Sean Wood, VP of Our Medical Practice and Pharmacy Technician

It Takes a Village: Pharmacy and Provider Support for Discharged Patients

Sean Wood, VP of Our Medical Practice and Pharmacy Technician talks with Julie Soukup, VP of Sales for The Medical Memory about a newer way to look at patient discharge from hospital to homecare where the Clinical Pharmacy and Provider team are intimately involved to ensure successful outcomes and prevent readmission. He emphasizes the importance of ensuring there's no duplication, effective compliance, and other clinical directives.


A multifaceted approach means a lot of information and a newer perspective on how to work with patients. So this system ensures patients stay compliant with their providers and medications. Everyone is informed, including patients and their families.

Transcription of Podcast


Sean Wood

Fri, Mar 03, 2023 2:29PM • 27:04


patient, provider, communication, gaps, pharmacist, care, nurses, outcomes, calls, practice, hospital, compliance, big, dallas fort worth, recording, medication, years, serve, hipaa compliant, village


with medical memory recording hundreds of 1000s of patients with their HIPAA compliant mobile app, we felt it was relevant to start discussing the best practices in patient communication, especially now that so many providers are recording these patient interactions with video. My name is Julia and I spent 15 years working with physicians to strengthen their communication skills. listen in as we learn tips from the industry's best and patient experience, how can we strengthen these patient and family conversations and help our nurses and providers optimize their time, especially now that the camera is on?


So quiet on the set, Roll camera, this is Scene one, take one patient now.




Hi, I'm Julie with another episode of take one patient, I'm very excited because I'm here with Shawn wood. He is the VP of mid south transitional medicine or medical group, excuse me. And their role is really to help patients transition from inpatient medical care into long term suitability at their home. So I'm really excited that he's coming in to talk about you know, how the implications of communication and all of those things are impacted, especially when the family is integrated in that support. So thanks for joining us, Sean, why don't you kind of start and tell us like a little bit more about about kind of what you guys do and a little bit more about yourself? Excellent. Well, again, thank you for having me on the show and this podcast episode. Yeah, so essentially, we've been, I am, like I said, Shawn, with mid south transitions Medical Group we've been established for well over four years. Doesn't seem like a lot of time. But I have a healthcare background. They've been well over three decades, mainly in the pharmacy world. But we've established this practice over four years ago. And we focus on the patient who has a high risk to readmit to hospitals, especially the frequent fliers going through the ER, those are very sick patients. Usually, they have a lot of a lot of needs. They don't have a lot of great communication and many different references. But we help fill the gaps. That was the real reason versus missional move. We wanted to create the practice in the first place. The practice is not just a typical doctor's office, we focus on house calls, traditional house calls, medical house calls for sure. And telemedicine, we utilize the technology, we now have access to fingertips, even in the rural areas, and we increase that access to care literally 24/7 365 with the type of care that we provide,


in the sense of in comparison, transitional medicine in the past, oh say 10 years has been evolving from insurance companies, Medicare, things like that to have more compliance driven better outcomes. And that's where they give you interesting metrics to meet and they don't always tell you how to get there. And so, we've felt that we should step into that game. Myself, my five other business partners, I have three physicians, our owners, one nurse practitioner, a pharmacist and myself. And we we have that in the whole capacity. We now employ over 60 nurse practitioners and less than four years from nothing, no charts, zero at the beginning. And we operate and we're based out of Texarkana, Texas, but we have multiple offices in Tyler Texas, Jonesboro, Arkansas, Little Rock, Arkansas, we're even serving as far as Dallas Fort Worth. So we're we're living the main mid south when we created it, we created for the Mid South United States as a missional move once again to to help increase the access to care. And in solve a lot of those gap problems with the gaps of that family members. So all the way through to even the caregivers, we all have different levels of gaps that we must cover in order to optimize the patient's outcomes. Absolutely. And I would I would imagine that's a very


nerve wracking time for a patient that's going from an inpatient setting to now okay, I don't have the nurse, the team, the machines, all of those things around me. You know, they're often probably I'm sure, incredibly nervous family members are nervous. How do you ensure that patients you know really kind of stay compliant as they are moving into more of their care at home? Gotcha. So in this case, the type of practice we are thinking of it definitely like a brand new specialty that didn't exist even 10 years ago, as much as like say cardiology. gastroenterology are in commonplace these days and times and has been historically for some time. Anyway, so what we do is we help coordinate care. We're not acting like a social worker, but we are kind of in one respect, but we're doing it on the provider level. And so what we do is in the house calls telemedicine space, we execute many aspects of wants, including non care coordination, care execution, obviously, treating patients according to providers and we


