[inaudible conversations] all right, so before we have the doctor, up to give what will be great keynote remarks, i want to start the morning off with having a conversation with you about something that is near and dear to me as one of those two represents a Success Story of the great specialized care system, spinal cord injury does the system of care. Before i get to exactly what the topic is, i want to ask a couple questions. What are some of the reasons why one becomes a clinician . Why do you choose to become even. Raise your hand if its money. A bunch of millionaires in here. Social status. Everybody respects about her. Job security. You always have people focus on getting better. If you are a healer, youve got some job security and its probably a combination of all of those. But again, from perspective of the statement, im willing to bet somewhere on the list of what brought you into your discipline was compassion. What is compassion . A feeling of deep sympathy for another whose stricken by this. What are we talking about . People of become disabled, diagnosed with disease with a strong desire to alleviate the suffering. It puts you in a position of the healer. As clinicians, you literally alleviate suffering. By show of hands, how many of you are va clinicians . Im a neo, we cannot doubt of the say you have compassion with each and every patient you touch, each and every one of them. Not a lot of hands. Should be more than that. If youre trying, at least you aspire to show compassion with each and every patient. Alright, so so tell me this. Then why are we in this position, where you enjoy the privilege of providing care for the nations, our heroes . Is your system now where they go away. Ill talk about an excellent nba has to make it more successful. Specifically spinal cord injury and disease system of care that is enduring that earthquake in testing its foundation. How do we get there . What happened . We could talk about phoenix. We could talk about toma, all the other major things. But im talking about what i see when i go to your individual facilities and i talked to the nurse says and leadership about making a Foundational Mission a priority. Im talking about when access to care is denied. You show it. I believe that. The question today, is that enough . I dont believe its enough. Not with what is going on today. Lets separate the power to heal from another critical aspect of care, that we consider important. Empathy. The psychological identification with vicarious experiencing or attitudes of another in this case, the veteran. Suffer trauma, suffer disease, trauma, exposure. This is what we are talking about. How is empathy different from compassion . Unlike passion come empathy is not about alleviating suffering. Its about something rarely if ever found, a military cultural competency you wont see outside of the va in many cases. It is your Competitive Edge talking about competing with other systems. That is the edge you have if you know what it really means. The question is, do we know what it really means to be empathetic what role does it play in your role as healers . That is the question we are going to test this morning. I want to do that by revisiting my journey, taking you on my journey. I want you to bear with me. Close your eyes for a moment and stretch. Close your eyes. I see you. Empathy. I want you to stretch your imagination. Open your eyes. That is how fast this happens. No warning. At this point, stop moving. You are quadriplegics. Stop moving. The side of the room, youre paralyzed. You are lucky. You could to move your arms and legs, but you cant move anything else. Bear with me. Your nose itches, you cant move. You cant. You are paralyzed. You have to accept it. Over here come you can wave your arms and stretch, but dont stretch her legs because you cant. You just have to accept it. I want you to take this journey with me for just a few minutes. Wife is sitting there nearly paralyzed right now as you are. After the accident he just suffered, not a chainsaw or lawnmower, the jaws of life. Your car is cut open mic you can. You smile twisted burnt metal and its going to haunt you for the rest of your life. Your body is extricated from the vehicle. The next thing you going completely unconscious is this. The first sound you hear when you wake up. This is what it sounds like to be maintained by a machine. You wake up to that sound. Thats what woke you up in fact. The next set of sounds will haunt you as you try to figure out what the heck happened while staring into the dark. Hospital sounds, missouri, cheerfulness, misery. A mix of everything. Youll be visited by a litany of people, people, doctors, nurses, social workers psychologists, nutritionists as he faced a mobility, sleeplessness, hunger, anxiety, depression and nonstop pain. And meanwhile, your marriage, kids, bills, classes, the thing you didnt get done all appears to freeze, but it doesnt. It simply moves on without you. And then on the preexisting conditions, all the choices you make that got you here, diet, oral hygiene, addictions, education model, trauma, exposure to combat, all of that now im foreseeably matters and has an impact. Now it matters. And then your own mind begins to play tricks on you. You shook your head come even though youre paralyzed. If you ever heard about the running dream bigger patients have . This is the dream were typically about 3 00 or 4 00 in the morning just as the sun is coming up during the middle of the dream sequence where you are in a wheelchair. You now understand what happened to you and your body starts to force you to think about what it was like before this happened to you. Youre moving along and suddenly take the first step, you stand up, take the first step, step, step, trot, trot are running as fast as you can and then you wake up. No matter how hard you try, you cant go back to sleep to get back into that body that knew what it felt like to run. This is your mind doing this to you. I want to talk a little bit about my first medical family conference in the way it went. By uncle bill is a vietnam veteran gunnery sergeant. When i became paralyzed, he