about the work that you’re doing today, and maybe just a little bit about you personally.

Molly Smith (guest):

Yeah, sure. Absolutely. So thank you so much for having me. Always a pleasure to work with Sanford. And just really, I think your broader focus on rural health care across the nation, I think showing a lot of leadership there, we really, really value that. So, as you mentioned, I work at the American Hospital Association. We are sort of hospitals’ national representatives in Washington. We have about 5,000 member hospitals. Everything from kind of your larger academic medical centers all the way down to frontier hospitals. So a really wide range of different organizations, but frankly, who all share the same mission, which is to provide really high quality care to their communities. And as you know, hospitals provide the highest acuity care. They are unique in that responsibility, and so it’s just been a real honor over the last 10 years to get to represent hospitals.

And it’s been obviously a wild ride. Health care is always a very top priority for policy makers, for really good reason. It affects all of us on a day-to-day basis. It has a big impact on our federal budget. So, there’s just always a lot going on, and really looking forward to talking to you about particularly what federal policy makers are thinking in terms of the health care space and how it is impacting rural providers specifically.

Dr. Tommy Ibrahim:

Yeah, no, I love that, Molly, and I think you’ve heard me say obviously with the focus on hospitals that the AHA has, I think you specifically, your broader teams have done a fantastic job to also keep the lens on provider-led health plans as well that might be part of sort of those larger integrated health care delivery systems and advocate on our behalf as well. Sort of apart from kind of that broader payer landscape that often coincides with a lot of the work that AHA does. So you guys have done a phenomenal job there. We’d really love to just kind of understand, particularly something that’s shaped your perspective around rural health care and coverage, particularly for provider-led health plans and integrated health care delivery systems like us.

Molly Smith:

There’s a little bit of it in my blood, I guess you’d say. Both of my parents worked for the Indian Health Service (IHS) and were both, they actually met and got married in a definitely a very, what we would call a frontier hospital 20 miles above the Arctic Circle in Alaska. Despite not being American Indian by blood, I actually was born in an IHS hospital, and that’s simply because my mother went into labor while she was in an IHS hospital. And so there you have it.

So there’s an aspect of this that has sort of been in my family, and I grew up getting to hear the stories of the importance and the need for health care access in all of our communities because we’ve got Americans everywhere and people who have joined us in this country, and everybody needs health care. And as we know, getting access to care can be very time sensitive, and so the need to have providers sort of on the ground, bricks and mortar, and workforce who are ready to care for people in even sort of the most far-flung places is really important to this country and it’s definitely one of our values, is sort of taking care of our communities, and certainly hospitals are a fundamental part of that.

So actually that sort of was in my blood, and both my parents having worked for the government in that capacity really sort of opened my eyes to what the opportunities were. And I actually began my career at the U.S. Department of Health and Human Services within the Centers for Medicare and Medicaid Services (CMS). And that of course is the agency in Washington, or at least at the national level, that runs the Medicare and the Medicaid programs. So that’s where I first got myself professionally introduced to the world of hospitals. And in fact, my career started in hospital payment policy. So kind of goes back.

But to your point about the role of hospitals and health systems that have kind of gone all the way down the value chain to become, to get an insurance license and offer kind of insurance products and sell plans is one of, I think, the proudest innovations, and one of maybe the more exciting innovations that we’ve seen over the last 10, 15, 20 years.

So Sanford is in good company. There are about a hundred or so hospital systems around the country that do have health plans, and one of the things that I think this really aligns with, one of the main drivers of policymakers right now, and I think a lot of stakeholders, which is really trying to get the best value for the money that we are spending in health care and recognizing that when a provider is able to do that, when they’re able to take on risk, financial risk in that way, it also actually opens up a lot of flexibility for them to really care for a patient population perhaps in different ways. So we certainly have seen a lot of innovation in that space. The government has clearly prioritized and has said that they would like to see more of that happening. Of course, it doesn’t necessarily mean that every organization can go all the way down the chain, and so we’re seeing sort of an evolution we call it, but it’s a huge success story and I think something we want to see more of.

Dr. Tommy Ibrahim:

Yeah, no, I love that. And you know where I stand on that, Molly, I mean, we’re as an integrated health care delivery system, it’s the language that we speak. You know, we’re constantly looking about how do we differentiate for our members and for our communities and bringing a provider-led health plan and sort of that full suite of capabilities is really what we believe is going to be the future of how we manage the populations that we’re privileged to serve.

So thanks for sharing that. Thanks for sharing your personal story. I mean, I’ve known you for so many years already, and I didn’t know that about you. So that personal connectivity to rural health care obviously translates into all the work that you do and are so passionate about.

So maybe switching gears just a tad, staying obviously on the policy front, a lot of focus right now going into the premium tax credits and how that’s going to shake out over the course of the next couple of weeks that set to expire here on December 31st. Obviously this was sort of the genesis of the prolonged and the sort of the longest historical you know, government shutdown in our nation’s history, and continues to obviously create a lot of uncertainty for people that are anticipating hopefully continuing coverage into next year.

The estimations are pretty drastic, right? I mean millions of people will lose coverage effective January 1st. And obviously that has a ripple effect throughout our industry, throughout the communities that we serve. So really would love to kind of get your take on where you see all this going, and particularly, do you see a light at the end of the tunnel for an extension of some kind?

Molly Smith:

At the point in time where we’re speaking, I think that it is probably fair to say that that the extension is not going to happen this year. And frankly, that’s something that we’re all concerned about. And for exactly the reasons that you mentioned. There will be several million consumers who will see an increase in their premiums as well as some of their, potentially their cost sharing as well.

And, you know, the government itself has estimated that those increases are going to be so significant that there are going to be people who either cannot afford to continue paying or simply choose not to given other priorities within their budget. So it is a very, very real likelihood that millions of additional people will be going without what we consider comprehensive coverage in 2026. That being said, there is still a lot of discussion here in Washington about whether this is something that can be picked back up in the new year. In fact, just yesterday a number of Republicans sort of crossed the aisle, if you will, and joined with the Democrats in the House to sign onto a discharge petition to bring this back up in the House in January.

So, the issue is not totally dead, but I will say I think that there is a lot of interest to, among many policy makers, looking to the future and looking to what this means for other options for getting coverage. So there’s a growing kind of conversation out there about alternatives. We can certainly get into that, but I think for now, the advance premium tax credit extension is something that unfortunately will not get resolved in the next two-and-a-half weeks or so.

Dr. Tommy Ibrahim:

It’s unfortunate, obviously something that we’re continuing to watch very closely, and getting a lot of calls about from our members with just incredible amounts of questions that we’re trying to walk them through and obviously support them through as well. So we’ll keep close touch on that as I’m sure you guys will as well. Let’s stay maybe on that topic of affordability. Obviously having health insurance is sort of step number one to getting access to care and affordable coverage and affordable care at that.

But it seems like there’s a sort of a growing trend and obviously a bigger discussion about affordability coming out of Washington, D.C., which is important particularly in sort of these economic times. A lot of what I’m hearing about some of the kind of bolder models that are being proposed, the access model that was just recently launched, or actually thrown out by CMS as a potential opportunity, seemed to be somewhat encouraging. Sort of aligned with value-based care, all focused obviously on controlling total cost of care over time. Would love to kind of get your initial thoughts on where you stand and AHA stands with those programs.

Molly Smith:

Yeah, absolutely. So you’re certainly right. I think affordability is going to be the key word, and not just word obviously, but the key motivator for policymakers in 2026. Although I think it’s worth noting that it has been a priority for a number of years. Obviously there have been some competing priorities, if you will, whether it was to expand coverage or frankly, to deal with the pandemic.

But I think there have been longstanding concerns about whether or not the health care system that we have in this country is affordable, whether it’s for individual patients, whether it is for the government or for employers who of course pay a significant amount into the system. But I do think that we’re going to see efforts maybe really accelerate.

And so I think there’s a couple of different ways that policymakers are thinking about this, and you’ve really hit on probably one of the more exciting, which is where can we lean into innovations, whether it’s innovations in the way that we help people manage their health, which is really what the access model is about, and we’ll come back to that. Or just innovation and how we organize and deliver health care services in ways that we can do it more efficiently or take costs out of the system.

So in that bucket of innovating to try to help people better manage their health. So for those listeners who may not be familiar with the access model, that is really around supporting providers in using technologies, whether it’s like wearables, like watches, and all of these kind of tools that now exist that a lot of people rely on already to kind of look at some of their own health statistics. But really providing a vehicle, or a financial vehicle, as well as sort of thinking about how providers can actually engage with their patients around leveraging that information that’s being collected to better manage their health.

There’s a lot of other work I would say going into the whole MAHA movement around Make America Healthy Again. So really trying to get people sort of more knowledgeable about what are the different factors that actually are the underlying drivers of poor health that then ends up driving a lot of utilization and illness that is very costly to take care of. So that is definitely a huge priority for this administration, and I think Secretary Kennedy in particular has really sort of been a big champion of a lot of that work.

But, you know, there are a lot of other things on the affordability options list, if you will, and some of those are kind of more, again, in that realm of innovation, and how do we think about, for example, paying for care and can we move more providers into what we’ve sort of traditionally thought of as accountability or value-based models where they take more of the financial risk for managing the health of a particular patient population. They are moving very, very quickly to try to get even more providers into those relationships.

Particularly through the innovation center out of CMS, we have just seen a ton of models, and one of the consistent themes, I think, across those is the mandatory nature of most of them. I think for many, many years the government tried to entice providers to participate in these with various different programs and various different carrots. And I think now, not that there’s an intention to be punitive at all, but I think there’s a real message coming across which is like, “OK, the time is really now actually, there’s no more sort of sitting on the sidelines to this. We need to really get everybody into these new reimbursement models,” which frankly, an organization like Sanford is just incredibly well-positioned because Sanford, with a health plan, already has both sort of an expertise and a technological infrastructure, and frankly, sort of mentality among the workforce about what it means to actually manage and be accountable to the premium dollar in that case, but in some of these other models that will really serve you well.

But there’s a lot of work to be done, though, to bring other providers and frankly, even other plans along who maybe have not really thought about managing population health to drive their financial sustainability and success, but rather have used other tools, whether it’s just like rate reductions, or cutting benefits or something like that. So I think there’s a lot of work to be done, but clearly a message from the government that everybody needs to get on board.

Dr. Tommy Ibrahim:

Yeah, I know for sure, we see it as well. And to your point, about 50% of our members here at Sanford Health Plan actually get their care, all of their care, most of their care within a Sanford facility. So we are really well structured to kind of provide that end-to-end continuum of coverage. Let’s stick on the topic of innovation. Obviously, there’s been a really impressive pivot. I would say to your point about sort of CMS, CMOI, really looking at new alternative care delivery models through the use of technology.

There appears to be sort of a growing relationship that’s developing with the venture capital ecosystem and you know, leveraging sort of the newest technologies in the market. We’re sort of excited about that trend, obviously. And particularly with the rural health transformation fund that’s being proposed and some of the potential funding capabilities that are out there, looking at ways to also tap into some of those areas to continue to drive that strategy forward, because we do fundamentally believe that the two really need to be intertwined.

Tell me a little bit about your thoughts about the Rural Health Transformation Fund in particular, and where you see some of those dollars flowing, which programs will probably get the most support for those dollars.

Molly Smith:

Yeah, so it’s really interesting, and hopefully soon, in a couple of weeks, we’ll have even more information. But this is a $50 billion fund that Congress included in HR-1 or the One Big Beautiful Bill. And the intent behind this $50 billion is exactly as its name, to help transform access to care in rural areas. I think there is a broad recognition among policymakers that rural areas are particularly vulnerable to, some of the destabilizing forces. Whether it’s insufficient population to financially maintain clinical services, or recruiting the workforce to come and live full-time in rural areas. There are a number of just particularly kind of unique challenges.

So the way that Congress designed the program is that every state had an opportunity to apply, and in fact, all states did apply. It doesn’t necessarily mean that everyone will have a winning application, but let’s presume that there are rural areas all across the nation, and most states will be able to tap into this. But the administration, when putting out the applications, was pretty clear about some of the things that they thought were going to be most impactful and that they wanted to see.

And to your point, technology was clearly high on the list. I think, again, there’s just, a huge recognition that whether it is telehealth, and telehealth that kind of directly can connect patients with providers in various places, or frankly even connect providers to providers. So, for example, if you’ve got an advanced practice nurse or a physician assistant in a rural area, but they need to tap into the expertise of a psychiatrist or someone else who’s maybe not available in that community, that you could use these technologies.

But unfortunately, we still have a lot of gaps in access to those technologies, whether it’s because they’re expensive to adopt or because the connectivity doesn’t exist. So we do expect for a number of states to receive funds to try to bolster the technical infrastructure and the deployment of some of these tools.

But I would say another really big thing was around workforce, and really around how do we make sure that we’ve got an appropriate minimum level of services in rural communities, but then can also either bring in the right workforce or frankly move people out. So that’s also another thing that the government was really interested in is, are there different models of organizing the delivery system?

And one thing in particular they talked about was like, these hub and spoke models. So would it make sense for, in some rural communities, to have one anchor institution, maybe in a more suburban or urban area, but that could support a constellation of rural facilities that could, again, either quickly transport patients if needed or simply tap into their expertise when needed. So those are the types of things that we are expecting and frankly, were reflected in states applications.

And now what I think remains to be seen is how the money is going to get divvied up. And then, the government has been very clear that one, they want results in year one, and those results are really going to be the key to unlocking future years’ allocations. So I think that this is something that we’re going to be seeing quick movement on in in 2026, and it is going to be really exciting to watch.

Dr. Tommy Ibrahim:

Yeah, no, that’s super insightful. Very helpful. And I think consistent with what we’re seeing as well and targeting also in terms of some of the projects that we’re exploring.

Let’s maybe talk a little bit about Medicare Advantage. Obviously a huge topic of discussion over the course of the past year. There’s a number of wonderful aspects to the program that we continue to be really bullish on as an organization. Obviously with sort of the growing trend of that over-65 demographic continuing the preferential sort of drive of seniors to opt for a Medicare Advantage program as opposed to traditional Medicare continues to expand and grow. And particularly in rural markets like ourselves, there always is seemingly an under penetration of Medicare Advantage relative to traditional, which I think poses some long-term growth prospects for MA in rural America, which is something that we get excited about as a health plan.

Having said that, the economics have been incredibly challenging, as you know. I mean, the utilization rates are incredibly high. You know, we’re seeing a lot of inflationary pressures, cost pressures, driven by higher utilization, higher medical and surgical claims. Pharmaceutical spend continuing to really be disproportionately escalating with many other sort of regulatory factors and uncertainties abound.

So how do you see that market progressing in the future with some of what you know about all of the regulatory questions that are out there around risk adjustments? Where do you see all of this going for MA participants?

Molly Smith:

I think this program is going to survive and frankly continue to thrive. And there are really two primary reasons for that. One is that, to your point, Medicare enrollees are choosing Medicare Advantage. It looks a lot more, it looks very similar to what they are used to from their job-based coverage. Oftentimes in fact, there’s sort of a pretty easy transition between maybe the way in which they were getting covered and the companies that they were using when they were employed into a Medicare Advantage product. And I do think that that will continue. So the consumers will drive it.

But I think the other reason is some of what we’ve already touched on, which is this kind of inherent value proposition around creating incentives for the MA plan to really try to manage the care better, and to really ensure that they’re driving to the best health outcomes for their enrollees. I think all stakeholders continue to really believe that aligning these financial incentives and creating also the flexibility through these alternative ways of paying, are really what is needed to make providers able to do these things, to better care for their populations.

So given that kind of commitment to those models, and again, I think a really fundamental belief that those are ultimately the right ones, we will figure it out. But it is clearly a very uncertain period right now for Medicare Advantage plans. There is a lot of concern in Washington that the program, the participants, the companies that serve the program have been overpaid by the government. And it is true that the federal government spends more on the Medicare Advantage program than it does if those enrollees fulfill the fee-for-service program. There are a lot of reasons for that, but there’s been particular concern by policy makers that there’s been some level of gaming by certain payers in particular. Certainly not universal.

I think the biggest challenge that we have before us is how do we address those very valid concerns where there is problematic behavior, but not lose access to this really important program that a lot of beneficiaries rely on, that they want, and that is working again to really align incentives. So I think here at the American Hospital Association, one of the things that’s so important for us is to really tap into our members that have health plans to really understand what are the dynamics that are happening, what is working in the program, where do you think some of this gaming might be happening, and how do we isolate that? Because frankly, a lot of hospitals who don’t have plans are really frustrated for good reason with some of the really big national MA carriers.

And so it’s easy to sort of say, you know, there’s been abuse of prior authorization, or there’s been abuse of the risk adjustment program, and they’re getting more money than they deserve, you know, let’s throw the program out. I think that for us, we feel a real responsibility to try to do right by the health care system to try to figure it out and get it right, which is just an incredible opportunity for us to partner with organizations like Sanford to figure that out.

Dr. Tommy Ibrahim:

Yeah. No, I love that. Thanks for saying that. I mean, I think you’re absolutely right. I mean, provider-led health plans often get pulled into that broader narrative when we try to always sort of play by the rules and do what’s best for seniors. And you know, I also see the other side of it too. I mean, on the care delivery side, we’ve also had some of those frustrations that you note with other MA carriers. And given the fact that we obviously own our own health plan and operate a pretty significant Medicare Advantage line of business, can see sort of the flip side of it, and are more sympathetic to sort of the variations that happen there.

You know, sticking with that theme though, I have been very impressed with you know, CMS’s willingness to sort of have an open door policy and have a conversation about some of these things. To take a look at the variations between some of the larger payers that are out there and smaller plans like ourselves. And they express sort of a willingness to listen and address some of the variables that impact us maybe adversely than they would other plans. I mean, just recently, I know you guys had a little bit of a role to play in this, Alliance of Community Health Plans (ACHP) was involved as well, but CMS actually did make a pretty large concession to move away from the health equity index, which is absolutely well-intentioned but would’ve adversely impacted smaller plans like ourselves that wouldn’t just meet some of the basic requirements to qualify for that particular measure and replaced it with the reward factor. So thanks to you and your leadership in AHA for really diving into some of that, but that seems like a really positive win for smaller plans like ourselves. Would you agree?

Molly Smith:

Yeah, absolutely. And I think that to your point, well-intentioned policy, but at the end of the day, I think that one of the biggest challenges with a policy like that, and frankly this can happen a lot, is that the way that it was structured really was, just by de facto, sort of benefited bigger plans that had millions and millions and millions more beneficiaries who could perhaps even qualify them to participate. So that’s one example of kind of a specific aspect of that program, which was just, which plans are eligible for this new kind of incentive financial award. And the reality is some of the highest quality plans in the country, which are smaller provider-led health plans, didn’t even qualify just because they don’t have millions and millions of …

Dr. Tommy Ibrahim:

Population. Yeah.

Molly Smith:

Exactly. And so that is a perfect example of one area where we really need to be a lot more thoughtful when we’re making policy about not stifling competition by making it so that only these behemoths can play in the market. I mean, we already have a lot of consolidation in the insurance space. I think most Americans can name kind of the top five insurers off the top of their, like on one hand.

But what I think that, again has been so exciting has been these newer, smaller entrants who are deeply embedded in their communities. I mean, you have physical infrastructure, your workforce is in the community, you’re not going anywhere. And what I think we’ve seen from provider-led health plans is that they bring competition to Medicare Advantage markets. They bring stability. There’s a lot less kind of coming and going from markets, because you’re really committed to the population and not just necessarily the returns that you might get in a given year.

And frankly, we’ve actually looked at the performance, the quality ratings that CMS does of health plans, and we’ve been able to segment out the provider-led health plans, and they do meaningfully actually perform better as well on the metrics of things like access to care and timeliness of care, and frankly, patient satisfaction with their coverage.

So just given all of those reasons, I think it’s just so important. And I’m very optimistic that the government does recognize that and has an open mind for what other changes need to be made. Because frankly, there are some other changes that need to be made to continue to make this like a viable market for smaller more regional plans.

Dr. Tommy Ibrahim:

Yeah, I totally agree with that statement, obviously. And we’ve been thinking about how do we sort of keep the momentum going now that the conversation’s been started and sort of a realization that we are very different. In keeping with that, other policy reforms, I know there’s a lot of focus obviously on prior authorization and denial rates and how we manage some of those back office processes that get in the way between care and the member.

Tell me a little bit about what you think we could be doing right now to continue to advocate on behalf of smaller plans like ourselves and to continue to get that differentiation narrative out to sort of a broader audience.

Molly Smith:

One, we need to be always sort of elevating the story of how provider health plans kind of do things differently. And frankly, there’s probably no one better to tell that story than your enrollees themselves. And as I mentioned, they’re already telling it through the surveys that they do of their satisfaction with the plans, and we really need to elevate that.

But I mean, you mentioned prior authorization. I think this is such a great example of where an integrated delivery system has just such a different opportunity to do things differently. To really take a look at, I mean, we’re always going to have prior authorization. It’s totally appropriate that we have a mechanism for health plans to, one, to make sure that the care that is being sort of recommended for their enrollee is actually covered by the health plan. I mean, it would be terrible if there was no mechanism for that, and then all of a sudden you got something that you otherwise couldn’t afford and you didn’t know in advance. So there are reasons.

What I think has happened now is that it’s become just a very, very blunt tool that some payers use when they realize they can’t meet their financial targets, and all of a sudden they start squeezing on prior authorization. Where we see it work very differently in our members that have plans, is that they’re able to sit down, the provider kind of side of the house, if you will, and the plan side of the house and say, “OK, what is the care that needs to be delivered for patients with whatever the condition is?” Let’s take our, like hypertensives, let’s take those with chronic obstructive pulmonary disease (COPD), whatever the condition is, what is the right care pathway for them? Do we have that enabled? Where are there places where we can say what we don’t need?

We know this is all covered. We all are aware of what the rules are. Providers kind of go forth. But also there’s access to information and data that is just easier and kind of safer to access when you’re all part of one system. So I think that those are some of the inherent benefits of being an integrated delivery system.

And again, I think this is just why the performance is bearing out when CMS or when the surveyors ask consumers what they think about their plans, or frankly, when we look at disenrollment information, and we do know that Medicare Advantage beneficiaries are two and a half times more likely to leave one of the big traditional kind of commercial insurers than if they’re enrolled in a provider-led health plan. I mean, I think that speaks volumes. I think that we need to continue to kind of elevate not only the performance results, but the stories about how and frankly also I think the stories about how maybe will help others kind of learn how to do things better too.

Dr. Tommy Ibrahim:

Yeah, totally agree. And I like that statistic that you shared about seniors opting for smaller regional plans, a lot like ourselves. We believe that our reputation and sort of the loyal base that we’ve established here really does sort of lean in that direction. So this has been an absolutely fantastic conversation. Always insightful, Molly, to connect with you. I mean, there’s a lot going on right now in the health insurance space. There’s a lot going on in sort of the hospital industry overall.

Maybe just a couple of pearls of wisdom from you, like where do you see the next two to three years going here and what would you sort of recommend to provider-led health plans like ourselves as we look at differentiation, as we look at continuing to evolve our model amid all of the industry challenges? What would you suggest to us?

Molly Smith:

Yeah, so I think one of the most interesting things that’s happening right now, and we haven’t touched on this a bunch, but there’s all these new access points for care that are springing up. So whether it is direct-to-consumer primary care, or concierge primary care, there are just like this ever proliferation of websites now where people can go and speak to a clinician and get a prescription for any range of drugs. And in fact that’s something that is being encouraged by the administration in terms of working with some of the large pharmaceutical companies to offer more direct-to-consumer offerings.

I think this is both – it’s fascinating. It potentially could be transformative for populations that otherwise have really struggled to get access to care, which really could include a lot of rural populations. But it introduces a real change, a potential change, to kind of the traditional business model of insurance.

I mean, I think that historically, the insurance model has really been predicated on establishing a provider network where you can, and this is whether it’s provider-led or it’s a big traditional insurer, you establish a provider network where you negotiate rates and then you try to manage utilization. Like we were just talking about, you either maybe try to do it in a way that is more driven towards like actually managing population health, or you just throw on prior auth on everything and just try to like, manage it that way.

But in any event, it seems clear that people are going to increasingly access care outside of their traditional kind of network. So I think one of the things that’s going to be really important for provider-led health plans, but frankly probably any health plan, is to really be watching and talking to their enrollees about what they want in terms of access to care, and then helping them meet it, whether it is building it yourself, building the access points that they want or partnering as appropriate. But it’s going to really take, for many organizations, a different look at the way that they organize their benefits, the providers with whom they contract.

So all of that I think is really both exciting, but it could be a little challenging because it really could disrupt some of the traditional ways that health plans have sort of managed their business model. So I think that’s sort of one really interesting thing, and I think it’s going to move. I mean, it’s already moving and it’s been moving so fast.

And the last thing I do think that we just need to double, triple, quadruple down on, this value kind of adoption. And I think in the rural space in particular, what I think is incredibly exciting and we need to continue to learn from is that the traditional way of thinking was that managing risk didn’t work in rural areas because there wasn’t a big enough population to sort of spread risk.

But organizations like Sanford and others around the country have clearly proven that wrong, and in fact have really been innovative in thinking about how do they even build more kind of risk and accountability into individual providers in rural areas? That has really seemed to work, including to bring stability actually through more sort of stable financing mechanisms of rural providers. So I think that that is just a huge, huge opportunity for us nationally. And one really where we really need to learn from the Sanford’s of the world and then export that more around the country.

Dr. Tommy Ibrahim:

Yeah, I appreciate that very much. I think you brought us full circle back to sort of the foundational concept of just member centricity, right? Listening to our members, really optimizing for an ideal experience for them, trying to drive affordability, quality and service. And that is sort of the thesis that we are centering our strategy around as well. So I appreciate you validating that.

Molly, this has just been awesome. I appreciate the time that you’ve given us today. Thank you for sharing your expertise and your insights. On behalf of Sanford, on behalf of the entire organization, thanks for all you do for us and for how you represent us with the AHA. It really is an important relationship and a partnership that we value.

Courtney Collen (announcer):

Thank you for listening to “Reimagining Rural Health,” a conversation series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health Series on Apple, Spotify or news.sanfordhealth.org.

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The business of caring for America’s seniors

Alan Helgeson (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations, and real-world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools, and partnerships advancing rural health care and strengthening care in communities across the country.

Joining us in this episode is Steve Flatt, chief executive officer at National HealthCare Corporation (NHC), alongside Nate Schema, president and CEO at Good Samaritan. Together, they’ll discuss opportunities to strengthen the quality of care delivered to older adults living in America’s nursing homes, including how workforce policies, regulatory reform, and AI can transform the future of senior care in both rural and urban communities.

Nate Schema (host):

Steve, welcome. First of all, thank you for doing this. I’ve had the opportunity to meet you and get to know you a little bit here over the last five years. And to say that I’m excited is a little bit of an understatement. I was doing a little bit of homework prior to our conversation, Steve. And I know a lot of people know you as being a part of NHC, obviously, one of the most reputable organizations in the country.

However, I also know that you did not have the traditional path into leadership that many operators have and how I grew up in the sector coming up and kind of going through this. And if I’m not mistaken, you were a president of Lipscomb University, which happens to be your alma mater as well. Tell me about your journey and transition into health care and what led you here.

Steve Flatt (guest):

Well, Nate, I’m going to give you the very abbreviated form. I’ve lived a long time. So, I’ve been blessed to have some different opportunities in life. And at one season or another, I literally felt called to go into a new opportunity. I did attend Lipscomb, played basketball there, played. When I graduated, they actually hired me to work as director of admissions and sent me to Vanderbilt to get my master’s and doctorate. So, I worked there five years after that, 10 years in total, left to go into full-time ministry, was actually the senior minister for a large church in the Nashville, Tennessee, area. And then also was president of a K-12 Ezell-Harding Christian School, which had 1100 students. So, a dual role, which was unusual.

Went back to alma mater in ‘97 as president. Was there for eight years, and actually – well, I won’t go into detail there, but got approached by one of our board members, Andy Adams, whose father founded NHC, and he said, “Hey, how would you like to come into senior care?” And I was 49 years old. It seemed like an unlikely transition, but I’d done leadership training for NHC. I knew the quality of the company.

I knew they were considered one of the top five or six long-term care/senior care companies in the country. So, what seemed like a very improbable conversation, I remember it occurred Good Friday of 2005, and three months later I was on board with NHC. And I’ve just celebrated my 20th anniversary, and it’s about to be nine years as CEO.

And I’ll tell you, I mean, I’ve loved every job I’ve ever had. I really have. But I feel like this was a calling and it’s been a blessing to me. And I’m like you, Nate. And by the way, I’m a big Nate Schema fan, as you know, (laugh). But I work with some of the best people in the world. It’s a real joy.

Nate Schema:

Oh, that’s awesome. Well, and I do think you’re a little too modest on that whole basketball resume: three-time MVP over four years at Lipscomb, all-time leading scorer. I don’t know if that record still holds, Steve.

Steve Flatt:

Oh, no, no, no (laugh). I’m not even sure it’s top 10 anymore, honestly. A little bit of trivia. A couple guys came along 15 years after me. Lipscomb actually has the two all-time leading scorers in the history of college basketball. Doubled my point total, John Pierce, Philip Hutcheson. Look it up. It’s worth Googling. But they both had like 4,500 points in their career.

Nate Schema:

Unbelievable. Unbelievable. That is unbelievable.

Steve Flatt:

It was a great place. I enjoyed that experience. It was fantastic.

Nate Schema:

Well, thank you for joining “Reimagining Rural Health” podcast series. Obviously very important to us here in the upper Midwest. I know that you care for folks all over multiple states now, Steve, this conversation is pretty darn important. As we look out over the next few years and how we reshape, how do we keep access to care close to home? And obviously Good Samaritan and NHC have been doing this for a long, long time. And while care is delivered in a little different way today, or quite a bit different, we know that there’s going to need to be some fundamental change here as we move forward. So as you look at quality at NHC, how has that definition evolved over the last few years or since you became CEO maybe in 2017?

Steve Flatt:

And, you know, quality is one of those nebulous things, Nate, that’s sometimes hard to define somebody like excellence. Somebody said, “Well, I know it when I see it.” I’ve always thought of quality though, whether in my past life or coming into health care as really a kind of a dual thing. It’s a measure of how well something meets customer expectations, while at the same time meeting appropriate specific standards. In other words, there is an objective and a subjective part to it. You know, we’re in health care, we’ve got to do things the right way, whether it’s wound care or anything, any diagnosis. The care objectively, it has to be administered the right way at the right time. All of that. And that should be measurable. We measure weight loss, and falls, and pressure injuries, and all these rehospitalizations.

But the other part of quality though, you can do those things and still not have a quality operation if people aren’t satisfied. I mean, ultimately we’re about the quality of life that our patients and residents are getting. We want them to feel that. If they’re not experiencing that and check all the boxes over here, then to me it’s not quality. Either one without the other is insufficient. And really that definition has never changed in the nine years I’ve been CEO.

I will say one thing, since becoming CEO, I probably have an even greater appreciation for the customer satisfaction side of that. You know, we may talk later about (Medicare’s search tool) Nursing Home Compare. That’s one thing I really think we need an objective customer satisfaction standard that can be put on Nursing Home Compare. Right now, it’s all the objective side. It’s all, you know, all those measures and those are OK, most of them. But we need that, to me, the full picture for the patient of the resident.

Nate Schema:

And I couldn’t agree with you any more. I always think that, especially as a consumer, looking at all of the data that’s available out there, it almost at times feels like you need a Ph.D. to understand, and really understand what’s driving all these different measures. You know, this is something you and I do every day, and it’s really, really complex. You know, which is it, a long stay measure? A short stay measure? How these point systems all come together? And, by the way, there’s a curve.

And so, you know, not all locations in a state could be five-star. And so I’ve got some pretty strong feelings about that. But before I get to that point, you know, tell me about what you think it is when we look at Nursing Home Compare, what would a better system look like in your mind? It sounds like, and I agree with you, a consumer-facing component, there should be a standard there. What else needs to be there moving forward?

Steve Flatt:

First of all, I’ve already mentioned, number one thing I would add some type of objective normative customer satisfaction score. And those have to be fairly carefully crafted. I know we have CoreQ scores as a part of our daily work today. I’m not sure that needs to be it in that four, but that’s a start. We could start and we could work on a normative objective customer satisfaction score.

I think another thing that has to happen with, as you and I both know, Nursing Home Compare’s predicated on the survey. I mean, that is the basis. And we just need survey overhaul. Candidly, there’s so many things wrong. Number one, lack of frequency. We’ve got some centers having surveyed in five years. Where does that put them on Nursing Home Compare? You start with the survey and then you’re graded up or down from there.

And those surveys, as you know, are extremely subjective. And the other thing is, they are designed to focus. I mean, they’re centered on what can we tell you you’re not doing correctly. Now, I’m OK with that. I’m OK with that. We need to know the things we’re not doing correctly. But when the focus is looking for the minutia for tags and sometimes letting that molehill turn into a mountain. How many of us haven’t had to appeal IJs (immediate jeopardy tags) that were nowhere close to IJs? I mean, nowhere close. I mean, there’s just a problem with the survey. So to me, that’s part of Nursing Home Compare. I could say if you leave it alone, at least put less emphasis on it. But I’m frankly a proponent for overall survey reform.

The other thing I would do with Nursing Home Compare, I do think staffing, it’s good to measure. Because I’m a believer that staffing and quality correlate very, very highly. But you know, we got people caring for patients that aren’t allowed to be counted in that, you know, in that staffing you may have a DON (director of nursing) who stays after hours and cares. You can’t count his or her hours. That’s just one minor example.

But to coin a politician’s phrase: “It takes a village.” It does. And I just think anybody that’s part of that village to render that care that’s rendering legitimate hours ought to be counted. So I think that skews it just a little bit. So those are three things that come to my mind that I think I would change about Nursing Home Compare.

Nate Schema:

Oh, hundred percent.

Steve Flatt:

I did feel like you’ve got to have something out there. And in an obviously an internet age, people use that more and more. But I bet it’s your experience. It is mine, Nate, particularly the smaller the community now maybe in large cities, that’s where you go to.

But smaller communities, our patient residents rely upon what their doctor tells them where they ought to go. Or maybe a hospital discharge planner or social worker there. Or even more just the reputation you’ve had in the community over years and that, you know, they look at that more than they do Nursing Home Compare.

Like you, I’m also a big proponent, I tell folks, family members, “Hey, if you got time before that discharge, just go visit, go visit.” We walk in there, see how the place smells, see how it looks, look around at the attentiveness of the staff and just get the vibe of the place. I think frankly, all those are things that our customers, both as patients and families, rely on even more.

Nate Schema:

I think we could probably spend an hour on this topic alone. Because I fundamentally agree with you that we need an entire overhaul of the five-star system. You know, being a part of an integrated health system here with Sanford Health, it’s been kind of interesting. And at times I’m more than a little envious of my hospital colleagues when they’ll share with me, “Oh yeah, we just had our hospital surveys,” and the going through the accreditation process. And I know that that’s quite the process for them, but it does not appear to be near as punitive, you know, and there’s so many more opportunities to continue to improve upon all the wonderful things that they’re already doing. Can you imagine a system like that in our space?

Steve Flatt:

Absolutely. And I’ll add to that one thing. I know we’re limited on time, but you know, we’re not JCO (Joint Commission) accredited for our skilled nursing facility. We don’t have time because we’ve got all the other onerous things that we have to do with the state surveys and so forth. But if the survey process were dictated by JCO, I would love to be JCO accredited and do our surveys basically the same way you’re talking about the hospitals. I’d do that. I’d invest that time, I’d invest that money because it would be more productive for our staff, and it would be far more productive to our patients and residents. So whether it’s that or something like that, I hope we can morph into that. And for all the listeners, I want you to know I’m a past board member of the American Health Care Association. We got that on the agenda. Nate’s a current member. So I think it’s up to Nate and his goal to get it changed. And I’m going to give him 12 months to get it changed. So Nate, there you go. There’s your charge.

Nate Schema:

No pressure. No pressure.

Steve Flatt:

You didn’t expect me to turn on you on your own podcast. Did you like that (laugh)?

Nate Schema:

Oh, that’s great. That’s great. Well, you know, earlier this year, and speaking of, you know, rules that just were untenable, there was this proposal out there to increase staffing levels in nursing homes. It was struck down in the courts, thankfully. The intent was improve quality, but providers like us argued for all kinds of very rational reasons that a one-size-fits-all staffing requirement was just not going to work.

So as you think about that, think about the impact of our workforce and our caregivers. Thinking about even just that survey backdrop that we just talked about for a few moments, knowing how in many ways our current process drives away top talent, it drives away some of our best people because of the onerous processes that are currently in place and the punitive process that’s in place.

But beyond those staffing rules, what does make a meaningful difference when you think about workforce and quality improvement and how those things work and go hand in hand?

Steve Flatt:

Well, as we said a little earlier, I think they do go hand in hand. And the most important driver of the quality of our operations is the quality of our workforce. And it’s just this massive problem. I’ll try not to get long-winded. You’re totally right about the staffing rule. It was a trifecta of errors.