We have other facets within the practice. And this is kind of where it gets to be a really cool deep dive, is we have a clinical pharmacy in which I'm my, I'm one of the big members there. And we helped focus on the medications and the there's a lot of huge amount of gaps in medicine, making sure there's compliance making sure to not duplications of therapies, overdoses of certain same drugs in the same class. There's huge disconnect. And it is really its own pandemic. And that's, that's a big issue, on top of the one we've all lived through, and still getting a good bite from. So those things are very key. And we have not only the Clinical Pharmacy team inside the practice that is under the directive of the provider saying okay, go do your thing, go to your service, your license forward what you can do, we also have dietician nutritionist to do the same thing, under the direction of provider. So it's a very big village to treat a patient you have multifaceted multi disciplines, like what you do say if you're going through graduate school and in the doctorate programs, and so forth, you round with physicians and hospitals and nurses and pharmacists, they do that as well. Maybe they work as a team to take care of that patient they're seeing they're even though they're in training and getting through the metrics in the hands of schools, it's very important at principle for that, that does continue in private practice or in the serving the patients, whether it be in a facility based a long term care facility, a nursing facility, even at the you know, the normal will be called nursing home. But really even a patient's home that's even bigger, because there's a lot more dynamics a lot more obstacles, there's so much that you can try to cram into that. And they will try to solve that problem during the trays of the phase of transition from the acute care facility, ie hospital, back to their home, where their residence is to make a new normal for them.


So how, you know, understanding that and you know, your entire team is helping to be able to do that. And multi facets, which means probably a lot of information, and then newer perspective on how to work with patients and help with patients. And it also allows us to times the non patient side, because that's just them, usually they do have kind of a little support team or family that's helping, how do you recognize the it's a newer space? How do you ensure kind of communication about either changes or about new perceptions in medication? How do you ensure that patients and their families best understand some of that the information that you guys are providing? Because it sounds like it's pretty, pretty robust, which is awesome, but also, and you know, a lot of different specialties? Yes, yes. So what the, like you said one degree to communication, we have a lot of access, and a lot of people will have needs, when they say they go to SunSaver, you go from the hospital back to their residence or primary residence, for instance, then they have the discharge planners at the hospital, they've got to find out they need home health, if they need specific duties, or respiratory therapy at the house. And those are those who are fine to do that recording, they didn't care and then actually getting it all to be more symphonic, in the way it has happens for the patient at the time of the treatments or the services rendered. That's where the gaps come in. And so what people like mid south do, what we do, I should say, is what we kind of oversee the prime of the care, we don't replace any any provider in the patient may or may not have, we do not do that at all specialist, whatever, we're there to cover gaps, and we're at the same time protecting their compliance is that the other providers they may have have. And basically, you protect them, protect them to make sure that they're compliant there acts up that CO CO group of compliance, it really just gels together.


There we go. My screen timed out on the SRE. Seeing a Medicare patient Medicare says okay, if you have a readmission to a hospital, from a certain criteria, all cause partial cause within a certain timeframe with the same diagnoses that go back, they're not going to pay for it. And that facility is going to get deemed while we help protect the interest in that capacity. But that's not the prime focus. The prime focus is making sure the patient has these gaps covered. And we coordinate with home health agencies, we don't replace them. We're not a home health agency. We just work together with all these different players. That village is treating the patient. And it goes it's really it's actually simple, but it sounds vastly complex, but it does. It's a lot of a lot of effort, communication, interfacing with different systems like EHRs. And then, of course, where's your focus? There's your patient, you got to take care of them first.