was one that came on the conference, marine corps, drill and start your and he didnt want to see me this way. He said dr. , is my nephew ever going to walk again . Dr. . No. My thoughts are what . Thats it . That simple . What about the 3 that what began . Statistics. They might be one of the 3 . You are a doctor. You are not god. How do you know . How are you so certain that you can basically define my life in two letters, one word, no. Speaking of god, why me . What did i do . Does anybody even care . A completed rehab and tried to move on with my life, my new life and now im a veteran who is homeless. Now im an angry veteran. Now im not compliant. Im overweight, making poor dietary choices. Im a burden to you, a veteran being denied access. The veteran being denied the drug i need. Im a veteran and its a wheelchair fixed right now, a veteran who fears retaliation if i complain. Im an undesirable. I am a human being and i need your help. Please dont make me wait. Please dont make me wait a second longer. Does anyone care . I wonder if thats the last question he asked before he died alone. Hes not an abstraction to me. This is a person that i talked to, touched, got to know. I dont need to tell you what happened to him because it is right. Heres the thing. He became disillusioned with the relationship he had with his providers in the va. Some have a dramatic brain injury. He was an opioid abuse her. There were reasons. An undesirable. He undesirable. You said you know what, im not doing this. I will pay for my care in the private sector. And now live with paralysis. Please move your legs, move them around. Move your arms, quadriplegics. You are doing it for me. Move your legs, stretch. Feels good, doesnt it . Now tell me, anybody who is a healer, ever deny access to care. Ever slow down in admission, ever put put something aside and make someone wait who never had that get that ive just given you. Or leave a better and isolation or put policy and process and rules before compassion. I know you are all people, you have to make a living forget to follow rules to keep your job and your professionals. Guess what. We are not professional patients. You dont give us our purpose. We give you your purpose. We are why you exist and im thankful that you exist. So in closing, we talked about this yesterday. There are forces out there that want to eliminate this specialized system of care pic again were not talking about expanding to the community and all the things that have to happen to give greater access to quit talking about this specific system of care. And they will move a step closer to be successful with every that we end up finding out about. Every one of those would be the reason. Your Competitive Edge in these times is to provide care with passion, but more importantly your ability to emphasize. I want to thank you this morning for empathizing with me. Thank you. [applause] do you want to do that after his talk . [inaudible conversations] good morning. My name is carl blake, associate director of Government Relations for paralyzed veterans of america and here in washington, d. C. Before introduce our keynote i want to say to sherman, im one of those 3 . 3 . Im a pva member who is fortunate to have been able to move my legs. But it rings very true listening to what sherman had to say because what you do matters to me as an actual user of the va Healthcare System so i thank you all for being here. You all make a huge difference for a lot of people like me and i really dont know what we would do without folks like you. So this morning im stalling a little bit. We are fortunate to be joined this morning by our keynote doctor baligh yehia. He is currently the deputy undersecretary for health, for Community Care. It probably goes without saying that he maybe has the toughest riddle to crack in washington, d. C. , right now, how to deliver on access that is continuing to grow while expanding that access into the trinity which is a complicated proposition, all the while his rather by a political minefield trying to solve this problem. I certainly dont envy what dr. Yehia has to deal with, even though we kind of cross paths, this i do with the political environment entirely. So its a complicated proposition. I asked him, i said whats the one thing you want these folks in this audience to know most . And he said they need to know that im a practicing the a physician. You will note he raised his hand when sherman asked the question. He has a vested interest in the system that we are talking about today. I think you probably have his bio. I couldnt do justice to the number of awards if received, his background. He received his m. D. From university of florida. He did his residency at Johns Hopkins and hes been at the university of pennsylvania medical system forced sometime that there is also a professor there while also practicing in the va and while navigating the political minefield that is Community Care policy with va at the national level. So please show a nice warm welcome for our keynote speaker this morning, dr. Baligh yehia. [applause] thank you all and hilly okay . All right. Thank you for having me today. Sherman and i have done a couple of conversations together that are on different panels. Im always inspired by what he has to say and i think its important for clinicians to be moved by talks like that because i think it shows that you are open and that you are there to do the right thing for patients. So thank you for your story. What i want to talk about today is really how we move [inaudible] we cant hear you. [inaudible conversations] [inaudible] i can use the podium mic. Can you guys hear me okay . All right. Lets start again. So today were going to talk a little bit about how to move towards a highperforming network. They have already limited me because the folks in november i like use my hands and i like to walk around some going to do my best to stay in front of this microphone. I think we should start where many Healthcare Organizations across the country are starting, which is how do you maximize value for our patients . For us its our commitment to that trend. Many of you