Number one, one size fits all, that doesn’t work. Your little communities with less than a thousand people, the staffing rule for a very long-stay population shouldn’t be the staffing rule for something that’s almost exclusively post-acute. And that’s churning patients over and over. I mean, they’re just different. And we know we largely have a bifurcated population when post-acute and long-term stay, some weighing way more to one of those than the other. That didn’t work.

Number two, they didn’t want to pay for it. So, there were $11 billion shortfall in an industry that’s already underfunded.

And number three, the people aren’t there. So it was a perfect storm of a mistake. I’m glad it was repealed.

Now, going forward, I would like to hire more. I mean, it’s not that I’m against more staff, I frankly think that reimbursement rates need to start taking in staffing as opposed to just layering on it, using a stick and saying, everybody’s got to have 4.1. Everybody’s got to have this many RN hours, this many CNA hours.

Let’s set a standard that’s reasonable, say for the most rural, the most less labor intensive settings where it’s largely set a floor, but then incent make the payment based upon the staff you’re hired. I mean, that makes sense to me. I know we’re doing it based on patient acuity. I’m not against that. I think that makes sense too. But it could be dovetailed in there, either the Medicaid and or the Medicare level to we’re going to incent you to hire more people, but we’re going to help you pay for it. I mean, that’s the key. And that, to me, that makes a lot of sense.

Now, there’s also the component of outcomes. You know, the quality, you ought to be rewarded for that. I don’t care how many staff you’re hiring or not hiring. So the patient acuity, you know, looking at that as part of the reimbursement model, the staffing amount, and then the outcomes. To me, those ought to be the drivers of how you’re paid in conjunction with one another.

Now that still doesn’t address what do you get the workers, it would help you pay for them and maybe allow you to even have better escalation of pay as they stay. I think that’s a big part where folks, you know, we want to retain even more. I hate to say you’re always going to have a lot of 90-day turnover at certain level CNA, and housekeeping, and dietary. I wish it weren’t that way. Some people just need a job, need something, they need some money right quick. They go try it, they don’t like it, they’re gone. And I’m not sure all the onboarding and orientation and, you know, signing bonuses in the world are going to keep that from happening. And you can lower it, but it’s not going to go away.

So helping identify the people that are going to stay with you right now, 67% of our people stay with us over a year. I don’t know how that even compares to your company or the national average. It’s not a metric that’s in Nursing Home Compare. We think it’s so. I mean, I want that to be 80%, and that’s a big lift. I mean, if I could get 75 to 80% staying with us a year, I’m going to have a more stabilized workforce and that’s going to result in quality period. We’re doing OK. I mean, we’re proud of our quality. I think our retention’s OK. But those are just, I don’t know if I’ve rambled a little here, Nate, I don’t know if I’ve really addressed your question or not.

Nate Schema:

No, I think you absolutely have highlighted all of the different ways that staffing and quality are so intertwined. And I agree with you on all fronts and, you know, it’s interesting that you bring up retention. That’s something that we’ve been hyper-focused on here the last couple of years. And, like you, I don’t know that we have an industry benchmark by which we measure that across the country.

We’ve taken the approach much like you, that if we can keep people 90 days, and we often say that we bubble wrap them for the first 90 days. And our goal is to improve our retention by 3% here in 2025. We’re just setting our 2026 goals. So they’re blending together a little bit here and we’re about 83% right now across the organization. Which again, like you, we’re like, you know, this is OK, but we have work to do.

But we know if we can capture the minds and hearts and find those folks that are called to this work and have a sense of vocation and really have a passion for this, those are the folks that we want and to invest in. And we know that those folks will be here for the long haul. And then to your point, if we can get them 90 days and then they can stay a year, man, we have a heck of a shot at making sure that those folks are going to be here for the long haul. So, completely agree with you. That is an area of opportunity for us across the sector.

Steve Flatt:

And to help with that first 90 days, and ultimately the year. I mean, we’re doing things, I suspect these are similar things that you’re doing, but I mean, one thing we’ve had for years, this is getting more in vogue now, but we’ve had a foundation for geriatric education that our founder, Dr. Carl Adams, set up. And it’s an endowment, really. I mean, we paid out this year we’re paying out 275 scholarships for students to go on to school. And these are folks that work with us. We pay their way, they come back and they stay with us for three years. You know, that drill. But 275 is our high-water mark. So we feel good about that.

We have improved our onboarding process and frankly, we made an upgrade. And with we’re on UKG (an employee training software program) and really trying to utilize all of its capabilities to help us in that onboarding along with better staff training internally.

Then we put our CNAs, in particular. It’s in its infancy, so I can’t tell you any outcomes yet, but we’re creating a career path, career ladder for them. I think, you know, if some are going to stay CNAs, what if you’re a master CNA for sure. I mean, what if you become, you are recognized as a master CNA. Some may go on, become an LPN and RN and they’re not CNAs anymore.

But different career paths that we think are important for our food service folks, we’ve implemented something called Pineapple Academy, which is a training program, and it’s got level one, two, and three where they’re literally three- to five-minute training videos to help. And we think it does a lot of things. It actually helps them do their job better, but it adds a level of professionalism. Like, go in there and cook something or go in there. No, no, no, no. We’re training you in the art of food service.

And then the final thing, and I’m ashamed to say we’ve had this a long time, but we discontinued it in COVID everything just helter skelter. Well, we have something called “PIE,” partners incentive for excellence. And basically we fund that several million dollars. And every center has its own pie chart in the break room, the lunch room, and we’ve got goals, quality, and most of them are quality initiatives. And customer satisfaction is, you know, meeting budget for the center is one piece of the pie. But what you do is as you meet different levels of the pie, it’s funded and at the end of the year, you get a nice bonus, potentially, in fact, hopefully very nice based upon how you all did together with the pie. You know, have we achieved our goals?

And I think that’s so important for everybody understanding it’s not my job. Well, it is your job. If your customer satisfaction score is going to help put money in people’s pockets or take it out. And it’s not all about the money, you know, I mean, we’re a for-profit company. You’ve got to be driven by a mission. But if nothing else, that also, it creates speed of corps, comradery, teamwork, and a bit of competitive, like within a region. We want to get the best pie score of any center in our region. And it’s amazing. I just think it’s a good tool. We’ve been, so I’m glad we’re getting that back in play.

Nate Schema:

I had the opportunity to go to watch the AHCA Gold Award or the award ceremony here, a couple weeks ago in Maryland Heights there. An NHC community was, I believe, your first gold winner. I think Susan is your administrator. Susan Taylor. What would her pie score look like?

Steve Flatt:

Susan’s would be very good. It would be very good, Susan. We have something we may talk about in a minute. We have a culture we call “the better way.” We have 20 promises that we cover every day with every partner and a standup borrowed that idea from the Ritz Carlton founder, Horst Schulze. And one of our promises, number 14: “I promise to put my heart into everything I do.” Which to me is the most important of the 20 promises.

And she embodies that as well as anybody in our company that’s a 203-bed center. They stay 90. And it’s not a new building, Nate, it’s not a new building. They stay about 97% occupied largely with dementia patients. They’ve got virtually a zoo out there, got a menagerie, they have animals out there, and it’s all wonderful.

The residents there. They are, I mean, literally the people just loved and very deserving of the gold award. Susan’s done a great job. Jeff, the DON, super job. I mean, I’m proud of him. I’m really, really proud of- but we had several who got the silver and several with the bronze. So I think we’ve got another one that’s knocking on the door of gold. And maybe in another year or so, we may see that, hopefully.

Nate Schema:

It was pretty awesome to hear Susan’s story. And we’ve got 57 communities planning, or having an intent, to apply for the 2026 AHCA awards in various different categories. And we’ve got a couple of those gold applications out there. So we’re hopeful.

But hearing Susan’s journey at Maryland Heights, and my understanding is it was a 12-year journey. Of course, you throw the pandemic in there and that messes the timeline up a little bit for a lot of locations. But meeting her after her award, just to go say hi, thank you for all that you’ve done, and congratulations. She’s one of those folks you meet. And instantly, you know, she’s here for all the right reasons. So, congratulations. I wanted to make sure I shared that with y’all today, Steve.

Steve Flatt:

Well, thank you. By the way, Susan’s dad was a long-time medical director there. She grew up really getting a sense of that place and really what long-term care is supposed to be. She’s great. Thank you for that. I’ll pass that along to her.

Nate Schema:

You think about where we’re at here in the upper Midwest and the states that we’re talking to, North Dakota, South Dakota, Nebraska, obviously not as densely populated as Tennessee and some of our Eastern coast folks and colleagues.

One of the biggest things, and you touched on it, it’s technology. You know, I think about what these – where residents expect moving forward, especially these future generations, no different than I have five different streaming services, whether it’s Hulu, Prime (laugh), Netflix, et cetera, you know. Some of these deep rural locations, they don’t have the same technology infrastructure. Not to mention, these communities were built 40, 50 years ago in many cases. So, you have to overhaul the entire infrastructure to have access to that type of technology to ensure then that you’re able to make the investments to modernize and take advantage of those efficiencies.

I keep thinking about what AI could do for us, you know, knowing what we’re piloting in some of our hospitals today with our physicians, who are walking in, and spending more time just literally visiting with their patients and having all of that ambient technology, taking their notes for them, and in many ways, putting together some pretty incredible documentation and saving them so much more time so that they can spend quality time with their patients and make sure that we have the outcomes that we still need to get where we need to go.

But imagine what that looks like for an MDS coordinator (minimum data set coordinator, a resident assessment nurse), our case manager who, you know, in many of our buildings, we’re doing a lot of admissions in any given week, dozens and dozens in some of our busy locations. Imagine them being able to go in and just have a conversation with someone. And all of the right fields get documented in our electronic medical records.

I do think there’s opportunities. They look different than acute care, but I think we still have the same opportunities. And those are the types of things that I think the rural transformation funds could do for us. Some are very practical, whether it’s the Netflix, the Hulu, whatever, but some are, you know, how do we get the ability to deliver care more efficiently and modernize everything that we do?

Steve Flatt:

Well, in every state, every city, every location’s going to be different. You nailed it though, right at the start of your remarks. I mean, you got to have broadband, you’ve got to have the service, you’ve got to have it there, and you’ve got to have the building equipped to be able to do something with it. I know that’s easier said than done in, I don’t know, “Broken Arrow, South Dakota.” I’m making up a city (laugh). I mean, I know it.

But you know, one thing we did, I’ve been at NHC 20 years, starting in my second year. I wasn’t CEO, but I was over it among my other responsibilities. And we bit the bullet and went CAT-5 wiring with all of our buildings, some of them very, very old, all of them CAT-5 wiring.

And then we went to wireless, then we got wireless in every space in all the buildings so that we could use scanning for medications. But also so that patients and their families could use it. And now we’ve got it up to where they can actually stream movies. Because I mean that, believe it or not, you got 85-year-olds who want Netflix. I mean, they want to, “I want to watch this on Netflix.” And I’m grateful we made those moves when we did. Now I bemoaned it a little during some of those early stimulus funds, we’d already made the moves, and if we’d waited, I could have got paid for some of it (laugh), right? We’d already done it. But we looked for other ways to do that.

But now, going back to your – I know you know it’s here, but we’re using a tool called Oler, and it’s got some competitors out there, but it’s using about 800 SNFs (skilled nursing facilities). And we’ve been a key partner for them actually, to help them to develop it. And we’re about to go into another phase with it.

But right now, Nate, I mean, it takes that referral, which can be hundreds of pages, hundreds of pages can be yay thick, some of them. It all populates the MDS Bingo. And it does it more accurately than a human could. The human wouldn’t have time to look at everything on all handwritten notes, everything scans it all. Not just, you know, no matter what it is, we’ve been not just impressed, amazed by the accuracy of it, you know, one positive byproduct of that. It increases your reimbursement for PDP because you’re capturing everything. You’re not leaving things out. It’s what ought to be in there. I can’t tell you how excited we are about that one AI and it really is an AI tool.

That’s exactly what it is, you know, we’re using some, I’d call it AI to machine learning, some bots for accounts receivable that is going to, over time, you know, we’re not laying anybody off. But, you know, if people retire, it might not necessitate filling certain positions, which is just going to be the nature of the world. But going back to, we’ve got to, we’ll never- I say never. I’m a little pessimistic we’ll ever be on par with the level of technology hospitals are funded to use, but we’ve got to get up there close.

And I know you’re a part of a health system. You see it. You can go into a meeting and test it, you know, side by side, what are you guys doing? What we’re doing? But, tools like this, Oler, I think are the start of something that’s going to be fantastic. And it’s good for everybody. It’s good for the patient to make sure all that data’s captured, nothing omitted and so forth.

Nate Schema:

Oh, a hundred percent. Well, I think I’m even more affirmed having this conversation today that we’re focusing on the right thing. Because we’re piloting the exact same thing with our data analytics team that I built this out, and you’re right, we’re getting hundreds of pages, but to have a, you know, a referral packet come over in a summary page of one pager so we can make decisions. So, you’re not trying to, you know, spend 20, 30 minutes just trying to make the decision, let alone make sure all the right information gets to the right place in your chart. Yeah. So, man, I think we have some incredible opportunities ahead here.

And I think that that really ties into our last conversation looking ahead. And we talked about many of these things, you know, over the decades, quality in nursing homes has consistently improved, but the reality is reimbursement investment regulations have not kept up with the evolving needs of seniors and our rural communities. You know, we’ve talked about some common sense reforms, but what regulatory solutions will help advance quality in your mind?

Steve Flatt:

Well, in our industry, I think the things that would help advance quality is one, I’ll repeat. I think that regulation needs to take more of a carrot, not a stick mentality. These are things that have to be done. I get that. I get that. But let’s give some – we go back to the survey. If you happen to get a bad survey, what do they do? They take your CNA classes away from you. Well, how smart is that? (Laugh) if there’s a bad survey, it’s largely caused by the fact you have inadequate staffing and you’re trying to get that up. So now we’re going to just make it harder on you by taking away your CNA class for a year or two. That’s so counterproductive. And to me at least, it’s counterintuitive.

So, I think that’s one thing. I’m not saying just be lax, that is not the point. That is not the point. But, you know, it’s kind of like the teachers we had in school made at all levels. It’s like, boy, you got an “F” OK, and I’m kind of happy about it. Or, you know what? What can we do to make that better? What can we do to make that C a B? And I had some teachers of both types, and you did too. So, I think we need the emphasis on let’s make us better.

Another thing I think about, and I asked my chief nursing officer this, maybe we need more consistency of regulation between SNFs and hospitals. I think by that, I mean, and you’ve seen this being a part of a health system, let’s just take infection control. The regulations are different in the hospital than the SNFs. Now I know they’re different settings. But even like say a patient comes from the hospital with a wound or a catheter, we have to put up enhanced barriers. They’re confused by that. They’re worried about that. They don’t understand that wasn’t the way it was in the hospital. Why is that? Why would that be any different between the two? Patients don’t understand that.

So I think some kind of consistency there. And then (laugh), you know, as opposed to regulating us, talking about regulatory, the area that’s unregulated is managed care, and they’re beginning to give them a CMS, give them a few little rules. If anybody needs rules to get them in line and to not ignore the proper level of care for the patients or just put them off with these prior authorizations or denials just, “Hey, if we do this long enough, maybe they won’t even need it.” I mean, it’s just bizarre to me. I think we need regulatory reform for the insurance companies. Now, obviously, if I were heading an insurance company, I probably wouldn’t say that, but I feel like they’re pretty unfettered and we’re over here dealing with a morass of regulation that’s not making the situation better and neither are they.

Nate Schema:

It’s hard to even build upon that a whole lot, Steve. I think you’ve nailed it. We do have our own provider-owned health plan. If I was sitting right next to our CEO of the health plan, he’d say the same thing. Our provider-owned plan. There’s some unique distinctions and some very different things about what we do, why we do it, and how we do it than some of the big box organizations out there that we’re all very, very familiar with.

And the types of pressures they put around length of stay, the types of pressure they put around prior authorization and the barriers that we see as an integrated health system to moving people across the care continuum. We have people sitting in the hospital for two, three, four days waiting for an authorization. How is that better for the resident and the patient?

And two, we know it’s costing the system more money. So there has to be a way to break through that. And obviously I think we’re advocating heavily for that. Man, if there’s ever a time right now in history that maybe we could see some bipartisan support around something, I’m at least hopeful that there’s a lot of momentum moving the right direction to get that done. It fundamentally needs to change.

Steve Flatt:

And Nate, I don’t know if you guys, you probably don’t with that managed care system as a part of your health system, but I mean, we’ve run an I-SNP (Institutional Special Needs Plan) since 2016. We have our own Medicare Advantage plan, and we’ve now up to almost 1,400 participants. I can tell you the care those patients are receiving. I mean, you can do managed care and do it right, you can do it right, you can do it where you’re focusing on the patient preventing hospitalizations. But to do that, you know, you’ve got a skill in place, you’ve got to have more prevention with rounding MDs, and podiatrists, and dentists, and people coming in that help make sure they’re OK. That’s managing care.

I would argue that what United and Humana do it, they’re rationing care. They’re not managing care. They’re rationing care. That’s something the American public has not historically stood for. And I hope we don’t now. That’s all I’m asking for is managed care that’s really for the best for the patient, not the pocket.

Nate Schema:

Oh, you’re spot on. And we too have our own I-SNP plan and about 1,100 members, so very, very comparable. And the amount of services, and the amount of interventions that we have in place, and the protocols to ensure that these folks have the highest level of care in wherever they call home. And now we’ve extended that to assisted livings.

But these folks have people looking at their charts and putting things in place that didn’t exist five years ago, certainly 10 years ago, but they are being looked at from all different angles to prevent rehospitalizations, to ensure that they’re on the right medications, to ensure that they have the right interventions way upstream. And so the amount of resources being invested in our care settings, in our nursing homes, it’s incredible. We need to expand that model and get away from the rationing model that we’re fed up with. Quite frankly, just fed up with.

Steve Flatt:

Absolutely agree.

Nate Schema:

You know, we’ve talked and covered a lot of ground here, Steve, and so I might just end with as you see opportunities to partner across different care settings, how are rural health providers positioned to be leaders, you know, in this collaboration? I think we just talked about it a little bit there. You know, maybe the only thing we haven’t touched on is virtual care. You know, maybe just tell me about what other types of ways are you collaborating to ensure that these folks get access to quality care close to home?

Steve Flatt:

And that’s a great question. Again, our settings are not quite as rural as yours. We used telehealth to a pretty full extreme during the pandemic. It was a whole different world. I think everybody had to, and that has abated a lot in our setting.

I’m literally sitting here right now, Nate, I couldn’t tell you the depth of the usage of telehealth that we have. There is some. There is some, and some we’ve used in a couple of health systems where there was somebody that we could alert if there’s a change in a patient’s status to get counsel, whether or not to, you know, admit them to the hospital, use very judiciously. And not that often.

But beyond that, I will say, we’re in the behavioral health space. We have three behavioral health hospitals. We have used more telehealth on the psychiatric part of things for interviews of patients and so forth. But that’s an area where virtual health, you know, I think that is part of the future. I think it’s particularly necessitated the more rural the setting. I don’t think there’s question about that, but that’s an area that I would say our focus hadn’t been on that as much, much as on the AI opportunities at this point in time.

Nate Schema:

No, that makes complete sense. And we were fortunate to receive a transformational $350 million gift as a part of our integrated health system here a few years ago. And we literally just launched about two months ago. We took all 27 of our locations in South Dakota, up on our own virtual care platform with the idea, again, how do we prevent rehospitalizations? How do we, you know, how do we prevent burnout? One of the things that we’ve been really focused on, and we talked about a little earlier with our team members.

Oftentimes in some of these small rural communities, you might only have one RN taking care of an assisted living (location), and it’s just not feasible for them to be on call 24/7. So, how do we take some of that burden off of them and create a triage system so they can go home for the weekend and know that for a med change or, you know, maybe there was a fall over the weekend, they don’t need to get those routine phone calls over the weekend. They can manage anything else come Monday, but let’s take some of those nuts-and-bolts things off their plate so we can give them some relief during that time.

So, we’re really, really early into that space, and while telehealth is certainly not new, how we do it? And how we make those connections across our system? They’re going to be pretty darn important for us moving forward. So we’re not transferring people 40, 50, 100 miles to wherever they may need care.

Steve Flatt:

You’re far more of a pioneer in this regard than we are, so I’d love to pick your brain as that moves along and look for ideas that we could make applicable in our settings.

Nate Schema:

Absolutely. Yeah. Well, Steve, I cannot thank you enough. I think I have, I couldn’t take notes, but I have several notes and takeaways that I will likely be picking your brain about in the future. And like I shared, I think I’m more affirmed that we’re focusing on the right things after this conversation as well. So I just want to say thank you. You all are clearly an incredible organization, and that’s a reflection of your leadership. So, thank you so much for joining me here today.

Steve Flatt:

Well, Nate, thank you. Certainly back at you. I admire you so much as a leader and I admire your organization. And I just am honored to participate on this with you. And I’m thrilled to learn what you’ve shared with me all through this conversation that you’re, I mean, you guys are great. You do a fantastic job in some very challenging settings and I applaud you and it’s an honor to call you a friend.

Alan Helgeson:

Thank you for listening to “Reimagining Rural Health,” a conversation series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

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Mom with cystic fibrosis beats odds with every birthday

Chrystal Moldenhauer:

I was doing probably eight hours of therapy a day. I would wake up at four and spend two hours clearing out my lungs before my daughter woke up to get ready to go to school. Because I wanted to be able to interact with her without feeling short of breath and crabby from that.

And then she’d go to school, and I’d go home and I would do therapy for as long as I could physically do it. And then normally we’d, you know, get her to bed at whatever time. So I’d have three or four hours with her when I could breathe well. But normally after about three hours, my lungs started to fill up again and I couldn’t breathe. My last hospital stay, I told my friend, I think this is going to kill me.

Matt Holsen (announcer):

This is “Family Portraits,” a podcast series by Sanford Health. And now, Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

If you think about your childhood and that fun, carefree spirit with which you bounce through the days, it probably brings up a smile and maybe a glow to your face as you quickly pull up a mental image from that time. What if that memory was filled with question marks, unknowns, and dark clouds that even medical experts at that time could only shrug their shoulders on what might lie ahead.

The dizzying rate at which medical advances happen these days probably doesn’t even make you have a second thought about what’s possible. But in 1974, it wasn’t quite the same. No iPhone clouds. Clouds were something we looked up at. And medical breakthroughs, oh well they still happened. We first learned about the Heimlich maneuver. The patent was granted for the MRI machine and the first Tommy John surgery was done.

We didn’t hear about these things on TikTok though, or Snapchat still for other areas of medicine in 1974. It was very much a frightening world, especially if you were born then with a genetic disease.

Chrystal Moldenhauer (guest):

I was diagnosed with cystic fibrosis at the age of three months when my mother noticed some irregularities between my body and my older brother’s body. Something about my skin was tacky and she thought that was not right.

Alan Helgeson:

That’s Chrystal Moldenhauer. Now if you don’t know about CF or cystic fibrosis, the outlook then was not very good.

Chrystal Moldenhauer:

I believe they were told I may not make it a year. One year. It was very much a childhood illness. Kids did not live past their elementary years for sure.

Alan Helgeson:

Before we go much further, we jump right into what you might be told in 1974, but now let’s talk about what CF is.

Chrystal Moldenhauer:

Cystic fibrosis is a disease of the exocrine glands. So any gland that excretes anything is affected. I believe it makes secretions dehydrated, so much thicker throughout the body and it causes the most problems in the GI, the digestive tract, and then in the lungs and sinuses. So typically you’ll see people with cystic fibrosis maybe look a little malnourished and they cough a lot.

Alan Helgeson:

As you’re probably putting together, not a lot of options for treatments.

Chrystal Moldenhauer:

They did the pancreatic enzymes for digestion and they did percussing with the hands to try and loosen secretions in the lungs. And I think that that’s all I know of. That’s all they did for me. I’m sure they had antibiotics and such, but I wasn’t that sick yet. Back then I was considered to have a mild case at that point. I didn’t struggle with it until probably I was, I think 15 maybe was my first hospitalization. So I made it quite a while, being pretty healthy.

Alan Helgeson:

Okay, so as you have followed along the last few minutes, Chrystal seemed to have things a little bit better than what they maybe could have been given her condition. So how did we get here today? Well, that is the strange path of a genetic disease. They take you to places you don’t expect, kind of like Chrystal’s journey. And growing up in her family,

Chrystal Moldenhauer:

They treated me like a normal kid for the most part. I had to take digestive enzymes when we had meals. But other than that I didn’t have a whole lot of special allowances made for me.

So I was expected to do the chores and to contribute to the family. And I had a paper route in seventh and eighth grade and I was expected to ride my bike. You know, it felt like tough love, but it was good for me in the long run.

When I got sick at age 15, then I started to be hospitalized probably quarterly for three weeks at a time. And then there were obviously some changes that were made. You know, I was allowed to have special exceptions for homework, due dates and stuff in high school.

Alan Helgeson:

Chrystal is 15 now. This would be around 1989 and things would start changing.

Chrystal Moldenhauer:

Yep. I contracted Pseudomonas aeruginosa, most likely from a CF camp where we were all together, you know, enjoying each other’s company but not realizing we were sharing bacteria. It’s a bacteria that once it’s in our lungs, it never goes away and it becomes a superbug. It becomes resistant to antibiotics, which is what happened to me.

So by the time I turned 18, they had been so aggressive in treating me that they had run out of antibiotic options and told me we can’t do anything else for you because that particular CF center didn’t know about some of the different airway clearance options that were available.

Alan Helgeson:

When you think about a bug, a bacteria that never goes away, what does that mean to someone like Chrystal that has cystic fibrosis?

Chrystal Moldenhauer:

It always is active. I always have a low grade lung infection, so I always do therapy twice a day to keep my lungs cleared up. Anytime I get a cold virus, it kicks usually down into my lungs and flares up the Pseudomonas bacteria.

Alan Helgeson:

While talking with Chrystal and her family at this point, she made eye contact with her daughter and they smiled at each other. So I had to ask them what was going on. It happened to be about the cold virus and how it affects life at their house.

Chrystal Moldenhauer:

Well, we chose to homeschool because the virus activity in grade school was manageable, but then when COVID hit, it became a real hardship. Every virus is dangerous for me, but COVID was especially. So we pulled her out and started homeschooling, which we’re enjoying. But we still allow her to do extracurriculars with her friends.

And so when she brings home a virus, we try very hard to not share it. (Laugh) Sharing is good, but not that.

Lucas Moldenhauer:

So when family, brothers and sisters from my side or her side want to come visit, we always have to be very careful. Have they’ve been exposed to any viruses, you know, for a week or so before coming to visit us? Because we just can’t run that risk of Chrystal getting sick again if it can possibly be avoidable.

Alan Helgeson:

That’s Lucas, Chrystal’s husband.

Lucas Moldenhauer:

Because cold and flu season is right around the corner and that’s when all the best holidays start. And right? Thanksgiving, Christmas, Easter, all smack dab in the middle of cold and flu. And so it’s definitely a challenge because I have five sisters and she has a number of siblings. And what are the odds that everyone’s going to be healthy?

Alan Helgeson:

For Hadassah, Chrystal and Lucas’s daughter, it’s hard for friends to understand those extra steps needed for things we often take for granted. Like the sniffles.

Hadassah Moldenhauer:

Sometimes I just go to school with like a mask on and everybody’s asking me questions and saying, why do you have the mask on? And I’m just like, I want to say because you’re really sick, you’re always just sick. I’m like, probably shouldn’t say that. So I just say, I just want to keep the risks down and my mom has a disease and whenever she gets sick she could possibly go to the hospital. It’s always a possibility. When I was younger, if I ever got sick, she almost was in the hospital.

Alan Helgeson:

And it’s for reasons like this that Chrystal and her family are extra cautious.

Chrystal Moldenhauer:

So CF has become a very isolating disease. You can’t go to support group with other people who have it. The movie “Five Feet Apart” kind of shows that, that we not only keep a physical distance, but the CF Foundation recommends having one person in the building who has cystic fibrosis. So my husband had a work party for Christmas and one of the spouses had CF so I didn’t go because it’s just not worth risking me giving my bacteria to him and vice versa.

So it makes you feel isolated and alone in that part of it. But I think a lot of people overcome that with online connecting. You know, it’s not the same, but it’s something.

Alan Helgeson:

For people with cystic fibrosis like Chrystal, there’s some things that we might not think about that are a pretty big deal.

Chrystal Moldenhauer:

It’s been probably two big things I’ve noticed. When people are struggling with a cold virus, they’ll often say, oh, it’s no big deal. It’s just a little sniffle. And I bite my tongue because I want to say there’s no such thing for me. There is no little sniffle. You know, every virus can be a big deal for someone who has a superbug bacteria in their lungs that they’re struggling to keep under control.

But when it flares up, you don’t know always if the drugs are going to work to keep it at, you know, keep it back down to a manageable level or if it’s going to be the last virus you have.

The other thing I think I’ve noticed in my adulthood is when people make comments about, Hey, are you short of breath? Or why are you breathing like that? Or you know, like they draw attention to it. It doesn’t help (laugh) the situation because I’m already self-conscious about my breathing.

Lucas Moldenhauer:

Because of the medications that came out 15 years ago and then 10 years ago. And then again five years ago, her quality of life has gotten so much better. But like when we got to know each other back in college it was a terminal disease then, and it still is a terminal disease now.

Alan Helgeson:

While talking with Chrystal and sitting with her family at their dining room table, she would have really hard breathing at times. You can probably hear it. I asked her if I could mention that.

Chrystal Moldenhauer:

Yeah. A lot of times, I still remember the times people have commented on my breathing because we were walking up a hill or doing something and I wanted to just tell them, look, I’m really proud that I’m able to walk up this hill. Don’t discourage me.

Alan Helgeson:

So while we’re here today and Chrystal is telling us her story for people with CF, the simple process that we probably don’t think much about having to do is a lot. And I mean a lot of work. For Chrystal, for many people with CF, treatment may have included using a vest.

Chrystal Moldenhauer:

Well I can tell you what I know from my experience. And that is that it is a vest you wear and you hook it up with air hoses to a machine that pumps air out at different frequencies and different pressures. And so, you’re breathing against a vest that’s filled with air. So it’s a workout.

But it shakes your chest at different speeds. The idea being that as you breathe intentionally, deliberately, deeply, and you’re sitting in a chair usually and I have a nebulizer with medicine in it that I’m also inhaling and then makes you cough. It stimulates a cough. And then the coughing is what clears out the infected mucus.

Alan Helgeson:

Now it wasn’t only one time a day, right?

Chrystal Moldenhauer:

Well at that time it was twice a day. But I was not really compliant because I just figured well I’m going to die anyway so who cares. I mean I wasn’t dating Lucas yet, didn’t have obviously a child. So I didn’t have a whole lot that I was trying to live for. So I just kind of blew it off.

Alan Helgeson:

So why would you not do it if you know you needed to?

Chrystal Moldenhauer:

Throughout my life my birthdays have kept up with the life expectancy. So for example, when I turned 21 I thought it was my last birthday because the life expectancy was 22 at that time. So I was messed up most of my birthdays (laugh).

Alan Helgeson:

And the vest is still important today?

Chrystal Moldenhauer:

Yep. Yep. Very basic. But it works. And when I get sick today I will do more vesting and so then I’m coughing out more junk and you try and get the bacteria load down in your lungs by getting the junk out.

Alan Helgeson:

As a kid that really defied the odds with each year, and then here we are now, imagine life as a kid and then the stages of growing up and the grit and determination it takes to get through it all.

Chrystal Moldenhauer:

I was starting at a new school, we had moved to a new town in Wisconsin and I had to wear this weird metal brace thing on my face for orthodontia. So everybody was pretty much distracted by that and not noticing my invisible disease, my breathing problem until we got to basketball practice in the afternoon.

So the most of the day went fine. I would attend class and just looked like a normal kid. And then when it was time for basketball practice, the other nine players would run up and down the court and my coach made me stand in one place because he didn’t like to hear me cough.

And then after that I would go home and I’d have to practice trumpet or something, you know, I picked the instrument that needed the most lung power. That’s OK. It was worth a shot.

And then I think mealtimes was always something I really looked forward to because I had quite the appetite because I didn’t take my enzymes faithfully. So a lot of the food I ate just went right through me and I’d just be really hungry all the time.

Alan Helgeson:

Chrystal, while we were talking I learned that going through everything, she learned to be really quite the fighter. And it applied to pretty much everything in her life, including her school.

Chrystal Moldenhauer:

It was a preparatory school and it was very competitive and I’m competitive (laugh). So I think probably I felt like it was the one thing I do in my life because I thought that was going to be the length of my life was high school, maybe a little bit into college. So I probably studied too hard and missed treatments and set myself up for a cycle of getting sick and then having to get back to school and catch up, which caused me to get sick again. You know, probably was a thing for me, a pattern.

Alan Helgeson:

That didn’t seem to slow her down. She would go on to become the class valedictorian.

Chrystal Moldenhauer:

And I was also a homecoming queen, I would like to say (laugh), which was a long time ago in a galaxy far, far away. But yeah that was – I thought that was all it was going to be for me. So I was going to make it as big as I could in that venue.

Alan Helgeson:

During this time Chrystal had a very difficult home situation and over the course of several years. In the ages of 18 through 25, she would say she was homeless by choice.

Chrystal Moldenhauer:

For that period of my life, CF saved my life in a way. I had very supportive social workers at the CF Center in Wisconsin.

Alan Helgeson:

Her academic achievements would cover her tuition, and aid would take care of room and board during the school year.

Chrystal Moldenhauer:

Holidays were tough being alone in the dorm for Thanksgiving or Christmas or Easter if a friend couldn’t take me in. But then like during the summers, I’d have friends house me two weeks here, two weeks there. Because they all knew my home situation as well. So they wanted to help me stay healthy.

Alan Helgeson:

And almost no contact with parents.

Chrystal Moldenhauer:

Very little. It just wasn’t a healthy – I didn’t get along with my stepmom, so it was a two-way street, and it’s much better now. But yeah, it was, I had to cut off contact just for my own well-being and sanity at that point.

Alan Helgeson:

So eventually school comes to an end, right? Maybe. Well Lucas came into the picture.

Music:

“I’m just driving home thinking of you. I’m wondering if you, me too.”

Chrystal Moldenhauer:

We met when I was 23. I was finishing up year five of a seven-year journey through a four-year degree. I think I visited his family at the beginning of that summer and it was probably early June. And his mom asked, so how long can you stay?

Lucas Moldenhauer:

I have five sisters. So what’s one more girl in the house?

Alan Helgeson:

Chrystal and Lucas. School sweethearts. A college love story that’ll just make your heart sing.

Chrystal Moldenhauer:

I was second alto and he was first tenor.

Alan Helgeson:

Eventually they married, and then things get tricky. Remember CF doesn’t really stop and wait for love.

Chrystal Moldenhauer:

Right after we got married, we moved to Wisconsin so he could be in the seminary near Milwaukee. After the four years of seminary, we requested that the church send us back to Minnesota so that I could go to the University of Minnesota again. And so that happened. Thankfully we lived in the Twin Cities metro for a dozen years until I got tired of the traffic.

And I asked my CF doctor in the Twin Cities for a recommendation for another CF center with the same level of care because the Minnesota center was world known as probably the best one in the world. So they recommended Sanford. And I said, where is that (laugh)? Sioux Falls, where is that? So I’ve never been here but we tried it and that was 2012. And loved it.

Alan Helgeson:

They loved it but they drove quite a bit each time they came to Sioux Falls.

Chrystal Moldenhauer:

So it was a horse apiece, it was an hour and a half-ish to the cities or an hour and a half to Sioux Falls, but the traffic was much easier coming west. So that was a good thing. We didn’t know it at the time, but I was pregnant my first visit to the doctor in Sioux Falls because I had started the new medicine five months before.

Lucas Moldenhauer:

Which new medicine?

Chrystal Moldenhauer:

Kalydeco, there we go. Yep. Kalydeco. Anyway, so I had started that five months before and they had said there’s a chance you can get pregnant. And we both kind of laughed because we’d been married 13 years by that point. And yeah, we were pregnant. Just didn’t know it at that time. We were very new, like six weeks or something.

Alan Helgeson:

A baby!

Lucas Moldenhauer:

Again, the miracles of all the blessings of the new meds that kept coming out in her lifetime to just keep pushing that life expectancy further out, further out, further out. Yeah, so we were coming out here to Sanford, fell in love with the care, fell in love with Sioux Falls as a community. I’ve told this hundreds of times, how just walking down the sidewalk in Sioux Falls, people would wave at us that we didn’t know and they would wave with all five fingers in Minneapolis. We were used to getting waved at was just one finger (laugh). So we fell in love at so many levels.

Alan Helgeson:

We’ve been talking about CF and now Chrystal and Lucas are expecting unfortunately more health issues.

Chrystal Moldenhauer:

For me, I have diabetes as well, CF related diabetes, which acts like Type 1. So I take insulin. So for me that was almost a bigger deal than the cystic fibrosis. But the diabetes part we managed very aggressively and deliberately and Sanford was amazing for that. They stayed in contact and got my numbers every week that I was recording and making sure that the baby wasn’t getting too much of whatever is bad. If you have diabetes and you’re pregnant –

Alan Helgeson:

Not just pregnant.