So, yeah, and so with that, you know, one of the things I remember when we were talking,


the first time we met, is that you were I thought it was really key that you were really also saying you know, you just


but it just now is like, at the end of the day, we're all really, really focused on the patient. And the more that we work on, like developing those relationships with patients, making sure that they are in kind of, the more that our team can better support that. So talk to me a little bit about that. How do you how do you go about that? How do you communicate that with patients and, and their families? Kind of Where's where's your mindset? In that capacity? Gotcha. Oh, I'll dive in on the medication specifics a second. Now, in my my arena, getting being a medication and been pharmacy overwhelmed, 30 years seemed done and everything there is basically you can do in pharmacy,


there's this latest thing that's coming around, called pharmacogenomics. It's a it's a one and done type of test that will test genetics, your genetics, like a swab, like the 22 and me similar concept. And you can swab your cheek and have it analyzed. And I'll tell you, what drugs in certain classes that you do need by your provider authority and treatment, but it will tell you which ones will minimize a side effects will be more optimized for you metabolically. Now, that is like super cool. And super Medicare. Yeah, and that is Medicare. In other insurance companies allow that for certain majority of the major classes of drugs, for a lot of the


standard American treatments are being done diabetes, cardiovascular type drugs. So you have this allowance, this little tool, one and done. There's not a big series of tests. But that is a great tool that improves communication from the providers. So they can you know, treat the patient their little village, but also that can give the patient less confusion. Why don't I take all these meds I just get they get overloaded with all the meds. And so that can mean that that little test can can facilitate the communication from provider level and shrink that gap of communication. And then that take it right down to the patient. And then, hey, I don't have to take this extra pill or two, or this one might work better for me, I finally get it. Now I make sense. Why had these side effects. So that's that closes the loop. And then when you have that engagement with the patient, they only 90 Develop a great relationship in the bond and a trust. You just made their world a little bit better. Yeah, absolutely. Well, it's interesting. You talk about even having that as a tool.


So that the patient better understands like, Hey, this is what it is. This is what it's saying. This is why we're changing something, especially if someone's been on a medication for a really long time, I could see being a little resistant, like, oh, wait, no one can take that. I've been on that for 15 years. Nice that I thought was interesting is it allows you guys to communicate provider to pharmacists, and and that place a lot easier to kind of be on the same page for how you're


taking care of that patient. That's right. And you always want to have that, that dialogue because pharmacists go to school to be drug experts, pretty much doctors go to school to be medical experts in treating patients. And if you have these hybrid


specialties in one locale so to speak, then you have a bit greater chance of a return for that patient. That's the bottom line. And at the same time, you you save the system's insurances and stuff over time, tons of funds, they don't have to pay out for other potential events, other worsening conditions, diagnoses, other undiscovered diet, you never know how far that that intervention will take and make something better. Or eradicate something that was can be costly, and all kinds of capacities later. So that's why it's this model is extremely important. It's the way not only that the insurance companies are seeing it in a way. But they're also wanting to say, Okay, you have to do this, but they don't tell you how to get there. And so when you we figured this out, not saying we're the only ones doing it in the United States, but we really put that with the missional mindset with the depth. And we just said we're gonna go and we did it. And it's the effectiveness the outcomes that are the metrics do show


proof of concept way beyond that. It's, it's just that effective. And so that snippet that we've pretty much started to dive in here today is where you're going to see a major shift and change in the whole healthcare paradigm, because the current system is so fractured and broken, we all know it.


There's other technologies, other tools that we can all use to drive that compliance, not that we're forcing it down somebody's throat, just to try to be more congruent in the way the outcomes are going to be. You know, how would it take this to get to the outcomes over that that village? And these different things it's really cool stuff. Well, and it's interesting because it actually makes me think about you know, one, you know, medical memory