have seen a slight slimmer to this which is really the aaa of healthcare, which is how can we get better health, better care and experiences and then better value for our patients. This is really a low bit of what many Healthcare Systems and plants and organizations across the country are striving to do in this environment, which is really maximizing the good expenses and care and positive outcomes of the want for our patients while at the same time being as efficient as possible in using our resources. When we think about how to maximize the Value Proposition for our veterans i think we really need to start with them and we need to think a little bit about where they are. We have veterans that live in every corner of the united states, literally in the smallest of cities or smallest accounts to the largest of cities. This is very unlike other Healthcare Systems or health plans, where they actually get to choose which market they enter into and then they compete for patients. We are very different. We need to provide healthcare to a population that can live anywhere. And so that fundamentally makes what we do different than entering into a market organically and say hey, we think is a good market to begin, we are going to try to attract patients to a. We had to go with the patients are, not other way around. Its important to note that we cant have the physical infrastructure in every single one of those locations. So it really starts, we really start to think about how do you create a network of providers across the country to take care of our veterans that live anywhere. We also need to the thing about this in the context of increasing demand for care. As many of you know we have an aging population, and with age comes more comorbidity conditions and other issues. You can see in this graph the number of appointments both inside and outside the va has been growing in recent years. Not only are we trying to make changes to develop a highperforming network, we are doing in the context of more individuals coming to us to receive their healthcare. We also need to think about the location, and so i am like many of yo you are the one of your patient is different and theres unique nuances about who they are as an individual of what their medical condition is. We have the same thing in different geographies. I just put up three different locations for you as an example. When we think about alaska or maybe some more of the front to states like montana you will see a large proportion of the care is actually being delivered by partnerships. Or in alaska happens to be great partnerships with our dod facility and our Tribal Health partners in that state. So actually more care is delivered outside of our walls than inside of her walls. Rejected when you think about new york city where we have a lot of different clinics and different access points, and so more likely they will be treated by a va provider versus a committee provided. Its important to think about that as we think that moving towards the highperforming network. He can it be the same in every location. It has to very buy that geography and the population density of that trend it has to ver vary by that geography. It varies by specialty. For decades now there are sort of things weve been partnering for, freestanding dialysis clinic. We buy a lot of dental care. Most were all Maternity Care is done outside of the va wall. Community Nursing Homes and home health whereas there are certain things that are provided within a va facility such as Mental Health care services, geriatri geriatrics, rehab medicine, spinal cord energ injury. Not only do they vary geography also very by what type of care is purchased. So thats important because when you think about how do we design the right system and it is definitely the topic of discussion these days here in d. C. , is whats this right proportion of va Community Care and how can they work together. You need to think about all those different nuances. I3 you need to think about all those different nuances. I really am a person that doesnt think of this as all or none. I really given us two sides of the same coin. Va care and Community Care are linked and have been linked for decades and will talk about them in the sector. It just seems to happen right now theres a lot spotlight on Community Care but weve been in the business of partnership at va for decades upon decades. What do i mean by a highperforming network . I want to talk about the characteristics of that, that we are striving towards and then talk more about how do we get there throughout the rest of our time together. First, it means strengthening and growing our Foundational Services. You might have heard this term by the secretary or others. Every single Healthcare System across the country dhat excel in every single area. I think its important for us to invest in the services that are most important to veterans, that a most unique to the va and make sure that their stateoftheart and worldclass. Thats what foundational seundatices means is making sure that they care that cannot be provided of our walls is delivered with excellence to all the veterans that need it. At the same time it means identifying those seundatices tt are readily available in the community and delivered in a high quality, and partnering with the right people to help deliver that care to our veteran population. Agan, its hard to be 100 perfect in every single field. Most Healthcare Systems focus their efforts on developing certain excellence and we want to make sure that we do that as well. We also want to move towards a process of monitoring uality satisfaction and value. And again a lot of Healthcare Systems across the u. S. For their own entity can do that. We are now moving into this world of partnershusi and networks but we dont have the best clarity on what is the quality of our community partners, how are they using an organ healthcare . What is the veteran satisfaction with those providers . So we need to develop those competencies as a system so that we can make sure we provide our patients with information on not on the quality care in va which i think is well