Chrystal Moldenhauer:

Very much. Yes. High risk pregnancy. Yes.

Alan Helgeson:

Thanks to the expert high risk OB team at Sanford Health, baby Hadassah went nearly full term.

Chrystal Moldenhauer:

At 38. I called and said I can’t breathe now. I need to be done. So they induced at 38 weeks and I refused pain meds and the nerve blocker because I had to still do therapy and I needed to be able to walk up, walk around and get up. So yeah, it was a natural birth and went great.

Alan Helgeson:

And they just kept driving back and forth, back and forth from New Ulm. You get to know which convenience stores have the best coffee and donuts along the route. After a while. A long while.

Chrystal Moldenhauer:

We did that for my entire pregnancy until she was a year old. So for two years and then we moved back to Wisconsin. So we never moved to Sioux Falls at that point. We moved to Wisconsin to give her a chance to get to know her 27 cousins in Wisconsin, and I tried a different CF center there and also had poor results.

So then I started commuting from Wisconsin, not moving here yet. We commuted for almost a year I think. And every time I’d be hospitalized they would come and stay in a hotel for that two weeks. So we were draining our savings and we were also paying rent in Wisconsin and et cetera.

And I was getting sicker and sicker because the new medicine had stopped working and they were developing a newer one but it, I wasn’t having, I wasn’t able to take it yet. So that was when we made the decision when she was 3, we need to move to Sioux Falls so we can be together as a family. Otherwise, she’s not going to have a mom for much longer.

Alan Helgeson:

Unfortunately with Chrystal getting sicker, another move was necessary.

Chrystal Moldenhauer:

He didn’t have a job. We didn’t have a job. We knew one person, we had a place to rent and when we were sitting there signing the lease papers, we said, Hey, do you know anyone who needs a handyman? Someone who’s good at building things? And the landlord said, actually yeah I do. And that led to a job that lasted for six years and it led to so many connections and pretty cool.

Alan Helgeson:

Some of those connections began way before coming to Sioux Falls with a willingness to embrace science and clinical trials for CF research.

Chrystal Moldenhauer:

So I’ve always been interested in clinical trials partly because I know it’s the drugs can’t be developed unless people volunteer to take them. And I always try to come in at the end of the trial process. So it’s been proved safe. And the clinical trial for the drug Kalydeco, I was involved in it in 2008 already.

So then I am on standing notice with my friend at the University of Minnesota. If there’s a trial that I can be in, they let me do that. I’ve done them in Ohio. I’ve done them here in Sioux Falls. Just anything to get some newer meds going. Thankfully Sanford and University of Minnesota work together so they share information and they’ll call each other and say, Hey, this is a study that Chrystal might want to do. They all know I want to be in them (laugh). Sign me up.

Alan Helgeson:

Meanwhile, things just kept getting worse for Chrystal over the course of several years. The average day was filled with therapy of just trying to stay alive.

Chrystal Moldenhauer:

It was rough. I was doing probably eight hours of therapy a day. I would wake up at four and spend two hours clearing out my lungs before my daughter woke up to get ready to go to school because I wanted to be able to interact with her without feeling short of breath and crabby from that.

And then she’d go to school, and I’d go home and I would do therapy for as long as I could physically do it. And then I would take a break and walk the dogs or take a nap and then I would get right back at it until I picked her up from school.

And then normally we’d, you know, get her to bed at whatever time. So I’d have three or four hours with her when I could breathe well. But normally after about three hours my lungs started to fill up again and I couldn’t breathe. So then he would, my husband would have to take over and I would go do therapy and then go to bed and get up and do it the next day. It was my full-time job.

Alan Helgeson:

No time for work elsewhere or hobbies.

Chrystal Moldenhauer:

That was it. Yep. Nope, I didn’t have a job. My last hospital stay, I told my friend, I think this is going to kill me. Because I just couldn’t, I just could not get ahead of it.

Alan Helgeson:

In 2019, Chrystal began taking a medication for CF.

Chrystal Moldenhauer:

Well I remember taking the medicine for the first time. When I took it the first time, within an hour or two, it was like reverse drowning in a way. Stuff was coming out. I, it just, without any effort on my part, which is saying a lot because I was struggling to clear secretions before that medicine and this just thinned everything out. And it just was coming out for hours for about a day and a half probably. And then it was all out. There was nothing left in there.

Alan Helgeson:

That was 2019. Now, today, thanks to research, clinical trials, amazing medication breakthroughs and clinical expertise, Chrystal’s daily routine is a lot different.

Chrystal Moldenhauer:

So now I do this, a similar thing. I get up earlier than my daughter and I get my therapy done, but it’s just a half hour, it’s not two hours. And then I’m good to go until bedtime. So I have however many hours that is, 14 hours that I can have a job, which I have now and do homeschool with my daughter and do all her extracurriculars and do chores around the farm and whatever I want.

Alan Helgeson:

Oh, and they have a few animals to care for too.

Chrystal Moldenhauer:

So we have almost 80 animals here, chickens and sheep and dogs and cats. And so I enjoy animals and I’ll feed them and make sure their water is set and take care of any cuts or bruises or illnesses.

Alan Helgeson:

Chrystal, Lucas, Hadassah and their more than six dozen critters are doing great. Does this mean that Chrystal still doesn’t need medical care these days?

Chrystal Moldenhauer:

So I still see the pulmonary care team here at Sanford and that’s probably every six months instead of quarterly. It used to be every three months. So now it’s every six. And once a year I’ll see the endocrine for the diabetes.

And then as I age, you know you have those other issues that probably come up with just basic family practice doctor stuff. So I actually have for the first time in my life a normal family practice doctor. I’ve always just seen my CF doctor so often that I never bothered getting a normal doctor. I’ll do my yearly checkup with her and then the normal female stuff or whatever, you know. But that’s about it for me.

Alan Helgeson:

And for their daughter, while you may be wondering, how is it determined if she may or may not have CF? Chrystal and Lucas already know the science.

Chrystal Moldenhauer:

So children of CF parents will always have the gene. They’ll have one copy because each parent passes one copy. So if both parents have CF, then yes, they’ll have two genes and possibly the disease. She just has my gene because Lucas doesn’t carry it. So she has one copy of the CF gene.

Alan Helgeson:

Hadassah knows having this one copy makes her special.

Hadassah Moldenhauer:

Well my mom always tells me that I have to drink a lot of – or, not drink – I have to eat a lot of salt. Not like just put it in a spoon and just – I have to, I like salt more because my mom always tells me that me and her both lose a lot of salt in our sweat. So we need to eat more salt on things.

I don’t know if this is with a lot of kids, but when I’m running most of the time like if I run for too long it gets hard to breathe a little bit or like stings, which is just, I think it’s probably just because of my mom and then well my gene. And then whenever I get sick, I get extra sick.

Alan Helgeson:

So what would Chrystal today tell 15-year-old Chrystal?

Chrystal Moldenhauer:

Oh boy (laugh). Good question. Oh man, I don’t know. Chill out maybe. I mean like, don’t worry so much. It’s going to work out.

Alan Helgeson:

A lifetime of experiences and many miles to get to specialist care have made Chrystal stronger and led her and her family to a community where care and cutting-edge research go hand in hand.

Chrystal Moldenhauer:

Yes, I’ve found real lasting partnerships with the care team here in Sioux Falls at Sanford. People that really know their stuff, but they also know that I know my body. So, they’re very respectful and open to my ideas and my input, and they’re more supportive of me not wanting to lose ground.

I’ve had other experiences in other care centers where I was told, well you have to expect to lose ground. It’s a progressive disease. And in my last virus I fought with back in spring, my doctor said, you know, we did one round of antibiotics and you’re not back to baseline. I don’t think we should stop Chrystal. Do not accept anything less than your baseline.

And I was like, wow, that’s awesome. That’s why we’re here is for that. A little bit aggressive, but I love it. That’s what I needed.

Lucas Moldenhauer:

Here we are where we wanted to be, where we needed to be, even though sometimes we didn’t know we wanted to be here. But we found home, and we love the Sioux Falls metro, we love the Sioux Falls Sanford medical team, and it’s just all come together.

Chrystal Moldenhauer:

God always gives us what we need and adequate. He puts us where we need to be with the people we need. So I’m just very thankful.

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Busting myths about the HPV vaccine

Dr. Rebecca Cooper:

Even if we can prevent one case of cancer in someone you know or love, that’s so important. Right? Yeah. I don’t know anyone that looks back and says, “oh, I wish that I did the same thing,” knowing that you had the chance to prevent this.

Courtney Collen (host):

This is the “Health and Wellness” podcast brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. In this episode, we are addressing some of the most common myths around the HPV vaccine.

Dr. Ashley Sands is a specialist in pediatric infectious disease treating infants, children and young adults at Sanford Children’s Specialty Clinic. And Dr. Rebecca Cooper cares for people of all ages as a specialist in family medicine at the Sanford Health Family Medicine Clinic in west Sioux Falls. Dr. Sands, Dr. Cooper, welcome. Thanks so much for being a part of this conversation.

Dr. Ashley Sands and Dr. Rebecca Cooper (guests): Thank you so much for having us.

Courtney Collen:

There’s a lot of conversation around vaccines right now in general, and thankfully a lot of science-based evidence and data to support the efficacy of so many of them. Today we’re focusing specifically on the HPV vaccine. We’re going to focus on some of those myths one by one.

But first, before we dive into those, I want to level set with a quick overview of the HPV vaccine, what it protects against, maybe a little bit about its history and why we are recommending it for our patients.

Dr. Sands, I’ll start with you.

Dr. Ashley Sands:

Sure. So the human papillomavirus (HPV) is a virus that is sexually transmitted and generally causes genital warts. So little bumps on your genitals or person’s genitals. 80% of the virus will go away without ever knowing maybe that you even had the virus or that you were infected. It’s that 20% that stays around and then can cause in a number of years, 15, 20 years, cancers.

So we know that it is the leading cause of cervical cancer in females. It can also cause vaginal and vulva cancer, and it also causes anal (cancer), and people often don’t realize this, but it can cause oral cancers as well, so head and neck cancers.

Courtney Collen:

Dr. Cooper, why do we recommend this vaccine for our patients?

Dr. Rebecca Cooper:

Great question. It’s one of only two vaccines that we have that actually prevents cancer. So if we give this vaccine before kids or young adults are exposed to this, we can actually completely prevent this from infecting cells and later causing cancer, which is huge.

Courtney Collen:

Let’s dive into these different myths one by one in no specific order. The first one, my child is way too young to worry about HPV. What would you have to say about that?

Dr. Ashley Sands:

I think that’s a fair question. But we know that when we give the vaccine well before a child or an adult is exposed to that pathogen, we are able to build immunity in the person’s body and so when they do come in contact with that virus, 10, 15, 20 years down the line, their body has immunity and just gets rid of the virus without causing any of the harmful effects.

There was a study that just came out of Scotland that showed children who were vaccinated by 13 years of age had zero cases of cervical cancer 15 years later. Whereas children who were vaccinated later, even starting at age 14, there were some breakthrough cases of cervical cancer in that population.

The important thing to know is that the sooner that you get it, the more prevention of cancer your child or you will have in the future.

Courtney Collen:

Yeah. So important. Thank you. Myth number two, boys don’t need the HPV vaccine. What would you say to that, Dr. Cooper?

Dr. Rebecca Cooper:

It’s just not true. We know that one, men can get anal cancers and head and neck cancers from HPV, but not only that – they can contribute to spreading this cancer to women. So for parents that tell me that, oh, my boy doesn’t need this. He doesn’t have a cervix, sure, that’s fine, but you would never want to know that your son contributed to a cancer case in his future partner.

And again, we’re looking at population health here as well, and so we’re trying to reduce the risk across the population. And every person that can be part of this helps decrease this incidence.

Dr. Ashley Sands:

It also causes penile cancer. HPV can cause penile cancer.

Courtney Collen:

Oh, really?

Dr. Rebecca Cooper:

You don’t want that.

Dr. Ashley Sands:

You don’t want that.

Courtney Collen:

No, certainly not.

Dr. Ashley Sands:

You don’t want that for your child at all. So it does help prevent cancers in both boys and girls.

Courtney Collen:

Thank you. If my child gets the HPV vaccine at age 9, the benefits will wear off before my child is at risk of getting HPV. That’s the third myth. What would you say to that?

Dr. Ashley Sands:

I say, that’s also incorrect. We know that this vaccine gives lifetime immunity. And as I said, we’ve had this vaccine around for 15 to 20 years, and we have seen that adults who received it as a child do not have cancer, do not have cervical, do not have HPV-related cancers as adults. So the immunity lasts.

Courtney Collen:

Do you recommend this for adults as well?

Dr. Rebecca Cooper:

Absolutely. So it used to really only be recommended ages 9 to 26. They’ve really expanded this now from 27 to 45 as well. That doesn’t mean that every single person needs to get that, but really most of us do recommend it.

Unfortunately, we never know what’s going to happen in our lives and so really it’s only protective for people. There’s very minimal risk. And so almost everyone that I know in primary care recommends this up until age 45 for anyone that wants it.

Courtney Collen:

Myth number four: the HPV vaccine is about preventing STDs and my child won’t be sexually active for a long time, so it’s better to wait until my child is older. What do you think?

Dr. Ashley Sands:

Yeah, so as we’ve said, the earlier that you get the vaccine, it does have life lifetime immunity. So the earlier you get it, you just don’t have to worry about it. And we don’t know when children will become sexually active. So getting it before they come in contact with that virus is really the best thing to do.

Dr. Rebecca Cooper:

Additionally, we don’t know what your child’s future partner is going to choose in their life. Maybe they made different choices than what you would have or what you wanted for your child and that’s not something that your child deserves. To have a long-term consequence of cancer is just not an appropriate consequence for choices that you wouldn’t agree with.

Courtney Collen:

Thank you. Are there any side effects to this vaccine?

Dr. Rebecca Cooper:

I mean, same side effects as you get with any vaccine. People get a sore arm. You can feel kind of run down from your immune system ramping up and making those great antibodies. But overall, it’s very well tolerated for people.

Courtney Collen:

Myth number five. The HPV vaccine hasn’t been around long enough to know it’s safe. You said it’s 15 to 20 years old. Dr. Sands, what would you say about that myth?

Dr. Ashley Sands:

So over these 15 to 20 years of vaccines, we have had all of these studies. It used to be two strains of HPV, then it turned to four, and now we’re at nine strains. So we, we know that it’s well tolerated. We know that it prevents cancer. It really has been studied quite well for a vaccine that is still an adolescent, if you will.

Dr. Rebecca Cooper:

And I think there’s actually been over a hundred million doses administered now to date, which is just a ton (laugh).

Courtney Collen:

I have 135 million doses distributed.

Dr. Rebecca Cooper:

Yes. And so, which is good. That’s good support. That’s good support.

Courtney Collen:

And when in the clinic, when you come, when young adults come to see you or adults, at what point do you bring up the HPV vaccine? Is there a certain age range or conversation appointment that you bring this up? What does that look like?

Dr. Rebecca Cooper:

I bring it up starting at age 9 and pretty much every at least wellness visit after that, I try to ask every time that I see people if they would like any vaccines today or have any questions. But certainly at least once a year, starting at age 9. But I bring it up almost until it is completely out at age 45. Because even if we start at 44, you can still get three doses.

Courtney Collen:

Myth number six, adults don’t need the HPV vaccine. Again, remind us how young or how old we can be to receive this vaccine and why.

Dr. Rebecca Cooper:

We start giving it now at age 9 and it’s approved up until age 45. So it used to only be until 26, but now they’ve expanded because we found that it literally prevents cancer. And so why would we not do that?

Most of the thought is that after age 45, the risk of obtaining new strain of HPV significantly decreases, and that’s why we, it’s not really approved beyond that. But really it’s only protective for people.

Courtney Collen:

Another myth here, the HPV vaccine causes infertility in young women.

Dr. Ashley Sands:

I’ve talked about this with some of the parents of my patients. So as we said, over 135 million vaccines have been given. We do not see a link of infertility with the vaccine. We do see a link of infertility in cervical cancer related to HPV. So I would say that the HPV vaccine could actually work to prevent infertility if you’re preventing the cervical cancer.

Dr. Rebecca Cooper:

Additionally, the way that we treat these early cases of cervical dysplasia, which is the pre-cancer and then cervical cancer, is by surgery and removing those abnormal cells. So most of the time with pap smears, we try to detect those pre-cancerous or cancers.

But we literally remove the abnormal cells and so that even if it’s not cancer, can increase the risk of pregnancy complications for young women because that’s who this is happening in. It increases their chance of delivering early, of having issues with their pregnancy.

And to treat cervical cancer, most of the time we take out the abnormal cells, including the cervix and potentially the uterus, and that you can’t have a baby if you don’t have a uterus.

Courtney Collen:

One of the other myths here, along that same line, you don’t need pap smear tests if you’ve had the HPV vaccine. Is that true?

Dr. Rebecca Cooper:

No. Pap smears certainly detect HPV. That’s the most common cause of cervical cancer and pre-cancer. But there are other things that can contribute to this. And the vaccine is not a hundred percent for all types of HPV. We vaccinate against the nine most common and the ones that are most likely to cause cancer. But we know that there are other ones that contribute. And so we still certainly recommend pap smears.

Courtney Collen:

The HPV vaccine is only effective if given before the first sexual encounter.

Dr. Rebecca Cooper:

It’s most effective if given before the first sexual encounter. So the HPV vaccine doesn’t cure any strains of HPV that you’ve already acquired. It only protects against new strains. So when women have abnormal pap smears and cervical dysplasia, we still recommend it because it’s still protective against anything they may acquire. But unfortunately, it doesn’t do anything for strains that you’ve already acquired, which is why it’s so important to get the vaccine before any contact may occur.

Dr. Ashley Sands:

So it is two doses if you start your vaccine series before the age of 15. If you are 15 or older, then you would need to complete three doses of that vaccine over a six-month period.

Courtney Collen:

OK.

Dr. Rebecca Cooper:

And we’re happy to catch people up anytime. I have a lot of patients that maybe got it initially and then they got very nervous and afraid or, you know, or all the propaganda that’s around this on social media and they waited a few years. It’s OK. We can continue the series. We will complete it very happily.

You don’t have to restart.

Courtney Collen:

You don’t have to restart it. OK. Good to know. Let’s talk about that for a moment, because there is so much conversation online, and that could be influencing people one way or the other.

How would you combat some of this misinformation or encourage parents to talk to their pre-teens, their teens, their young adults to get this vaccine? You know, how would you kind of lay it out for them to have the conversation to eventually get them protected before it’s too late?

Dr. Rebecca Cooper:

I usually just try to address it head on and ask what their fears are, what their concerns are. I don’t know any primary care doctor that would not be happy to have this conversation with you or infectious disease, anyone.

But we love to talk about this stuff because it’s something that most of us are incredibly passionate about. And so most of the time, if you can tell me your specific fears and questions, things that you saw on social media or Dr. Google, it’s easier to just have that conversation and put it all out in the open.

Parents still get to make their choice. We’re not going to hold you down and vaccinate your kid against your will. So just know that. But it’s a safe place in our clinic to have that conversation, and no one is ever going to fault you for asking those questions.

Courtney Collen:

Sure. And it’s not – go ahead.

Dr. Ashley Sands:

I was going to say the same thing, and I’m happy to point parents and patients to the data and the sources that have all of these doses that have been given and no cervical cancer or show this rate of decrease of HPV-associated cancer so that they can see some of the source material and make the decision themselves.

Dr. Rebecca Cooper:

I mean, even if we can prevent one case of cancer in someone you know or love, that’s so important. Right? Yeah. I don’t know anyone that looks back and says, “oh, I wish that I did the same thing,” knowing that you had the chance to prevent this.

I do a lot of pap smears. I do a lot of pap smears in my clinic, and I follow all up, a lot of abnormal pap smears and women are so terrified. When you get that phone call that you had an abnormal pap smear, most often, it really ends up fine. Truly.

Like Dr. Sands said, we clear a ton of this virus on our own – 80% of this gets cleared. But if you’re in the 20% that doesn’t, it’s terrifying for young women. I have women in my clinic all the time that are just terrified of what might happen and the implications of what that looks like and the procedures that we go through to confirm if this is pre-cancer or cancer, they’re not great. They’re not fun, and this vaccine can prevent all of that. So not only the cancer itself, but the anxiety that comes with everything that leads up to that.

Courtney Collen:

Such valuable information. Dr. Sands, do you have anything else you want to add to that?

Dr. Ashley Sands:

I say just bring the conversations and come ask the questions. As Dr. Cooper said, we never shy away from having these conversations. We want to understand your concerns and want to help address them and talk through the information that we know and things that we can share with you to help make that informed decision for yourself or your children.

Courtney Collen:

Absolutely. And that’s what it’s about at the end of the day. Dr. Sands, Dr. Cooper, thank you so much for your time, your insights and helping us address some of these myths head on. Really appreciate your insight and expertise here in this conversation.

Dr. Ashley Sands:

Absolutely. Thank you.

Courtney Collen:

Thank you. This episode is part of the “Health and Wellness” podcast series by Sanford Health. For additional series by Sanford, listen wherever you hear your favorite podcasts and on news.sanfordhealth.org. Thanks for being here.

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Your surgical options after a breast cancer diagnosis

Dr. Jesse Dirksen:

There’s a lot of different treatment options and paths for the patients to go down, and we want to make sure we have the right path for that patient.

Traditionally we’ve always done surgery first but there are some certain types of breast cancers like triple negative or HER2-positive, or those women who have cancer in the lymph nodes where we will actually start with chemotherapy first and then do surgery afterwards.

Courtney Collen (host):

This is “One in Eight,” a podcast series by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. One in eight women will be diagnosed with breast cancer during her lifetime. So we want these conversations to shed light on awareness with expertise from our Sanford Health providers that could save your life for the life of someone you love.

Today’s episode focuses on after a diagnosis, understanding your surgical options and what you could expect through care at Sanford Health. I have Dr. Jesse Dirksen, who specializes in breast surgery and serves as the clinical chair of the Edith Sanford Breast Center. He’s located in Sioux Falls, South Dakota. Dr. Dirksen, welcome.

Dr. Dirksen:

Thank you for having me.

Courtney Collen:

Thanks so much for your time. Let’s start with this: How is a surgical treatment plan determined for a patient?

Dr. Dirksen:

You know, that’s a great question. For most patients, there’s two surgical options: they can do something called a lumpectomy, or we can do what’s called a mastectomy.

Now a lumpectomy means we literally just take out the tumor, a little bit of tissue out around it, and we can preserve and save the breast. Mastectomy means we remove all the breast tissue, and then there’s options there where we can do reconstruction, and I’m sure we’ll talk about that later.

But fortunately, you know, most women who come to us are diagnosed on a mammogram, and we find a mass before it’s felt. And then that does make a patient amenable to doing a lumpectomy, a less invasive surgery where we can preserve the breast.

Now, one of the other factors we go into that is it’s a team-based approach and every Monday we have what’s called a tumor board, or a breast cancer conference, where all the doctors get together in a room and we talk about all the new patients for the week. And there’s surgeons there, there’s oncologists, radiation doctors, radiologists, pathologists, geneticists, plastic surgeons, research people, clinical trial people, nurse navigators. So it’s a big team and we review everybody’s imaging. We go over their pathology report, and then we talk about the treatment plan, just so we have a unified agreement on what’s the best plan for the patient.

Courtney Collen:

How important is that collaboration when it comes to the patient’s care?

Dr. Dirksen:

It’s not just one physician’s input. We need all the disciplines involved and make sure we have the right safe, effective plan for the patient. And, you know, breast cancer, it is becoming pretty complicated. There’s a lot of different treatment options and paths for the patients to go down, and we want to make sure we have the right path for that patient.

Traditionally we’ve always done surgery first but there are some certain types of breast cancers like triple negative or HER2-positive, or those women who have cancer in the lymph nodes where we will actually start with chemotherapy first and then do surgery afterwards. So the team approach is definitely preferred in this day and age.

Courtney Collen:

Sure. Absolutely. And I feel like knowing that would really put a patient at ease and give them the confidence to know they are truly in good hands.

Dr. Dirksen:

Exactly. For being a patient, understandably, it’s a very anxiety-inducing time. Very scary. And to have the knowledge that you have a whole team, multiple doctors, support staff, looking at your case even before we start a treatment, is very reassuring to them.

Courtney Collen:

Absolutely. We talked about a lumpectomy and a mastectomy. As a hidden scar, certified breast surgeon, Dr. Dirksen, you perform procedures like the nipple sparing mastectomy. Is that what it sounds like? Do you essentially keep the nipple intact?

Dr. Dirksen:

Yeah. To, to answer that question in a long way, about two-thirds of women will go down the lumpectomy path. And again, lumpectomy, we just take out the tumor, preserve the breast. We really try to hide scars with this procedure.

Generally we’ll make an incision around the nipple or the aeriolar border, and we’ll take out the tumor through that incision, and that scar hides really well afterwards. Sometimes we make an incision along the fold of the breast underneath or in the armpit.

There’s been a greater emphasis in the past five to 10 years about cosmesis. You know, obviously we want to do a good cancer surgery. But we really care about outcomes, cosmetic outcomes afterwards.

Some women choose mastectomy or need a mastectomy, whether the tumor’s large or if it’s involving the skin or the muscle. And we have some amazing options with mastectomies nowadays.

I do have some women that decide to do what’s called simple mastectomy. Simple mastectomy means we remove the nipple and the skin, and we take out the breast tissue down to the muscle. We leave the muscle alone. And then we try to make the front part of the chest as smooth as we can. And then those patients, when they’re healed up, they can wear prosthetics inside their bra. And we have ladies in the Bloom Boutique that specialize in that and can help the patients with that process.

Now, a fair amount of patients will do what’s called breast reconstruction. And we do what’s called immediate reconstruction. So I get the plastic surgeons involved, and they do reconstruction during the mastectomy, so everything’s done during one surgery. And that process has changed significantly, too, over the past decade. I have four wonderful plastic surgeons here at Sanford, and they typically now put implants on top of the muscle, so it’s much less sore, quick recovery, and they’re usually able to get the full implant in right away.

And then you inquired about nipple sparing mastectomy. So this has been a really popular option, especially in our younger patients where we make an incision along the bottom fold of the breast, and I take out the breast tissue through that incision. And then the same surgery, the plastic surgeon puts the implant in through that incision. So when the patient’s upright, that scar isn’t even really visible.

Now, obviously, saving the nipple in the skin is a very nice cosmetic outcome for patients and it’s a very desirable outcome. It works really well for A, B, C-cup breasts. When we get to larger breasts, it can be a little bit difficult. And then also we want to make sure that that cancer is away from the nipple, that it’s safe to do. The plastic surgeon and I communicate a lot, and obviously number one is cancer. We got to do a good, safe, absolutely sound cancer surgery, but we really have a lot of emphasis on cosmesis now.

Courtney Collen:

Thank you. Are there any myths or misconceptions people have about breast cancer surgery, specifically around fears ahead of surgery? Maybe we can debunk some of those now.

Dr. Dirksen:

Absolutely. And I see these when patients initially come in, obviously they have a lot of fear and anxiety and, you know, they get on Dr. Google and talk to their neighbor and unfortunately there’s a lot of untrue information out there, and a lot of myths, you know, kind of even coming back a little bit.

A lot of patients are concerned about their biopsies. Patients are worried about the needle activating or spreading the cancer, but that’s not true.

And then I also have some patients worried about when we get to the OR, I hear, oh, if you open cancer to air, it’s going to activate it and spread it. But that’s not true.

Also, I think probably the biggest myth I come across in the clinic is, understandably so, women come in and say, remove them both. I just want to double or bilateral mastectomy. I don’t want to deal with this again. The truth is that we’ve have 50 years of data, a lot of clinical trials, and we have shown that a lumpectomy with radiation has the same outcomes as a mastectomy in terms of survival, how long a patient’s going to live, and also recurrence rates, the rates of cancer coming back. So really what a lumpectomy versus a mastectomy boils down to is tumor size to breast size. It has nothing to do with the type of breast cancer.

Some women think, oh, if I have an aggressive breast cancer, I have to do a mastectomy. And that’s not the case. So if I feel like as a surgeon, I can get around the tumor safely, have a good margin, and have a good appearance of the breast when we’re done, that does allow the patient to do a lumpectomy.

Other myths I hear too, they’re worried about, you know, being disfigured after surgery and with a lumpectomy, generally the size and shape and the contour of the breast is well maintained. Again, we try to hide those scars really well. And our reconstructive options have come a long ways, and there’s different sizes and shapes and profiles of implants, and we try to get as natural looking breast as we can. You know, I always tell patients nothing is ever going to look and feel like your own breast tissue, but if you need a mastectomy, we generally try to get that shape and contour recreated for the patient.

Courtney Collen:

Thanks for walking me through some of those. Really important for the listener to hear as well. Now, walk me through the date of surgery, Dr. Dirksen, followed by that recovery time pain management involved in post-op.

Dr. Dirksen:

Yeah, great question. So, two paths. So a lumpectomy patient, typically a lumpectomy surgery will take about one hour to confuse the listeners even more. A lot of times with invasive cancers, we do have to take out two or three lymph nodes under the armpit just to make sure that the cancer hasn’t spread.

So sometimes there’ll be an incision on the breast and one in the armpit. And again, that surgery takes about one hour. Usually it’s two hours in recovery, and they go home that day. So there’s no drains, no hospital stays, stitches are buried, they dissolve.

My only limitation on patients: there’s no lifting more than 20 pounds for two weeks. So still a big surgery, still some recovery, but patients kind of get back to normal day-to-day stuff pretty fast.

Now, with mastectomies, let’s say we did double or bilateral mastectomies with implants, that total surgery takes about three to four hours. So I do the mastectomies, lymph node surgery, plastics comes in, puts in the implants about three to four hours, and then those patients spend usually one night in the hospital, sometimes two.

The body does like to swell with that surgery. So my plastic surgeons do have to leave drains in on each side to collect the extra swelling. And the drains are annoying but they’re easy to take care of. They usually leave them in for around two weeks and then take them out in the office.

And then most plastic surgeons tell those patients, no lifting more than 10 pounds for about six weeks.

We always try to monitor pain control. We have some really good local anesthetic numbing medicine that we use during surgery, and there’s some new anesthetics that last up to three days. So that really helps with initial pain control. You know, we always make sure they have the appropriate pain medicine when they go home. And if they have any concerns about infection or anything like that, we make sure that they call right away.

Courtney Collen:

I’ve met so many patients who received a diagnosis and then it was like they were on the fast track to care. And depending on how aggressive their cancer diagnosis is, you know, things are happening quickly. Dr. Dirksen, what are some of the emotional challenges patients may face when making some of these big decisions and so quickly, you know, and so suddenly in many cases of their lives.

Dr. Dirksen:

You make a great point. So again, I’m usually one of the first people to see the patient after diagnosis. And, like we stated before, it’s a very scary time, anxiety inducing. It’s one of the biggest hurdles that a patient will face in their life when they hear that cancer diagnosis. And it’s not only just the patient; it’s their family. It’s their spouse, loved ones and family members and children.

So the goal of my visit with that patient is not only to explain what’s going on, what your cancer diagnosis is, and also the options for treatment. But I also want to let them know that we have an amazing team taking care of them. We have the latest and greatest here at Edith Sanford. And also we have great support staff too.

Fortunately, during my initial visits, we have what’s called nurse navigators and they work with all the breast cancer patients here. They’re a great resource for support groups, or whether you need some mental health coaching or any other services that we can provide at Edith Sanford. We really care about the emotional, psychological impact, not just the physical one.

Courtney Collen:

Thank you for that insight. Really important as we talk about this. How can we as loved ones or friends support those patients in feeling empowered through this process?

Dr. Dirksen:

Yeah. Oftentimes I find it just as challenging for the significant other, spouse or, and especially the children dealing with this because as a generalization, you know, most husbands are fixers and they can’t fix this and it’s challenging for them. I think as a loved one or a significant other family member or spouse is just support that patient with what they need from day to day.

And the mentality of patients never ceases to amaze me. I have some patients coming in really anxious. I have some patients coming in very tearful. I have some patients coming in with, we can do this, let’s beat this, you know – a really positive, let’s do this type attitude. So every patient is different and kind of what they need can be different too.

Courtney Collen:

Thank you for that. Let’s talk about how early detection could change the surgical journey. If we found a lump early, for example, could that possibly lead to less invasive procedures?

Dr. Dirksen:

Absolutely. So, you know, we think a lot about mammogram, and mammograms have been scientifically studied for decades, and we know they’re one of the screening tools that actually saves lives. And it decreases mortality rates.

So currently at Edith Sanford, we’re recommending the average-risk woman to begin an annual mammogram starting at age 40. There’s a lot of different guidelines out there, different societies, but starting at age 40 mammograms once a year. If patients start these, and generally mammograms will pick up on a cancer even before we can feel them.

So over 80% of the cancers I see, I can’t see or feel them. They’re only detected on a mammogram. And if we can find that cancer at a smaller size and earlier stage, that definitely allows the patient to do a lumpectomy, a less invasive surgery, be able to preserve the breast and then also, we’re hopefully catching this cancer before it spreads.

And the very first place breast cancer goes to is to the lymph nodes in the armpit and their lower glands that fight infections and drain fluid. And our radiologists here do a really good job of not only doing mammograms, but a lot of times they’ll ultrasound the lymph nodes in the armpit and they’ll get a good look at those. And they can be pretty accurate on whether we feel that there’s cancer in the lymph nodes or not. And if they’re concerned about the size or shape of the lymph node, they can do a needle biopsy to determine if there’s cancer in that lymph node.

Courtney Collen:

Talk to me about breast self-exams. Before we turn 40 and start those regular annual mammograms, how can we stay proactive about our health? I mean, some of the patients I’ve talked to are in their late 20s, 30s, getting diagnosed with breast cancer because they found a lump themselves in the shower or wherever they were. But a breast self-exam is how it starts for some people. And, talk about the importance of that before 40.

Dr. Dirksen:

That’s an excellent question also and there’s a lot of controversy with this right now. Most societies, medical societies, cancer societies are actually discouraging women from doing self-breast exams, really. And the theory with that is most lumps that patients feel will turn out to be benign non-cancer. So it leads to kind of a unnecessary workup or biopsy.

However, at Edith Sanford, we encourage what’s called breast awareness. We want patients to be comfortable with how their breasts look and feel to kind of look at the shape in the mirror, feel the texture of the breast. So if they do notice a change, they’re made aware of it, and they can contact their primary care provider to do the appropriate workups.

So we do encourage women to do their breast exams, be familiar with their tissue, and then if any chang is noted, they can alert their primary. Now you’re absolutely right. I just saw a lady yesterday, a young gal in her upper 20s, and she found her own lump, so it does happen.

Courtney Collen:

Yeah. Very scary. But again, important to stay aware of your own health, have that breast awareness. And then of course, you know that relationship with your primary care provider to begin the conversation if need be.

Dr. Dirksen:

Another hot topic in the breast world right now is dense breast tissue. So a lot of patients will get their mammogram and then they’ll get a letter saying they have dense breasts. And what do you do about it? 50% of all women getting mammograms will have dense breast tissue. So it involves a large percentage of women.

And the one category we really care about – well, we care about all categories, obviously, but is extremely dense breast tissue, and this is about 10% of women. And with extremely dense breast tissue, sometimes that can lower the sensitivity of mammogram, where it can be a little bit harder to detect things. So in those patients, we do have other capabilities.

We have what’s called contrast enhanced mammogram. We have ultrasounds and then also breast MRI. So I would encourage women with extremely dense breast tissue to maybe talk to their primary care about it. And see if there’s other imaging modalities that we can utilize in them.

And then also at Edith Sanford, we actually have a breast specialty clinic, which is a breast clinic for women who might be at high-risk of breast cancer. And patients can be referred to this clinic. They can self-refer themselves and they meet with a breast provider, and also they actually meet with a genetic counselor. And between these two visits, same day, typically the provider decides if there’s any additional imaging we should be doing. It teaches the patients how to do self-breast exams at home. And then the genetic counselor can estimate a patient’s risk.

And some patients have a very strong family history of breast cancer. Maybe they’ve had multiple biopsies before, they’ve had high-risk lesions, et cetera, et cetera. And if a woman’s risk is high enough, then the clinic would keep monitoring these patients. They would qualify to do mammograms and MRIs, and then also they would talk to the patient about genetic testing. And this is DNA testing. And if the patient meets criteria, they can do genetic testing, which means they take some blood, they send it to a lab, they run a patient’s DNA to see if there’s any genetic mutations or breast cancer genes in the family.

And if the testing comes by clean, great. If we do find a genetic mutation or a breast cancer gene, then that would put that patient at very high risk of breast cancer. And then we have some options for that patient. And then also that patient has the ability to tell family members about that, and then they can pursue testing for themselves.