is a HIPAA compliant app that video records, information for patients or whatnot. But it's interesting because it makes it easy to one of our doctors that that started doing the does the discharge medication via video, because he's like, I can't get to each one of these patients. So we I'm at least gonna give this custom discharge instruction via video so that the patient has access to it. But even what you're even kind of saying is, you know, even if you take kind of that some of that information isn't just useful for the patient be useful for other providers to be able to watch or see or to where you could not necessarily do you have to do a home, like a house call, as you said, or, but maybe explaining, hey, this is the task, these are the things these are what we're seeing, these are some things that you may want to do different, having even a recording of that, that the patient could access. But then some of these other provider teams could see what you as a specialist are seeing as it relates to them. And I mean, yeah, I mean, outside of using and I'm not even sure if you guys use video, but that's one way. I'm even like thinking in my mind, I'm like, Man, those videos could even be for the one pharmacist that's doing into patients could be useful cross functionally, but like, I mean, how do you guys communicate? Obviously, you're not always in a room altogether with every patient? How do you guys communicate effectively? About a patient together? And and do you use video? Have you ever thought about kind of that capacity? What are you? What are your kind of thoughts? Yeah, in our current EHR, they have a telemedicine platform that utilizes that, like what we're doing a chat like this, or we're in the same as medical men it was, so there's ways to do it, it's a matter of making sure for the providers that that software or platform is compatible with their EHR. That's a big issue I've seen since we opened the practice four years ago. And then, you know, if it works, and it's still patient friendly, the stuff we see on the provider or the business side of it, it is not necessarily patient centric, and that that I think, is one of the value in what you were talking about will come out because it's more patient centered, but then the providers can see the simplicity of this and the Deuce and then have the follow the paper trail, so to speak, and then, you know, make that continuity care a lot better and outcome. And that that's very important, very important. That is that's really the whole purpose in itself. Along the road of treating the patient, you have to have the data, you have to have facts. And so you can make the best decision if you are the provider or the non physician provider, or the specialist, whomever it may be. But if you don't have these ingredients, you just increased risk and event potential for diversity and you don't want that, for sure. And that's where I think sometimes, you know, live like a telemedicine is all at times, like back and forth, like we're talking now. Whereas the recording seems to always be helpful, because not only the patient can rewatch it, but their family members can rewatch it or anyone else in that bubble could be like, sorry, I missed something, am I understanding this right, and be able to have kind of that resource to help themselves be compliant? Especially as things are changing from the things they always used to? Do you know, to?


So oh, sorry, go ahead. No, it's I agree that that utilization of technology is awesome. It will change lives literally. Right? I agree.


So that also means that I mean, one of the other things that you you did talk a little bit about is is not only just taking the time to build that relationship with with the patient and yesterday kind of the questions, but also kind of transitioning them to feel more empowered and more involved in their own care or their family also empowered and involved, especially when you're transitioning kind of in that space. Talk to me a little bit about that, or what would it how do you teach your nurse practitioners to kind of help a patient transition in the way that they're thinking with that? Will you first find some good ones that have been spirit? Any higher? Will that No, yeah, I don't make them I'll try to give them guideposts kind of like boundaries. Like if you're on the road and you know, markers me say, Okay, if you have the right spirit about yourself, which we do, we screen them in our hiring process, for example.


But we make sure that's first part of your foundations. And then you do what you are trying to go do. But make sure you think of it in a mission lose sense. This is the patient is the mission. And the mission is never going to be done. But you will need them remember who you serve. And it's not a command we're not going to count their head up or anything like that. We're just saying just remember who we serve. We can't forget that we that's that's it's just out of the question you have to remember. And then on top of that, and the other ingredients, we we give the tools like for you know, having, say a pharmacist, do clinical medication therapy, management's that backup provider and what they are doing, and we're shepherding over watching those events. God bless you


So it's kind of cool how you can make them look like in a sense, rock stars, nothing. They don't, they don't already rock stars, you just shine brighter with that aspect of that. And then that affords, you can take the time with provider and show them the the ingredients, and they're like, Whoa, how cool is that. And then, you know, even to the big C suite, folks, if you show them the numbers, if you build it, they will come, the numbers will come and you'll see the revenue side, which is a whole deeper dive, probably another conversation. But it all works together synergistically. But you gotta remember who you serve. And the first is a patient. As we've said many times here, I just can't say it enough, honestly, because it's true.


But we just all did this stuff in unison, which we do. And we never, it's never 100%. But you definitely aim for the 100%. Always. And when that dynamic works, it's on fire, and it goes insane. And it's a good insane


in this day and state. So hopefully that was helpful. When you're really talking to it. As far as like really looking at the people that you hire that have you know that that energy or that servant's heart or things on those lines, because I definitely recognize that and also like being a tool when we're integrating into hospitals, you know, a lot of times and set now I have a question for you about that is, is sometimes we were like, Oh, there's another thing Oh, like, there's more to kind of do. And even though they know in their core, you know, this is what's best for the patient. This is what's best for their family. I know it will help them heal, I know it will help them better understand their care, but they do feel overburdened, or overstretched or any of those things, you know, how do you even as its leadership team, or maybe it's, you know, align that core value that you said from the beginning, you know, how do you help some of those nurses that that might feel especially now overburdened over overwhelmed to? Can you do the literally the little things that may take just a few minutes longer to serve and to educate kind of the patient? I mean, what what advice do you get to other leaders trying to implement or what do you even kind of tell some of these nurses? brings me back to a interesting book I read a long time ago. It's,