Courtney Collen:

I had a fascinating conversation with Dr. Andrea Kaster about this exact topic and why breast density affects your mammograms. And it was eye-opening because here I am thinking, well, you know, you can’t just touch your breast and say, “I think these feel dense. I should probably go get checked.” But she said it’s very common and that it is a hot topic right now. So I would point listeners to our conversation as part of this “One in Eight” series about dense breast tissue. Thank you, Dr. Dirksen.

Dr. Dirksen:

The only other thing I would mention is we do offer preventative surgery too. So for women who are at, truly at high risk of breast cancer, or those who are found to have a genetic mutation like a BRCA, BRCA1 or BRCA2 gene, we do offer prophylactic or preventative mastectomies.

Now, this isn’t a right option for most people, but for those who are extremely high risk of breast cancer we can do bilateral double mastectomies with reconstruction before a cancer sets in. And mastectomies gets rid of about 98% of the breast tissue so we can lower a patient’s risk of breast cancer pretty low.

And unfortunately, there’s a lot of high-risk women in our community and surrounding communities and this has become more of a popular option for that patient. And again, not a good option for most patients, but I do want to make women (aware) who are truly at high risk, this is another avenue for them to pursue.

Courtney Collen:

Yeah. Thank you for adding that in here. Dr. Dirksen, thank you so much for this insightful and thoughtful conversation. Learned so much. Appreciate your time and all that you do with the Edith Sanford Breast Center here in Sioux Falls.

Dr. Dirksen:

No, thank you. And thank you for doing this.

Courtney Collen:

Thank you. This was another episode of “One in Eight” by Sanford Health. For more podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series

Debunking the biggest myths about breast cancer

Dr. Keely Hack:

It is really hard to, I think, follow recommendations if you don’t have any idea why someone is recommending to do these things. And so a huge part of our job is really providing that education of, “I recommend this for you, and these are the reasons why.” So that people really could feel empowered and educated to make the best decision that they can for themselves.

Courtney Collen (host):

This is “One in Eight,” a podcast series by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. One in eight women will be diagnosed with breast cancer during her lifetime. So we want these conversations to shed light on awareness with expertise from our Sanford Health providers that could save your life or the life of someone you love.

In this episode, we are addressing some of the biggest myths around breast cancer from detection to diagnosis and treatment, and we’re debunking them right here.

I have two guests with me now from the Edith Sanford Breast Center. Dr. Keely Hack is a specialist in hematology and oncology, and Dr. Jamie Williams is a breast radiologist specializing in all aspects of breast health, focusing on early detection of breast cancer. If you ask me, there are no two better medical experts for this conversation, so I am super grateful to have you both.

Welcome, Dr. Hack, Dr. Williams. Thanks so much for your time.

Dr. Jamie Williams:

Thank you so much for having us.

Courtney Collen:

When you think about some of the misinformation that can spread quickly about breast cancer, do you find yourselves often clarifying some of these things for patients in the clinic?

Dr. Keely Hack:

Definitely. Yeah. A lot of questions.

Dr. Jamie Williams:

I view that as a really big part of my job actually, is we have women come into our clinic for diagnostic breast imaging every day, and I try to speak with each of them individually and educate them and make sure if they have any questions or concerns or things that they want to clarify, we can talk about it. So education is a really big piece of what we do.

Dr. Keely Hack:

Definitely.

Courtney Collen:

I’m so glad you mentioned that just to get things started here. OK. Let’s walk through some of these myths, misconceptions, and kind of debunk them as we go. The first one: “Getting a callback for a lump in your breast means you have cancer.” Dr. Williams, I might start with you there.

Dr. Jamie Williams:

We read screening mammograms. We recommend annual screening mammograms for all women, ages 40 and above, and about 10% of those screening mammograms will be a callback. So we’ll see something on the mammogram that we want to look at further. Of those callbacks, about 10% will go to biopsy, and then about 10% of those are actually cancer.

A very small percentage of those callbacks turn out to be cancer. But part of our job is to make sure that if we see anything, we’re going to call it back and we get additional views. We get ultrasound and help clarify what it is that we’re seeing.

So, it is not definitely cancer when we call it back. Actually, most of them aren’t. We need more information to be able to see if what caught our eye is something or isn’t. I think I see that women who get called back, especially early on, have a lot of anxiety.

Every woman that I see in my clinic has a friend, mother, grandmother, aunt, cousin, somebody who’s gone through breast cancer. And so it is a real fear. The anxiety is real. That being said, you know, I like to reassure people that it is part of the screening process is, you know, occasionally getting called back, staying in the moment and not writing the worst story ahead is an important thing to keep in mind.

Also, I think that as women go on, if they have a couple callbacks over their time, maybe previous ones have gone well. I have such amazing technologists and team to work with. We try to keep our patients calm and just understand that it’s a normal process of the screening process is to sometimes get called back. Most of the time it’s nothing. And if it is something, we’re going to be there to take care of you.

Dr. Keely Hack:

I think reminding yourself that, like Dr. Williams said, the vast majority of those callbacks are not cancer. And so kind of, I always often tell my patients innocent until proven guilty. Let’s remind ourselves that the vast majority of the time that these are not cancers. And to kind of live in that space until you hear the next steps. Because yeah, it can be, I’m sure very scary.

Courtney Collen:

“Only women who have a family history of breast cancer are at risk for breast cancer.” You’re shaking your head “no.”

Dr. Keely Hack:

No, I hear that often in my clinic. You know, when I’m seeing women for the first time and they’re still processing that initial diagnosis and they’re in shock. And I often hear, “This was not on my radar. Nobody in my family has ever had breast cancer. I never thought I was going to have to deal with that,” which it’s a big diagnosis to come to grips with, and there’s a whole lot of processing that goes along with that.

But what I often tell people is the vast majority of women who have breast cancer have no family history of breast cancer. There are a small number of women who have an inherited gene that we know increases their risk for breast cancer quite significantly. But the vast majority of breast cancers are what we call sporadic breast cancers. Those are breast cancers in women who have no family history, have never had any breast problems before.

There are a lot of women too who say, you know, “I did everything right. I’m super healthy. I eat right. I exercise, I’ve done all of these things, and yet still I’m here.” I think we like to think that, well, if we do all of these things and we don’t do all of the things that we know increase the risk that I’m going to be fine. And I wish that were true. I wish we had more control over those things. But there’s so much that we don’t have control over. And so there’s a lot of women who end up in my office who never expected to be there.

Courtney Collen:

Those who have a family history of breast cancer who might be worried that they would get breast cancer or carry that gene, whatever it may be, doesn’t necessarily mean that they’re going to be diagnosed, you know? Is that true?

Dr. Keely Hack:

That is absolutely true. Yes. They certainly have a higher percent risk. The average risk for women is 12.5%. About one in eight women will develop breast cancer in their lifetime. And people who have an inherited, say, a BRCA gene mutation or a check two mutation, they have an increased risk, but it’s not a hundred percent sure that they will develop it.

You know, that’s a space they have to live in, knowing that, OK, my risk is increased, but how do I pay attention and how do I make sure that I’m getting the screening? So we do increase the screening, and I’ll probably let Dr. Williams talk a little bit more about how we do that, but kind of making sure that they know what their risk is, that they know what to watch for, and that they keep up with their screenings.

Courtney Collen:

Yeah. Dr. Williams, maybe we can speak to that now. When someone has a history of breast cancer, what does that mean for them? Do they wait until they’re 40 for that first mammogram? Talk through what that care journey looks like.

Dr. Jamie Williams:

For family history of breast cancer, the general guidelines I like to give patients is we look at first-degree relatives, so moms and sisters first. And if you have a first-degree relative with a history of breast cancer, particularly if that age was under 60, that’s one of those things that I would look at and say, hey, let’s make sure you get your lifetime risk of breast cancer calculated.

Or if you have multiple second-degree relatives. So if you have second-degree relatives, include grandparents, aunts. Typically, you know, there are online sources that you can do it yourself, but you oftentimes we have our patients go to the genetic counselor so we can make sure that it is done correctly and get into the electronic medical record.

So if I have a patient who I see either in their family history on the form that they fill out when they come to get a mammogram, or in talking to them in clinic, that I see a pretty significant family history there. I think, hey, let’s go get that lifetime calculated. I’ll usually recommend our breast specialty clinic and have them go see our genetic counselors to get that officially calculated.

And what I like to counsel my patients on is when you go see the genetic counselor, they’re not going to draw your blood and do a genetic profile. What they do is they ask you all sorts of questions regarding your risk factors for breast cancer, including family history, which is probably the largest component there. And then they put that into a statistical model. That model is able to calculate and a patient’s estimated lifetime risk of breast cancer.

And the reason that’s important is because if that person’s estimated lifetime risk of breast cancer is above 20%, we do recommend additional and earlier screening than the general population. So the American College of Radiology recommends all women get screened from a family history perspective before the age of 25. But obviously as we age, new family members may develop breast cancer. And so we have to continually update that family history as well.

If you are at an elevated lifetime risk of breast cancer above that 20%, then we recommend yearly MRIs starting as early as 25 for some of our really high-risk patients. And screening mammograms starting at the age of 30 yearly. And so completely different screening regimen that we recommend for our high-risk women. And usually that’s largely based on family history.

Courtney Collen:

So under 25, where would that conversation start? Like in the clinic with your primary care provider?

Dr. Jamie Williams:

Correct, yes.

Courtney Collen:

Thank you.

Dr. Keely Hack:

We do have our breast specialty clinic here. And so that’s a place where women, if they’re concerned about their lifetime risk, and maybe they’re under 25 or maybe they’re over, but they can ask their primary care provider for a referral to this breast specialty clinic. And that often will include that visit with genetic counseling, and it will include a visit with a breast specialist.

And that breast specialist is either a physician or a mid-level provider who will, they usually will follow them yearly if they are determined to be at elevated risk and make sure that they’re staying on top of their breast exams with a breast specialist and making sure that they’re staying on top of that screening schedule that Dr. Williams talked about.

Dr. Jamie Williams:

Absolutely. Dr. Hack, that is a great resource for our patients.

Dr. Keely Hack:

Such a great resource. Yeah.

Courtney Collen:

Thank you. “Breast cancer only affects older women.” We’ve seen younger women diagnosed. So I already know that’s not true, but can you speak to that a little bit to talk about the age range that you see in the clinic when it comes to a diagnosis?

Dr. Keely Hack:

Yeah. So increasing age is probably the number one risk factor for developing breast cancer. But unfortunately there are a number of women younger who do develop breast cancer. A lot of them have a strong family history or have a known genetic mutation that they’re carrying. But not all of them, certainly, you know. We see women sometimes as young as 25-ish, pretty rarely younger, but it’s not impossible.

I think the thing to really keep in mind is if you are younger than 30, if you’re any age, and if you feel something different in your breast, don’t think, “I’m too young. This can’t be breast cancer.” If you go and see somebody to have it evaluated and they say, “no, you’re too young,” advocate for yourself because we do see people younger. And the sooner that we catch it and diagnose it and can start a treatment plan, the easier that treatment is likely to be, the more successful we are likely to be in curing that breast cancer. So, don’t ever be afraid to advocate for yourself.

Dr. Jamie Williams:

Yeah. We have women diagnosed in their 30s and 40s pretty routinely. Thankfully it is less common than in older women but the other thing to remember or to know is that oftentimes breast cancers in younger women tend to be more aggressive. And so that earlier detection is even more important for our younger patients compared to our older patients. Now, every patient and every cancer is unique. And so that is painting a wide brush there.

But you know, I echo what Dr. Hack said is that particular for women in their 30s and 40s or late 20s, if you feel something in your breast, it is far better to come in. Get it checked out. Most of the time it’s not cancer. But we’d always rather be safe than sorry. And that’s a conversation we have all the time.

Dr. Keely Hack:

Absolutely. Yeah. I certainly don’t say that to try to scare people. But you know, if you feel like, “Hmm, this is a hard lump and this definitely wasn’t here before and I’m really concerned about it,” always best to get it checked out.

Dr. Jamie Williams:

We are always happy to take a look. Always. I know I tell my patients all the time, if you’re concerned, for patients who have lumpy, bumpy breasts, they say things are coming and going and I have a hard time knowing when to come in and when not to.

A general rule of thumb I like to give my patients is if you feel a new lump and it stays around for about six weeks, through a menstrual cycle, that’s when I usually say, “Hey, come in and get it checked out.”

Courtney Collen:

Thank you. Yeah. Great insight there both of you. Next myth here: “If I’m diagnosed with breast cancer and need to undergo chemo for treatment, I lose my chances for having a baby or preserving fertility.” Dr. Hack, I’ll start with you.

Dr. Keely Hack:

Thankfully that is not true. We do know that chemotherapy can decrease fertility. And that there is a risk. And that is why we are very cognizant of making sure that women have the opportunity to meet with a fertility specialist before they start treatment.

So kind of anybody who is, you know, that age, that upper cutoff age is kind of debatable. Generally, if you’re under 45, we want to make sure that we’re at least asking if you desire future fertility so that we can make sure that right away early on we’re getting you in to see that fertility specialist to talk about what the options are.

Also, often we’ll give people an injection of something called Lupron, which decreases the activity of the ovaries during chemotherapy with the hopes of kind of protecting the ovaries from the effects of chemotherapy. There have been some studies on that and some that suggest, yes, it’s helpful. Some that suggest maybe it’s not as helpful. But from the data that we have currently, we are still using that in hopes that it will offer some protection.

I do have a number of women that have taken care of who have gone through chemotherapy breast cancer, and then they bring their babies in after they deliver. And it’s just such a wonderful, joyful event. It gives me goosebumps. I think I have goosebumps right now. Oh.

So yeah, some of those women do get pregnant naturally after breast cancer treatment. We know that women under 40 have a much higher likelihood of having their menstrual cycles return and their fertility return after breast cancer treatment. But we also usually will do some IVF and have some embryos preserved as well. If that’s what women choose to do. They don’t have to do that.

Courtney Collen:

So, women have options. Options for sure. Yes. OK. Up next here, Dr. Williams: “Mammograms cause breast cancer.” Can you clarify?

Dr. Jamie Williams:

Well, we know from huge studies with a huge number of patients that screening mammograms is the only thing known to reduce morbidity and mortality of breast cancer. And so one thing to talk about would be radiation. And so I know that mammograms do have a very small amount of radiation, but we know that the amount of radiation that we use to do a mammogram is so small that it is not causing the breast cancer.

And any small number of breast cancers that are caused years and years past after the radiation exposure pale in comparison to the number of lives that we have saved because of using mammograms. And so radiation exposure, typically it requires 20 years or more for that to manifest.

And the amount of radiation dose that is in a screening mammogram is so tiny. It’s less than background radiation for a person living on human earth for just a couple years. So the radiation shouldn’t be scaring people away from a lifesaving tool that we have in medicine.

Courtney Collen:

So I’ll add to this because people are talking about it: “Thermography can detect breast cancer just like a mammogram using less radiation.” Maybe just give us an overview of what thermography is and then speak some truth to that because I know already that that’s not true. Speak to thermography versus mammography.

Dr. Jamie Williams:

I’ll repeat it. Because it’s important that we know that screening mammograms are the only imaging modality to reduce the morbidity and mortality of breast cancer. And so thermography is not a tool that we know does that.

Now thermography was approved by the FDA to be used in conjunction with mammograms. Separate from mammograms and alone without a mammogram, they’re not licensed to be used for a screening modality standpoint. Now, we do not offer thermography here.

My understanding from reading about it is that it picks up heat signals from the breast with a detector, and it can detect differences in heat signals up to a centimeter below the skin. So anything below a centimeter in the tissue, it cannot detect. And so if there is a breast cancer that is within a centimeter of the skin, it may show some increased heat in that area. But that means that it’s missing a lot of cancers that are deeper in the breast that we can see on mammography and cannot be seen with thermogram further, like I said.

And the other thing to emphasize is thermography has not shown any significant benefit to catching cancers when it’s not used in conjunction with mammography.

Courtney Collen:

Sure. Thanks for clearing that up. But “mammograms are the only breast health check you need” – is that true?

Dr. Keely Hack:

I would say no. A breast exam is also an important tool. There are unfortunately some breast cancers that aren’t able to be seen on mammogram. That’s pretty uncommon. But you know, if you feel a lump, that is something that that should be evaluated.

And so we do recommend that women have visits, and this is a bit controversial. We talk about this in our breast leadership meetings, but kind of whether self-breast exams are recommended or aren’t recommended kind of goes back and forth. Some governing bodies recommend them. Some do not.

We see women with breast cancer every day. We recommend them. It’s important to know what your breast normally feels like. You know, we’re not saying, oh, it’s on you to catch any breast cancer that comes along. But if you can know what your breast normally feels like, then it’s easier to notice when there’s something that’s different. Having a clinical breast exam with your physician every year is also an important tool as well.

Dr. Jamie Williams:

The most common symptom for a woman to present with in which being diagnosed with breast cancer is a palpable abnormality. Meaning that you feel something, either your doctor or you feel something in your breast. And so it’s a really, really important symptom that when patients come in, even if they had a screening mammogram, we always do an ultrasound because, like Dr. Hack said, there are certain types of breast cancer that are what we call mammographically occult. And there it’s pretty rare.

But sometimes we can see the cancer better with ultrasound than mammogram. And so we do treat palpable abnormalities very seriously and that’s why we recommend self-exams because like I said, the most common symptom to be diagnosed with breast cancer when you come in for a breast symptom would be a palpable abnormality.

Courtney Collen:

Thanks for that insight. Good to know. “Women with smaller breasts have a lesser chance of getting breast cancer” – is there truth to this?

Dr. Keely Hack:

Nope. No. Really any breast size, any breast shape, all at risk. It’s really the mammary tissue, or the tissue that produces milk during lactation, and the tissue that carries the milk from the lole where it’s made to the nipple. Those are the areas where almost all breast cancers are formed.

The ductal carcinoma is a breast cancer that forms from a milk duct. And about 80% of all breast cancers are ductal carcinoma. So regardless of whether the breast is large or small, they all have that tissue, and so they are all at risk.

Courtney Collen:

Does it have anything to do with having breastfed during those childbearing years?

Dr. Keely Hack:

So there is data to support that breastfeeding does lower the risk of developing breast cancer, but it certainly doesn’t completely prevent it.

Dr. Jamie Williams:

Rather than breast size, breast density is what we know is associated with an increased or decreased risk of breast cancer. And that is something that we can only know what it is based on a mammogram.

So on a mammogram, when we talk about breast density, that is the composition on the mammogram of fat tissue to breast tissue or what we call fibroglandular tissue in my world. And that fibroglandular tissue, as Dr. Hack said, is the tissue that makes milk for women when they’re pregnant and afterwards to nurse. And so breast density is a completely separate issue from breast size. And so it’s far more important for a woman to know what their breast density is than their breast size.

Dr. Keely Hack:

Yeah. And it’s, I think, also important to note that you cannot tell, like Dr. Williams said – the only way to know breast density is by the imaging. It doesn’t feel any different. Correct. It doesn’t look any different on like to the eye looking at the breast. It’s only based on imaging.

Courtney Collen:

So, I can’t sit here and say, you know, “these feel heavy and they feel dense.” That’s probably the case. It is truly something that you come in and have confirmed.

Dr. Jamie Williams:

You have to have the mammogram to know what your breast density is.

Courtney Collen:

Sure. OK. Thanks for clearing that up. Some believe underwire bras or deodorant-antiperspirants cause breast cancer. Is there truth to this, Dr. Hack?

Dr. Keely Hack:

I get that question fairly often in my clinic and I tell my women I still wear deodorant and I still wear an underwire bra because we don’t have any data to suggest that there is any correlation there at all. You know, a lot of women use deodorant and a lot of women use underwire bras.

There’s a difference between what we call correlation and causation. We can see that, OK, a lot of women who had breast cancer wore deodorant and wore underwire bras. Well, a whole lot of women who didn’t develop breast cancer also did those. So just because two things can be true together doesn’t mean that one caused the other, if that makes sense.

Courtney Collen:

Sure. What else do each of you hear inside or outside of the clinic on this topic that might be worth addressing?

Dr. Keely Hack:

So one question is diet. I get that question all the time. A question of, boy, you know, did I eat too much sugar or should I stop eating sugar? Now that I’ve been diagnosed with breast cancer, because sugar feeds cancer, right? Our body has to have sugar. Our brain cannot burn anything but sugar. Our muscles and other organs can burn sugar, fat, or protein, but the brain can only burn sugar. And so if we don’t eat sugar, our liver’s going to make it.

So, I tell people, you might as well enjoy it if you’re going to get the sugar. I mean, not to say that you should eat cake and cookies as your whole diet. You know, a well-balanced diet. I would not stress about eliminating sugar. You know, that stress that you have about your diet may increase your stress hormones. And whether that causes a problem or not is debatable, but potentially. So don’t try to eliminate sugar. Eat the cookie. Yeah. Have the birthday cake. If it’s your, you know, grandchild’s first birthday. Yes. Do those things that are joyful in life.

Another is supplements. What kind of supplements should I use? Or are there supplements that can prevent breast cancer? We don’t have any data about any supplements that there are these headlines that come and go in kind of the popular media from little small studies. Those often aren’t studies that have been redone.

The studies that we base our recommendations and information on are very large studies that started out maybe as a small study and then somebody did another study to say, hey, if I look at the same thing, am I going to get the same result? Because if you do the same study and you get a different result, then that really wasn’t probably a true thing. And so we don’t have any data about any supplements that are helpful.

And another question I get a lot lately, and this is primarily for people who have been diagnosed and are undergoing treatment, is Ivermectin. That’s a very common question currently that has no data to support that it is helpful. So what I have to tell my patients is all of our drugs that we use to treat breast cancer have been through a number of steps of research.

So they started out in a lab, in a Petri dish where they were combined with cancer clone cells and shown that they killed off those cells. And then they go onto animal studies, and then they go on to human studies to find what’s a safe dose, what’s an effective dose. Ivermectin hasn’t gotten through all of those because it didn’t work beyond the Petri dish, essentially. So when you see research about it, it’s in those earlier stages. It hasn’t been shown to be effective in humans to treat cancer.

So, and there is potential risk. Particularly there can be liver damage or liver inflammation associated with that. I really don’t want to see people taking that risk for something that is not going to be beneficial.

Dr. Jamie Williams:

One myth I hear a lot is that mammograms are painful. I think the vast majority of women – no one’s going to say that they enjoy it – but most women say at most it’s a little uncomfortable. We have really wonderful technologists who work with our patients, explain everything and make sure that the patients as comfortable as possible during the exam. So I don’t want patients to not get screening mammograms because they’re concerned about the myth that they’re painful because the vast majority of patients do not feel pain during a mammogram.

And they’re very fast. I mean, a typical screening mammogram is done in five minutes or less. And so that’s something that I tell patients all the time is to not be afraid of a mammogram because of the discomfort perspective.

The other myth that sometimes or probably the most common question that I get asked prior to a biopsy is that, if this mass is cancer, will it spread by biopsy? We don’t have any data to indicate that doing the biopsy where what I’m talking about is a core needle biopsy. So if we call you back from your screening mammogram, or if there’s something that we need to take a tissue sample from, we will do an image gutted biopsy where we take a tiny pieces of tissue from it, send it to pathology, they look under the microscope and help us diagnose what it is that we’re seeing.

And so if it were to be a cancer, there’s no data to indicate that the actual act of biopsy increases your risk of metastatic disease or spreading the disease. So that’s an important one that I talk to patients about all the time.

Courtney Collen:

A cancer diagnosis is nothing to take lightly. Talk about the importance of these conversations and more so encouraging patients to bring these concerns, these questions up with their doctor.

Dr. Keely Hack:

I think a really important aspect of a relationship between a person, a patient, and their provider is openness and trust. And that goes both ways, really. We want people to know that this is a collaborative relationship. This isn’t a, you come into my office and I just tell you this is how it’s going to be and you’re going to do this and this and this. That’s not at all how it is. Maybe 50 years ago it was. I don’t know. But that definitely is not how it is today.

We really want to partner with people, we want to educate them because it’s really hard to, I think, follow recommendations if you don’t have any idea why someone is recommending to do these things. And so, as Dr. Williams said, a huge part of our job is really providing that education of I recommend this for you and these are the reasons why, and these are the things that maybe might happen if we do do this or if we don’t do this. So that people really can feel empowered and educated to make the best decision that they can for themselves.

Courtney Collen:

And this is why these conversations are so important too, to help. I appreciate you. Thank you so much.

Dr. Jamie Williams:

You so much for having us.

Courtney Collen:

This was another episode of “One in Eight” by Sanford Health. For more podcast series by Sanford Health, find us on Apple, Spotify, and news.sanfordhealth.org.

Get more episodes in this series

Hospital at Home moves care where patients heal best

Alan Helgeson (announcer):

“Reimagining Rural Health,” a conversation series brought to you by Sanford Health. In this series, Sanford Health leaders and expert guests share insights, innovations, and real world solutions to the toughest challenges in health care today. Each episode explores the ideas, tools, and partnerships advancing rural health care and strengthened care in communities across the country.

Joining us in this episode is Dr. Constantinos (Taki) Michaelidis, medical director of the Hospital at Home Program at UMass Memorial Health, alongside Susan Jarvis, chief operating officer at Sanford Health Fargo. Together they’ll share how their organizations launched and scaled hospital at home programs in both urban and rural settings. The lessons they’ve learned and the impact they’re seeing on patients, providers, and their respective health systems.

Susan Jarvis:

Taki, thank you so much for joining us today. I’m really excited and I’m looking forward to talking with you about Hospital at Home. You have been instrumental in helping us here at Sanford and Fargo get our Hospital at Home program up and running. And you’ve been leading the Hospital at Home program at UMass Memorial since 2021.

So we’ve got a lot of experience, our program, we’ve only been going not even a year. But can you share with us, how did the Hospital at Home program there at UMass Memorial come to life? How did you decide to embark on Hospital at Home? And how does it work for you at UMass?

Dr. Constantinos (Taki) Michaelidis:

Yes, and Susan, and to the whole Sanford Home Hospital team, it’s just such a privilege to be here with you today. So much of this important work only arises because of collaboration and supporting each other. And there’s so many nuanced issues that arrive in home hospital that are unique to what we do in caring for vulnerable populations. So I hope this is only the second, third, or fourth of 20 or 30 conversations over the coming years and decades.

So just a step back for the moment, Susan, to your point. So my name is Taki, although it says Constantinos Michaelides. Everybody calls me Taki. I’m an internal medicine physician by training and have been privileged to work in home hospital for getting closer to 10 years, the last four at UMass Memorial Health. So a little bit about our health system and then we’ll dive right into the question you asked, which is a really fun one and an important one. So we’re the primary safety net provider health system in our central part of Massachusetts.

We are based in Worcester, Massachusetts and care for, we’re the Level 1 trauma center, the NICU, the tertiary care center, the primary teaching affiliate of UMass Memorial Chan Medical School, and have about 1300 beds across our main academic medical center and our four partnered community hospitals. And where we were in, you know, 2021 was, you know, about a year, year and a half into the real challenge of the COVID pandemic.

And our health system had been operating the COVID field hospital for the state of Massachusetts. So providing excess surge capacity to care for our complex patients admitted with COVID. And then in November 2020, the waiver came along, the CMS waiver, which obviously underpins everything we do in home hospital. I’m sure we’ll talk much more about that waiver because it is so important.

That waiver came along and our health system leadership was looking at our main academic medical center, looking at our partner Community Hospitals and saying, holy cow, we have a capacity crisis still. It’s not uncommon for us to start our morning with 90 patients boarding in our emergency department, 100 patients, 110 patients. And as all of us feel in our health system, I’m sure in your health system as well, we know that’s not the experience we want for our patients, our family members, our loved ones. There’s so many challenges with boarding in terms of quality and safety and cost.

We stood up our program to address that challenge. Started most of our planning in about January, February, 2021, launched the program in August of 2021. And now we’re actually a little bit more than four years in. We’ve cared for getting closer to 3,900 patients and patients are doing great. And I’m looking forward to discussion around quality and safety and satisfaction.

But the short answer is it’s been an incredible journey and looking forward to hearing more about your journey too and sharing things where we have many common challenges and where we might have solved them in unique ways.

Susan Jarvis:

Well, we looked at the Hospital at Home program when the waiver came out and we, like everyone, we were very challenged through COVID. But we did not embark on the Hospital at Home journey at that point. We focused more on we did have some, we had built a new medical center here in Fargo and we’d moved into in 2017.

So we had a hospital, a different campus, where we had some beds that we were able to bring back online pretty quickly. And so through COVID, we were able to use hospital beds that we had planned to decommission and turn into clinic and other types of space for our cancer center. We had to delay that a little bit until Hospital at Home, until COVID was over. But then from the Hospital at Home standpoint, we though, you know, kind of post COVID, we’ve continued in Fargo to be very, very busy.

We have continued to bring other beds online and we built up all of the shell space that we had at our new medical center and we still have capacity challenges. So we do still almost on a daily basis have patients who are waiting for beds in our emergency department. We have various overflow areas and so we took another look at hospital at home.

And we said, you know, we know we’re more rural than some of the programs that are out there, but we really want to give it a shot. And we want to see if this could help in some way with our capacity issues. And it was really our hospitalist group that came forward and said, hey, we think we have patients that would be great for this and we want to be really involved and we want to try this program. So with your help, with the help of the people in the industry that are doing it,

I’ve just found that the Hospital at Home kind of group is just very welcoming. They want to share what’s happening, very helpful. And what you have done for our team has been very much appreciated and helped us get off the ground.

Dr. Constantinos (Taki) Michaelidis:

And such a kudos, because I think your word “journey” is exactly right. It is a journey and you folks are rocking it. And I love the perspective around your clinical team, your physicians coming and saying, you know, we believe in this. We want to get this off the ground. That is such an accelerant because as all of us know, there is culture and change management for sure in this work and having a really strong team of nurses and doctors and APPs working together who believe in the model upfront.

You’re already years ahead of many other systems. So kudos to say the least.

Susan Jarvis:

And we are just at the beginning. And I want to talk a little bit in a minute about the bumps in the road. You have been very encouraging to help us understand, like it is going to build over time. But before we get to that, I would like to know a little bit more about your role as medical director. What made you so interested in this work? And what do you do kind of on a day-to-day basis as a medical director?

Dr. Constantinos (Taki) Michaelidis:

Yes, thank you for that question, Susan. And you know, there’s a personal story there and then certainly a professional journey. On the personal side of things, my mom was a nurse up in rural New Hampshire and spent decades going home to home as a home care nurse and just loved everything about being in the home, caring for her patients, getting to know them in a deeper way, understanding their social determinant challenges. And so I think I maybe had some home in my blood.

And when I came out of my own internal medicine training, trained at a really lovely program, and still I would notice that very, very often our patients would call in 5:01 p.m., 5:02 p.m., and oftentimes not feeling great, and we would often tell them to go to the emergency department. And I always ask myself, wouldn’t it be lovely if we had a different set of tools to care for our most complex patients?

And I think all of us can think of maybe our own frail family members or complex and vulnerable patients where you know, they’re doing well at home. Maybe they just need a little bit of acute care. And if you keep them out of the ED or the hospital, they might avoid some of those things that happen in the hospitals that all of us want to avoid.

So for me, that was where my personal excitement about home, acute care at home got started back a number of years ago. And then from a professional perspective as the medical director on this journey. So I am the medical director of our UMass program and have an amazing dyad nursing partner, Casey Phillips, and she and I work very, very closely together.

And so I oversee certainly our physician team, work with my boss, who’s the chief of hospital medicine, Dr. Greg Leslie, who’s a lovely and thoughtful progressive human being. And the question is always simply, what else do we need to build? What else do we need to add on to our already awesome program to make it even better and care for a broader range of patients? We take a very needs-based evaluation approach to our patients in the ED and on the floor is what do they need and how can we meet that need?

And so I do a little bit of certainly care for patients in the model, do a lot of growth work, a lot of change management, a lot of incentive alignment, a lot of working with our executive team who are very, very supportive, but my gosh, so busy as well and trying to be respectful of their time and sort of linking the frontline care with the executive leadership kind of primary principles around how do we build capacity? And I would love to hear your perspective on this.

In my own perspective in terms of capacity is that you know, lots of rural, urban, suburban health systems across the country are facing the same challenge. And whether it’s a critical access hospital in a rural part of the country or an urban medical center in New York City where they’re spending four or $5 million to build a bed, I am very, very convinced that we are not going to build our way out of this crisis of capacity in these United States. We ourselves also built a 72-bed lovely unit that opened just about a six months ago, and we saw a little bit of a decrease in boarding and that’s been a real nice win, but the boarding is still there and I think we’re going to have to all get way more creative across our country as we think about capacity, especially with the silver tsunami coming down the road for sure.

Susan Jarvis:

No, I agree 100%. And I think I do think the Hospital at Home program is going to be instrumental in helping us get through the silver tsunami and provide care in a different way. Just think, you know, going forward the next 10, 20, 30, 40 years, we’ve got to adapt. We, health care has done that in the past where we’ve changed how we deliver care, you know. I think about outpatient surgery in the ’90s and you know, when it was all inpatient and then it became outpatient surgery and then just all of the things, and I think this is just the next logical step in how we deliver care and how we deal with the capacity issues because I think we do all have them for sure.

Well, we talked a minute ago about bumps in the road and new programs and challenges and that type of thing as I was saying.

Dr. Constantinos (Taki) Michaelidis:

Sure.

Susan Jarvis:

We are very early in our journey here, and so we’re experiencing some challenges. You talked about change management, and change management is huge with this program as you get buy-in and that type of thing. When you stood up your program, what were the biggest challenges or hurdles that you had to figure out going forward to get it successful?

Dr. Constantinos (Taki) Michaelidis:

Yes, I love that question and would love to hear your perspective on this as well. There are so many different things that arise from being in the home that are unique about being in the home. And you know, I think about, you know, our, you know, New England terrible winter storms where we’ve got two, three feet of snow. And I’m sure you say, we say two, three feet of snow. Yeah. And you folks are like two, three feet. That’s it. That’s it. All of our ambulances have plows on the front, which I love. When you shared that story earlier, I was like, these folks know winter.

Susan Jarvis:

Do you have snow in New England?

Dr. Constantinos (Taki) Michaelidis:

And so I think there’s so many different nuanced areas. One, stepping back for the moment, one piece that I would share is, when we stood up our brand new brick and mortar 72 bed hospital about six months ago over several years of planning, I think about all the folks who are at the table, nursing and pharmacy and the physician medical group and facilities. And there was so much effort and took two or three years of planning.

And if I had to step back and say one area that I think all of us in home hospital probably could do a little bit better is maybe all of us could be a little bit less scrappy and a little bit more saying, you know, hey, we are building a 20, 40, 60, 80 bed virtual unit.

I would never build an 80-bed unit with a friendly doc and a friendly nurse holding hands saying we can do this. You don’t get resources, you know, that’s, that’s, you know, 60, 70, 80 million dollars. That’s a full hiring strategy. It’s, you know, it’s a multi-year approach. And so I think we’ve got to be careful where even though I think there’s a lot of ways in which building a program is less expensive than building $5 million beds, $3 million beds, it is still a real endeavor. And so I think we don’t want to underestimate the resources required to build and stand up a virtual hospital. So stepping back to your original question around, what were some of those bumps?

I think part of it is just all the good old fashioned things. We need great nurses and medics and physicians. We got to hire them and train them. We need logistics management. We got to build resiliency for weather, for electrical storm or electrical downtimes with storms. We’ve got to make sure we’re adhering to all of our policies. We’ve got to think carefully about patient acquisition. How do we align incentives? It’s definitely a multifactorial approach, but would love to hear from your perspective. What would you identify as some of the key things that were bumps in the early days?

Susan Jarvis:

Well, you know I love those comments about you have to plan and resource it appropriately. And I think we maybe started with a scrappy nurse and a few scrappy doctors. And I think we’ve learned, you know, we’ve got to put a little more infrastructure around that as we go. And it is kind of like, you know, you’re, you’re not sure or your patient or you’re going to get buy in from your patients. Are you going to, is it going to be a successful program? So how much do you invest versus trying to be scrappy and build it as you’re kind of building the program?

We had the COVID pandemic and then we had our capacity issues and we had our physicians who came and said, look, let’s look at this. The other things that we had in place already, we had been working on a virtual nurse pilot. So we had virtual nursing and then we had community paramedics already. So we’ve had community paramedics here in Fargo for over a decade.

We actually train community paramedics. We own and run the 911 ambulance service in the Fargo-Moorhead area and some others throughout our footprint. But years ago, they came forward and said, hey, there’s this new program of community paramedicine. It’s going to be great. It’s going to help us fill gaps. And so we had community paramedics and they’re used to going out into the home.

And they’re used to noticing things that you might not always notice when you’re in a home and that type of thing to make sure that we were taking care of the patients appropriately. So we had a lot of the infrastructure in place, but it’s still, even after we got the waiver, I we took a good bit of time to make sure we had all our i’s dotted and t’s crossed when we went for the waiver, but it still took us about a year after we got the waiver to get enough staff of the rest of the staff to be able to implement the program.

And all along then we were working on our infrastructure and what was the technology going to look like and how are we going to get drugs to the patients, all of those types of things. And so that took a while, a little bit longer than I expected it to take to get staffing to get started. And again, we started small.

The other thing I would say, and we are still encountering this, although I think as we get the word out about the program, it’s just patients buy in when they come in and we say, you would be a great candidate to be in your home, but also in the hospital. And we get a lot of skepticism still. And I wonder how you countered that in your program.

Dr. Constantinos (Taki) Michaelidis:

Yes, and holy cow, that is a deep and nuanced question, and we probably could spend two hours just talking about that alone. You know, a couple of thoughts. The first is that what we find is that when we reach out to a patient or a caregiving team on our own and say, think this patient is great, do you mind if we reach out to the patient and family? In the aggregate, about 20 to 30% of those patients ultimately end up with us.

Whereas when the patient is referred to us on day one or day two or day zero of their hospitalization by a confident physician or nurse or case manager who knows that patient and has already raised the idea with a patient, our accepting rate is typically closer to 70 to 80%. And so part of what we’re trying to get to is, you thinking about our emergency departments, they’re so busy down there, a really sick patient comes in with a pneumonia on three or four liters of oxygen.

And probably between the time we talked to them and the time they got into the ED, they’ve probably been down there somewhere between 10 and 20 hours. They’ve probably had four nurses and doctors all say, you know, you’re really sick, you’re going upstairs, you’re really sick, you’re going upstairs. And then we come along and we say, you’re really sick, you’re going home. And you know, that’s just a little bit, a little bit sort of chaotic in their mind. Like, what the heck? Do these folks know they’re talking about? Get all these different messages.

And so what we have done with our emergency medicine doc and nurse colleagues and our ED is we’ve done some very basic like seed planting efforts for them where we just say to them, all you got to do is understand rough idea of what we provide and just tell the patient, I think you’re a great candidate for the program. Let me have those friendly hospital home docs and nurses come and talk to you so that we’re setting things up early. And then I will say too, the advantage that we’ve had now that we’ve been operating for about four years, and I think you folks will have that advantage probably about a year or so from now.

It did take us about one to two to even three years to build the flywheel of patient expectations. And so now what ends up happening is that we’ve cared for about 4,000 patients is that many of those patients who come back three years later already know about us or their friend or their son or their mother or their daughter or their husband was cared for by us. And so they no longer think it’s kind of nutty.

They just say, yeah, like you took great care of my son, my mother, my grandmother. That’s just normal. Like why would I ever come back to the hospital if you can do that at home? And so I think the number one thing that we feel very strongly about, and I’m sure you folks have seen the same incredible outcomes, is that when we provide high quality, safe, patient-centered care and we delight patients or families and they’re sleeping well at home and they’re respected and given autonomy of being in the home.

They just say amazing things about us and they say, they rave about us to their friends and families. And so I think we probably hit that flywheel about two or three years in. Thankfully, is the first year was hard though, for sure. It is very hard because you’re like everyone, every single person you’re talking to has never heard of you ever before. So that’s new.

Susan Jarvis:

We are starting to see some patients who have been in the program and then they come back in and they say, can I go back into my home and be in the hospital? So we’re starting to see, you know, get a little traction there. And I do think our doctors and nurses are doing a great job of, you know, talking about the program and that type of thing. But the more they hear patients’ stories about how great it was and our patients have been very satisfied.

Dr. Constantinos (Taki) Michaelidis:

Yes.

Susan Jarvis:

I think, you know, like you said, just that flywheel will just really start humming. So that’s great. Just to change the subject just a little bit, we talked a little bit about snow and snowdrifts and you get to your – but I think yours might melt after you get yours. And I think ours stays here for a long, long time. But so we are very rural.

Dr. Constantinos (Taki) Michaelidis:

For sure. Yes.

Susan Jarvis:

But you have some rural areas too and I think that that has probably we probably have some similar unique challenges maybe barriers around transportation or language or weather or any type of thing like that. So how did you counteract, what, what were those types of barriers and then and how did you counteract those and how what do you do every single day to make sure you if you don’t have a snowplow you can get out there to take care of your patients?

Dr. Constantinos (Taki) Michaelidis:

For sure, for sure. And we’d love to hear your approach on this as well. You know, I think we are very lucky that our snow does melt after a couple of months at least. You know, when we thought about building and scaling our program over time, we thought about a combination of geographic reach and payer contracts and building capabilities to meet our patients.

And that’s how we thought about the opportunity and expanding the opportunity. You’re 100% right. We are in an urban environment in Worcester by about 20 minutes outside of our main medical center. You’re in suburbia and another 30, 40 minutes you’re at the New Hampshire, Rhode Island, Connecticut border, surrounded by farmland and cows in a beautiful part of our state. And so we kind of have to build capabilities to go everywhere. And that includes things like four-wheel-drive vehicles. We got to build redundancies for power loss.

So for instance, we have a strategy for if there’s a storm that knocks out electricity or power or heat in one of our patients’ homes. We bring backup O2 cylinders for every one of our patients on oxygen. We build communication resiliency, so they’ve got phone or internet, so if one goes down, they have a backup strategy to get in touch with us. And then most importantly, and I would love to hear, you folks might have had a real nice advantage with your local community paramedicine capabilities that we were.

We had to build those kind of ground up when we launched. And so we didn’t quite have that same foundation you folks did. That said, as we’ve gone further and further out into the community, those local EMS and 911 partnerships are critically important. So anytime we go into a new area, we partner with local EMS and 911 systems, we build communication pathways and awareness. So when they, you know, arrived to one of our patients’ homes, when we need their help, there’s like a sign in the door, they see the patient with the bracelet on, they say, my goodness, this is a home hospital patient.

And we remember all the pathways that we worked on together for escalation. So I think the other part is that as we move further away from our main medical center, we typically, it’s more and more important to bring the capabilities with our paramedics, with our nurses. And so we have urgent med packs, we have point of care testing, we use the i-STAT device quite a bit for phlebotomy and lab tests in the home.

And so I think that’s been a real capability. And I’ve seen some of our peer programs who even, again, we’re operating about 40 miles or so radius. And we have some peer programs in North Carolina that are operating almost about 150 by 50-mile radius. And for them, they have incredible on SUV capabilities in terms of medications and diagnostic. So we’d love to hear more certainly around how you thought about the opportunity in the community as you went further away and how you thought about your community paramedicines as an asset, paramedics as an asset and outfitting them for all scenarios.

Susan Jarvis:

Well, yeah, and I think that you helped us a lot with anticipating a lot of those things as we got our program ready. We are still going just about 25 to 30 miles as we’re getting up and going. But we get pretty rural after about 10 or 15 miles. So we haven’t expanded out as far. The 150 miles is very, very interesting.

I love the idea of exploring like what else could you have for that group that is providing the care that they need? So we’re still learning, I think. The biggest thing, you know, besides having them well trained and everything that they need is we do have the ability to have snowplows on our vehicles. So to get out there and make sure we get out and see patients.

Dr. Constantinos (Taki) Michaelidis:

Yes.

Susan Jarvis:

Funny story, we started the program last year and the day we said, we’re open and we’re ready for business, we had a blizzard. So it was back last winter. We did not admit anybody that day because brand new program, which we tried, but people did. They’re like, what? You want me to go home in this? And so we didn’t. It took a couple of days for us to get our first admission.

But all of those things you have to take into account and you have to make sure that you’re able to provide that care. I think we are very fortunate in the EMS world. We have a lot of resources with our EMS services. And one of the things we’ve talked about is how are we going to scale this? Because we do have also critical access hospitals throughout the rural footprint. How could we perhaps use local resources for the in-home visits?

But our virtual nursing at, you know, back at the hub here in Fargo. Do you do any of that type of kind of set up right now?

Dr. Constantinos (Taki) Michaelidis:

We do a little bit for sure, although we know that as we go, probably the next step to move further away from our medical center will by mandate for us to meet the patients’ needs, have to involve more deeply involved care with the local 911 systems. And there’ll be some interesting questions about credentialing and partnerships and communication for sure. I have worked in prior home hospital care models that used a more decentralized supply chain.

And there’s some real strengths to that model as well, where if you’ve built a partnership where there’s a critical access facility that’s like, let’s say 300 miles away from you, but they have some real capabilities and they’ve got a local 911 system that works for that critical access hospital, but maybe they just need a little bit of physician support, a hospitalist, a virtual acute care nurse to backstop them and provide the backbone of the continuous hospitalization experience, that there may be some interesting ways to do that work. So I do think the decentralized supply chain is really, really interesting.

Susan Jarvis:

That’s really interesting to explore. Well, your program has been up and going for several years now, and you talked a little bit about the word of mouth and people are saying, this is a great program. What do you, how do you measure success from a quality standpoint, from a patient experience standpoint? And can you tell me a little bit about maybe a patient’s story of someone who was in the program and how it impacted them in a positive way?

Dr. Constantinos (Taki) Michaelidis:

Sure, and thank you for that question. It’s probably the most fun thing to talk about in the program because it really brings to light the power of the home. And in some ways, think the home is, we’re re-recognizing the home as the right site of care for many populations, in particular, our most complex, our most disadvantaged, our most medically frail population.

Recently about a number of years ago, we had cared for a gentleman, 67 or so, who came into our emergency department and he had a history of high blood pressure and diabetes and end-stage kidney disease and actually had a kidney transplant a couple years earlier. Was living in the community, his girlfriend lived next door, his daughter was a nurse practitioner who had a good relationship with but lived about two, three hours away.

And he’d come into the ED just feeling off or so and had his initial set of labs there in the waiting room. And he was in the waiting room for about eight or nine hours and just got very frustrated and he left without being seen. And I think all of us know that that is obviously something that we want to, that’s partially why we build home hospitals. We want to reduce those left without being seen to zero.

Our emergency medicine team called him back and he came back to the hospital with a very severe infection of his transplanted kidney. He was screened by our nursing team after seeing the transplant infectious disease doctors and kidney doctors. We asked him the home safety questions. He was brought home. We met him outside the home and we provided all the good old fashioned acute care that you and I both know is so standard. Your team does an amazing job every day. Our team does an amazing job every day.

And over the course of the next four or five days, he did great, and he was discharged after about five or six days with us. And I love that story for two reasons. One is that a good old fashioned acute care, which is so critical, it’s also just standard. We both do it all the time. Our hospitals do this work all the time, which is amazing. But what was particularly unique is the other things we found in the home. So for instance, he was showing signs of mild cognitive impairment that hadn’t previously been well recognized. He had medication bottles that his primary team thought had been stopped months ago, but he was actually still taking some of them.

He was having trouble affording some of his medications. And so suddenly we’ve got the cognitive impairment, the medication errors, him skipping some of his transplant medications, and we can bring a medical and social SWAT team into the home. And we are involving social work and his daughter in our care team and doing multidisciplinary huddles and de-prescribing and getting rid of old medications and doing all of these things to reduce his risk. And in subsequent several years, he’s not had a single readmission.

And so I think that’s the real positive, a real, real power, I would say, of the home. It’s good old fashioned acute care, which both of our teams do all the time, with the power of the home all together. And I think to your point earlier around quality and safety, and would love to hear how you folks are thinking about this too, we’ve said to ourselves, you know, we have a reasonable and thoughtful quality and safety infrastructure in place at our medical center, and we want to continue and simply build on top of that.

So when we look at all of our usual metrics, we track those in our hospital home specific dashboard with a couple of nuances in the Press Ganey, these scores around HCAHPS to make sure we’re identifying the experience in the home and not maybe the experience in the emergency department before they got to the home. They’re both very important, But we also want to separate them so we can understand the opportunity. And so what we’ve seen is, 60 to 70% reductions in mortality, five to 15% reductions in 30 day readmissions.

We’ve seen essentially no harm, great events like DVTs, CLABSIs, CAUTIs, falls with injury. We’ve never had one of our paramedics or nurses in the home ever injured by a patient or caregiver in part because patients don’t get delirious and agitated in home. They’re just so much happier to be home. Our patient satisfaction in terms of top box recommend and overall rating of care, they’re in the 89 to 92% range over the last several years, which for us in our health system is probably the highest patient satisfaction unit in the entire health system. And so it’s been super rewarding for the whole team. And we’d love to hear too how you folks are thinking about quality and safety and patient satisfaction in your program.

Susan Jarvis:

Well, first, I just want to say that patient story is amazing. I mean, that just really encompasses what we can do with this program for our patients in their home. We have the staff that are the people that are used to looking for those things and intervening in our community, paramedics, and that’s part of their training, right? And to be able to wrap that all together and really provide that wonderful care for that patient. Just amazing story.

So thanks for sharing that. We’re, as again, as I said earlier, we are really, really new in this. Our, you know, we’re, quality, our quality measures are looking great for the patients that we’ve had in the program. The biggest thing is the patients are so satisfied and so happy and it’s been a great experience for them. And so we’re still in the process of building out how we make sure.

I love your point about separate out from the emergency department visit and the Hospital at Home stay. I think we have not done that and I think that’s very important to do. Across the board, patients have been extremely happy, extremely satisfied. And we even have one patient who actually called back up and said, hey, I want to do a story, a promotional video. I want to tell the world about what the great experience was that I had in your Hospital at Home program.

And so we’re in the process of doing that. We’re going to use that to promote the program as well as get some local media involved in that type of thing. So I think both of us and not just us, but people that are doing Hospital at Home across the country really believe in the program and really feel like it is kind of, I don’t know, the next step or the next big thing in how we take care of patients. And it’s going to be with us for a long, long time if we’re able to get our CMS waivers extended. Both of our programs rely on the CMS waiver.

We are having this conversation late in third week of September of 2025 and our waiver is set to expire in about a week on September 30th. So what message do you want to share with our policymakers about the program? I think you’ve done a great job of sharing how great the program is. What else would you like to share?

Dr. Constantinos (Taki) Michaelidis:

Yes, Susan, thank you so much for that question. It is so critically important to where we are today in a home hospital in the United States. That CMS acute care at home waiver that was passed in 2020, and we’ve now seen three extensions across multiple administrations, blue and red, that will expire, to your point, in about a week or so, on September 30th.

And so I would just ask our folks in Congress, the House and the Senate side to please, please pass at least a five-year extension of the acute hospital care at home waiver, as well as the telehealth waiver. They are so critically important to everything that we do. And what we’ve shared with our local representatives is that there’s so much bipartisan support, red states, blue states, we all face the same issues around capacity and meeting our community needs.

And most importantly, from a cost perspective, the Congressional Budget Office, when they looked at prior versions of this bill, they scored the bill as budget neutral. So Susan and myself, we’re not coming to Congress saying, please give us $500 billion or trillion dollars. Instead, we’re coming to Congress and saying, hey, this doesn’t cost you anything extra.

And by the way, it’s the lowest mortality, safest, highest patient satisfaction care model that exists in the hospital environment today. And so let’s get this done and work together. That would be what I would say. Susan, would love to hear your perspective.

Susan Jarvis:

Exactly. I think we’ve got, we need a little bit more stability in the waiver. We need the five years. We, as we’re starting, we’re working with our payers to say, Hey, will you cover this? We’ve had payers say, you know, we want to wait and see what happens with the waiver. If this program is, you know, if the waiver is not going to happen, then we don’t want to invest the time in figuring out how we’re going to pay for, you know, get the patients paid for. And so the stability there is very, very important.

You know, we had a little bit of pause when we launched the program, we’d gotten the waiver and then we launched the program and I think the first waiver, we launched in December and the first deadline for the waiver was the end of March. So we took a leap of faith and we said we’re going to do it.

But then, you know, it is just the uncertainty is kind of hard. And so if we could get that for at least five years extended, I think we can just really run with it and just make the program even better and continue doing what we’re doing for patients and grow the program and really expand. So I agree 100%.

Dr. Constantinos (Taki) Michaelidis:

For sure.

Susan Jarvis:

Well, thank you so much for sharing your insights. We serve different populations. We’re, again, a lot more rural. But the common thread, I think, is really, really clear that this program relieves pressure on hospitals while giving patients care where they want it most and where they’re most comfortable. And that is in their homes. Sustaining this model is going to continue, we’re going to need continued policy support and collaboration. And I’m really, really hopeful that we can shape a future where it becomes a permanent part of care delivery. So final words from you.

Dr. Constantinos (Taki) Michaelidis:

Yes, Susan, just so grateful for this conversation. I love the word you use, regulatory stability, collaboration across this important enterprise of home hospital across the country, and continuing to push this model forward for our most complex patients. Kudos to you and your team. It was such a privilege.

Susan Jarvis:

Thank you so much. Great conversation.

Alan Helgeson (announcer):

Hear more episodes in this series or other Sanford Health series on Apple, Spotify, and news.sanfordhealth.org.

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Tips for finding senior care, from a senior care nurse

Alena Goergen:

What people maybe don’t realize is they push and push, but most of the time your loved ones, they don’t want you to burn out the candle at both ends. They don’t want to become a burden. You know, that’s a term we hear a lot is we didn’t want to be a burden so we said it was time to come here, and so I think you don’t ever want them to feel like they were a burden, but you want to make sure they’re getting the best care and they’re as safe as possible. And someday, for most people, that means requiring some skilled care.

Courtney Collen (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about navigating aging services and how to shop for senior care with tips from the inside. Our guest is Alena Goergen, director of nursing at Good Samaritan Society – Miller Pointe in Mandan, North Dakota. Our host is Matt Holsen with Sanford Health News.

Matt Holsen (host):

Thanks for being with us here today, Alena. We appreciate it.

Alena Goergen (guest):

Of course. Thank you for having me.

Matt Holsen:

Yeah, you bet. First off, tell us a little bit about your grandparents and when did you know it was time for a change?

Alena Goergen:

Yeah, for us, I think every family’s probably a little bit different. But for us, you notice changes in them. Things that they leave out on the counter because they don’t want to forget. Maybe a day missed in their MediPlanner here, or maybe some changes with their activities of daily living.

You just notice those subtle changes, maybe falls. You know, for my grandparents, my grandpa was falling, and my grandma wasn’t taking her medicine routinely, so (laugh), we felt like it was time they got a little bit more assistance.

Matt Holsen:

Yeah. What’s the difference – for people who don’t know – between assisted living and nursing home care? How do you know what level of care you need?

Alena Goergen:

You know, that can be difficult. Both assisted living and nursing home staff can absolutely guide you through that layer of questions.

Assisted living typically has some requirements. Your loved one needs to be able to ambulate independently, so walk with a walker or a cane and do that alone. They typically have to be able to use the restroom themselves.

And skilled nursing is a little bit different. We provide a little bit more of that comprehensive care. So, if they need help ambulating from their bed to their chair or getting from their bedroom to the dining room, need help using the restroom, need help bathing, those are the things in skilled care that we can provide for them.

Matt Holsen:

When it came to your family and your grandparents, was home care an option?

Alena Goergen:

We did some services with home care, and then I think, you know, my grandma’s got some dementia, and her disease progressed to the point where the pop-ins from home care wasn’t enough. She needed more 24-hour supervision, and that supervision we needed to have provided by a skilled nursing facility.

Matt Holsen:

A lot of the talk, usually when you’re making these decisions, is the financial component. How did you navigate that from long-term care insurance to Medicare managed care and maybe Medicaid?

Alena Goergen:

Absolutely can be very complicated. I would encourage people to go and visit with social services at their prospective facilities. They’re very, very knowledgeable, very useful.

For my family, it was a little bit easier. My grandparents were North Dakota Medicaid prior to going to the nursing home, so that was a very smooth transition. There is a little paperwork involved, but like I said, social services was instrumental in assisting us with getting that stuff completed and making sure we had all the i’s dotted and the t’s crossed.

So, as far as nursing home insurance, and Medicare, that’s very complicating. But the nursing home, between the business office and social services, can answer a lot of questions about who pays for what and when they pay and what kind of liability a family would have. So, I would encourage anybody to go visit with them and get those questions answered.

Matt Holsen:

Yeah, how did you feel when you were navigating this? A professional who works in long-term care, and you’re saying it’s complicated?

Alena Goergen:

Probably, that was my biggest hiccup was that I, as the director of nursing, I focus on the clinical care of the residents. I don’t focus on how they’re going to pay to live here. So, it was definitely my biggest learning curve in making sure that they could come and that they could stay and that we were going to get the bills paid and get them what they needed.

So, yeah, I absolutely had to lean on social services quite a bit to help me through that. But we got there.

Matt Holsen:

You have some great teammates, I bet. Before moving to Miller Pointe, had your grandparents received other senior services?

Alena Goergen:

They had, yes. And the community’s got some great home and community based services, they’re called. So, we did have laundry service coming in, we had an aide coming in that would help with bathing. I primarily did the medication pack refills, but we did have them come in and do some cleaning, some cooking.

So, some of those services are available, and they definitely helped my grandparents be able to stay in their home longer. And that’s usually the goal is to stay at home as long as they can until that becomes not a reality.

Matt Holsen:

How long have you been a nurse, and how long have you been working at Miller Pointe?

Alena Goergen:

Yikes. I have been a nurse 19 years. I’ve been at Miller Pointe 15, actually.

Matt Holsen:

Did you look at anything through a different lens when you were thinking about the center being your grandparents’ home?

Alena Goergen:

Yes and no. I mean, there’s always going to be, you know, that transition from home to a facility comes with a little bit of guilt, I guess I would say. You know, everybody feels a little bit of that when you need the help and you can no longer do the care yourself.

But for us, I think, I run a facility so that I want to bring my grandparents there, and so it was an easy decision to make. I want them to be here. I know that it will come with some challenges, but I know what kind of care they’re going to get, I know what to expect from the staff, and I wouldn’t want them to be anywhere else.

Matt Holsen:

When you mentioned feeling guilt, what do you mean by that?

Alena Goergen:

I think a little bit of caregiver — just the burnout, and you can’t push to the point where you’re now suffering or doing without. And I think you try so hard to meet all of their needs at home so that you can meet their wishes of staying home and staying together, and that becomes too burdensome.

And I think what people maybe don’t realize is they push and push, but most of the time your loved ones, they don’t want you to burn out the candle at both ends. They don’t want to become a burden. You know, that’s a term we hear a lot is, we didn’t want to be a burden, so we said it was time to come here. And so, I think, you don’t ever want them to feel like they were a burden, but you want to make sure they’re getting the best care and they’re as safe as possible. And someday for most people, that means requiring some skilled care.

Matt Holsen:

Let’s talk about the surprises. What has surprised you the most through this experience?

Alena Goergen:

How little I knew about the financial part (laugh), for sure (laugh). And I think how important the family involvement is in making sure that the facility can develop a care plan that is really all-inclusive and kind of adopts all of your loved one’s nuances and their niches.

They meet with the dietitian, and I saw her go into the room and visit with them, and she came out, and a couple breakfasts later, my grandpa was like, “Boy, I sure hate wasting all this milk.” And I said, “Well, just tell them you don’t like milk; you’ve never drank milk before.” And he said, “Well I didn’t tell him that because I didn’t want to seem picky.” So those details, that family involvement, and giving us all that information, you know them better than everybody else.

So, it was surprising to me how much I needed to convey to the staff to make sure that they knew these are their preferences, these are their likes and dislikes. These are kind of their routines and their tendencies, and this is their religious preference and those types of things to make sure that transition is as smooth as possible.

Matt Holsen:

And as a staff member, you welcome that input, I would assume, right?

Alena Goergen:

Absolutely, absolutely.

Matt Holsen:

As a director of nursing and now a family member of Miller Pointe, what questions should a family member ask when looking for a nursing home for their loved one?

Alena Goergen:

I think that’s going to depend on your loved one. You know, for my grandparents, they’re not group activity kind of people. So, I didn’t need to know a lot about the activity calendar, but I did need to know about what offerings we had for religious services, because they are religious. And so, I needed to know that information.

We have some families who come, and their loved ones are card players and they’re craft-doers. They want to make sure that we’re going to offer those services.

So, focus your questions around the things that are going to meet the needs of your loved ones that you’re bringing in. You know, if you have questions about laundry, if Mom was real particular about how laundry got done, let’s ask those questions so we can hammer that out in the beginning.

And food, lots of food preferences. So, let’s talk about those, and focus your questions on the things that are most important to your loved ones so that we can make sure that we’re going to meet their needs from day one.

Matt Holsen:

A little more tailored experience.

Alena Goergen:

Yes.

Matt Holsen:

Who would you suggest folks reach out to ask those questions or to meet before they make these decisions?

Alena Goergen:

I think there’s a handful of people. I do a lot of tours as the director of nursing. I meet with a lot of families and answer those questions. Social services, they have a lot of the answers that people are looking for, so we tailor a lot of those tours to them when they’re available. But really anybody in the clinical staff or in social work can help you answer whatever questions you may have about that transition.

Matt Holsen:

How are your grandparents doing today? How did they adjust to the move?

Alena Goergen:

Great, actually. They’re doing very well. They live in a double room, which that was their goal is to just live together forever. Doing really well. Happy to be together, happy to have the care that they kind of knew they needed, and happy to know that their loved ones can just come and visit and be their family member and not their caregiver. They love that.

Matt Holsen:

Yeah, that’s the ideal situation. What should a family member expect in terms of communication and updates on their loved ones?

Alena Goergen:

Lots of communication, actually. The nursing home facility should be updating you anytime there’s a clinical change with your loved one, anytime there’s a medical change, anytime there’s a treatment change, anytime we have a question on how you want something to be handled. Communication with the nursing staff and the social services staff is really a very ongoing open line of communication.

We also have a lot of families who call just to check in and we welcome it. You call and just say, “Hey, I was thinking about Mom. How was her day today?” We’re happy to tell you. We know that she’s your mom. You know, we get it (laugh); our loved ones live there too (laugh).

Matt Holsen:

Absolutely. And how would you frame that for those family members? Because that interaction improves their quality of life, their well-being, right?

Alena Goergen:

It does.

Matt Holsen:

Like, don’t feel like you’re bothering the staff.

Alena Goergen:

Absolutely not. No. We love to know that they have people out there that care about them. We love to know that you’re engaged and that you want to be involved in their overall care and that you want to provide feedback to us. You know, every opportunity we have to learn something more about the patient is a better situation for them. We learn about them, and they have a better experience.

Matt Holsen:

What does a typical day look like right now for your grandparents?

Alena Goergen:

Well, really, they’re retired. They remind me a lot. So, (laugh), they can do whatever they want, but breakfast, they do. My grandpa’s a minister, so they do Bible studies together. They will attend the music activities that occur after lunch, and then in the evening, most of the time, they have a family visitor, so they’ll do that.

Matt Holsen:

They’re living the life.

Alena Goergen:

You know what, they’re having a great retirement. (Laugh)

Matt Holsen:

That’s great to hear. What role do family members have in the care of their loved ones?

Alena Goergen:

Yeah, it’s instrumental, and I’m learning that more from this role than I ever had in all my years in long-term care is how much my involvement helps the nursing staff provide the best possible care. My grandparents, they currently love the staff that are taking care of them, and it’s because they know things.

You know, at Christmas time we do gifts; the staff buy gifts for all the residents. And my grandpa got malt mix, and he said, “How did they know I like malts?” “Well, I told them you like malts (laugh).” He still talks about getting this malt mix from the staff at Christmas time, and he was so excited. But it was information that they sought out from his family member to provide a more tailored experience for him. You know, for him to feel like they knew him and they care about his well-being on top of just his happiness is huge for them. It’s a trust factor that builds over time, and it’s really invaluable.

Matt Holsen:

I was about to say, those little things do mean a lot and build a lot of trust, that’s for sure. We’re talking about tips from the inside. What are some pro tips for family members who want to support their loved one after they move into a nursing home?

Alena Goergen:

You know, I think there’s lots you can do, and I think it’s a tailored thing towards your specific family member.

Like I said earlier, my grandma’s got dementia, and so we put together a lot of photo books of the olden days, and her siblings, and her cousins, and her home. And being able to bring those and go through them with her, it’s a great experience for her.

My grandfather likes to play on his computer and watch train videos, and he was in the Air Force, so he watches a lot of videos, you know, things about the military. And so, we made sure that he got his computer set up.

And so those little things that, you know, you bring those things to help have a pleasant experience when you visit, and you bring the things in that help them have a pleasant day when you’re not there to visit. I think just overall it’s a warm, home-like environment that they can enjoy, and they can feel like they’re safe and well cared for and not a burden to anyone really.

Matt Holsen:

Is there anything else that we haven’t covered yet that you’d like our audience to know when it comes to tips from the inside?

Alena Goergen:

I think I would say come and visit. I think there’s a lot of misnomers out there about skilled care, and I think getting a feel for the place, taking a tour with one of the employees, looking at the other residents as you walk around and seeing how comfortable they are and them enjoying each other, making friends with other residents, and enjoying activities. I think it really helps people get a better feeling and a little bit better layer of confidence when you’re looking for placement for your loved one.

That is a scary experience. We know that. I know that firsthand, and so I understand, but I think, getting to know these facilities and just giving them a chance, we are never going to turn down an opportunity to take you on a tour and answer your questions. So, to be able to do that and kind of get a feeling as you walk around that this place is actually really warm, and these people look well-groomed, and happy, and well cared for, I think it would really ease a lot of that.

Courtney Collen:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcast. And on news.sanfordhealth.org.

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Functional fitness: What is it & why is it needed as we age?

Charlotte Stier (guest):

Functional fitness is important for everyone, and it really is important, especially as you age, because you might not have the capabilities that you did when you were younger.

Courtney Collen (announcer):

This is the Health and Wellness Podcast brought to you by Sanford Health. The conversation today is all about functional fitness—what it is and why it’s beneficial as we age. Our guest is Charlotte Stier, a physical therapist with Good Samaritan Society – Sioux Falls Village. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Thank you for joining us today. We’re gonna be talking about a topic, functional fitness, but before we get there, Charlotte is here because Charlotte works at Good Samaritan Society – Sioux Falls Village. In your role as a physical therapist, what are some of the common things that you see and that you might do during a normal day?

Charlotte Stier (guest):

Well, a really common one is balance. That’s a big common theme, especially in the older adult population that I work with. What I do specifically is, I am in charge of the outpatient realm that we have. So I go to more of the independent living, the assisted living facilities. I go to them, to their home, and I do their rehab there, or I ask them to come to the gym where we’re at.

Alan Helgeson (host):

Why is it that as people get older there are more issues with balance? What happens to us physically that changes?

Charlotte Stier (guest):

Balance incorporates not just how you’re moving, not just your feet, it incorporates your vestibular system and it incorporates your eyesight as well. So it could be a combination of factors for, say, someone that has neuropathy for whatever reason, maybe it’s from diabetes or Parkinson’s, that impacts their footwork and how that works. So it could be from that reason, it could be poor eyesight—you know our eyes age as we get older—your vestibular system inside ages as well, and so it just starts to decline and if we don’t work on it, we lose it.

Alan Helgeson (host):

That explains things very well. I was curious about that and I appreciate how you answered that. Thank you. Well, we’re here today to talk about something and I’ve been in health care marketing for a good number of years, and the last several years you hear more and more about this topic. And I’m excited to learn about functional fitness. What is it?

Charlotte Stier (guest):

Yeah. Functional fitness. I love this topic. Functional fitness, in my own words, is any movements or activities that directly translate into your everyday lifestyle, whether it be putting dishes away into the cabinet or it could be a sport even. It’s how you walk, how you move, just whatever is important to you that you do throughout your day-to-day life.

Alan Helgeson (host):

So when it comes to functional fitness, is this an example? I know I look like I might be a certain age, but really I’m about 22.

Charlotte Stier (guest):

Sure. Yeah. (Laugh)

Alan Helgeson (host):

But I hear that I have arthritis in my thumb, and it hurts like heck when I try and open a pickle jar. Is showing me how to do some of my things with my fingers and my thumb and stuff like that, an example of functional fitness?

Charlotte Stier (guest):

Yes, definitely. You would relate it directly to that. So I would make goal of opening a jar without pain, and that’s how we would train and that’s how we would focus on that.

Alan Helgeson (host):

And it’s different for everybody, right?

Charlotte Stier (guest):

Exactly.

Alan Helgeson (host):

OK. And you go out and meet people where they are in a variety of settings?

Charlotte Stier (guest):

Yep.

Alan Helgeson (host):

OK. So it’s good to hear about that, and that it’s a service that’s offered for folks, and we don’t have to settle as people age and just go, “I can’t do that anymore.”

Charlotte Stier (guest):

Exactly.

Alan Helgeson (host):

How does functional fitness differ from a regular gym workout?

Charlotte Stier (guest):

That’s a great question. Functional fitness focuses more so on incorporating the whole body movements a lot of times. Not always, but a traditional gym workout you would see someone train your biceps, you’ll go train specifically your quads or whatever it might be, whatever muscle group you wanna work on at that time. Functional fitness, you’re looking at what movements do we need to incorporate to make squatting down to use the restroom per se. That’s always a very common example, especially in our older adult population. So we’re gonna train some squats that directly relate to exactly what you want to do. We’re gonna work on the form, we’re gonna work on the strength, the speed, coordination of that movement, and that directly relates to their goal.

Alan Helgeson (host):

It sounds like with functional fitness, it doesn’t take the place of a traditional workout, right?

Charlotte Stier (guest):

Right. You can incorporate—sometimes it depends on the person and how they present in that specific scenario—and say, OK, this muscle is weak, so we need to work on that. But we’re also gonna incorporate that into a whole body movement.

Alan Helgeson (host):

Now, why is it particularly beneficial for seniors?

Charlotte Stier (guest):

Well, seniors typically don’t care about how much weight they can lift, right? They’re not caring about getting a 500 pound deadlift anymore, like some of us younger folk might be. They care about, can they lift their grandchildren up into the air? Can they put dishes away into their high cabinet that they have a hard time reaching? Things like that. And so functional fitness–we’ll go back to the example of lifting their grandkids up into the air—one thing that directly relates to that in the gym is actually a thruster, and that can be functional fitness. OK, you need to squat down, pick up your grandchild, and then lift them with your arms up into the air. So we train that specific movement, and that directly relates to their goal.

Alan Helgeson (host):

If I were to go to a gym and I’m talking to my personal trainer and I said, as part of my routine, I need something that acts almost as a functional fitness for this. Are they likely to understand what that means as well? Or is that something different?

Charlotte Stier (guest):

I would say so, yes. I think that’s very common now, especially in today’s world. In the workout realm, we really look at functional fitness more so. I used to be a CrossFit coach and I love CrossFit realm personally, and a big part of it is functional fitness, is why you’re working out. Is it to play with your kids? So that you can play with your kids all throughout your life, or your grandkids or whatever it might be.

Alan Helgeson (host):

So truly anything you’re doing in the gym really is functional fitness.

Charlotte Stier (guest):

Right.

Alan Helgeson (host):

That’s a good way to explain that. Let’s get to the “sciencey” part of this. What is some of the science behind this and why does that really matter?

Charlotte Stier (guest):

Yeah, that’s a great question. So specificity really matters in functional fitness because it directly translates into your goal. That’s actually one of the 10 principles of neuroplasticity, which we could go down a whole rabbit hole of that realm of getting into stroke rehab and neuro rehab and that realm. But that also translates into any sort of functional fitness, in my opinion. You know, that specific task needs to translate into what their goal is. If their goal is to walk again, it’s hard to just say, “OK, do these seated quad exercises and you’re gonna walk again.” You need to actually practice walking. You need to practice that specific movement and help them in however it works best for that patient at the time to do that.

Alan Helgeson (host):

Very important that we understand that, because that is what you need to know in order to go through this. Let’s move on here to the actual movements themselves, because I know people wanna know, what are some of the things I can do? So talk about examples of functional fitness movements and the types of equipment we would use.

Charlotte Stier (guest):

Definitely depends on the person’s goal, what you’re gonna do. But I’ll use the walking example again. Say a person had a stroke. Their left arm and left leg are both affected. So in order to help rehab that, you’re gonna strengthen both of those muscle groups on both of those sides, but you also want to directly practice walking. So we have ways where we can help them into certain positions so that we’re assisting their limb as they’re walking, but then their body is actually doing most of the work. That makes that neural connection to the brain: “Oh, I can do this. I’m remembering how to walk again.” That’s where a big part of that specificity comes in. Other moves: my favorite one is the squat. We have to do that all the time. Right? We’re sitting, we’re standing, all throughout our day. The squat directly relates to that.

Alan Helgeson (host):

Are there certain types of equipment that, with those two things you talked about, or with the walking, let’s talk about the walking. Is there some equipment that you might use specific towards that?

Charlotte Stier (guest):

One commonly is the parallel bars that we use a lot. That’s just the most helpful. They can use their hands on both sides. Then there’s also a barrier there so that if they lose their balance, they’re not gonna fall one way or the other.

Alan Helgeson (host):

Let’s go to seniors and that age group. I know it’s hard to talk about in a general sense, but if you’re talking to the senior population, are there movements that benefit seniors the most?

Charlotte Stier (guest):

Well, if you’re gonna make me choose one, I would say the squat. (Laugh)

Alan Helgeson (host):

OK.

Charlotte Stier (guest):

It always depends on the person’s goal, but the squat, and I would say overhead lifting, are kind of that thruster motion of where you’re squatting down and then you’re doing a shoulder to overhead movement. That one is really probably one of the best ones because our shoulders start to really decline as we get older too. There’s just a lot of structures in a small space in our shoulders, and they have a hard time as we age with that. To keep the shoulders healthy, as well as being able to squat down to your floor, to the chair, whatever it might be, and then to pick something up, lift it up into your cabinet, that’s one of my favorites personally.