Gosh, 15 years ago, I think it was but there was one sentence that stood out to me the most, and this may sum to all that ups to answer your question. It was a there in Dallas Fort Worth area for about 100 years, there's a car dealership family, literally a family of folks called Sewell village, and the Grant's great grandson is named Carl Sewell, if he's still around with us, I'm not sure at this time, however, he wrote a book called service from the heart. And I didn't want to read it at the time, I was kind of cold, I had to. So I did. But that was one profound sense. And it made the whole book and all that my naysaying and not want to read the books, I have a lot of other stuff to do. It totally like sold me, in a sense, not a car, it sold me on the passion for people. And you can kind of see it bleeding through the screen and on the audio. But he said, I'm not in the car business, I'm in the people business, I just happen to sell cars. So in essence, every one, whatever we do for an occupation, we must remember where the people business, we just happen to do fill in the blank. And that blank is okay, I went, I'm now a hospital administrator or, you know, I'm a nurse or a doctor fill whatever the blank is. But you're you're in the people business. And you must remember that going back to the core tenants. And then on the second side of that this is outside Carl Searles book is you reinforced that by the leadership, and you show them and you shower them with love in a appropriate way. Like, you know, they're giving gift cards or whatever. But you'd want to hear them have the input if they see something that can improve the quality of the practice or what they're doing. Don't let it be on a deaf ear, no blind eyes, listen, and then be receptive, and then discuss it. And at least they had a voice, whether or not it actually comes to fruition. But to be really genuinely open as a leader or a business owner or whatever, and just do it, and gotta have that and then you reinforce your core tenets and NFA hey, I want to buy you lunch today. You know, that's the way it's gonna be and maybe do that, and surprise sporadic things. We've done that many times too. And retention retention for employees is, gosh, amazing. I can show you my Facebook posts and my employees are posting is not me. Almost like, Wow, I feel really honored. I'm like, dude, thank you for saying that. And that's really cool you but that value add has its own degrees of continuity, and then they pay it forward and they're really your best marketing tool or whatever. It's not if you have an organization that's doing it for all the right reasons, right. Well, it's interesting because they're the


It ties into what you said at the very, very beginning, like it takes a village, it takes, you know, that integration, it takes everybody on board to, to take care of these patients. And just as you said, you're like, I'm not saying it takes, you know, leadership or a few nurses, like, you know, all a village, I'm saying, everybody, you know, and that, you know, if if your teams are feeling empowered to have a voice, to have ideas to try new things, you don't care as much in that village in supporting patient care. And I think you kind of said that the beginning and that kind of like wraps it up, kind of on how that even goes in that mindset. And that kind of core value of of saying, you know, we all listen to your ideas, too. We're just let's let's try it. You know, let's, let's try some try things and


always put patient centered first, absolutely. It scored like you said, yeah, absolutely. That's great. Well, Shawn, you are such a pleasure to chat with. And I really appreciate your your time and your wisdom. And I really think that you guys are doing a lot of cool things. As you said, it's a little bit different, a little bit more innovative, to really kind of support what I think is a hard time for a lot of patients. So I look forward to many more chats, kind of as we were needing to evolve with your business and as we're looking at patient communication. And thanks again for hopping on. Absolutely, again, Julie appreciate the time and you know, I look forward to Well, I'd love to do more of these things. Awesome. Thank you. No problem.


And cut. Thank you for joining us on this episode of take one patient. We hope you have a nugget or two you can implement into your practice with your patients today. For more information about recording your visits with a HIPAA compliant app, go to www.va Medical memory.com or you can follow me on Instagram at Julie recording doctors. Thanks again.

We need your consent to load the translations

We use a third-party service to translate the website content that may collect data about your activity. Please review the details and accept the service to view the translations.