Alan Helgeson (host):

A few months ago I talked to one of our experts at Sanford Sports and he wasn’t the first one. We hear this all the time anymore. The word modifications. And you’re shaking your head yes. Modifications, I’m guessing, can be based on someone’s capabilities, right?

Charlotte Stier (guest):

A hundred percent, yes. Definitely. You see that a lot of say, someone maybe can’t lift their shoulders overhead for whatever reason. We would modify that to, OK, we’re only gonna go to halfway and we’ll just make that work with—so maybe they do want to put their dishes away, still into their cabinet, but they really struggle with, there’s maybe something wrong internally with their shoulders and they can’t, it can’t be fixed—and so what you do is, OK, let’s take a stool, a step stool, for example. We’re gonna work on your balance, your strength, your agility. We’re gonna directly do some stair stepping to work on that safely, in order to be able to help them achieve that goal.

Alan Helgeson (host):

I think the word modifications might be one of the most important words these days because it lets people know that if you have—like I do—a bad knee, that shouldn’t keep you away from anything. Right?

Charlotte Stier (guest):

Definitely.

Alan Helgeson (host):

You guys can make anything work. And you will. OK. How can physical therapy aid seniors in functional fitness?

Charlotte Stier (guest):

It’s what we do as physical therapists. I can come in and look at a person and go, “OK, I’ll test all of your different muscle groups. We’ll see what’s weak. We’ll test your balance, see what we need to work on there.” But the biggest part is what their goal is, and what they want to get back to doing. And so then we can take that goal and say, “OK, great, now we’re gonna work on, we’re gonna combine those.” So you’re weak in this area, say it’s your squats—easy example—and you wanna be able to squat down to your chair, or be able to get up from your chair. That’s the goal. OK. We’re gonna directly take that, we’re gonna relate that, and then we’re gonna do movements that will achieve that goal. And you get creative. Like you said, it’s fun. Because physical therapy is not black and white. It’s very much gray. It’s a very much gray realm of, you have to be creative because there’s no black and white answer.

Alan Helgeson (host):

Well, my shoulder pain is different than your shoulder pain, than person C. Right?

Charlotte Stier (guest):

Exactly.

Alan Helgeson (host):

That’s where the fun part is, and the expertise is. Because you see what the variance is and come up with the right solution. For someone listening to this today and they hear about the term functional fitness and they go, “Oh, I need that.” Probably the next thing they’re gonna do, they’re gonna go to Google, they’re gonna go to ChatGPT, they’re gonna go to YouTube, start looking up things and looking at videos. So my question is: is functional fitness something I can do on my own, or do I need an expert to teach?

Charlotte Stier (guest):

In my opinion, you need someone to teach you. It’s very hard to see where your specific weaknesses are. Even myself, who, I’ve been in the fitness realm for a long time, and I really love it. I still need someone on the outside, a coach. Someone telling me, “Hey, no, actually this part is weak and you need to work on this,” where maybe I might know that, but I don’t wanna actually work on it (laugh). And so it’s best to have someone to teach that for you and to show you, “Hey, this is how you do this safely and this is how you do this well.”

Alan Helgeson (host):

So you said the term “safely.” Is there a risk if you try to watch Jane or John on YouTube and see a video, is there a risk that you could find greater injury in something?

Charlotte Stier (guest):

Yes. There’s always that risk for sure. If you aren’t taught properly how to move. We like to break movements down into step A, B, C, D before you actually do the full movement. Because if you start—if you try to just do the full movement—you might think that you’re doing it, but unless you have someone watching you or you have a mirror or a video, and saying, “No, actually you need to engage this muscle instead of this one,” you might get injured in that.

Alan Helgeson (host):

Alright, so Charlotte, we’ve listened to this, we’ve heard about functional fitness, and I’m hearing that I need that. That’s gonna help me do what I need to do. What’s next?

Charlotte Stier (guest):

Well, you can start by going online if that works best for you. You can go either through Good Sam or Sanford Health. Either website, the main websites, good-sam.com, and under their services tab there is a rehab therapy tab, and then you can look at all the options on there. I believe there’s a phone number that you can call and look into it. There’s also a resources tab underneath the rehab therapy and there’s some articles in there. There’s one article on fall prevention tips, things that you can do around your house to help with that in that main rehab therapy page. You can look up the number, you can get in contact with a physical therapist or occupational therapist—whatever best fits your needs—and go from there. Sanford Health, the main website, I believe it’s sanfordhealth.org, you go to medical services tab and then click on physical therapy, and this lists out all their rehab specialties within Sanford and you can find a location and a physical therapy that meets your needs.

Alan Helgeson (host):

As we’re coming to a close here, Charlotte, this is some great information. Things that we never knew about a term that we hear a lot about. We thought it was a super high specialized thing, and it really isn’t. What are some of your things that you’d like to leave with us as parting thoughts about functional fitness and what we should know? That big takeaway that you want us to have.

Charlotte Stier (guest):

Yeah. Functional fitness is important for everyone. Anyone can do functional fitness. Anyone. And it really is important, especially as you age, because you might not have the capabilities that you did when you were younger. So you need those goals that will directly translate into your specific moves, your lifestyle, and maybe you don’t have access to a gym or certain equipment, that’s just fine. That’s what we as physical therapists are here for.

Courtney Collen (announcer):

This episode is part of the Health and Wellness series by Sanford Health. For additional podcast series by Sanford Health, find us on Apple, Spotify, and news.sanford health.org.

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Mentor, trainee share lessons from admin training program

Alan Helgeson (announcer):

“Reimagining Rural Health” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country. From improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations.

Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Matt Holsen, with Sanford Health News, talks with Rachel Baldwin, administrator in training at Comforcare, and Clara Stitt, preceptor and administrator at Comforcare. The topic is leadership development, and workforce and work-life balance.

Matt Holsen (host):

Clara and Rachel, thanks for spending time with us here today. We appreciate you joining us for this podcast about training senior care’s next leaders. You both have pretty unique, and I would say, special jobs as administrators. What drew your interests in nursing home administration in the first place? Let’s start with Clara.

Clara Stitt (guest):

I definitely wanted to help people. I had some background as working in a nursing home in high school, and I wanted to help people and still work in health care. Working as an administrator was a way I could use the skills that I naturally possessed and still be able to help people.

Matt Holsen:

Rachel.

Rachel Baldwin (guest):

For me personally, I’ve spent nearly my entire career in health care, starting as a caregiver when I was younger, then into HR, and then serving as an executive director in assisted living for several years. But my deepest connection to the administrator position came through a personal experience when my son suffered a traumatic brain injury from a life-changing accident at 16 years old.

He spent months in the hospital, from the ICU to the neuro floor, then inpatient rehab, followed by two years of outpatient rehab that just recently ended. Through that journey, I was able to witness firsthand what the power of an interdisciplinary care team can do. That’s what led me into the nursing administrator position.

Matt Holsen:

Thanks for sharing that personal story. So you feel like you have a big calling for this, I would assume?

Rachel Baldwin:

I do. Definitely. Yes.

Matt Holsen:

Clara, tell me a little bit about your background and how you became a preceptor.

Clara Stitt:

I started at a Good Sam when I was 16 years old up in International Falls, Minnesota, my hometown. Then I went to college, and I kind of naturally just fell into the Administrator in Training program at Good Sam. I applied. That was back in 2020, so about five years ago, and I became a preceptor. They were asking for who would be a preceptor, and I volunteered. I had a really good experience with my administrator in training, and I think our facility was a good size, and we had kind of a handle on things. So we were excited to bring somebody in.

Matt Holsen:

For people who don’t know, what is a preceptor?

Clara Stitt:

Every administrator in training has to be with a preceptor. I’m basically like the mentor for the administrator in training, showing them my daily routine, and leading them down their path to be an administrator.

Matt Holsen:

Tell me a little bit about your guys’ relationship.

Clara Stitt:

Rachel is just about finished with her administrator in training program. Rachel was with me for over six months, and now she’s moved on to help out some other buildings, see some different buildings. I can let Rachel speak for herself.

Matt Holsen:

Yeah, walk us through the administrator in training program.

Rachel Baldwin:

It’s a structured program where you get to spend, like Clara said, six months, depending on where you’re starting from. You get to spend time with every leadership position in the facility. So you get to see firsthand a little bit of everybody’s job, and then how it all comes together. Working under a seasoned administrator is very helpful and lets you be able to experience it without having such extreme pressure right off the bat.

Matt Holsen:

It’s a big role. A lot of responsibilities. I’m glad they offer that kind of support.

Rachel Baldwin:

Absolutely.

Matt Holsen:

How do you prepare to become a preceptor?

Clara Stitt:

At National Campus, they did a preceptor training program. So it was a robust program where they brought us to National Campus, all the preceptors, for several days. We learned about different strength trainings, and how to lead people, and we actually got to see each other’s strengths. So we got to prepare for our individual administrator in training before we even met them. We know we’re not educators by background, so this was the foundation on how to be an educator and a mentor.

Matt Holsen:

Rachel, what’s been the most impactful part of the program for you?

Rachel Baldwin:

I would say the workshops were very impactful. Listened to panels of experienced administrators and people in other roles, and them just being very raw and real with you.

Matt Holsen:

It gives you a lot of insights that, if you didn’t have this program, you’d be probably sitting somewhere wondering about a lot of different context and a lot of different things that now you hopefully know, and you can hit the ground running maybe.

Rachel Baldwin:

Right.

Matt Holsen:

Clara, tell me a little bit about how this works. So, what’s a day in the life look like when you’re at your location in Austin, Minnesota?

Clara Stitt:

A lot of it is informal training. With Rachel, a lot of the times what we did together was just basically we would go in meetings together. She was my second set of hands. She was right there with me, every single phone call, every family member that came in.

She was just there with me watching how Good Sam works and who I reach out to for different things. Just kind of learning how I navigate my day. That’s just part of her training. There’s also a formal program where she rotated with different departments as well.

Matt Holsen:

Rachel, what was the most important for you as you considered a career to pursue? When it comes to health care administration, everybody probably comes to it in unique ways. What drew you to it, and what was most important about it?

Rachel Baldwin:

Well, for me, when I was younger starting out as a caregiver, I think being able to help people and make an impact. Especially people when they’re at their most vulnerable state in life, and family members too. Just them knowing that they have somebody that they can rely on, that’s going to be there, and they trust that person, helps transition a little bit easier and gives them more peace of mind.

Matt Holsen:

It sounds a lot like Good Samaritan supports new leaders through the AIT program. What does that support look like in the next five years of an administrator’s career?

Clara Stitt:

This question is perfect because I’m at year five—

Matt Holsen:

(laugh) Good.

Clara Stitt:

—since my AIT. It really looks like getting knowledge of the supports that are out there. I still talk to my preceptor, Laura Salonek, on a semi-regular basis. There’s people who I met and people who were in my AIT cohorts that I still talk to. It’s a lot of support, and people know you. You’re introduced as an AIT, you’re introduced to the other team members at workshops. People who work at National Campus and who are your supports, it’s nice that you get to meet them in person so then there’s a face behind the email that you’ll be sending later.

Matt Holsen:

Great connections made, I’m sure. The AIT program has an experience that I’m super interested in called “Day in the Life of a Resident.” Rachel, can you tell me a little bit about that?

Rachel Baldwin:

As that part of the program, everybody gets to be a resident at the facility that they are the administrator in training at. Basically, they get a diagnosis and get to act out that diagnosis. For me personally, I was in a wheelchair; I had a heart attack, I believe. So I had right-sided weakness, and my right arm was in a sling.

I spent the night. That was an experience. You really get to feel that vulnerableness that the residents feel when they come in, and put yourself in their shoes. You really have to act out that position. You’re pushing the call light when you need help, and you’re eating the diets. I had the minced and moist diet, so it helps you get a better understanding for sure.

Matt Holsen:

I would assume that’s something you went through too. Why is it important to do something like that?

Clara Stitt:

It’s important, I think, at the beginning of the administrator in training program because it puts you in the shoes of the residents. You’re in a room that, there’s nothing special about you. You’re just a regular person, just like all of our residents. So it brings you into their shoes and gives you an example of what their days are like, and it gives you compassion for what they’re going through and how vulnerable they must feel on their first days in a nursing home. Because it’s a huge shift.

Matt Holsen:

Huge shift. So you’ve spent time together with your AIT. How do you know your administrator in training is ready for the next step?

Clara Stitt:

Something I’ve heard a lot of administrators, preceptors, do in the past is they go on vacation and they let their administrator in training act out their role and be the point person for all of the staff. Then I get feedback from the staff on how Rachel did. Then she can come forward with things where she maybe struggled. Of course, I’m just a phone call away, but it gives her the opportunity to act autonomously.

Matt Holsen:

Rachel, what would you tell other health care organizations that are seeking out strong leaders?

Rachel Baldwin:

I think strong leaders are not simply found; they’re intentionally developed a lot of times. Hearing Nate (Schema, president & CEO of Good Samaritan Society) talk about ‘bloom where you’re planted,’ and investing in the people. That, to me, was spot on. I think showing people that you’re willing to put that investment into them means a lot. Most people, if they’re good people, they want to give back for that. They know that you put that trust and confidence in them, and they don’t want to fail.

Matt Holsen:

Clara, if someone’s thinking about applying to be an administrator in training, what should they think about?

Clara Stitt:

I think they should think about where they want to live. I think they should look into the qualifications that are necessary in your state. Different states have different qualifications. Then just look at the Good Sam website, see if there’s a job opening for an administrator in training, and go for it.

Matt Holsen:

Why are you personally proud to work in long-term care?

Clara Stitt:

I’m personally proud to work in long-term care because we get to meet all of these different residents with their amazing stories, and we get to help people. That’s the simplicity of it. We get to help people.

Matt Holsen:

Rachel, I’d ask you the same question: why are you proud to be in long-term care?

Rachel Baldwin:

Same reason. Just being able to make an impact or guide people to make an impact for people when they’re in a vulnerable state in their life, and it’s not an easy change for them.

Matt Holsen:

Knowing that you both have gone through the AIT program, last question: what’s the best piece of advice you’ve ever received?

Clara Stitt:

One thing I’ve received as advice, and I really live by: if you ask, it might be a yes, but if you don’t ask, it’s always a no. So, go ahead and ask your crazy questions; ask for the moon. The worst thing that happens is they could say no, but they might say yes. Some incredible things happen just from stepping out on a ledge and getting some confidence.

Matt Holsen:

I love it. That’s great advice. Best piece of advice you’ve ever received?

Rachel Baldwin:

I think somebody once told me—actually a previous supervisor: lead with your heart, but manage with strength. Being a leader, that says it all right there. We want to care for our staff, but we want to be respected. We want them to do the right thing, and if not, we have to have the strength to do what needs to be done in situations where they’re not great situations, unfortunately.

Matt Holsen:

Is there anything else people should know about the AIT program?

Clara Stitt:

The AIT program was the best thing I’ve ever done. My whole career I’ve gotten so many opportunities just because I did this, and I would never have done it any other way.

Matt Holsen:

That is fantastic to hear. And I want to say thank you for joining us for this podcast. We appreciate it.

Clara:

Thank you.

Rachel:

Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series, or other Sanford Health series, wherever you get your podcasts and at news.sanfordhealth.org.

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How to have the ‘girl talk’ with your teen

Dr. Amy Kelley:

If you are willing to talk about those things and not judge their questions and you know, not get upset that they’re talking about those things, you are going to be their safe person and that’s what you want to be.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. I’m so glad you’re here.

In this episode, we are having the girl talk. This conversation is all about puberty. We’re diving into what it is, but also how to approach, navigate and get through what can sometimes feel like an awkward or uncomfortable conversation with the daughter or preteen in your life.

I am so excited to bring in Dr. Amy Kelley, an OB/GYN at Sanford Health, who specializes in pediatric and adolescent gynecology. Dr. Kelley, good to see you.

We know this is a time of understanding yourself, your body growing and transitioning into the next phase of your life, but the conversation with a parent or caregiver can be awkward. So I want to start with this. What is physically or physiologically happening in our bodies during puberty, and what are some of the earliest signs in girls?

Dr. Amy Kelley (guest):

It’s interesting because I don’t think it’s awkward, but I suppose I do this every day and talk to people about it a lot. And I think that it’s definitely worth looking in the mirror if you’re going to talk to your kids and kind of say words that maybe you might have a hard time saying. Because if you look and feel awkward, then your kids will kind of look and feel awkward too.

And so the more comfortable you can get yourself versed in kind of the language that you need to use, which honestly is just like our body parts, but there are certain body parts and certain things that we’ve been taught are like really private. And it’s OK that they’re private.

But when you have a kiddo, it’s really important that they know the real words for things like their body parts. So I think that if those things like breasts or vagina or any of those things are hard for you to say without blushing, then looking in the mirror and saying them like a million times and making funny faces at yourself so that you really can say that without blushing will help make the conversation go better.

And if you really can’t do that, then I would maybe consider talking to your kids when you’re getting ready for bed and you’re like talking to them about a bedtime story or something because then it’s dark and so it doesn’t matter as much. Or if you’re in the car, then you don’t have to look at them if you feel really awkward. There you go. Those are a couple of like tips I have for parents.

Courtney Collen:

Good pro tips.

Dr. Amy Kelley:

But I think that you know, puberty is a time when basically your child is going from being a child to being an adult. And so their entire body, including their brain, changes a lot. And so it’s about maturing certain organ systems, the reproductive system in particular, but also other things.

Your kids grow taller, they start making pubic hair, they start smelling more like adults. And their brain changes quite a bit and matures. So, it really is kind of an all-encompassing thing. It’s not just about your reproductive organs.

Courtney Collen:

So when would we typically start to see some of these signs in young women?

Dr. Amy Kelley:

Yeah, so really anytime between about 7 and 13 would be pretty normal. African American girls and Hispanic girls often do go through puberty a little earlier. So sometimes they even will exhibit signs at like 6.

But typically I tell people if it’s before 7 they should probably talk to their pediatrician. If they haven’t started any puberty signs by 13, they should also talk to their pediatrician. But there’s a wide range of what’s normal.

Typically girls will, you’ll see breast development first. Although some girls will get underarm hair and pubic hair first. One of those two things is usually what comes first.

Courtney Collen:

How can parents distinguish between normal development during that kind of normal age range and something that might need medical attention that might be a concern?

Dr. Amy Kelley:

Yeah, so honestly, sometimes it’s hard to know. And so I think just being able to talk to your pediatrician about it is really important and making sure you’re going to your well child visits during those years to make sure things are developing normally is really important.

But really because of the wide age range that puberty happens, there’s a huge breadth of what is totally normal. And so it’s really hard to generalize that, but I would say if you’re concerned about it, you should just talk to your pediatrician. But average is between 8 and 13 for starting to get breast development or pubic hair.

Courtney Collen:

Talk through some of the biggest, most common misconceptions about puberty.

Dr. Amy Kelley:

I think that a lot of people are like, my kid is crazy or super emotional. And some kids are so, I mean, that’s not a complete misperception. I think that there are some kids who really do fine and don’t have mood issues going through puberty. And so, I wouldn’t assume it’s going to be this huge tumultuous thing for your kid because sometimes it is not. So I think everybody kind of goes through it a little differently.

I think the kiddos who have the hardest time are the kids who are really early or the kids who are really late. Because middle school is all about “am I normal? Am I lovable?” Those are like the things your brain is trying to figure out in middle school. And so, to have puberty happening at that time too is difficult. It’s a lot. It’s a lot.

Courtney Collen:

I know we’ll get to kind of the emotional and social development that someone might be going through during that time, so we’ll get to that in a little bit. But talk through maybe how do hormonal changes affect puberty?

Dr. Amy Kelley:

When you go through puberty, your ovaries turn on and you start making estrogen. And for some people estrogen is a huge mood changer. You know, like it will make them, it makes them a little bit more emotional.

But the other thing that’s going on is your brain is changing. And so the part of your brain that kind of functions to control emotions gets a lot bigger during puberty. And so, you know, something that was not a big deal, like I stubbed my toe, it hurts a little is not a big deal before puberty. But suddenly when your part of your brain that controls emotions is getting bigger and you throw some estrogen in there, then suddenly, I stubbed my toe, ouch and tears, or this person said something mean to me and tears, when normally maybe it wouldn’t have caused that.

But it’s that filtering of everything through that emotional part of the brain that sometimes makes things very dramatic.

Courtney Collen:

Like exacerbates everything.

Dr. Amy Kelley:

Yeah. It’s like it puts an exclamation point on everything. And the hard thing is that your frontal lobe, which is the part that kind of controls like your actions, is not completely developed. So if you think about you have this emotional like machine in your brain that throws extra emotion into everything, but you don’t have the frontal cortex to control that emotion, that’s really why some teenagers get very, seem very “hormonal.”

It’s not necessarily even about the hormones. It’s also about the changing brain. And I always tell parents that that means that you are their frontal cortex. So, they are not going to think about the consequences. They are just thinking about the emotion of it right in the moment.

And so part of being a parent of teens is helping them slow down that emotional part and think through the logical. Like, that person is mad at me, but that doesn’t mean they’re not my friend. Or I’m really mad at the math teacher, but I still have to do my homework because I still want a good grade. You know what I mean? Like, so that is kind of the hard part of being a parent of teens is that you are their frontal cortex until they have developed it, but you can help them develop it by making them walk through the consequences of what they’re doing.

Courtney Collen:

That makes so much sense. And it’s such good insight. And you are in the thick of it with what, 18-year-old twins? Right now? And a 13-year-old.

Dr. Amy Kelley:

Well, he’s not quite 13. He’ll be 13 in a month.

Courtney Collen:

You are a seasoned pro at parenting, I’m sure, for this stage of life.

Dr. Amy Kelley:

Well, giving advice is different than taking it, you know. We’re very good I think at giving other people advice and sometimes it’s a little harder when it’s you. But yeah, I mean I understand the what’s behind some of those things. Yeah. It doesn’t always make it easier to deal with as a parent, just knowing that though.

Courtney Collen:

And of course we’re talking about, you know, you have boys and we’re speaking about girls and it’s a little bit different. But that kind of, that frontal cortex, that idea is it could be for both.

Dr. Amy Kelley:

The planning part of your brain isn’t fully developed until 25. And so, when we think about older teens and how sometimes they don’t make the best decisions too, that’s really kind of why – that frontal planning cortex isn’t completely developed.

But again, it’s our jobs to help develop that by making our teens and young adults walk through the consequences of their actions so they can make better choices. If they’ve thought about it, then usually they can make pretty good choices.

So I think the other thing I think’s really important with teens is talking about the things that you’re worried about. Like if you’re worried about there are drugs out there, there’s smoking, sex, whatever it is that you’re worried about – as your kids become teenagers, not talking about it doesn’t really help because it’s still out there.

But talking about it and saying, this is what we expect, you know, as a family, these are our values and this is the behavior that we’re expecting of you or the choices that we’re hoping that you will make. And talking about what are you going to do in the moment? Like, you know, what would you say to a friend? How would, if you want to say no, how would you say no? If you needed to call me, how would you call me? Because a lot of times if you’ve thought through a lot of those things beforehand or they’ve thought about it, they’ve made a pathway in their brain. If I need help, I can call my mom about this or I can say no to this friend. Or I can say no to my boyfriend if I don’t want to have sex.

If you’ve never talked about those things, they have no pathway in their brain to make a good decision.

Courtney Collen:

I feel like that’s just such a great approach to parenting this day and age because there’s so much going on. Yeah. And with social media at play, you know, having that conversation just authentically approaching conversations and talking through things and how we feel and what we’re concerned about. I feel like that’s just a great way to connect with your child and build that foundation. I mean, is that true?

Dr. Amy Kelley:

Yeah. And you don’t want it to just be like one talk. Like a lot of people talk about the sex talk, but really if you’re doing a good job with that, it’s not one talk; it’s over time. You may have a talk when they’re 8 or 9 about puberty, yes. And what to expect and maybe what sex is very basically.

And then as you get older you add more to it and you use things like, the neighbor is pregnant, how do people get pregnant? You know, and then talking about, or you watching a TV show and there’s a teen pregnancy on the show. Well that’s a great little in to be like, Hey, do you know how to prevent pregnancy? Yeah. And have we talked enough about that? Do you have questions about that?

Courtney Collen:

And it’s age appropriate.

Dr. Amy Kelley:

Yes. As you go through. But I think that sometimes people have a misperception about what age kids should know this stuff because unfortunately with social media, the average age that somebody runs across porn on the internet is 11 and usually it’s something silly like when will I have breasts? Or, you know, like it’s questions about things they want to know. Yeah.

But we all know if you Google, when am I going to get boobs? What are you going to get on the internet? We all know what you’re going to get. But when you’re 11, you don’t know what you’re going to get. And so I usually talk about 8 is great, 9 is fine, 10 is too late. Now it’s never too late. But usually by 10, kids know more than you think they know and then you have to reteach them some stuff.

So it’s so much easier when they’re 8 or 9 because they’re not embarrassed because they don’t really know that much. And it’s actually easier because you just approach it from a science standpoint and isn’t this cool how babies are made? And they might be like, “ew, gross.” But they might be like, “that’s cool.”

Courtney Collen:

Absolutely.

Dr. Amy Kelley:

And they’re not going to be as embarrassed about it. The longer you wait, the more embarrassed they’re going to be to talk to about it.

Courtney Collen:

And they might think they know and then you’re there to basically clarify what they think they know is right from their friends who have older siblings who may not know the full, you know, the full scope of things. So you have to juggle that too on top of catching them up.

Dr. Amy Kelley:

Yeah. And you want to be their safe person. You want to be the person that they come to with questions, not their like – yes, they’re going to go to their friends with things too. But if you are willing to talk about those things and not judge their questions and you know, not get upset that they’re talking about those things, you are going to be their safe person and that’s what you want to be.

Courtney Collen:

Let’s shift to having the talk now, Dr. Kelley. When is the best time for parents or caregivers to start talking to their daughters about puberty?

Dr. Amy Kelley:

So I would really say like around 7 or 8. And honestly, if you’re an African American and you’re seeing some signs of puberty in your daughter or your daughter is African American, whether you are or not, if you’re seeing some signs around 6 or 7, then you probably need to talk to them at that point.

And really the first signs are going to be pubic hair or underarm hair or some breast development. And because once that happens, you’re kind of on a time clock. So, most of the time after breast development, you’re going to get your period between two and three years after breast development starts. OK.

Now, sometimes for certain reasons it’s a little bit accelerated and it’s a little less than that. Sometimes it’s a little more than that. But the average is about two to two and a half years. And so you kind of know when you start seeing that, you’re like, “oh, I’m on my timeline now. So, we got to talk about that in time for the period.”

So I don’t think you have to tell them everything at once, but I do think like telling them, “Hey, have you noticed this? I’ve noticed that you have some dark hair in your underarms. Did you notice this? What do you think of that?” And kind of just asking them how they’re feeling and going from there. Like, do you know what that means? And talking about how they’re going to start going through what we call puberty, which is how you become a teenager and then an adult.

And girls, because they usually go through puberty first before boys, I think that it’s even a little bit more important to have that conversation on the early side. Schools, you can’t rely on the school to tell your daughter she’s going to get her period. And the reason why is because some schools will do it in fourth grade, some do it in fifth or even sixth grade. And if you’re 11 or 12 in fifth and sixth grade that your kid might already have their period by the time the school has talked to them. Particularly if you’re African American or Hispanic.

And so I think it’s really important if you see any signs to kind of start having that conversation.

Courtney Collen:

You had some great tips about ways to approach like body hair, underarm hair, specifically or growing breasts and then approaching that kind of age appropriately. Are there any other like good tips, age-appropriate tips, ways to explain that first period or body changes?

Maybe when we get a little bit older to 7 or 8, say, or 9, would you still approach it the same way, kind of like, “hey, have you noticed this? How do you feel about that?” Any other tips along those lines for parents or caregivers?

Dr. Amy Kelley:

Yeah, I think that I would just kind of start with the same kind of thing. Sure. And then, you know, talk about when, like if you’re a mom, you can say, “I experienced that too when I was going through puberty and these are kind of the things that are going to come next,” and talking about how breasts may grow enough that maybe we’re going to have to talk about getting a bra for you. And hey, once you have underarm hair, you might smell weird. Like you are going to sweat more and maybe we should think about deodorant and like doing something along those lines.

There’s great books out there to kind of help with that. So if you have kind of a more introverted kid who maybe wants to read about it, there’s lots of different age, good age-appropriate books. The American Girl Doll series is kind of a classic. But there’s, it’s called “There’s Something New About You” and it’s really made for like that 8-ish age range, 8, 9. And then there’s actually follow-up books to the American Girl Doll books. Like there’s two more for older kids, but of course sometimes kids outgrow dolls.

So, another great book series is called “Girlology.” It’s like biology but “girl” instead. And it’s written by an OB/GYN and a pediatrician together. And there’s three in that series and one of them is about puberty for like ages 8 to 11. There’s one that’s kind of a middle school book that’s a lot about like sex and consent. And there’s one that’s for older middle schoolers, early high schoolers that’s a lot about contraception and protecting yourself and making good choices.

So I really like that book series too because it definitely kind of grows up with your kids since there’s three different ones.

Courtney Collen:

Great resources. Thank you for that.

We kind of touched on this at the beginning of the conversation, Dr. Kelley, but what advice would you have for parents or caregivers who feel uncomfortable or unsure about how to start the conversation? And you kind of gave some great options, like if you feel this way or that way, maybe in the car, it’s casual or maybe before bed it’s dark, you know, less eye contact.

Dr. Amy Kelley:

Those are two ways to kind of, if you feel uncomfortable to kind of allow you to not look at your child or if it’s in the dark. Like you may, they may not see if you’re a little bit uncomfortable.

But I think just starting with the basics and let them lead the conversation a little bit. You know, a conversation at 8 about puberty and sex is very different than a conversation at 14 or 15. And when I talked to my kids about this, like we were laying down in bed and one of them had asked me a question about the neighbor being pregnant. And I’m like, OK, this is it. This is it. I’m going to do it.

Courtney Collen:

Your day has come.

Dr. Amy Kelley:

My day has come and they were like 8-ish, 8 and a half. And I was like, “Hey, you asked me how people get pregnant because you know, our neighbor’s pregnant or I think it was maybe even the dog, like their dogs were having puppies or something and somebody was with child or somebody was with child or puppy. And I said, so like, let’s talk about how that happens.” And I was just very scientific about it, you know, like, this is how babies are made. It’s like super cool. It’s, and you know, sex is something that happens only between adults. And I told them like the name, like use the names of their parts. You know, I use the word penis, I use the word vagina. Because actually unfortunately the age of sex, average age of sex abuse is 9. And so that’s kind of the other reason that I recommend your kids know the basics about sex at 8 or 9 is because it can help protect them.

Courtney Collen:

And it includes like the names of the actual body parts.

Dr. Amy Kelley:

It’s important because your kids have to know the names of their body parts because if something happens to them, they must be able to tell you what happened. And to tell someone else what happened. And if they don’t know the right names, that can lead to confusion and misunderstanding. If they tell like a teacher or something.

I actually had somebody who called their vagina pocketbook and told their grandma that someone was hurting their pocketbook and their grandma didn’t know that was the name and so it kind of delayed that being found out. And so I always tell people kind of that story, like you have to tell your kids the real names of things.

But also like if you tell them if they know what sex is and they know what makes babies and they know it’s only for adults, like literally that’s totally all they need until they’re like 11, 12. Then I think that it also helps protect them. Like if someone tries to trick them. They can be like, no, my mom said that’s only for adults. Like, why would I do that? They can kind of help protect themselves.

But puberty wise, that’s kind of how I cleared the fence over to puberty and I was like, remember you guys are talking in school of like, the girls are going to talk to the health teacher about periods. And I’m like, remember how we talked about what happens when you make babies and how the sperm and the egg have to meet? I said, you have to go through puberty before you can have sperm and eggs. And the way that girls get those is this, and I kind of talked about the menstrual cycle with them.

And some, some people are like, well, why would you tell boys that? But because they should know. Because they should know what happens.

Courtney Collen:

Because then they get into their 20s and they start having a girlfriend and they’re like, what’s going on with your body?

Dr. Amy Kelley:

Yeah. Honestly, I really think when they’re young too, you don’t have to tell them all the details. And you can kind of let them ask you questions and let them lead you down what they think is important too.

And it’s interesting. Kids will react in very different ways. I had one twin who was like, “la, la la la, la I don’t want to even talk about it.” And then I had one who was very, very scientific. Like, he had a microscope and he was like, can I look at sperm and eggs under my microscope? And I was like not easily. Like, well, let’s put that on ice for now. It was just interesting. Kids do react different, and they might, they’re going to react a total, maybe completely unexpected from what you thought too. That was not what I thought my kid would say.

Courtney Collen:

Could your twins be any different?

Dr. Amy Kelley:

Right. They’re totally different.

Courtney Collen:

But at least they’re getting, and you know, it helps to have a mom who’s an OB/GYN. But I mean, any parent can really kind of fill their son or daughter in when they feel it’s appropriate.

And especially for young men, even though, you know, we’re talking specifically about girls. Informing them about what’s going on. I just went to a period pad donation drive where organizers were collecting tampons and pads and a dad brought his boys in. They were at that age where they were starting to learn about what happens as women go through puberty and they were proud to pass along their donations, a big case of tampons and pads.

And that’s awesome. Other people in the community. And I was like, yeah. Like, go dad. And or you know, whoever might be in their family having the conversation with them. But it’s a good thing. It’s OK to spread awareness about.

Dr. Amy Kelley:

Well, and I remember when I was in middle school and unfortunately your period isn’t regular a lot of times when it starts and it surprises you and like, yeah. We had girls who, you know, would have like red on their pants or obviously got their period when they weren’t expecting it and it’s like, can be really embarrassing. Then you’re known as the girl who bled on your seat.

And like, and I don’t want my kids to make fun of people for that. I just want them to help them. So I think that that was like one of the big reasons why I thought it was really important for everybody to know about periods. Totally. So they can have that empathy for other people. And, you know, hopefully not make fun of girls.

Courtney Collen:

Just be more aware and understanding. Yeah, absolutely. At the end of the day, kind at least. Yeah. Right.

Dr. Amy Kelley:

Absolutely.

Courtney Collen:

OK, you just brought up a good point. You don’t really know when your period’s going to come, right? Yeah. Between that age range, so it could just come in at school, you don’t know, you absolutely could find some blood in your underwear.

Do you have any advice for moms or caregivers sending their kids to school? Should they have a little Ziploc bag with an extra pair of underwear to stay in their locker? Or a, you know, maybe a pair of period underwear, which are fantastic. Anything that they can take and when should they start maybe thinking about that?

Dr. Amy Kelley:

Yeah, I think probably somewhere between 12 and 24 months after your kiddo maybe starts getting breast development. So typically, they’re going to get their period, like I said, about maybe two to three years after they start breast development. And so kind of when you start to get close to that two-year mark, it’s probably not a bad idea to have like a go bag. And if you’re not sure what to put in a go bag, like you can go to the internet. It will help you.

Courtney Collen:

As it does.

Dr. Amy Kelley:

There are plenty of companies that sell little first period like kits. But you can make your own too. I mean you don’t have to buy one. But having just, like you said, an extra pair of underwear or, like a pad, making sure they know how to use them. Like you know, where the pad goes in their underwear. And just kind of going through that with them really might help alleviate some anxiety.

Because hopefully you’ve talked to them and they know, hey, my period is going to come soon. Like probably in the next six months to a year. And so I’m just going to have this in my backpack just in case.

Courtney Collen:

And hey, if you’re like a crafty or Pinterest-y type of mom, maybe you get all the things and you decorate it and you put it in a little discreet box and you say, “Hey girlfriend, like let’s talk about this and I’m going to give this to you when you need it.” And it’s like, you know, it’s just like part of the conversation.

Dr. Amy Kelley:

Yeah, the other thing is, I think it’s not a bad idea to just have like a little kid at home that maybe has some period underwear, some different kinds of pads and maybe if you have a swimmer or gymnast or something, maybe a couple of different tampons just so they have like a variety of things that maybe they want to try.

Just a note for parents who have health savings accounts you can get reimbursed for period underwear and periods. So a couple companies, Thinx and Ruby Love, take HSA money. So just FYI parents, you know, I mean that or flex spending money, which is a super nice thing to know.

Courtney Collen:

Either way, insurance related. Yeah. Fantastic. Because I can’t say enough good things about it. And that’s a whole other conversation like the menstrual cups and the period underwear which have come so far in comfort and style and anyway. I’m sure perfect for those adolescent girls.

So we talked about the internet and being able to find resources there. Let’s talk about social media and peer influence. They have a lot to do with shaping our young people today, Dr. Kelley, which can be a good thing or a challenging thing. How is social media in influencing how girls perceive puberty and body image today? What are you noticing in conversations with your patients and their families?

Dr. Amy Kelley:

I would like to say it doesn’t have as much of a role, but I don’t know that that’s always necessarily true. But I’m a big proponent of wait until 8, meaning wait until eighth grade before getting a phone because we definitely know that it’s not good for mental health of teenagers now.

In all honesty, my twins got their phone when they were in seventh grade, so I kind of like jumped the gun a little bit there, but they did not have social media until they were 16. I would really encourage parents to do their best to kind of wait until their kids are older for social media.

Honestly, that’s hard because they can kind of sneak it in, you know, I mean unfortunately it’s – kids are smart. And even with barriers that you put up for them, like they figure out how to get around them. So, you know, that that can be a hard thing.

But I do think it’s totally reasonable to monitor your kids’ social media accounts and until they’re 16-ish if they have them. Because you want to know what’s going on there and that they’re safe. That’s the biggest thing. But I think that unfortunately it is really hard to figure out sometimes what is good information and what is not good information.

There’s influencers, particularly in women’s health who, you know, they’re trying to sell things to you. And they’re not necessarily giving you good information. They’re just trying to sell you things, whether that’s supplements to make your periods better or, you know, to make you feel better or whatever. And so I think that letting your kids develop a healthy dose of skepticism is not a bad thing. Or at least having them, like every time they’re getting information from the internet, thinking about who’s giving me this information? Who’s paying for the website? What are they trying to do?

Because if you have that mindset rather than “Oh, this influencer is telling me the truth and they’re a great person.” Maybe they are a great person, but they’re also an influencer trying to make money. And so I think that, you know, having the sense to go through those kind of things and sometimes adults aren’t very good about that either. We’re working on it. So maybe we all need to think about that a little bit more: if somebody is trying to sell us something they make money from, maybe be a little skeptical of that.

Courtney Collen:

Yes, a hundred percent.

Dr. Amy Kelley:

But I think that I’m hoping that with time and us knowing that social media is not great for mental health of young people. That hopefully we can continue to maybe put that off until middle-late teens.

But yeah, I think that you’ve just got to have your button in there all the time. If you’re letting your kids have some social media, you got to like, be following them in front of things, things you got to know of who their friends are and try to – it’s so, so hard because they’re always one step ahead of you. It’s rough.

Courtney Collen:

Especially when it comes to social media. And that was my next question about filtering out misinformation. How do we do that and help them develop a healthy self-image? But it really sounds like, you know, when it gets down to it, just making sure you’re having that open, honest conversation or at least keeping that line of communication open. To allow them to ask questions.

And then maybe when they do see something, they’re comfortable to approach you about it and then you’re getting in front of it to like clarify or kind of dispel some misinformation. Or at least helping them build that healthy dose of skepticism, like you said. Which is always a good thing.

Dr. Amy Kelley:

Well, and I always try to give my patients and my kids websites that I know are good because there’s, especially with reproductive health, there’s several studies that show at least 50% of reproductive health websites have misinformation on them. So you do have to be really careful.

So I usually am always trying to encourage parents to go to places that I know have good information and the people that pay for that website are people who are trying to help, not sell things.

So I really like Young Women’s Health, which is a website from Boston Children’s Hospital. And you can literally go to Young Women’s Health and you can like search almost anything you can imagine and they have a little blurb about it with other resources. You can type in eating disorder. You can type in periods. Or they have a really good tampon video that goes through anatomy and shows people how to put tampons in. Love it. So I really like that website. A lot.

And there’s some other really good ones out there as well. But I think that giving people good resources can be helpful because I know they’re going to Google stuff. So I might as well give them a good website to look at that I know is accurate.

Courtney Collen:

Absolutely. Which they can get in the same place that they’re getting their social media information too, so. Absolutely. Yeah. Good information.

Safety and awareness are so important in our youth, especially in women. We know that we talked about it a little bit at the beginning. Why is it important to include discussions about consent, boundaries and abuse in puberty type education? I mean, one of the tips you had was to use the actual body part names, which helps lay that foundation. But why is it important to include some of those other things and how would you include that?

Dr. Amy Kelley:

In today’s world, like consent is, is absolutely needs to be taught from the time your kids are little. So that is something you can start teaching them as soon as they can talk. You know, like they don’t have to give hugs to people they don’t want to give hugs to. That’s their choice. You know, like these are there when you’re teaching them to toilet train, you know, mom’s helping you wipe, but nobody else really needs to help you here. And if Mom’s with you and like we’re at the doctor’s office or something looking to see if there’s a problem, that’s OK. But otherwise nobody else needs to be touching or looking here.

And as they get older just talking about how this is their body and they get to decide what happens to their body that I think that that’s just a really important thing. But it’s definitely, you don’t have to wait to link it with sex. You can link it to like, everything in life you need consent for, you know? Yeah. So I think starting when they’re little is good for that.

But safety things. We had a couple of rules in our house, when my kids got access to the internet, if you find something scary, you come talk to Mom about it. Mom’s never going to be mad because sometimes you can end up in weird places on the internet. We couldn’t have internet in our rooms. Like it had to be in spaces that everybody could be in. So you know, they’re not looking at things that they wouldn’t want you to see as you walked by.

But also, like, you don’t friend people you don’t know in real life. You don’t play games with people that you don’t know in real life. Now as my kids have gotten older, that’s shifted because now they’re old enough that they can make some of those choices on their own and I’m not so strict about it.

But I think that those kind of rules are really important to keep your kiddos safe. And schools are doing a much better job with that than they used to. You know, my kid that’s younger, he knows you don’t give your real name on the internet if you’re talking to somebody. And I’m like, we only talk to people we know in real life, but you know, they have taught him at school, you don’t give your address to anybody. You don’t give your full name to anybody. You don’t give your phone number to people. You don’t tell them all these things. And so I think schools are starting to catch up a little bit with some of that safety stuff.

But I think having some parameters and boundaries around the computer, but also like having boundaries around yourself. Like what is acceptable behavior? Is it OK for people to say mean things to you that you’re going on a date with? No, it’s not OK. Definitely putting boxes around what behavior is OK with dating is I think an OK thing to do as they get to be teenagers too. Whether you have some rules about dating or whether you just have, you know, rules about this, like, I want to meet this person first. That’s OK. Or, this is what I want from a relationship.

It’s not ever OK for somebody to hit you. It’s not ever OK for somebody to call you names. And just kind of knowing that. But then we have to also, as parents, we also have to model that for our kids. And so our kids learn relationships from us. And so that sometimes means that you get a little microscope on your own relationships, which can sometimes be hard because then you’re teaching them, but maybe you’re not showing them some of that – how you should be treated or how you want to be treated.

So I think that like, it’s also really important to model those behaviors. And that can be a little bit harder. It’s much easier to be like, do what I say, not what I do, you know, but your kids will pick up what’s going on with your relationship. So I think that it’s also important if your relationship needs some work, as your teens get older, I also think it’s OK to be like, yes, you know what, you’re right. Dad spoke to me really meanly and we should probably talk about that and we will take care of that. But that’s an adult thing. It’s OK to be like, yeah, we’re not perfect and we’re working on it.

Courtney Collen:

Absolutely. Kind of like you can’t always control what happens in the situation, but how you react and respond to it and then look back on it is a great teaching moment.

Dr. Amy Kelley:

Yeah. In a lot of cases. So yeah. But it’s hard. I think if you look at relationships in general, like teen, there is some evidence that there is more violence both emotionally and physically in relationships under 20, when you’re under 20.

And so I do think that you have to be like on the lookout for that and make sure that your kids are safe in their relationships. But I also think that one of the other things I often just caution parents about is dating someone much older, especially for young women. So since women do go through puberty earlier, sometimes they get treated as older than they are. You know, a 12-year-old that’s gone through puberty could look like a 16-year-old too. And so they often get attention from older men who may or may not realize their age.

I think that it’s also teaching our daughters about boundaries with everyone is important. But also like letting them be kids. And so, you know, maybe your 14-year-old doesn’t need to date the 18-year-old. That’s hard to police, but I think you do have to just be aware that they’re more likely to have sex early if they’re dating someone who’s more than two years older than them. They’re at risk for an unplanned pregnancy.

So I think that us just being aware of what those risk factors are is important too. I mean, it’s so hard to be the parent of a preteen and a teenager, and there’s nothing that prepares you for it either. Like there’s not a class you can take. So I think that we all just need to also just be kind to each other as parents as well.

Courtney Collen:

I have a 2-year-old at home and I feel like I’m going to blink and then have this conversation in a few years with her. I’m going to be calling you to come in and like be my sidekick for this. And I have another little girl on the way, so I’m like, oh my gosh, this is going to be double trouble.

Dr. Amy Kelley:

We all need a village to help raise our kids. And fortunately, it is not us alone that is raising our kids. Right. You know, social media is, all of these other things are, and so I do really think parents get way too much of judgment.

And so, especially if parents are listening to this, they’re like, oh my God, I gave my kid a cell phone at in sixth grade. Oh my God, I’m terrible. No, you’re not terrible. We’re all just doing the best we can. And I think trying to, especially as a physician and primary care doctors, I think we have to also have lots of grace for parents. I think we all love our kids. We all want what’s best for them. And we’re all trying to do the best we can. So I try not to judge other parents. It’s just a hard world out there.

Courtney Collen:

So exclamation point. Yeah. For sure. We are doing the best we can and the world is changing every single day. And we never know what tomorrow’s going to bring. But again, when it comes down to it, having that line of open communication, keeping that open no matter what type of household you’re in, what type of situation you’re in that relationship with, you know, if you’re caring for an adolescent girl, or it’s your daughter, granddaughter maybe, you know, that’s important. What else would you say to parents as they kind of think and we wrap this up?

Dr. Amy Kelley:

I think I would say two things. One is that your kid is going to grow up and be an adult. And I think thinking about what kind of adult you want to help them become. They’re going to become an adult that maybe you don’t anticipate. Like your kids aren’t going to be exactly what you think they’re going to be. But I think helping them become what they want to be is really important.

I always tell parents that connection is what protects your kids. So connection equals protection. So I think we’re all so worried about protecting our kids from all these other things. But they’re going to get exposed to that. They’re going to grow up. They’re going to see all these things. So we need to teach them how to deal with all the things in the world. So connection allows you to help protect your kids because they will come to you. And you are their safety. And so, if you can be that, that’s how you’re going to protect your kids by having that strong connection to them.

Courtney Collen:

I appreciate this conversation. So valuable and such a great resource for our listeners. Dr. Kelly, thank you so much for your time and for all that you do in the OB/GYN space in the adolescent space and of course being a resource for us here. Thank you so much.

Dr. Amy Kelley:

Yeah, of course. Thanks for having me.

Courtney Collen:

This was another conversation in our series, “Her Kind of Healthy” by Sanford Health. A reminder you can find any of our Sanford Health podcast series wherever you listen and anytime at news.sanfordhealth.org. I’m Courtney Collen. Thanks for being here.

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What makes small-town nursing homes tick?

Matt Holsen:

What is the most important factor for keeping small town nursing homes open and accessible?

Cassie Greene:

The community. Having the community involvement and the community buy-in.

Alan Helgeson (announcer):

“Reimagining Rural Health” a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high-quality, low-cost services in rural and underserved populations.

Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Matt Holsen with Sanford Health News talks with Cassie Greene, senior director, Good Samaritan, and Joe Bartolo, administrator, Good Samaritan Society – Algona, Iowa.

Matt Holsen (host):

One of my favorite things to do is to go visit and cover stories in nursing homes in small communities. And so if you could just introduce yourself for us, tell us where you’re from and your connections to long-term care and small communities. Joe, we’ll start with you.

Joe Bartolo (guest):

So, my name is Joe Bartolo. I’m the administrator in Algona, Iowa, at the Good Sam location there. I’ve been there for going on 24 years in about every role in the nursing field and now as the administrator. So, I’ve got a pretty good history there.

Matt Holsen:

And tell us about Algona.

Joe Bartolo:

So, Algona is a smaller town, about 6,000 people. We’ve got two nursing homes, we’ve got two assisted livings, obviously one of the nursing homes, the assisted livings, and a senior living on our campus. So, we’re fairly large compared to our competitors.

Matt Holsen:

And Cassie, you’re a former administrator in Auburn, Nebraska, is that right?

Cassie Greene (guest):

Yeah, so I am just transitioning out of the administrator role from Auburn, Nebraska. I’ve been there for a total of 15 years. I started there as a social worker. We have a nursing home, and assisted living, and home health in Auburn, and we are the only senior care provider.

Matt Holsen:

How big is a town like Auburn?

Cassie Greene:

Auburn is 3,500 people, so not quite small enough to just be one, but we are holding our own.

Matt Holsen:

What do you think is unique about small-town nursing homes?

Cassie Greene:

We are so blessed to be a small-town nursing home. We have the support from our community, from our churches, from the surrounding communities, from our schools. Everybody is one, and everybody is holding each other up to make sure that we succeed.

Matt Holsen:

Joe, what would you add to that?

Joe Bartolo:

I’d probably say the same. You know, we really rely on the community. I think the investment of our staff that are from the small communities is probably a little bit better than when you see your larger communities, your urban areas. I don’t know if they’re as committed as they are with us because of that connection.

Matt Holsen:

Yeah, you guys are pillars of the community, I would assume. Joe, why do you think it’s important to connect nursing home residents with members of the community?

Joe Bartolo:

Well, you know, the residents at the nursing home were, for the most part, pretty big members of the community at one point. And so, you know, to allow them to continue to have that connection, whether we take them out or bring people in, I think is vital for their well-being, for their spiritual, their mental and their physical well-being. So, you know, a lot of the service groups that they were a part of are still thriving, and to help out a little bit, maybe in a different capacity, I think is really important.

Matt Holsen:

I want to ask you both about what roles volunteers play. Joe, I’ve been to your location; we covered your basketball team coming in and that intergenerational, you know, activity. Talk a little bit about what role volunteers play.

Joe Bartolo:

Yeah, volunteers are important to us. You know, obviously in this day and age, staffing crunch sometimes is difficult. So, if you get volunteers to come help, like in our case when we had that volunteer of the year, do coffee for a couple hours; it, you know, takes a load off of the staff to have some of those residents packed into the dining room while he’s right serving them. Or if it’s someone just coming in to help wheel people to and from, getting church services set up, it’s really important. It takes a load off of the staff for sure.

Matt Holsen:

Cassie, how valuable do you find volunteers, or how do they play a role in your long-term?

Cassie Greene:

Yeah, I would echo what Joe just said. Volunteers are critical in our building. We have students from the Auburn High School that come in and do crafts with our residents, or even accompany us to a lunch bunch at a local restaurant, or go bowling with them. So, it really is just keeping that connection to the community there and allowing them to have a both life in and out of the center.

Matt Holsen:

When you think about events and activities, what are the top ones that your residents enjoy the most?

Cassie Greene:

Yeah, my residents really enjoy when those FFA (Future Farmers of America) students come in, or those FBLA (Future Business Leaders of America) students come in, or even the art students. When they are getting to touch hands with them, and to get to tell their stories, and get to just love on somebody.

You know, just this week we had the local art club come in, and they built birdhouses with our students. So, really, it’s just having that connection and being able to see life throughout and, you know, getting to share their story with a child who might not know them or talk to them without coming in and being connected by us.

Matt Holsen:

When our team, Sanford Health News, comes into a lot of locations in small communities, the farm time always comes up, right? Joe, what would you add to this?

Joe Bartolo:

Yeah, I would say when schools come in, I think they really enjoy the choir groups, when the speech groups come and do their practices before they go to their competition. Sports groups, prom, homecoming, you know, they see them in their dresses.

They were obviously a student at one point, and they were in the choir, they were in the speech, they were on the basketball team, the softball team, football team, whatever it may be. So, you know, it just maybe takes them back to a place in time and puts a smile on their face.

Matt Holsen:

Yeah. And we’re talking about, you know, the community being engaged. What can that do for a resident’s well-being?

Cassie Greene:

Oh, it’s huge. I would say that our success comes from our community being engaged. Our community supports us in everything we do. We have pastors, we have ministers. I mean, it doesn’t stop. We have everybody in the building, the mayor is in the building, he comes in and visits, you know, somebody who was a longtime mayor before him. We have a lunch bunch that is within our building for those individuals who cannot go outside of the building. And our communities, they show up; we put our ask out, and they are there.

You know, one of the, I think, unique things about Auburn and a small community is the amount of visitors that we have within our building. There is not a day that goes by that I do not see up to 20 visitors in that building. And it’s not necessarily just family members; it is people from the community coming to see how we are doing and what they can do to help us.

Matt Holsen:

And this is not something that bothers staff, right? This is something that is a huge help to staff, or how would you phrase that, Joe?

Joe Bartolo:

Yeah, it’s — I think it’s welcomed. Like I said, especially sometimes if you have a family or a service group come in for a resident who’s maybe struggling and you’re spending some extra TLC time with that resident, and you’ve got some visitors or people from the community that come and talk to them, obviously it helps relieve the staff a little bit. But it does change that mental well-being, maybe picks them up a little bit, and their day’s certainly better. So, I think there’s a lot of perks to it.

Matt Holsen:

Do you recall a specific experience from a community or volunteer event that made a lasting impact on you?

Joe Bartolo:

I think for me, on a personal level, with the basketball team when they come in, you know, I’ve got my three families: I’ve got my family, I’ve got my work family, and the basketball family, which is —

Matt Holsen:

Yeah, explain that a little bit real fast.

Joe Bartolo:

Yeah, so life is busy with the five kids, with my wife and I, and then obviously, you go to work, and there’s a lot of stuff that we do on a day-to-day basis at work. And then, you know, after school a lot during the basketball season, I’m coaching them, and so my time is fairly occupied with that. So, when I can have those group of girls come in and do the activities and things, that’s pretty significant to me anyways. That, like I said, two huge parts of my life connected together.

Matt Holsen:

And your residents become real big fans of your basketball team, too.

Joe Bartolo:

They do, yeah.

Matt Holsen:

I saw that in person.

Joe Bartolo:

Certainly follow everything that we do — and we’ve got a couple girls that work for us, so it makes it even more special.

Matt Holsen:

Yeah. Helps in recruiting as well.

Joe Bartolo:

Yep.

Matt Holsen:

Is there an experience that made a lasting impact for you?

Cassie Greene:

Yeah, I would say just when we bring in the students, you know, my children go to Auburn public schools, and so when I see my kids come in the building and it’s not necessarily because I’m forcing them to come or I’m asking them to come with me and they’re just walking in and they’re happy and they’re meeting up with somebody that I’m not asking them to do, that just really warms my heart and lets me know that there is hope for our future.

Matt Holsen:

Cassie, your former center in Auburn was recently featured in a docuseries highlighting the heroes of long-term care. What did the series focus on in Auburn, and why did you think it was important to be part of it?

Cassie Greene:

Yeah, so Nebraska Health Care Association and Peter Murphy Lewis came up with this initiative to go and document seven nursing homes, and we happened to be one of the lucky ones in Nebraska. They chose a different theme in each nursing home, and ours was culture of the community.

And I felt that it was important because our community really is unique. We have everybody in that building, and I felt like it was our way to shine and to show like there are ways, like that Joe’s center does as well, is to bring those kiddos in and let that intergenerational mix, let those old hands touch those young hands, and just watch the magic happen and let them see their lives and their memories shine through. And so I thought it was really important for my staff and my residents just to be part of something so special, and it was one of the best experiences we have ever had.

Matt Holsen:

It was really interesting to watch, and thanks for being a part of that. Joe, you’re not only a leader at Good Samaritan in Algona, and we’ve discussed this already, but you also have an active leadership role in the community. Tell us about that, and why that’s important you think? You mentioned you’ve recruited a few folks from your basketball team. I assume you do more in the community than the basketball team too.

Joe Bartolo:

Yeah. Yeah.

Matt Holsen:

But why is that important?

Joe Bartolo:

I think it’s really important. Cassie said it, that intergenerational mix, you know, I think everybody that’s probably been in the field as long as we have had some sort of connection early to the nursing home. Likewise for me as a child with my grandma, as the activity director at the local nursing home going down there, you kind of feel you have a love for what long-term care is.

And so if we can get those kids in there and get them involved, I think it certainly helps with the recruitment. It helps them understand that, you know, the generations that came before them and the impact they made, whether it’s on the community or schools, whatever it was, I think it’s vital.

Matt Holsen:

Especially in a small community and rural areas, nursing homes are often what the only health care provider in the community. How does this affect the way your community members see you?

Cassie Greene:

Yeah, you know, in Auburn, like I said, we are the only senior care provider. So, we, again, have the assisted living, the skilled nursing, and the home health. But we actually are on top of a hill. So, the nursing home is on top of the only hill in Auburn, and we call it the Health Care Hub. So, across the street is the hospital, down the hill is the dentist, the pharmacy, and the health clinic. So, you can come to the nursing home, and it’s like a one-stop shop. Everybody comes in and out, and it’s really easy access to get the care that you need.

Joe Bartolo:

Yeah, I would say for us, we’ve got a lot of really great nursing homes in our area, but we are the only one that has the full continuum of care, I would say, with the senior living, assisted living, skilled nursing, all on the same campus, and then we do the outpatient as well. So, I think that sets us apart. I think that’s an advantage for people to look at where if they come into senior living, you know, they probably know, eventually down the road, they’re probably going to have to go to assisted and then to us.

And in a lot of cases, you know, people come to us and they’re not quite ready to go home. At the nursing home, we can transition them down to one of those lower level of care, and I think that’s a big deal, to give them more of their independence back, or we can send them home, and they can come back and do outpatient while they live at home.

Matt Holsen:

What is the most important factor for keeping small-town nursing homes open and accessible?

Cassie Greene:

The community. Having the community involvement and the community buy-in. I am so blessed to be able to say that our facility is agency-free and that … come(s) from the excellent buy-in from my community. Everybody that works at the Auburn facilities, they’re local. So, our local community really has invested in us and has continued to keep us agency-free through this staffing crisis that everybody is experiencing. And it truly would not be possible without our community support.

Joe Bartolo:

I would say the same thing. We recently, in the last six months, have gone agency-free, and I think it’s a lot of our local workers coming back to the workforce and making them feel at home. The community’s invested in us; we’re also invested in them. Chamber ambassadors, what we do with the schools. And I always challenge our leadership staff to get involved in a local service group so we can show that we’re out there and we want to be a part of it.

Matt Holsen:

What advice do you have for someone who might be intimidated about going into a nursing home?

Cassie Greene:

I would tell them to take the chance. Go meet with the social worker, go meet with the administrator, the director of nursing, job shadow. It doesn’t hurt to go in and just take a walk through a building, see how the culture is within that building, and really just take the chance. Some of the best stories and memories that I have are from being in a nursing home and getting to see those residents and their families on a daily basis. And, you know, they have great stories, and it really is a humbling experience.

Matt Holsen:

What is the best thing community members can do to support their local long-term care centers?

Joe Bartolo:

I think come into the centers, walk around, see what’s going on, listen to what’s going on, you know, attend some of our events that we put on.

I think maybe from a government standpoint, as far as the reimbursement goes, getting educated on where our downfalls are. When we have our local town halls or when we have those senators come into town, to attend those and listen because at some point, somebody in your family’s going to be affected by it, and I think you can help by being a branch or another voice for us.

Cassie Greene:

Yeah, definitely advocation, you know, advocate for us. When you hear the news, sometimes it’s a one-side story and it doesn’t always fit all nursing homes. So, before you take the buy-in of what is being told, come and talk to us and take a walk around the building and figure it out for yourself.

When those senators and legislation is making bills for us, they have the best intentions. But sometimes, until you’re boots on the ground, you don’t know what is actually going on within a building.

Matt Holsen:

I want to thank you both for your time and for all you do in our rural Good Samaritan communities. Thanks for being with us.

Joe Bartolo:

Yep, thank you very much.

Cassie Greene:

Thank you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series wherever you get your podcasts and at news.sanfordhealth.org.

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You can learn to be resilient, says author-speaker

Alan Helgeson (announcer):

“Reimagining Rural Health, a podcast series brought to you by Sanford Health. In this series, we explore the challenges facing health care systems across the country, from improving access to equitable care, building a sustainable workforce, and discovering innovative ways to deliver high quality, low-cost services in rural and underserved populations. Each episode examines how Sanford Health and other health systems are advancing care for the unique communities they serve.

In this episode, Matt Holsen with Sanford Health News talks with author-speaker Chad Foster on the topics of leadership, resilience, and overcoming adversity.

Matt Holsen (host):

Thanks for being with us here this morning.

Chad Foster (guest):

Thank you for having me. Pleasure to be with you.

Matt Holsen:

You have an incredible story that’s inspired people around the world. Can you share a little bit about your story and how you got here today?

Chad Foster:

Sure, yeah. I have a bit of a unique story. I grew up, was able to see pretty well, couldn’t see well at night, and ended up losing all of my eyesight when I was in college at roughly 21 years old. And, you know, wasn’t sure what I was going to do. Wanted to go into the medical field to help other people.

Then after I went blind, you know, I wasn’t even sure if I could help myself and switched my major to business. Ended up becoming a better blind student than sighted student. You know, made straight A’s, made the dean’s list, got a job in tech. Ended up moving up through the tech ranks and negotiating billion-dollar deals and doing some things that some people would consider remarkable.

I guess the kicker is I did it without being able to see. And so now I do things that most blind people don’t do. Like jump out of airplanes, and fighting jujitsu tournaments, and downhill ski on double black diamonds. So, I try not to feel limited by my circumstances. And so now that’s what I do is I teach people the anatomy of resilience. How did I go from blind and broke to negotiating billion-dollar deals? And so I like to teach people the anatomy of resilience so that they don’t have to feel limited by their own circumstances.

Matt Holsen:

That is an incredible message. Of course, we work in health care, so we want to know if leadership as a concept is sick; what’s its diagnosis?

Chad Foster:

You know, I’m not sure if leadership itself is broken, but I do feel like as a society, we have a tendency to shy away from some of the hard truths, the hard reality. And so I do feel like we’ve shifted as a society to be a little more fragile. And some of that’s our own doing, you know, trying to shelter people from the harshness of situations.

In my situation, there was no sheltering me from the harshness of my situation. I went blind, and it was either figure out a way to move forward or, you know, go in my corner and cry for the rest of my life. And so I had to figure things out. And so I think that actually forced me to grow up. It forced me to be accountable. And I think if I had to say there’s one thing that is probably missing more so than anything, it’s probably that accountability.

Matt Holsen:

What would you say resilience means, and how can it make leaders stronger?

Chad Foster:

Well, resilience, there’s actually an anatomy of resilience, a formula for resilience. A lot of people think it’s something you’re born with or not. I don’t believe that at all. I think it’s a set of learned behaviors. So that’s what I’d like to teach.

I’ll break down the five pillars really quickly here, but there’s a lot of nuance to these that we’ll go into here in just a few moments when I keynote. But the first one is, you have to learn that. You have to choose your response. That’s pillar number one. If you don’t choose your response, you just react to whatever’s going on around you, then you don’t have control of the situation. You’re not responsible for your circumstances, but you’ve got to own your outcomes.

Pillar number two is you got to tell yourself the right stories. You don’t get to control everything that happens to you, but you alone get to choose how you respond and the meaning that you attach to those circumstances. I could have sat around telling myself that I went blind because I’ve got terrible luck. But instead, I told myself that I went blind because I’m one of the few people who can deal with it and help other people by what I’ve learned.

Pillar number three is you’ve got to visualize greatness. And sometimes you got to do that in unfavorable circumstances. I had to figure out how to make blind look good. It’s a little tongue-in-cheek, but there’s a lot of truth to it because if you can’t ever imagine greatness in your unfavorable circumstances, how could you ever move towards acceptance of them, let alone thriving in them? And so that’s really important.

Pillar number four is where mindset meets action. You’ve got to get comfortable with discomfort. Because if you’re never getting outside of your comfort zone, then you’ll never grow. It’s where life begins is outside our comfort zones.

And then finally, pillar number five is you have to take advantage of your perceived disadvantages. Every perceived disadvantage offers us some advantage if we can just use it in the right context.

Matt Holsen:

I love that. And these are pillars that, you know, can help anyone. Of course, we work in health care. So, why is it especially helpful for leaders in health care, do you think, to look at these pillars?

Chad Foster:

Health care’s been through a lot. Not saying anything that your listeners don’t know, right? We went from a pretty tough environment and then into COVID chaos. And then shortly after that, everything that we’ve seen over the last several years, and most recently, you know, all the supply chain disruption and burnout, workplace violence, workplace incivility, all these things, people need to be more resilient.

I’d say, particularly in health care. I’d say one out of every three events that I do right now is in the health care space. And it’s because they’ve been under so much pressure for so many years. If you go back, things weren’t great before COVID, and that was in 2020.

So, we’re now looking at what six, seven years of pressure that the industry has been under? And you know, folks are hurting. And I think resilience is really important so that they can find the meaning and find the purpose in why they’re navigating the circumstances that they’re navigating. It’s the meaning we attach to those circumstances that determines how we feel about them. And it was Nietzsche who said, “He who has the why to live can bear almost any how.” So, it’s really important to find the right meaning to attach to those circumstances.

Matt Holsen:

Health care is always changing. What tips do you have for leaders who are trying to lead through that change?

Chad Foster:

Well, you have to get out in front of your teams and help them understand the right narratives to attach to them. The whole framework for resilient thinking, you know, as human beings, we tend to default to whatever comes to mind. We’re less intentional about how we choose to digest a situation.

Well, as leaders, it’s leaders’ jobs to go in and help their teams, their organizations understand, how do I help my team choose the right response? Help them tell themselves the right stories? How do I help them visualize their greatness in these circumstances? What can I do to set them up to get more comfortable with discomfort? And what perceived disadvantages can we take advantage of to help out?

And so, I think, you know, really helping the team understand and not default to just, oh, I’m going to react to whatever’s going on around me. You know, helping them understand how they can be more intentional about how they approach a situation.

Matt Holsen:

Exactly. I mean, you talked a little bit about, you know, how you can turn maybe something that you perceive initially as a problem into an opportunity. Do you think challenges and setbacks can fuel innovation?

Chad Foster:

Where would we be without them? Honestly, if you never had any challenges in your life, how rewarding would your life be? If you look back on some of the most fulfilling moments in your life, I’d be willing to bet that they’re probably some of the hardest things you’ve ever done.

But you’re proud of those moments because they tested you, they tried you, and you came out on top. A life without any obstacles at all, without any setbacks, any challenges, removes all opportunities for growth. The only way that we can ever grow is to face difficult situations. The only way that we can innovate is to get comfortable in the discomfort, to experiment, to face the fear, move towards the fear, do the things that are uncomfortable. And that’s how you expand. That’s how you grow.

Matt Holsen:

Very, very well said. You’re on a podcast right now, but we want to ask you, what book or podcasts are you listening to right now? What’s in your playlist?

Chad Foster:

Well, I’ve got a few things that I’m listening to right now. I’ve been really tied up right now working on my masterclass, trying to button all that down. But I’d say I’m really into anything that’s all about, you know, how do we control the stories that we’re telling ourselves and mindsets? So, I don’t really have anything that I’m actively listening to right now at the moment.

But I have a few favorites, you know, that I’ve listened to several times. I really like, you know, Chris Voss’—I don’t know if you’ve ever heard or listened to, or read, “Never Split the Difference.” Really good book. And people think it’s about negotiations, but it’s really more about human empathy and understanding, which I think we need now, maybe more so than ever.

A lot of people have conversations, and what they’re doing is just waiting on their turn to talk as opposed to really hearing that of the person and making them feel seen and heard. And he talks about it through the lens of negotiations. Specifically, he was the lead FBI international hostage negotiator.

Matt Holsen:

Wow.

Chad Foster:

And so that’s where the name of the book comes from: “Never Split the Difference.” You can’t split people, right? And so he had to figure out a way to secure the hostages, but it’s all about meeting people where they are and understanding.

And it’s not about what can I get out of you, but it’s about, you know, how can I get to know you better and maybe understand why you want something or think something that’s different than me? Maybe I can learn something from you. That empathy, that humility of being able to meet people where they are, not where we think they should be, that allows us to connect with them.

Matt Holsen:

Amen. How can our listeners learn more about your journey and, yeah, maybe your leadership lessons as well?

Chad Foster:

Yeah, if they go to my website, chadefoster.com, from there, they could find videos, blog articles, press, pretty much everything, links to the masterclass – all the things are right there at my website, chadefoster.com.

Matt Holsen:

Is there anything else you’d like to say before we wrap up here?

Chad Foster:

I think folks right now in health care are going through a lot. I just, I think it’s so so important to not only determine what stories you’re telling yourself about the circumstances, you know, why this is happening to you, why this is happening to health care. But making sure that you stay grounded in why you’re doing the work that you’re doing.

As someone who wanted to go into the medical space myself, what was drawing me in was serving other people. And I know that’s what’s drawn folks in here. And sometimes we get caught up in the day-to-day and we forget about that. But if you can stay grounded in why you’re doing the work that you’re doing, the meaning of the work, and how you’re contributing to that in your way, then I think it’ll help you navigate whatever unfolds in front of you.

Alan Helgeson:

You’ve been listening to “Reimagining Rural Health,” a podcast series brought to you by Sanford Health. Hear more episodes in this series or other Sanford Health series wherever you get your podcasts and at news.sanfordhealth.org.

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Coping with aging and the transitions that come with it

Dr. Lindsey Dahl:

They always think they’re alone in what they’re going through, but to remind them that everybody’s going through similar things and you can get together and talk about those things or just find something fun to do together.

Alan Helgeson (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is a discussion about helping older adults cope with aging. Our guests are Dr. Lindsay Dahl, internal medicine physician, and Lexie Eubanks, integrated health counselor, both with Sanford Health in Fargo, North Dakota. Our host is Mick Garry with Sanford Health News.

Mick Garry (host):

What are some of the things that, with mental health and aging, what are some of the main points? What are the things that you talk to older people about?

Dr. Lindsey Dahl (guest):

There’s certainly lots of things we are going through. Lots of life changes, right? So, you can start at retirement, which I think is a huge life change, and a lot of important things need to happen then to, I think, be successful in aging. So not only managing your multiple chronic diseases you may have, then navigating finding a purpose and keeping your mind going and figuring out what you’re going to do with your day.

The thing that makes me most nervous is when I ask what matters most, or what somebody is doing with their day and they say sitting and watching TV, that’s a big red flag to me. So, I think that’s a big thing to navigate.

And then certainly there’s caregiving as we get older, you maybe take on a caregiving role of a spouse. There’s death of friends and family. There’s dealing with the changes in, in your ability to do the things for yourself and be independent. So, I think it’s a whole range of changes and different steps that we have to go through and lots of areas where we can have problems navigating and need help and interventions.

Lexie Eubanks (guest):

I would very much agree with, especially with retirement, that’s a huge time. I always call that, you know, adjusting to a new normal, right? Where our lives just look so different. And even just aging as a whole, right? We’re always just having to adjust and adjust. And so, looking at mental health from the lens of being an older person or growing older is we’re having to, yeah, adjust our entire lives around these changes in our physical abilities, losses that we experience, finding purpose, like Dr. Dahl said, that’s a huge one there too.

So, sometimes we have to get a little bit creative in that time in our lives of how we’re going to ask for support and then be willing to receive the support when it’s there.

Mick Garry:

Finding purpose after retirement, which is something you both mentioned. Could you give me a little nitty-gritty on that? What is that challenge? And maybe some typical issues and ways that you try to get out of – if it’s a funk, or, I don’t know how you would define that professionally. But just making sure that you can kind of get through that as best you can. How do you go about doing it?

Dr. Lindsey Dahl:

I think it’s hard, right? We identify either as being a parent, and your kids go off to school, or the next thing you’re identify grounded in is your career and your job, right? So, I think that’s your purpose, right? So, when we retire, you have to find a new purpose. I think you have to – actually, a lot of people have to actively seek that out. What is your purpose?

And I think I’ve always sent people to the “Blue Zones” website, because I think they’ve done a good job at helping people learn to navigate and ask the right questions to what is my purpose now that I’m no longer working? And the one thing they talk about on the Blue Zones is the napkin test. It’s grab a cocktail napkin, on it write down the following simple recipe: G stands for gifts. So, G plus P plus V equals C.

So, G stands for gifts. The gifts that you’ve been given in your life. P stands for passion. So, things that you’re passionate about. And V stands for values. And then that equals C, which is your calling, or what you can find passion and values, and all those together are your calling. And what you can call your purpose.

And so, I think you have to just ask yourself the right questions to point yourself in the right direction to figure out your new purpose, which has probably always been there. But it’s just been directed in your job or raising your kids. And so, you have to direct those things somewhere else.

Mick Garry:

How do you sell that as an idea? How do you get to where there’s some motivation involved that this is going to help you? How do you get there?

Lexie Eubanks:

I think a lot of exploration of our values, right? Our values are the building blocks to who we are, the things that we find important. So, a lot of those questions around what’s important to you, right? What makes your life feel fulfilled? And as we go through different areas, our times in our lives, our purpose often changes.

And so, you know, I think that that’s a great place to start is really exploring values and having discussions about, you know, the things that make you happy and how in this time in my life am I going to be able to integrate those things into my life, right? To make changes to the things that bring us joy just based off of whatever’s going on in our lives. And sometimes, I say a lot of the time, it’s getting back to the basics. Like, let’s get back to basics, right?

Productivity is a big thing too, I feel like when it comes to purpose, right? As we wrap a lot of purpose into productivity and vice versa, that when we go to work every day, or if we’re caring for our children or even caring for another loved one, we’re feeling productive, right? We’re feeling like we’re contributing to the world around us, to our lives.

And so, whenever we no longer have those things, the productivity – we don’t feel as productive, right? So, looking at productivity through a different lens of, OK, what am I doing in my day-to-day that is still productive just with a different expectation than what it was when I was working full time, right? So, it can really affect our self-esteem, how we feel about ourselves whenever we’re not feeling that productivity piece when we don’t feel as valuable. So, purpose, right? That circles wrapped into, OK, my purpose here was being productive. Well, how can we now be looking at purpose in a different way?

Mick Garry:

I think it would also be connected here that this next one, but staying social, what goes into staying social? I mean we’re all social people, and it’s a quality for all of us regardless of age. That’s a huge piece of happiness. Maybe what are some specific challenges involved once you’re a little bit older? And how do you make sure you stay engaged? That social piece of your life is in order?

Dr. Lindsey Dahl:

That’s hard. Especially when we’re limited in mobility. It’s more difficult to go out. Whether we have heart failure or COPD and you know if some of our health conditions make getting outside of the house more difficult, if we’re no longer driving because we’ve chosen that, or felt like we’re not safe driving. I think then our world becomes very small. And there’s been lots of studies, right? Especially after COVID, that isolation and loneliness only worsen our medical conditions and lead to depression and cognitive changes.

So being social is very important, but it can be very difficult. I think you have to seek out ways to overcome those obstacles, right? And a lot of times that’s moving to a senior housing where they have social life built in, or looking into all the different kind of senior ride opportunities that they are, and that can be a lot in Fargo-Moorhead, but a little in the more rural areas.

There’s certainly senior centers in most communities. And seeking out the senior centers and doing the activities that they have there. But it’s hard to find new friends. And oftentimes, it’s difficult when we’re losing friends to find ways to meet new people. So, I think you just have to go again on what your purpose, what your interests are, and then seek out those opportunities.

Volunteering, I think there’s so much value in kind of multi-generational volunteering. So, whether it’s at schools or hospitals where you can be valuable and you gain something as well from helping out, whether it’s elementary or – my father volunteered at a university level. He wasn’t a professor, but he was an engineer. So, he went back and did some things volunteering at the university level. So, you can find those things. You just have to be willing to seek them out, right?

There’s lots of different clubs and organizations. Start a book club, right? All these things can help keep you social – cards. But I think, oftentimes, the piece that’s missing is the ability to get yourself to those situations. And then I think it’s time to consider moving to a more senior housing where those things are kind of built in.

Mick Garry:

What’s your experience in motivating people and maybe, appreciating, making sure they appreciate what may be intentional effort toward a greater social level? What can that mean for this person?

Lexie Eubanks:

Yeah. Well, and I think for one is really being able to identify how much it impacts our lives, right? When we don’t have that social piece as readily available to us. So, we’ll do a lot of discussion and exploring around, OK, how does this realistically fit into my life right now, right? What are some goals I can work toward to keep the social piece in my life? Or, maybe go a little bit outside of my comfort zone and trying something new.

So, keeping an open mind I think is a big one as well, of just, OK, we might have to be flexible in how we receive that social connection compared to how in other times in our life. So continued discussion on, OK, how do I keep that here? And then how do I keep myself, yeah, motivated, right? What are the things that are important to me collecting back on that, right? And that will then push us towards wanting to work through that goal.

You know, technology I think is great as well. It can be really intimidating too, especially maybe in the older generation where they hadn’t spent their entire lives with technology, right? But technology can be a great use of being able to stay social with your loved ones with FaceTime, Zoom. And not a whole lot of things came out great from COVID, but that is one thing is that we got really good about being able to utilize those different type of technology to keep connected with each other. So, that’s another too is kind of discussion around even technology safety, right? But then also just how can I utilize FaceTime, Zoom, all of those things to stay connected with those people that I care about if the mobility is really limited.

Dr. Lindsey Dahl:

Everybody’s in the same boat. So, you know, if you’re an 80-year-old, and you’re a widower, and you can’t get around, and you live in a place where older adults are: chances are the same kinds of things are happening to the next-door neighbor. And you guys, you know, get together and talk about it. So, I think we’re not alone. There’s people out there who are going through similar struggles, so why don’t you get together and play cards together? So that, I think one thing, they always think they’re alone in what they’re going through, but to remind them that everybody’s going through similar things and you can get together and talk about those things or just find something fun to do together.

Mick Garry:

One of the questions here, and I’m sure that you deal with this all the time, but, the transitioning from home to senior living. I know you both have alluded to it, the challenges there. But what are maybe some basic things as you’re making this significant transition from home to senior living, what are some things you should remind yourself of as you enter that part of your life?

Lexie Eubanks:

I think it can feel a lot like a big loss of independence, right? Just making this choice to move. And I think reframing the way that we look at a transition from home to senior living is that in a way, it’s really keeping your quality of life at the forefront and the biggest focus, right? That being in a setting where support can be available to you whenever you need them, is a way to continue living a safe, happy, likely healthier life based off of all the things that senior living type of setting could potentially offer.

So, for one, I think, looking at it differently instead of looking at it as a loss of independence of how, OK, the independence I’m going to be able to keep in my life because of this really, really big decision. I encourage folks when we start talking about a potential transition to start the process earlier than later because then you still feel a lot more of that sense of control of where I’m going to go. Being able to go on tours of the facility, be able to see what type of activities are offered so you really can make a good decision based off of your purpose, your importance, right? The things that are important to you in your life, being able to make the choice to – if you’re going to move somewhere that really aligns with your values and what’s important to you.

Dr. Lindsey Dahl:

I think this is a big challenge for a lot of people, is that they want to stay in their home. And I don’t know how many people who we’ve eventually got to move to the independent apartment in a senior facility or an assisted living facility when they got there, they thrive so much. I mean, everything was better, right? They ate better because they were eating socially, and who wants to cook for one person? And so, you start dwindling what you’re eating, right? So, you’re there and you have social meals, so you’re eating more, so you have more energy, you’re staying stronger, and you have a built-in social life. And so many people have commented to me, why did I wait so long to make that move? Because my quality of life is so much better at this place. So, we all don’t want to make that move, I think, because we’re thinking of it in the wrong way. And really it is adding to your quality of life.

Mick Garry:

How about keeping your mind sharp? And I know there are a lot of ways out there that accessible information that we have to this, but it seemed like it would always be something to remind yourself of that it’s not just a physical thing. That if there are exercises you can do every day that involve maintaining mental sharpness, when you’re talking to some people about that, what are you telling them?

Dr. Lindsey Dahl:

I think the biggest thing in literature for helping maintain cognition is exercise, daily exercise, a healthy diet. So, a heart-healthy diet is a brain-healthy diet. There’s been studies on berries, particularly blueberries. A half a cup of blueberries a day improves your cognition not only for study taking in younger people, but in preserving your memory throughout the aging process.

Staying socially and cognitively engaged. So, the worst thing for your brain is to be isolated and alone. You need to be using your brain.

And actually, the best activity is a complex movement activity. So, learning a new dance or yoga or tai chi where you’re having to incorporate your brain in complex movements.

Learning new things, right? We can all learn new things, we can all learn a new language, we can pick up the piano that we did as a child but haven’t done through our child-rearing years. So, all those things.

One important thing that I think we often forget is we need to have good hearing to maintain our brain function. So, if you are losing your hearing, you need to look into the hearing aids because that’s going to help preserve your brain function going on through the aging process.

So, I think all those are the most important. Getting good sleep and stress relief.

Mick Garry:

Lexie, anything to add to that?

Lexie Eubanks:

No, I think those are everything that Dr. Dahl mentioned are – I mean, we always joke and say, the best medicine is good food and exercise, right? Healthy food and exercise. And I tell a lot of my patients that we want to work through some of the stress that we have in our lives, or we’re dealing with certain symptoms of certain mental health diagnoses. We say, a great place to start is, what are we doing for exercise and keeping our bodies healthy, and what are we doing for food intake, right? To make sure we’re filling ourselves with the right things. And so, I mean, that’s kind of the surface level, right? The very bottom of where we want to start, right? With keeping our mind sharper. What are we eating? How are we moving our bodies? And then the social piece: how are we being able to still connect with others?

Mick Garry:

Another one here, and this one hits close to home: my father is 87 and doing great, but my goodness, his wife, my mom, many of his best friends, are gone now and other family members. Is this a significant part of aging? I guess we assume that it is, but how do you get through that if you’re seeing these people leave all the time?

Lexie Eubanks:

Wow. Absolutely. It’s a very hard topic, right? And grief is not linear. It’s very complex. It’s a very personal journey. You know how you grieve the loss of one person in your life; you likely will grieve the loss of another person in your life completely differently. It’s really hard to even prepare for loss even when you anticipate it may be coming. So, I think a lot of it starts with just having compassion for ourselves when we are feeling all of the feels, right? Whenever we are on this grief journey, we have to have compassion for how we’re feeling. Because you experience a multitude of emotions, right? Anger, sadness, denial, sometimes relief, depending on the circumstances, right? And even that can feel really difficult to feel in a grief journey. So, starting with how can I be compassionate to myself whenever I am feeling this grief, right?

And kind of normalizing the emotions and the sense of, you know, grief is fairly universal and that everybody will likely lose someone in their lives. However, the way we grieve is all very differently. So, we have to give ourselves permission to feel the feels. We have to give ourselves permission to grieve, and we have to give ourselves compassion in those moments. You know, a lot of the time grief, if you’ve ever had a significant loss, you know that grief never really leaves you; you just grow around it, right? We just kind of figure out where it fits into our lives. So, it also definitely can have us look at our own mortality, right? Whenever we’re losing people around us who are similar in age to us. Maybe someone who’s got similar health conditions to us – we have to be really mindful to not get wrapped up in the what-ifs, right?

We can start trying to, I call it like, future telling, tell the future. We don’t have a crystal ball. We’re not able to see into the future and know what, you know, the outcomes are going to be. So, we have to be really mindful if we’re spending too much time in what I would call those anxious, what-if thoughts.

So, grief support groups are something I recommend a lot. Being a part of a support group and being around others who are maybe experiencing a similar type of grief can help you feel connected and feel a lot less alone in a journey that’s really, really deeply personal. So, and there’s a lot of challenges with loss, and being able to hear other people’s experiences can really help with processing through those really difficult times.

Mick Garry:

This is a kind of an open-ended question, as have been several of these, but is there a time when you should consider asking for additional help? How do you know? What are the signs? And, as much as you are able to realize it on your own that, OK, it’s time to change things, and my age has something to do with this.

Dr. Lindsey Dahl:

Most people know. They realize it in themselves. And family, I think, helps support those decisions and maybe often have to push in the right direction for increased support. But, it can be hard because people can be very stubborn, and their desire is to stay in their own home even though they’re struggling to keep the house together and to do the snow removal and the yard repair, right? So, it starts with just getting help with those things. And, you know, when you’re not able to shovel the walk anymore, so, either you hire out the help or you decide you’re going to move to a place that can help you do that.

It’s harder when family members don’t see it or don’t want to recognize it in themselves, and it’s your mother or father, and you’re having to watch them, and they don’t want to listen to what you have to say. That can be a much more difficult situation, and it’s what they want. And trying to show them the pieces that would make their life better if they chose a different route and got some help, right? If we got help in this area, then you would be able to do this, which matters to you, right? So, I think it’s a lot of reframing to show what more supports or different living situations, what you would gain from that, right?

Lexie Eubanks:

And asking for help doesn’t take your autonomy away. If anything, it keeps you in control. Help comes in lots of different shapes and sizes, and you don’t really know what’s available out there to you for support unless you’re asking. So, again, kind of reframing of when I’m asking for help, it’s not because I’m defeated, right? Or that I’m giving up control over my life and my decisions by asking for help. That’s keeping you in control, right? And then we circle back to quality of life. What’s going to give me a good quality of life? That sometimes, it does come down to, I’ve got to ask for some help here so that I can continue to do the things that are important to me.

Mick Garry:

If you are a loved one, and you see issues here that your loved one is not probably realizing as well as they should, that it’s time for these types of changes. What are some basics involved? If you’re a, let’s say, a son or a daughter and you want to have this conversation, and I know that’s a long one and it’s a complex one, but maybe some basics on how to approach that.

Dr. Lindsey Dahl:

I think the biggest thing is sitting down and having those conversations and saying, look, we want to keep you as independent and healthy as possible, and we’re seeing some of these things that concern us. So, how can we help you address those to keep you doing as well as you are, right?

Sometimes, I think, it’s definitely going to the medical appointments with your loved ones. Asking them who you can come along so that you can help support them and be there for them. So hopefully they’re open to that. But going along to medical appointments, knowing what medications they’re on, and not because you’re taking those things over and you don’t think they have control and are doing the right things, but just so that you are aware and can help support should something change, right?

Mick Garry:

Just not being able to do some of the things that you used to be able to do and the frustration that would come with that. And then perhaps some level of depression involved in just seeing these things – seeing your whole life, all of a sudden, you’re not able to do them. How do you attack that?

Lexie Eubanks:

There’s been different times in all of our lives where what we were able to do in our 20s and 30s we might not even have been able to do in our 40s and 50s compared to now, maybe in our 80s, right? And so, we’ve done a lot of adjusting throughout the lifespan. It just maybe didn’t feel as heavy as it is now in this time in our lives.

And so, think some reflection back of, like, OK, think about if you’re a parent. When you became a new parent, right? And how much adjusting was done during that time in your life? And there might have even been some loss in there, and where your time is then spent, right? Caring for your kids compared to doing other things. And so, I think, reflection of when have you done really hard things before, right? How are we going to do a hard thing now?

Also, identifying the things we can still do, right? Yes, there may be some things we’re not able to do anymore, but there’s likely a ton of things we are still able to do, right? So, keeping track of those things, writing those things down, being reflective in your day of, you know what, I might not have been able to do this anymore, but I can still do this, and this is something that, you know, keeps me feeling really independent.

So, continuing to celebrate those wins and the things we’re able to, and still do, can help lessen the blow a little bit when it comes to adjusting to changes in maybe our mobility or our mind. But certainly, you know, we see some symptom – there can be some symptoms of depression or more anxiety around what I can and can’t do and sadness for loss. So really, it’s like back to reframing, right? Circling back to that, let’s look at this differently, and what can I still do? What is still keeping me be independent? And you know, where in my past life have I done something really hard and gone through it? We’re very resilient. Humans are very resilient. We don’t give ourselves enough credit, right? Highlighting that resiliency can be really helpful.

Dr. Lindsey Dahl:

And I think also taking those things to your primary care office visit. If you really want to be able to walk up the stands to watch your grandson play football and you think you can’t do that, why do you think you can’t do that? Bring that to your doctor’s appointment because is it pain? Have we exhausted all the things that we needed to do to treat that pain so that we can keep you climbing up the stands to the football game?

I think we very much can help you maintain those things if we know what your goal is, right? So, I think, and that may be different for your doctor to go with, this is my goal; help me make it, right? Than just going through all your problem lists. Say, this is what I want to do, and I’m upset right now and depressed right now because I haven’t been able to do it. Maybe framing it that way.

Your physician will come up with some ideas to help treat that thing better. I don’t have energy to do this. Well, maybe we need to hear it in that way to say, oh, we haven’t done a sleep study. We need a CPAP. Right? And then there’s the motivation to, oh, maybe I would wear a CPAP if I had energy to be able to take care of my grandkids. Right? So, I think it’s making your provider aware of those things so that they can act on them too. Because it might show something in a different light or a way to take care of a medical problem in a different way to help you maintain those goals.

Mick Garry:

What are resources we have available at Sanford to handle it? I mean, I’ve presented you with a number of challenges here for older people. What are things they can do? How can they reach out and contact somebody?

Lexie Eubanks:

If you live in a region where you have integrated health therapists or counselors, kind of go by both names in your primary care clinic; they’re a fabulous resource from a mental health aspect, right? Whether we’re doing the therapy or the counseling piece, or even if it’s just connecting you to resources in the community for mental health support, especially through big transitions, grief, loss. So, definitely a fabulous resource as well.

If you happen to have clinic social workers in your clinic too, they’re a great option as well that get you connected to some more supports and really help problem-solve and explore different areas in your life. Biopsychosocial piece of, OK, all of these things, maybe let’s get you some resources and continuing to be able to live a good, happy life. So I think both of those are fabulous resources within the Sanford system if available in the region you live.

Dr. Lindsey Dahl:

Yeah, I mean, I think a lot of health systems are providing things like balance and stability clinics. If you’re falling and have mobility issues, there are multidisciplinary teams that can help keep you mobile. There’s a bunch of different, and probably different in every area, but for caregiving support, whether that’s through Alzheimer’s Disease Association or memory cafes or just through Sanford Health, we have some different supports for that. So, I think it’s just asking around is the first step, right? Because there’s tons of resources out there. We just have to ask the right questions, I guess, usually to get pointed in the right direction.

Mick Garry:

Anything else that I didn’t ask you about that you think is a vital part of the messaging here?

Dr. Lindsey Dahl:

My grandmother lived to 107, and she always said, when you’d ask her why she lived that long, she said: she chose to be happy, she was always looking for her new adventure, she laughed every day, and she said a little nip of scotch never (laugh), never hurt, although I never saw her drink.

But I think she had wise words, right? And she stayed relevant. She was 107, but she could have a good conversation; she could get on Facebook, right? So that, how do you keep your sense of purpose? You keep learning new things. We can always learn a new thing.

Mick Garry:

My goodness, 107. That’s unbelievable.

Dr. Lindsey Dahl:

Yeah.

Mick Garry:

Lindsay, you’re about 25, so you got about a hundred years left.

Dr. Lindsey Dahl:

I’m 48 (laugh), and I make sure I, you know, what I recently started doing, which I know as a geriatrician what I see all the time, I certainly eat healthy, but I just started lifting weights, like actual heavy weights. And I think that’s going to be helpful for me to age well, to be strong.

Lexie Eubanks:

I’m going to go home and eat my blueberries (laugh), about a cup of blueberries.

Dr. Lindsey Dahl:

For sure.

Lexie Eubanks:

That’s a good place to start, right?

Dr. Lindsey Dahl:

Exactly.

Lexie Eubanks:

I think it’s hard from a health care provider standpoint, right? We got to practice what we preach sometimes. I tell my patients that a lot when I see them in the mental health space of, you know what, this is such a journey. And to be able to do it with each other, right? To be able to come to a doctor’s appointment and be connected with the right types of folks, who really do care about you and your well-being, right? Like, you know, what a privilege to be able to do that, to be able to do that for others. So, I think that’s always my takeaway.

And even just having discussions like this today that this is such a relevant topic and so important. And aging can be very taboo, it can feel – talking about it can feel very taboo, right? So, having these really open discussions about it, I think it can be so helpful just giving those folks the push they need to ask for that support.

Mick Garry:

Fantastic. Thanks so much for helping us out today.

Alan Helgeson:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcast series by Sanford Health, listen wherever you hear your favorite podcast and on news.sanfordhealth.org.

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Varicose veins may be more than surface-level problems

Dr. Nayan Desai:

I want to, through this podcast, tell people that it is a medical problem. People historically have equated varicose veins that it’s more a cosmetic problem. Thought about it as you know, more cosmetic problem, but that’s not true.

Alan Helgeson (announcer):

This is the “Health and Wellness” podcast brought to you by Sanford Health. The conversation today is about varicose veins, signs, symptoms, and treatment options. Our guest is Dr. Nayan Desai, interventional cardiologist with Sanford Heart, Bismarck, North Dakota. Our host is Amanda Potter with Sanford Health.

Amanda Potter (host):

Thank you for joining me, Dr. Desai. I am genuinely excited to talk with you about varicose veins. I feel like there are a lot of old wives’ tales and misinformation about the topic, so, really happy to have your expertise here. Just for everyone listening, can you just tell us briefly about yourself and your background?

Dr. Nayan Desai (guest):

Sure. So my name is Nayan Desai. I’m one of the interventional cardiologists at Sanford Hospital in Bismarck. I’ve been at Sanford Hospital in Bismarck since 2018. I came here from New Jersey, and I live in Bismarck with my family. My wife is also a physician, and we have two young kids, Ohm and Mira, who are 8 and 5 years old.

Amanda Potter:

Bismarck is a great community to raise a family in, isn’t it?

Dr. Nayan Desai:

Yeah, that is so true.

Amanda Potter:

So, let’s just start at the very beginning. What exactly are varicose veins?

Dr. Nayan Desai:

That’s a great question. You know, when people think about varicose veins, they come to my clinic, and they talk about is it a circulation issue? And the answer is kind of a little more complex. Yes, it is a circulation issue. When you think about the blood flow to the legs, you think about the arteries which give us the oxygenated blood to our legs that keeps the blood moving, helps the tissue to stay alive, and then the veins are returning the bad blood flow from the legs to the heart, right? So that’s where the veins come in. These are the same veins we see underneath our skin or when we get IV access. So yes, it is a circulation issue, but it is different than arterial issue. Like when you think about diabetics or diabetics with gangrene or, you know, having people amputate their foot because the blood flow was not good, that is an arterial issue. That is a blood flow issue because of good blood not reaching to their feet.

With varicose veins, I call it more a nuisance problem. So there are two different vein circulation systems in our leg. One are those superficial veins, which just run underneath the skin, and the others are deep veins, which are located right near the bone, which are carrying most of the bulk of that bad blood flow up to the heart.

So, with varicose veins, these are those superficial veins which are underneath the skin, and these are nuisance vein. It is a disease, I would say, of healthy people. So, when they come to my clinic, I say that you are healthy, you are active, you are on your feet a lot, you’ve been standing in prolonged occupations, and that’s why you have the problems with varicose veins.

Amanda Potter:

Wow, I’ve learned so much, and I love that it’s a condition of healthy people. That’s really interesting. Is there any relation to something like deep vein thrombosis or any other conditions?

Dr. Nayan Desai:

Yeah, so as we just kind of said, right, the deep veins are the veins which are running deep inside the legs. The varicose veins are typically the superficial veins. There could be a connection. So, imagine, like, if you have a clot in your deep veins, now the blood is not going up to the heart, right? So, the blood has to magically figure out a way to reach the heart; otherwise, your leg is acutely swollen, painful. And then those superficial varicose veins come into play in some people where they have deep vein thrombosis. But, typically, the deep veins — we like to separate this condition out from DVT, or deep vein thrombosis from varicose veins. But, as a sequela, if somebody has had scarring or deep vein thrombosis, they could later in their life get varicose veins.

Amanda Potter:

Interesting. So, you touched on it a little bit, some of the potential symptoms, but can you talk more about how someone might know if what they’re experiencing is varicose veins?

Dr. Nayan Desai:

So, with varicose veins, it is a slow disease process, right? It’s very seldom an emergency. It’s a nuisance problem. As I said, it’s a problem of healthy individuals, people who are older, genetics, pregnant women, people who are standing a lot on hard surfaces, right? Of people working in restaurant industry. We have our farmers and ranchers here in North and South Dakota. So, those kinds of people who are on their feet a lot, especially even smoking, and women who have been pregnant multiple times.

I say, you can blame it on your kid because the uterus, when you’re carrying the baby, is pressing on the veins. The veins are very light there. Amanda, like, even if you hold a little bit of pressure, they can collapse, right? So, the baby’s head can press on the mother’s veins, and that’s where they can get the problems with varicose veins.

Amanda Potter:

Are there any hereditary factors at all? Like, if my mother or grandmother struggled with it, is that a sign that I might struggle with it as well?

Dr. Nayan Desai:

Yeah, I think genetics are a big player, because there are some genetic conditions. But, yes, you would want to ask that history. When I see that patient, those patients in my clinic, I’m typically asking them, yes, is there any familial component, like, your mom had it, or your dad had it, grandparents had it? You are likely more predisposed to have it.

Amanda Potter:

Okay, so let’s say someone feels like they are struggling with this issue. What are their first steps? Do they go to their primary? Can they see someone like you right away?

Dr. Nayan Desai:

I feel like with every disease process, right, it comes in different flavors, I would say. So you have patients early on with mild disease – they’re like, huh, my legs just get a little bit achy. It’s more a nuisance, but I can carry out my daily activities.

And then you have those patients – every time I walk, I feel my legs are hurting, they’re heavy. And I want to, through this podcast, tell people that it is a medical problem. People historically have equated varicose veins that it’s more a cosmetic problem. Thought about it as, you know, more cosmetic problem, but that’s not true.

With varicose veins, you would see those veins are big enlarged. The blood is not reaching the heart. So, the blood is pooling in their lower extremities, and they would feel heaviness, pain, swelling worse at the end of the day and get slightly better when they’re elevating their legs.

So, yes, they can directly see a specialist, but through this podcast, what we want to convey to our patients is, what are the steps which I can take if I start seeing this problems on my own? And that would be elevate your legs, do leg exercises, strengthen your calf muscles, right? Those are simple stuff which we can do if you’re prolonged standing in one position.

Even health care, like I see patients, a lot of them are nurses standing in the operating room, doctors. And compression socks are a great tool. Those compression socks, as I said, those varicose veins don’t need a lot of pressure. You can just kind of press lightly, even with your hand. So, 20-30-millimeter compression socks, which is available through any local pharmacy or through any big stores, you can start wearing them, and that’s a great habit. It strengthens your musculature, it protects you from worsening symptoms of varicose veins, and it gives you good relief.

Yes, like anything in life, it’s an adjustment. So when you start wearing those compression socks, initially you would start noticing pain, swelling and it’s like, oh, it’s uncomfortable. But trust me, over a period of time you will like those compression socks. That’ll become kind of your second habit. And, for us, in our kind of guidelines and where all the society guidelines come in, we don’t want to do any invasive procedures till somebody has at least tried it for three months.

Amanda Potter:

So, what I’m hearing is that maybe a lower-risk intervention like compression socks or doing these exercises, that’s something anyone can start at any time. Would you say that’s correct?

Dr. Nayan Desai:

Yeah, and as I said, you have to be careful. If you have arterial disease — as we talked about at the beginning of this recording, if somebody has arterial disease, they don’t have good blood flow going down to their legs, they’re having gangrenous diabetic foot. It’s best to talk to your local doctor or your primary care physician before you kind of take that on your own. But if you’re otherwise healthy, you’re young, you don’t have any diabetes, your circulation overall is good except for some superficial varicose veins, then I think it’s generally safe to go ahead and start using those compression socks.

Amanda Potter:

You kind of touched on this again, that it’s a disease of a healthy person. But are there ever any times when it’s a sign of a more serious problem or something that people should be really worried about?

Dr. Nayan Desai:

Sometimes, you know, if you have had longstanding DVT or those clots in the deep veins, then you would start seeing a lot of superficial veins, right? And deep vein clots can be a big issue, because those clots can go to the lungs, and you can have pulmonary embolism from those, and that can make you really sick. Sometimes, with varicose veins, you could have obstruction much higher up, which means blood is not able to return way higher up into your pelvis. So, it’s kind of those two can become a more kind of from a nuisance disease to more a little more serious medical problem.

Amanda Potter:

So, let’s talk about the treatments that are available. What can people expect if they do need a more intensive treatment?

Dr. Nayan Desai:

When I see those patients in the clinic, I usually go through a checklist in terms of, tell me about your symptoms, right? And we spent a little bit of time talking about those symptoms. My legs are heavy; my legs are swollen. Some patients would just have spider veins, and they are not really same as varicose veins, but they would be more like superficial veins or nuisance veins, as I call. There are two main superficial veins in our leg. One is the great vein, another is the small saphenous vein. So, you could have leakage in either of those.

So normally when you think about those veins, Amanda, you have good valves in those circulation, right? Those valves open and close and allow the blood to go up against gravity. And with varicose veins, the definition is the veins are enlarged and they’re leaky. Now, the valves are not functioning; the valves are not able to close to allow that blood to go up to the heart against gravity.

And that’s where you would see pooling in the legs. You would see swelling at the end of the day, you would start seeing those ropey earthworms patients complain about in their calf or in the upper part of their thigh. Weight is a big risk factor. So, somebody who is overweight is obese, as you can imagine, that also puts a lot of extra pressure not allowing that blood to return to the heart. Itching can be a symptom sometimes because you can imagine those veins are stretching the skin, the skin is getting dried out, restless leg, pigmentation. If you allow these veins to sit with these varicose veins for a long period of time, you would start seeing the skin becoming dark in that area. You would have rupture of those varicose veins are bleeding inside, internally, underneath the skin, and the skin slowly becomes dark.

And if you really let the problem progress, you would start seeing ulceration, ulceration typically around the ankle. As you can imagine, somebody who is upright erect, the maximum pressure is right around their ankle. The blood is pooling there; it’s not able to reach up to the heart, and you would see skin breakdown and ulceration in those areas around the ankle. So, these are the different spectrums. Of course, people come sometimes very early on with just superficial spider veins to way down to skin pigmentation, swelling, and then the worst would be the ulceration.

Amanda Potter:

And by ulceration you mean open wound?

Dr. Nayan Desai:

Exactly. So, ulceration is like open wounds. These ulcers or open wounds right around the ankle, right around the bony areas of the ankle, on the inside of the ankle, would be more considered a venous, or from varicose veins. They usually don’t heal, as you can imagine, because the circulation is not good. The veins are not returning the bad blood flow, so the blood is sitting there.

So, sometimes, it’s not uncommon for these patients to have ulceration for, you know, six months, one year, two years. These are chronic, non-healing, open wounds, and that can be risk for sepsis infection. It’s an open channel and, you know, usually with our feet, they’re not usually the cleanest areas of our body, right? There are a lot of germs around, especially if it’s a hot, sweaty day. You can imagine what all goes inside from that wound. It’s a direct entry for those microorganisms to get into your system. So, these are the various flavors it would come in.

Amanda Potter:

Yeah, that’s so interesting and scary, like you said. I was sitting here thinking that’s not a good place to have open wounds down by your feet, by the floor, by the street, not a good place. So, if someone’s at that point, what are their treatment options?

Dr. Nayan Desai:

So, when they come into our clinic, as I said, if you have symptoms which are lifestyle limiting, which are affecting your daily activities of life, you have tried the basic conservative measures: leg elevation, leg exercises, compression socks for three months, then we would go ahead with a dedicated ultrasound. So, it is more an involved ultrasound; it takes about 90 minutes. Try and make sure that you have that time. The sonographer gives me a roadmap. It shows me how big those varicose veins are and how leaky those veins are, right?

So, I get that two information, the size and the leakage. And then we put that into a map, and we kind of see which veins are leaky, which veins are enlarged. And that helps us to then plan their treatment and then going straight into the treatment options, that the treatment options over the last, you know, 10, 15, 20 years has just kind of exploded in this field.

Just because of the need, you start seeing so many patients. The original treatment, if you would hear, I have had my vein stripped—the most barbaric treatment. And what that means is they would just go in and yank that leaky vein out, right? So, sounds barbaric. We don’t usually recommend or do it now because we understand that when we are taking away, or yanking those veins out, you’re still exposing so some small veins to come around and have the problem recur again in a couple of years down the road. So, I would say stripping is usually not the first line of treatment we would recommend. Some of the office-based procedures—we talked about those spider veins where it’s just more underneath the skin. Some people do have pain, but most of the time I think it’s cosmetic for patients when they see those small spider veins around.

And that can be easily treated with just an alcohol treatment. You would kind of make some alcohol and form in the clinic; you would go inside those small spider veins and inject alcohol. And what that alcohol does is destroys those leaky varicose veins or spider veins. And then we move on to something which is more involved or something which we do more in as a procedure. There are different procedures available. As I said, I call it a destructive procedure. When your veins are unhealthy, they’re leaking blood, they are enlarged. You want to get rid of those veins. You want to allow the blood to flow into those deep, healthy veins. So that’s why we would actually destroy these varicose veins. And there are various options available: you can destroy them with heat energy, you can destroy them with laser, or you can destroy or seal them off with a glue.

And the procedure that I typically do on my patients is the VenaSeal procedure, or a glue-based procedure. So, we would go ahead around their ankle, put a small IV in. It’s not painful at all, but you can keep the patients comfortable when we are doing these procedures. Run the catheter all the way up from their calf up all the way into their thigh inside that leaky varicose veins, and we would start shooting small amount of glue and seal that leaky vein completely off. And then patients is like, where my blood goes, it goes into the healthy veins, right? If you can imagine that leaky varicose veins can keep getting stretched, enlarged and start pulling more blood when it is not working correctly. So, now we are redirecting the blood to the healthy veins.

Amanda Potter:

Rerouting it. That’s amazing. So, sometimes I see med spas advertising that they do treatments for this kind of thing, or you might have even seen maybe some storefronts in, like, a strip mall. Can you tell me what’s the advantage of going to an actual health care system like we have at Sanford Health?

Dr. Nayan Desai:

As I said, I don’t want to kind of, you know, give that impression, but there are different clinics; there are vein clinics available where you’re seen and evaluated by a health care professional versus these are these more cosmetic med spas. The problem with those happen is they can only do that alcohol injections, right? Those are those simplified procedures. But if you are not checking if your main vein is leaking or not, you are kind of just doing it more for cosmesis, but you’re not taking care of the pain, heaviness, swelling. If your main vein, the great saphenous vein, or the small vein is leaking blood underneath the skin, doing those med spa treatments are not going to be effective long-term.

You would have recurrence of those varicose veins as well as those problems will still persist. Yes, the skin at that area might look better because you have gotten rid of that spider vein. But I tell my patients, what is our aim? Is our aim cosmesis, or is our aim symptom relief? And that’s where I can help you more with symptom relief. The cosmesis component may or may not happen depending on how long you have had the problem for.

Amanda Potter:

It sounds like it’s truly more of like a band-aid-type approach, just put a band-aid on it. But, hey, great business model because they’ll come back and (laugh), they’ll have repeat customers, right?

Dr. Nayan Desai:

That’s correct.

Amanda Potter:

We’ve talked a little bit about some of the measures that people can take to prevent varicose veins, some of the risk factors. If someone has this concern, how can they start that conversation with their primary provider or their doctor?

Dr. Nayan Desai:

When you start seeing those superficial varicose vein come up, I would say actively bring that up. Most of the patients don’t even think about talking to their primary care doctor because the mindset is that it’s very cosmetic. People don’t think that this is going to, kind of, affect their quality of life. They would not think that, oh, my legs are hurting at the end of the day, it’s my varicose veins, or I have itching in my lower extremities. I have started to notice swelling at the end of the day. Think about these as real medical problems and discuss it with your family doctor or your primary care doctor.

As I said, we live in North and South Dakota right here in our Sanford Health System. Our patients, usually in the winter months, are wearing long clothes. Sometimes, it’s not even easy for your doctor to kind of, in that 15, 20, 30 minute visit, to get to that. And, if you’re wearing long clothes with stockings and stuff like that, they might not be able to see your legs. But I would say when you’re seeing that for the first time, bring that actively up. Tell them that these are concerning. What should we do next? Do you recommend anything? And I would say are any of our Sanford primary care doctors are very astute in terms of recognizing the varicose veins, understanding that these are real medical problems, and then referring to appropriate specialists like myself, if needed or indicated.

Amanda Potter:

What would you say is the most important takeaway that you would like to leave people with when we’re talking about this issue?

Dr. Nayan Desai:

Don’t be embarrassed; be proactive. And I’m going to just repeat those lines again. Get medical attention. There are great treatment options available where we can seal those veins. We can, you know, remove those veins as well with small incisions. We call them phlebectomies, or inject alcohol or foam-based sclerotherapy and make your leg truly better. When I talk to my patients after, it’s not just the cosmetic look of the leg, but it’s also when they say, oh, I feel right away my leg is less heavy. I can walk distances now. I’m not aware about my leg as much as I was aware about it before the procedure. You know, I can stand on my feet much longer. So, it is truly game-changing. If you do have moderate to severe venous insufficiency from varicose veins, which in common terms are leaky varicose veins.

Amanda Potter:

It’s quality of life, right? And people don’t have to suffer with it, is what I’m hearing.

Dr. Nayan Desai:

Yeah, and one of the other questions I get asked, Amanda, is as a heart doctor, is like, oh, if I get my varicose veins sealed, if I need bypass in future, the surgeons typically use these veins for open heart surgeries and bypass. And my answer to that question is, if these veins are leaky and not working well, they’re not going to work well in the heart. You don’t want those varicose veins to go inside your heart as well. And at that time, the surgeon can either use some of the arteries in your hand or other areas of the body which are more healthy. So, thinking about, oh, I don’t want to get this procedure done because I might need open heart surgery 15, 20 years down the road.

Amanda Potter:

Well, Dr. Desai, thank you so much for your time today and for explaining this topic, and we just really appreciate your expertise.

Dr. Nayan Desai:

Thank you for having me.

Alan Helgeson:

This episode is part of the “Health and Wellness” series by Sanford Health. For additional podcasts series by Sanford Health, listen wherever you hear your favorite podcast. And on news.sanfordhealth.org.

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